Dentistry Uncensored with Howard Farran
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298 Securing Full and Partial Dentures with Small Diameter Implants with Steve Cutbirth : Dentistry Uncensored with Howard Farran

298 Securing Full and Partial Dentures with Small Diameter Implants with Steve Cutbirth : Dentistry Uncensored with Howard Farran

1/24/2016 7:47:03 AM   |   Comments: 0   |   Views: 612





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When young Steve Cutbirth broke his two front teeth sliding into second base, little did he realize that he would spend his adult life helping others who met similar fates.  The art and science of aesthetic restorative dentistry became his passion, one that has continued to expand during the past quarter-century.

 

Today, Dr. Cutbirth maintains a full-time practice in Waco, Texas, that is in the top 1% of practices in the country based on production with an overhead of 40%; but he doesn’t stop there. 

 

As Director of the Center for Aesthetic Restorative Dentistry, Dr. Cutbirth shares his patient-first philosophy and commitment to state-of-the-art excellence with like-minded colleagues. 

 

Dentists from throughout the nation as well as abroad attend the Advanced Restorative Series, which is a five-weekend course dealing with advanced restorative techniques, differential diagnosis and treatment of facial pain (TMJ), functional/occlusal problems, and practice systems.  Hands-on training and lectures by world-class specialists distinguish the program.

 

Dr. Cutbirth says the endeavor is his calling, and an outgrowth of the excellent training he had.  “It’s been such a rewarding venture.  The teaching center is set up the way I’ve always wanted advanced dental education for myself.”

 

Masters’ Courses limited to 12 restorative series alumni, expand the program and provide future teaching faculty.  “I sincerely believe that Dr. Cutbirth wants you to have a life in dentistry uncommon to those comfortable with mediocrity,” says Eddie Pruitt, D.D.S., Houston.  “He has an invaluable base of technical knowledge that he distills and presents to you on a platter.”

 

Dr. Cutbirth also conducts and annual update/review course on the latest studies and techniques.  Participants, who laud his informal, conversational style, “hold my feet to the fire.  There’s so much knowledge in the group,” Dr. Cutbirth says.  He’s convinced that the “toothache dentistry” mandated by healthcare systems is misguided; patients deserve the time it takes to provide them with a comprehensive examination and treatment options.  Only then can dentist and patient work together to achieve the optimal result.

 

His mentees concur.  “The techniques, skills and knowledge that I absorbed from Dr. Cutbirth’s courses have completely changed the way I practice dentistry,” says Tien Ngo, D.D.S., Dallas.  “Thank you Dr. Cutbirth and staff, for bringing back the passion for excellent dentistry, which I thought I had lost forever.”

 

www.centerforard.com 




Howard: It is a huge, huge honor for me today to be interviewing Steve Cutbirth. You’ve been a legend in my mind and so man of my friends minds for years, let me read the bio, let me [inaudible 00:00:19] my old grandpa readers. You’re a private general dental practice with focus on complex restorative dentistry in Waco Texas since 1981, began as a director now of the Center for Aesthetic Restorative Dentistry which I like to think of as CARD, because I’m a Cardinals fan and I know you’re a Cardinals fan, you hate the Dallas Cowboys, in Dallas for the past 15 years. The center teaches five to 10 hands on two day Friday, Saturday lecture laboratory courses for practicing dentists.

Each course builds on the previous courses, Porcelain veneers, Crown Bridge, replacing missing teach, especially in the aesthetic zone. Diagnose and treatment planning a mild facial and inter articular pain and dysfunction. Restoring the most complex cases including severe wear cases, restoring vertical dimension, full impartial denture stabilization with small diameter implants. By the final course the dentist should be able to comfortably retrieve a plan, restore complex cases in conjunction with appropriate specialists. You’ve been married to Sharon for 38 years congratulations, two daughters Catherine, Caroline living in Austin and Nashville, two great son in laws and we both have an incredible granddaughter, mine is Taylor Marie and yours is Genevieve right?

Steve: Absolutely, now are you a country western fan?

Howard: I grew up in Kansas you cannot be born and raised on country music if you grow up in Kansas.

Steve: You may have to become one, my daughter and son in law in Nashville are both country western singers, and he just had a number one hit called Smoke and the band A Thousand Horses, so look that up, they’re really good.

Howard: Pull it up and I’ll post it on Dental Town. I tell you what seriously I travelled all over, the three greatest music areas in my opinion is New Orleans Bourbon Street, Memphis Beale Street and Nashville I think what do you call that area? Second Avenue? What do you fall that strip …?

Steve: Broadway, they call it music row, and Nashville is Austin without the traffic, it is one of the most, if you can’t live in Waco Texas, Nashville is the second best place.

Howard: What’s so cool about in all three of those cities? Bourbon Street, Beale Street and what do you call it, Nashville you said?

Steve: Music Row.

Howard: Music Row, it just one restaurant bar night club band, live band, if you don’t like the band all you got to do is walk out the front door and walk a hundred feet and there’s another one.

Steve: That's true.

Howard: It’s just so interesting.

Steve: That is so true.

Howard: We call it dentistry uncensored, I don’t like to talk about anything that everyone agrees on, I like to go right to the controversial stuff. Mini implants, it seems like the oral surgeons and periodontists it’s like mini’s are some kind of you got [inaudible 00:03:24] and real men place real root form implants. I've noticed that dentists don’t understand the difference between Henry Ford model where he made 10 million cars they’re all of the same price, they’re all of the same color, and then general motors came out and destroyed them by having a low cost Chevy then a Pontiac then a [inaudible 00:03:47], then a Buick, then a Cadillac.

These dentists and oral surgeons and periodontists, grandma comes in she can’t wear a denture, they present a $50, 000 trim plant, six root forms on lower, sinus lift three forms on the upper. They say no to the Cadillac, they just say, “You’re out of luck.” Then there’s real dentists who say “If you can’t afford 50,000 why don’t I just take your denture, why don’t we do some mini implants?” The patients love those mini implants, do you agree or disagree that mini’s are kind of tabooing in the closet?

Steve: Okay, I teach both of them, I teach root form, I teach sinus lifts, I teach mini’s and I have become totally fascinated by mini’s. Now mini’s have gotten a bad rap because so many people are using them incorrectly. They’re using them to replace four missing teeth in the lower posterior arch and so you can’t clean underneath them, you can’t clean around them, it’s inappropriate, it’s not mini or root form it’s both. If we get around to looking at some of these cases once that I got going with mini’s I thought this is the implant Howard of the general dentist, this is the implant of the general dentist but they have to be used correctly, and to use a mini implant you absolutely have got to have the knowledge of how to reflect a flap and modify ridge. If you … the big fat ridge that most courses teach has been in my office one time in the last 10 years.

Most of them are either lipped or their knife edged and a mini implant is nothing more than a wood screw, it’s nothing more than a wood screw and it’s just a small root form implant, but the advantage is most of the time you don’t have to drill the depth you’re working in areas that there aren’t rows and vessels. If you ever lost one they’re easily replaced, it takes the fear factor out of it because you’re not working where the nerves and the vessels are most of the time, now I've taken it, when I get interested in something I think you and I have this in common I get kind of obsessed with it. Anything that I do with any restorative material or technique is got to be something that I would be happy to present to the restorative academy or the American academy of aesthetic dentistry, in other words it’s good dentistry, and so the things that we’ll be looking at today and talking about are good dentistry with mini implants but it’s not either or.

Howard: You wanted to show a case right now?

Steve: All right just looking a few, sure, you want to look at a few?

Howard: Sure.

Steve: We can depart from those cases if you’d like.

Howard: No just take it away.

Steve: If I could I think it might be interesting to go through the evolution of the mini implant process in my practice let’s see here okay. Now this is the ridge that you see when you go to most mini implant courses, when I went to the first one this is the ridge they showed you. You put four implants in that big fat ridge, you put the housings in the denture, oh my gosh everybody is so happy. By the way all surgeons and periodontists are very good people, they are very good people, but isn’t it reasonable that they would probably not want general dentists to be placing implants, could you imagine that.

Howard: Money is the answer what’s the question?

Steve: I said …

Howard: No that was a joke, money is the answer what’s the question?

Steve: All right, as I went back to my practice and I was ready to put these implants into big fat ridges this is what I saw, these kind of ridges and you reflect that tissue and that’s what it looks like a knife edge. If a dentist tries to place any kind of an implant into that ridge Howard guess what’s going to happen? It’s going to fail. Now with a mini implant and if you’re restoring or securing a full denture you need too many implants for every root form implant, so it is two to one. With a partial denture it’s one to one, because it gets back to surface area, remember I teach both kinds. With a mini you got less surface area and lateral forces are the things that can cause you to lose one. With partials you’ve got the teeth to take care of the lateral forces, so with mini’s you should just place two for every one root form implant and they work just great. The success rate is the same for a root form implants if you follow that scheme.

This is a fascinating case, this was one of the first people that came into my office, and this guy was a professor by the university and he quit teaching because he said every time he was speaking or laughing his dentures would rise up and he’s afraid he’d lose them. He had a full set of dentures placed and he quit teaching that semester. You can see this is tiny ridge, now with the techniques that you and I are going to talk about today I don’t want to toot my horn, I’m just saying dentists have to know how to do this. What will happen is they will be able to treat 99% of a denturlist case as they walk into their office, if they cannot reflect a flap and modify a ridge I would say that number is more like 15-20% because of the shape of the ridge.

You’ll notice again this guy’s got a little tiny knife edge ridge, I grew up ranching in West Texas and when you’re in the middle of the ranch and you’ve got nothing but [inaudible 00:10:35] and electrical tape you’ve got to fix it, so I said let’s look at this and what can we do? Back to our wood screw situation, we’ve got to create a flat surface here so we can screw the implant into the bone, just like a woo screw into a flat wall. I flatten the ridge, there.

Howard: That is gorgeous.

Steve: Retro fitted them to his existing denture, you know what this guy said when I got through? He said, “Steve if I had met you two years ago I would still be teaching at Baylor.” Now here’s a mandibular knife edge ridge and you can see she’s lost in vertical dimension, but this is what I found Howard, I completely agree with Gordon Christiansen these implants are fantastic if you’ve got a thin ridge. They are easy to replace if you lose one, it’s not like column four we do those and we teach those too, but these are just handy, so look at the width of that ridge, you want a millimeter of bone around the implant any implant. We reflect this tissue, who could put any kind of implant into that Howard? Even you with your great skill.

Look at that it looks like a wave in the ocean, you cannot believe some of the emails I've received from the traditionalist with mini implants whatever you want to call him saying I’m just ruining the technique because the technique is not to reflect the tissue, total BS, it’s just a small implant that’s all it is, it’s a small woodscrew implant. All we do is take a sterile course football diamond flatten that out, boom. Then you treat it just like any other restorative case, you can tell we’re missing a touch gingival right here. Not enough [inaudible 00:13:00] tissue, so when I went back to do the gingival graft I placed another implant. I don’t do anything in my practice that does not work from dental, sleep [inaudible 00:13:15], snoring appliances to mini implants, and I guarantee you if you place these correctly they are as predictable as root form implants.

Howard: What type of implant are you placing? What type of mini?

Steve: What, titanium?

Howard: You’re really agnostic to mini’s, if you’re an [inaudible 00:13:41] you really don’t care what brand it is?

Steve: No, not really I've had lunch with Victor Syndax, you’re familiar with that name?

Howard: Mm-hmm (Affirmative)

Steve: Victor’s a guy who discovered the mini implant back in the 70s, do you know the story on that?

Howard: No how do you spell his last name?

Steve: S-Y-N-D-A-X he’s 85 years old you ought to get him on the show he’s fascinating. The last two years my wife …

Howard: Will you tell him to be on the show?

Steve: He’ll do it, he is such a gentleman, but I want to meet people that are interesting, Dr. Pankey was one of my favorite people luckily I got the opportunity to spend quite a bit of time with him while he was alive. The interesting thing about them they don’t a lot about dentistry, they are renaissance people. Anyway we had lunch with Victor in New York the last two Thanksgivings, you want to hear the story of how the mini implant was …?

Howard: Yeah, but finish [inaudible 00:14:39] Pankey about how they don’t talk about dentistry they’re renaissance people, what did you mean by that?

Steve: I started at the Pankey Institute when I was 26 years old and every time I went out there to teach I was on the visiting faculty for 15 years, I would invent a way to go into his office and spend a half a day with him. During the last years of his life I had a letter correspondence going with him, just to get inside his mind. I don’t think Dr. Pankey ever had a conversation with me about dentistry. He talked about art, he talked about travel, he talked about ideas, he talked about investing. If I had done what he said Howard I would retire both of us right now. He was such a fascinating conversationalist, and Victor is the same way. Dr. Pankey said that any person in an important job or something that’s halfway stressful must take a significant vacation every three months to re-generate.

I followed that when I was 26 back then I went to the … met him the week before I went into practice and I've been in practice 38 years, my wife and I followed that advice all this time. Okay, so anyway you want to go back to these implants?

Howard: Absolutely.

Steve: I got fascinated by these, and so I started trying new things because the courses I’d seen you see somebody placing two implants in an extraction site and placing a crappy crown on top of it, you can’t clean it it’s non hygienic blah, blah, blah, that’s not what this is. I started at first just extracting [inaudible 00:16:41] teeth and then replacing them with dentures. These people are out of their mind happy, because like me you can spot a denture patient with no implants from across the room because they’ve got to hold them in with their lips and their tongue. These people have perfectly natural facial features, you can’t tell. Now that said I don’t want to be an all or nothing person, if I had to have all my teeth extracted and artificial teeth placed I would probably have all on four, because I can afford it.

Many of your podcast are on affordable dentistry, the thing that makes this so great Howard is it’s a wonderful restoration and it’s so much more affordable, we have had Baylor girls come to our office and other women come to our office wanting veneers and they say, “I want my teeth to look just like Dorris’ and Dorris was a denture patient with mini implants, she didn’t know those were not her teeth. Okay so here comes the evolution, I wanted to do something to minimize the time, because if you take the teeth out you’ve got to wait at least three months, three to six months before you place the implants if you do it at the same time. I was down in Mexico giving a seminar and a dentist down there had an idea of placing the implants at the same time.

This woman was a landmine and I thought, “What if I started with flattening this [inaudible 00:18:36] bone just a bit and placing the implants in approximately?” I told the patient “if it doesn’t work we haven’t lost anything, we take them out, we wait three to six months we were going to wait anyway, we come back and do it,” Howard fantastic. You need to know how to bone graft, you need to know how to place membranes it is not hard, it’s easy. The other thing about this is you get the implants at exactly the right level. Here we are three months later boom. Okay now here comes the next evolution I thought because the maxilla is the hardest because that’s type three D3 D4 bone, and you don’t have the [inaudible 00:19:20] areas like you have in the mandible. I thought, “What if you just went through the bottom of the socket?”

That bone is really hard down there because of the pounding of the teeth. This wonderful woman had been like this for 20 years, she’d married an accountant named Donald and said, “Donald [inaudible 00:19:45] Cutbirth to fix my teeth, so here we go. Little thin ridge out we go, now I’m only reflecting the maxillary tissue enough to see the [inaudible 00:20:03], because I want to maintain the blood supply. I’m trying not to reflect it all the way up to their eye balls because you lose that blood supply, even if the flap is a little bit open in the end, so these are 2.9 13 millimeter implants. The other great thing about this you don’t need a surgical guide they can be all 30 degrees and still draw, so here’s the bone graft.

Howard: What brand are these at your place? Are these three M-tech?

Steve: These are 3M.

Howard: Okay.

Steve: I primarily use 3M part dental, Ron Buhler started at M tech and now he’s got Part Dental, and then we’re also working with a Korean company called Dentis, D-E-N-T-I-S, I love the Dentis root form system. Any dentist that’s not using this type system is crazy because it’s got a platform on every [inaudible 00:21:08]. Once you get your working death with the root form implants you just go boom, boom, boom with those platforms and it automatically stops at the right dip, that’s another conversation. Now you notice there’s a little bit of opening of the flap, I’ll take that because we’ve got [inaudible 00:21:28] membranes on top, we’re also using platelet rich fibrin membranes and this will heal beautifully. You go to the lower look at that little tiny knife edge ridge Howard, how are you going to place an implant in that? Flatten it out. Here we go three months later, solid as a rock, that burn at the apex of the sockets is rock hard, re-line them. How about that for a life changer?

Howard: Oh my God that is amazing.

Steve: Wait till you see this next one, if you could do one case like that in your life, it’s worth going to dental school. There are some cases you’ve probably got some too that I can’t present because I’m pretty emotional and I can’t talk about the case because there is so much emotion behind it. This is the same thing, this woman was from Austin, she’d been like that all of her life quit smoking, by the way if people smoke I don’t do implants. I don’t do them, I don’t do well with failure, and if they’re going to smoke I don’t want the case to fail, and it’s …

Howard: How long do they have to quit smoking before you’ll touch them?

Steve: It’s not so much how long before it’s after, because whatever happened to those teeth, whatever smoking did to the teeth it’s going to do the same damn thing to implants. They quit and I want them to quit for at least three months just to prove they can, now if they’re big boys and girls I have them sign a sheet saying, “If you smoke these things are not going to work.” If they start again they are on their own, especially in the Maxilla. Okay.

Howard: It seems a lot of dentists I hear my friends they tell their patients they have to stop for 90 days before the implant surgery and then they can’t smoke for 90 days after. Three months before and three months after, what do you think of that advice?

Steve: Vitamin C, how much vitamin C should you take a day? You don’t know, it’s a guess, it’s the carbon particles that get around the implant that irritate the bone, that irritate the gum, it’s the compromise blood supply, I don’t have any trouble if they just quit. Now the other big enemy of implants root form or small diameter is bruxism, lateral forces especially in the first three months, the only ones I've … the thing I take pride in in my courses and I am no rocket scientist you’ll figure this out after we’ve spoken from the short period of time.

Howard: I doubt that.

Steve: I am every man, and I want them to see my screw ups or my failures as well as my successes, and if somebody is a big dog bruxer those lateral force will get you, It goes back to ranching with me, if you’ve got a French post in the ground and you move it right and left all the time it’s going to break down. Okay so look at this, the beauty of this is is you can recounter, wait till you see this woman’s profile when we get through. Take that big rhino horn bone off, place these implants in at the time of extraction now here’s what I’m finding, these are even more predictable if you place them at the time of extraction, but you place the implant toward the lingual of the socket, toward the lingual of the socket. That bone is so hard at the apex, I talked with Dr. Syndax about this in at Thanksgiving and he agreed that that’s some of the best bone you’re going to find in the maxilla if you wait too long it becomes less dense because you don’t have that tooth pounding it.

Here we go, remember they can be 30 degrees off. Now we’re using platelet rich fibrin in conjunction with cancellous bone, and covering it with rich fibrin membranes and resorbable collagen membranes. Looks like hell when you get through, you’d like to see just the tip of the implant sticking up and when you place it at the extraction site one of the tricks it's like throwing a pass in football; you’ve got to anticipate where that bone is going to be. Look at the bottom, how are you going to place any kind of an implant in that Howard? You can’t, not rocket science flatten it out, all the threads are covered with bone, now this was a thin area right here. As you … bone grafting is easy, you break through the cortical plate, get into the medullary trabecular bone where the blood is, place your bone graft material, cover it with a collagen membrane, again you just want at least the tip of the implant sticking up three months later.

Howard: Looks like you have two different kinds of implants there, you have ….

Steve: Yeah, the good ones are 2.9s, on the top the maxilla use 2.4 and 2.9 millimeter; it’s a wider thread, so you’ve got greater surface area, on the bottom the lower use 1.8, 2.0, 2.1. Park has got a 2.5 and a 2.0.

Howard: Who’s Park?

Steve: Park Dental that’s Ron Bueller’s new company. 3M …

Howard: Ron Bueller you said started a … Bueller, B-U-E-L-L-E-R he started M tech?

Steve: He started M tech, sold it to 3M and then he started another implant company.

Howard: What’s it called?

Steve: Park Dental.

Howard: Part?

Steve: Park, P-A-R-K.

Howard: Where did he get Park from, what does that mean?

Steve: That was the name of the company he bought it’s a less expensive implant, now I still … they only have a 2.0 and a 2.5. I want you and I to invent our own implants, have our own implant company so we can get it just way we like it. You know that phrase that guy says, “I’m easy to please as long as I get it just the way I want it?” Look at this woman, that’s a good looking woman Howard. Look at this lip; we’ve got a million of them, because you get it just right. Now I love what you talk about in your other podcast when you say, “I’m a minimalist,” I like gadgets, I've published cases, increasing vertical dimension and use the tip of a cotton tip applicator to increase the vertical because it happens to be three millimeters which is all you want in the interior.

I don’t like a bunch of gadgets, I want … Dentists sometimes don’t realize how much money they can waste on $100,000 gadgets, and how much they have to produce to pay for that, if you can do it with a pocket knife, an electrical tape and have an outstanding result let’s talk about that. Here’s where these things are just magnificent, removable partials, because if you don’t have an implant the partial moves up and down on teeth, if you’re just relying on class.

Howard: Right.

Steve: You got an implant you have a stop, this woman was a nurse lost that, was going to have to have dentures full dentures so we put the 2.9s in. Now I always pull the housings in the office just so I’m sure they’re perfect. If you have them processed they might be off just a little tiny bit. We did some restorative work on here, little bonding, placed some crowns. Look at the vertical, better?

Howard: Better, better.

Steve: Little thin ridge down here, you can’t place any kind of an implant in that ridge without some bone grafting, that’s why we teach these mini implant courses which is a two day course with a pig jaw. Then I take dentists down to [inaudible 00:30:27] Mexico. Doing aside with what you were talking about in another podcast I've listened to a bunch of them in the last few days, you were talking about dentists having spent 200,000 bucks before they place their first implant right?

Howard: Correct.

Steve: Guess what? It’s BS to begin with because all they’ve done is gone through simulation courses, dentists have got to place implants on real people to be confident placing them on real people in their office. I’m a think to the end and work back guy, I want dentists to apply the things we teach them, we’re not just doing a dental seminar, so we teach the many implant courses with pig jaw then we take them 12 at a time down to [inaudible 00:31:16] Reata to a gorgeous clinic down there. All the cases we want we’ve got me and three other surgeons with these 12 that hold their hand and get them through placing implants, and we teach sinus lifts and we teach root form and we teach mini, bone grafting, everything on real patients and just burn it down for four days and they come home and they’re ready to go.

I've got a good friend that spent 20 grand on a course at a leading dental school, he never placed an implant on a real person, he’d never placed an implant. You talked about you’ve spent 200,000 bucks and never placed an implant; I want to get these dentists placing implants. Total; cost beginning to end including the kit for 15 to 20 grand, they’re confident placing implants.

Howard: You know what you’re best marketing would be though? Your best advertising? It’s very hard to go from a full page Ad in a magazine to “I’m going to spend 20,000 bucks and go to [inaudible 00:32:20],” it’s just …

Steve: No, no you’re not going to spend 20,000 going to [inaudible 00:32:23] you’re going to spend I’m talking total from the pig jaw courses, [inaudible 00:32:30] and buying the kit.

Howard: Is how much?

Steve: 20.

Howard: Yeah, but here’s what I think you should do, we put up 350 courses on dental town and they’ve been viewed over half a million times, no one’s going to learn how to play sim plans by an online CE course, but if you put up a complete curriculum of online C going through all of these cases and sinus lifts and you just showed your magic. You will wow these guys when they’re sitting there in their couch on an iPad and then they’ll sign up for your course and then they’ll go down there and they’ll do it. I want them to make the decision to go I think Zig Ziegler’s right that people need more motivation than they do information. I you’ve been lecturing forever, you’re a natural, you should make an online CE course, then at the end if you want to sign up for more information go to this website, what is your website?

Steve: Okay, hey Bob?

Bob: Yeah.

Steve: What’s our website?

Bob: centerforard.com.

Steve: Centreforard.com, C-E-N-T-E-R F-O-R A-R-D.com

Howard: You went with that because arizonacardinals.com is already taken?

Steve: My daughter put it together when she was a CEO of our company, it stands for center for aesthetic restorative dentistry.com.

Howard: Center for ARD. What are they going to find on that website?

Steve: What are they going to find on that website Bo?

Bob: They can register online courses.

Steve: Our Card courses, our implant courses. See what we are really good at throwing the football the technical part; we’re not real good marketers.

Howard: I know that’s why I’m chasing you, I think if you put up … you have all these that records it, if you put up like an hour explanation of each [inaudible 00:34:42] the mini’s, or the sinus lift, or the bone grafting whatever and they saw this then they’re going to say, “Oh I can go do this hands on on a pig jaw in Waco or I could go to [inaudible 00:34:54].” I think it would bridge the gap, you go to bridge the gap between who’s Steve Cutbirth and I’m going all the way to Mexico. I think the online C that’s why I wanted you to do a podcast because I just want these guys to get her done.

Steve: Here’s the thing that’s so much fun about this because our practice is not based on production, we’ve never had a production goal, we’ve never had a practice management person come into our practice. We are in a small Texas town, Waco Texas, remember the branch [inaudible 00:35:29]?

Howard: Yeah I was [inaudible 00:35:30].

Steve: It’s not …

Howard: What year was that?

Steve: I don’t even know, most people in Waco don’t even know who it is, it’s in a little town called L, it’s about 40 miles outside of Waco, it’s almost closer to Dallas. We go in everyday and it’s about the product, it’s not about the money, and the money is taking care of itself. Years ago this … one of the things we teach is our delivery system, how do we communicate? Remember I think to the end and work backward, one of the big points it’s lacking in my opinion from teaching dentists all these years is communication. Because you and I Howard have an obligation to every patient that has the courage to call our office, to give them a clear idea of what their condition is and what their options are. I am a visual learner, you could talk to me all day long about how to do something, but if I can’t see it, I don’t understand it. We have developed a system of photography, if I show a denturelist person, we talk too much as dentists, you find that to be the case?

Howard: Yes.

Steve: We just talk and talk and talk and talk and talk, if I show a patient she’s about to lose her teeth or has lost her teeth, I don’t say a word sometimes in my consults, I bring out this, I flip to this, I haven’t said a word. While she’s looking I’m on the computer, I show her that and I show her this, [inaudible 00:37:23] to get that. you hear what I’m saying?

Howard: Absolutely.

Steve: We’re talking, we are BSing, quit talking start showing. It’s the same thing with these seminars, somebody’s going to get up and tell you the history of the mini implant or the dental implant who cares? Does it work or doe s it not? These kind of people with partials it’s so fascinating, look at this. What are you going to do with this woman? She’s been a cripple with a denture and a cracky partial for a long time. Look at that little nothing ridge, make it so you can put the wood screw in the ridge, you could put an implant in there, vine could put an implant in there.

Howard: You said these were 3Ms intact but you’ve also mentioned Ron Bueller started Park Dental; then you also mentioned another one from Korea.

Steve: Dentis. D-E-N-T-I-S.

Howard: Tell us about those two, and then there’s another brand name Stan Gold, talk about each one of those companies.

Steve: They’re titanium, they’re titanium. I like the three, the thing I like about 3M is they’ve got the 2.9 and the 1.8, sometimes you just need a 1.8, like this case right here see how we’ve got some we need a little more bone right there, so [inaudible 00:38:49] but I can’t get a 2.1 in there or even a 2.0 and if you extract a tooth you want the biggest implant you can place, the 2.9. The thing you and I like about the mini is you don’t have to drill the depth most of the time, you just screw it in and it bites.

Howard: Ron Bueller sold M tech to 3M and now he started his own Park Dental?

Steve: Yes.

Howard: It seems like a common business strategy in dental implants I mean who is the other guy? Jerry [inaudible 00:39:20] he started [inaudible 00:39:21].

Steve: Let me tell you this, let me just say this, Howard this will probably be the last interview I ever do with anybody. Can you use the word screwed? Screwed themselves, they were so far ahead of the palathon with 3M and with their implant the many implant when they bought M tech nobody else was doing it. They were supplying the implants for some of our course and I said, “People run with this, really teach people how to do it,” but they were stuck on giving 100 seminars a year just showing people how to do a big fat ridge with implants. The supply rep said, “We’ll go in to offices and have three cases scheduled and we can’t do any of them because there’s no bone, and dentist don’t know how to reflect the tissue flatten the ridge, create a ridge that’s acceptable to many implants.

They completely blew it with the mini implant; they lost their advantage now the palathon has caught them. I think they’ll end up selling their system, I really do, they’ve just completely wasted it, they had people at the top that had no idea what they were doing, they had no idea what they were doing and they just may let … they killed the goose that laid the golden egg.

Howard: Isn’t the marketing message today that you don’t need to lay a flap, you go buy a 3D CBCT for 100 grand remember they’re trying to sell the equipment, you got to buy the 3D then you’re going to send it to the lab who’s going to make a surgical guide, then you’re going to snap it in the mouth and Stevie Wonder can play [inaudible 00:41:08].

Steve: Guess how many surgical guides I've ever made?

Howard: Zero.

Steve: Zero. You got a 30% deal, and you make a surgical guide you go to all these stuff, remember I teach people how to increase vertical dimension in using the wooden end of a cotton tip applicator, if you understand the technique you can do it with your pocket knife. We are so gadgeted and that’s why dentists are … there’s good gadgets out there don’t get me wrong, but if it’s not improving the quality of the product don’t use it. Bear with me here you get in to all the surgical guides and things like that and trying to figure it out on the CT scan, well if you were having an implant placed, wouldn’t you rather somebody just reflect a flap and have a look? Rather than trying to figure out you’ve got this big lipped thing and then what’s it going to look like? Just reflect it, flatten it, get it like you want it and put the wood screw on the wall.

Howard: On my two implants I just had to make an incision under the armpit so that you couldn’t see it on my chest.

Steve: Usually a scrotal incision is the best one. Go up that way.

Howard: You’ve never made a surgical guide but what about CBCT, what percent of these cases do you use a CBCT on? Do you have a CBCT? What are your thoughts on CBCT? Because it’s a $100,000 decision.

Steve: It’s good for root form implants if you’re working in there, the sinus or the nasal office, right? Those are the big holes I’m worrying about, if I’m working in the area of the [inaudible 00:42:52] nerve or the [inaudible 00:42:54] it’s a good idea. [Inaudible 00:42:57] so guess where you’re not working, Guess. In the middle [inaudible 00:43:04] nerve you’re kind of around the sinus there’s a big … oh my gosh that was a funny thing. I was so worried when I started placing this up, what if you’re doing to the sinus? I talk to all the surgical people for 3M and [inaudible 00:43:23] they say, “I don’t know.” Then we gave a course on all on four at our teaching center at Card. This surgeon was placing these root form implants through the sinus into the zygometic arch dude, are you kidding me? What are we thinking?

You’re not going to hurt anything going into the sinus the problem is you want enough bone to stabilize the implant, the implant’s 10 millimeter long. It’s not an attractive thing if you’re there more than a millimeter too but if you’re a couple of … but the real problem is you don’t have enough implant in the bone because that bone over the sinus is crappy born it’s de-full blown, so your problem is stability. I don’t want to encourage dentists to go into the sinus but that’s not really the issue it’s that you don’t have enough bone to stabilize the implant in that area because it’s soft bone.

Howard: Do you have a CBCT? Again on these cases what percent of these did you get a CBCT on?

Steve: On these?

Howard: Yeah.

Steve: Zero.

Howard: You have Zero?

Steve: Yeah.

Howard: Do you have a CBCT in your office?

Steve: No, I've got an [inaudible 00:44:37] that has one it’s not cost effective.

Howard: So you’re of the camper, just have one available that you can use but don’t buy the $100,000 machine?

Steve: Just remember this what I’m about to tell you is going to change your life, ready?

Howard: Yeah.

Steve: Money will not make you happy, but it will let you be miserable in some very nice places. I want to charge the patient as little as I can, I want to have the things in my office that I need to deliver the highest quality dental product in the world, but I’m not going to go for everything that comes along. If I can share it with somebody how often am I going to use [inaudible 00:45:23]? How often are you going to use a [inaudible 00:45:26]? I’m in solo practice, it doesn’t make sense and I’m not using it for many of these cases, a lot of times I’ll use a [inaudible 00:45:36] and a CT scan, that standard of care. Most of the time though you could do these smaller [inaudible 00:45:45] implants with periodical radiographs and here’s how you do it.

Because you got angulation issues and things like that you drill the pilot hole and you screw the implant in partial way if you’ve got any question take a radiograph. You’ve got digital radiography …

Howard: What would you say to these kids though? Because one of the most controversial columns I've ever written in my life that just got eaten alive, it’s kind of like the reviews of Star Wars, you either loved it or hated it, but there’s just a lot of people who believed that the advantage of CBCT is that you can get a surgical guide and you don’t have to lay a flap and you don’t have to do any of these stuff. Then there’s other people like you who are saying, “Dude you’re a doctor.”

Steve: What are you talking about then?

Howard: I know, and here’s the thing that I want to say to my listeners because you’re talking to thousands and thousands of dentists right now is that all the … I don’t want to call you old, do you care if I say your age?

Steve: No.

Howard: I’m 53 you’re 61, when I talk to anybody who’s 16 over who has sung 10, 20, 30,000 implants they say, “I never use any of those surgical guides and you just lay back the bone and do it. Then you talk to everyone who’s 40 and under on this circuit and they’re like, “Oh no you need $100,00 Card cam, you need this fancy surgical guide and blah, blah, blah, blah” and I think the general market wants to hear they don’t have to do anything they can just …

Steve: You probably can’t use the word bullshit on your program can you?

Howard: Hell no.

Steve: Okay good, I’m glad to know that I won’t use it. There was a guy in dental school that taught us precision attachment dentures, I mean partials. I promise you when you got through to that course everybody there thought he was the only guy that could do it. Dentists are so in their own head about implants think of it like ranching in West Texas don’t screw up be careful, if you’re doing a root form implant the posterior. Don’t drill all the way to depth right from the get go, the distance in that you know is safe take a PA, measure, stay clear of that stuff just don’t get in such a big hurry. I found it interesting years ago when these different groups studied our practice and they said “Do you realize you’ve got one of …” I hate to say this because I hate to even talk about money because we never even think about that in our practice, we’ve booked to a system. They said “you’ve got one of the most productive dental practices in the United States maybe the number one at this institute.”

I said, “You got to be kidding me. Because we don’t do it the way anybody else does it,” they said, “How do you do it?” We booked to a system but we don’t get in a hurry. What I find Howard is patience are dying for somebody to just take the time to get it right, take the time to get it right, we just get so gadgeted out, I’m not against him I love scanning and [inaudible 00:49:02] and digital impressions and all that kind of thing but you don’t have to have it to do world class dentistry period. You just have to slow down a little bit and not delegate all these things to people that may not be up to the task and just take your time.

Howard: Talk more about the Card center, the center for aesthetic restore dentistry, you’re in Waco but this is in Dallas?

Steve: It’s in Dallas, well years ago …

Howard: It’s called …

Steve: I started with the Pankey institute the week before I went in practice, and so I taught out there on the visiting faculty for about 15 years, but I’m always kind of restless, I’m always thinking how could you something better? I’ll always be indebted to Doctor Pankey and Guy Hedex and Bill Bright and Mel Steinberg and Lauren Miller for showing me a way that I could be in dentistry. Because when I got out of dental school I really didn’t see a model that interest me, that sweaty headed dentist running from room to room seeing 30 people a day is not in my wheel house. They acquainted me with a different idea, then Baylor dental school asked me if I would set up a continuum program for them. They wanted an advance program, I said “I’m ready to go because I know how I've always wanted CE.”

We use the continuum method but we start the first two day course it’s half a day lecture, half a day hands on in the laboratory with models. We do the fine points of porcelain veneers, prep, impression, provision [inaudible 00:50:48] and the fundamentals of anti-aesthetics. Lip position, [inaudible 00:50:55], [inaudible 00:50:57], pupillary line those types of things, [inaudible 00:51:01] width. Second course is enter your Crown Bridge and replacing missing teeth in the aesthetic [inaudible 00:51:10], now here’s amiss [inaudible 00:51:11] Howard, these days everybody thinks when you’re missing … this is going to hurt, this is going to hurt. Everybody thinks if you’ve got a missing maxillary into your tooth you place an implant right? right?

Howard: Right, but that’s wrong isn’t it?

Steve: You see the people I’m seeing these attractive women with high lip lines dude I love implants, I love implants, but I've got a whole seminar on what can go wrong with an implant in the aesthetic zone. You may place a perfect implant but that tissue and bone is so thin that black implant may shine through the bone, you ever seen that?

Howard: Yeah.

Steve: Where you lose a propellor, or the gingival lines’ not right, just so many things that when I see these people they’re not coming to see me for a try, they’re coming for a result. A fix bridge in that situation, if you think to the end and work backward and it’s got to be magnificent maybe the most predictable result and if they’ve got a low lip line who cares? It’s not that bigger deal, but you know the one I’m talking about and you’ve got to go to our bag of tricks and say, “What do we have to replace that missing tooth with?” what do we have? Implant, removable fixed bridge. Someone like me I've got an implant replacing my cusp but I've got low lip line turned out beautifully those are the cases that you see at the seminars but I see the ones that aren’t like that. What were we talking about?

Howard: The Dallas Center.

Steve: Oh yeah, okay so the second one is replacing missing teeth in the aesthetic zone and anterior crown of bridge, the third one is a fantastic method of treating intra articular/TMG and mild fashion pain cases. We teach them how to treat this and from giving seminars on this and studying this and bringing in experts for the last 20 years we’ve come up with a method that is incredible and you don’t treat the disc, think about it.

Howard: How many different courses do you have at the Dallas center Card?

Steve: the fourth one is complex restorative including a lot of increase vertical dimension and how to restore this would be a work case, and then the fifth course is our system, how do you deliver the product? Then once you’ve gone through the five two day courses that’s called the advanced restorative series the next five are the master series, I give the seminar on Friday which is a complex version of what we talked about in that course a year before and then we bring in specialty people. That could include gingival grafting; it could include clear correct which is like in [inaudible 00:54:27] it’s an orthodontic traces …

Howard: That's out of Dallas isn’t it? That’s in your backyard?

Steve: He’s out of Houston, near Houston Galveston, fantastic orthodontic system.

Howard: He’s the one who started [inaudible 00:54:38].

Steve: No it’s another guy.

Howard: The clear correct?

Steve: Yeah.

Howard: I’m pretty sure that’s the guy who started [inaudible 00:54:45] then like apple then they run them off when they weren’t publicly created. Then the patents and the … everything expires and then[inaudible 00:54:54].

Steve: You could be right, I think he was just using … the story I heard from him was he was using [inaudible 00:55:00] and thought he could do it a different way and set up this [inaudible 00:55:05], you could be right, I’m not real good on details on things like that. We also … we teach everything that has to do with restoring the most complex case that could come into your office and we teach systems of restoration. So that you look at every case exactly the same way. Card is not about doing a full mouth reconstruction on every case it comes in, its golden real dentistry, you know what my least favorite word in dentistry or healthcare is?

Howard: Obamacare. Did I get it right?

Steve: No.

Howard: What is it?

Steve: Cell. Cell, I hate that word, that word has no place in health care when delivered by the practitioner. Our mantra is, “Do the right thing” what would you do for your wife, for your parents, or your daughters? Then do it well.

Howard: I want to ask you some controversial questions, you’re going over some things that … I just like to ask questions that I know are crazy debates on the message boards at dental own, we got 205,000 dentists on that website.

Steve: Okay.

Howard: Some people treat restoring the worn dentician, and they show these wear cases and then then basically repair them with 20 units of crown of bridge so these other people are saying, “that's interesting.” Because the patient wore down their teeth your treatment is to stick the tooth in a pencil sharpener and file it all down, so you didn’t treat the severe [inaudible 00:56:44], you actually wore it down another 20 years, what’s your comments on that?

Steve: Okay, again go to the end and work backward. What’s the patients objective? That’s why you got to interview somebody before you examine them, why are you here? We’ve only got so many options, if somebody’s worn their teeth down you either repairing the teeth they’ve got or you’ve taken them all out and putting something in right? Then it gets down to money, sometimes I’ll sing that Willie Nelson song, “If you got the money hone I got the time.” What I don’t want to make is a bad situation worse, so they’ve got the teeth, it’s like having multiple parachutes. I’d rather work with their teeth and do this giant take out the teeth put it all on four, and then I spend 60 grand on that and it fails and we’ve used our second parachute.

I try to think if it’s like me, he main thing with me if I had that situation is not really the money, it’s a result and if I can do something with the teeth and still have all on four or smaller [inaudible 00:58:10] implants with removable dentures as a backup I’d rather do something with the teeth. What we do is meaningless preps; I mean we can have a whole podcast I've got a whole series on increasing vertical.

Howard: You should do the online CE courses because then we give them ADA credit, AGD credit, I think you would …

Steve: Yea, well help me I don’t know how to do that stuff I just know how to do dentistry.

Howard: Every one of those five courses and the other five advanced courses if you just did a one hour course explaining what they’re going to learn over the next two days and giving away The Greatest Hits album, these kids are going to watch that and the next thing they know they branded the card the Center for Aesthetic Restore Dentistry in Dallas. Then they say they’re going to go down there and see it. I think it’s very counterintuitive and it’s the best marketing you can do.

Steve: Look at this; you’re going to find this interesting. What would most dentists do in a case like that Howard?

Howard: Probably refer to a periodonist for crown lengthening or something.

Steve: Most of them would probably replace those two crowns, she was from Austin too and they were going to replace those two crowns, and we’d restored her sister. I published this article it’s called Getting the Lines Right. What we teach dentists is how do you get the lines right? If you don’t get the lines right, and people think crown lengthening is gingivectomy, hell no, you Pat Alan? The great periodonist from Dallas. He taught me however much gingival you remove you got to remove the same amount of bone or it’s going to grow back and then you’re just going to have a crappy gingival line.

Howard: Absolutely.

Steve: All right, so once we do that, now we’re going to remove, we’re to bleach the teeth, we teach them internal teeth bleaching also. Now we’re going to do our crown [inaudible 01:00:17] and you’re going to change this woman’s life. First you do your gingivectomy just use pap stick [inaudible 01:00:23]. Then if you remove 3 mm of gum and you want the final gingival line to be 11 mm from the incisor lace to the gingival line then the [inaudible 01:00:38] crest has to be 14 mm. right.

Howard: Right.

Steve: Well actually here we go. Let that heal place the [inaudible 01:00:50]. This woman went from being a telephone answerer for a hotel company to in charge of telephone answering for this company across the United States. If you don’t know who the guests are and get the whole thing it ends up being a Luke warm result. Now, we’ve got the [inaudible 01:01:23] line parallel to the gingival line to the incisor plane and the lower lip.

Howard: We have so many cases, unbelievable. How many cases do you … How many PowerPoint cases do you have?

Steve: A million.

Howard: A million.

Steve: Every case I’ve ever done probably. Is that right?

Howard: See I see one case every morning from eight in the morning until two in the afternoon.

Steve: Just one?

Howard: One.

Steve: This is unbelievable.

Howard: Well, the thing … I think dentists would find this interesting in this cases just in case every case is exactly the way I want to do it. There’s not any compromise. It’s exactly the way … You may do mini implants with dentures instead of all on four for finances but there’s not any compromise. Look at this with this mini implants. This is a ….

Steve: How much are your courses at card?

Howard: What’s that’s?

Steve: How much do your courses cost?

Howard: What do they cost bob, how much do our courses cost?

Steve: Get bob over here. Introduce bob.

Howard: Come over bob. Bob come over here and take a look. What do they cost?

Bob: [Inaudible 01:02:43].

Howard: I want to see you on here. Here’s the person you will be dealing with right here bob.

Steve: Are you bob Jackson who played both baseball and football?

Howard: Bob Dirking is a … bob, there are two people that I know that are bonified geniuses. Bob is one and my wife is the other one. Bob is a technological genius, other genius too but he is a technological genius.

Steve: Your course is $1495 and that’s a two-day course bob?

Bob: $9.95 for the minutes.

Howard: And what … and the mini courses are about $1000 [inaudible 01:03:18].

Steve: That’s a pretty low cost course compared to pinkies, spear, and quays those to LVI. What do you say?

Howard: We’re not trying to make money off them. They’re $1500 basically a course and you go through five of them. What's that? About $7500 to go through the whole thing. Then here’s what I said when I… I meant what I said. I said it how I always wanted. Then you go through the masters courses. There’s five of those butt the same course so you spend about $15000 total. You’re automatically a member of our alumni association and our teaching faculty and you help me with the courses, in the laboratory and things like that.

Steve: Bring bob back.

Howard: Bob come back. You spend $2 a year and you come to all the courses. He wants you to come back here bob.

Steve: Hey bob, I know Howard is … you’re his technological manager so here’s the deal. I’m Steve at dental town and dental town has 2500 dentists. We put up 350 course [inaudible 01:04:20] half a million times. The other Steve is Steve goldsings so he goes like ‘hogo’ hogo@dentaltown.com but call him up and he has five different courses. Put a PowerPoint slide for each one of these course that will be like a … hers a one hour online [inaudible 01:04:38] course you can charge, make money there if you want to or whatever. The bottom line is they will start seeing Howard, they’ll start seeing the center, and after they see all these cases, they’re going to say wow I’m not going to learn to do this on my couch on an iPad. I’m going to Dallas, take the hands on course, and do this. Bob you can help him do that. That would be amazing.

Howard: The funny thing is we don’t do these courses to make a living, we make a little money. We do it because it is so much fun, these dentists are so interesting, and there has to be a different way other than just patching people up.

Steve: My theory on the teachers and all the lectures, I think I never met a child who at least one day during elementary school decided they wanted to be a teacher. Everybody has some middle [inaudible 01:05:32]. Everybody wanted to be a teacher and teacher. Some people just loved to share. They loved to share the information it comes from their passion and you’re obviously a massively passionate guy and so since you just love it and your passionate and you’re successful you just can’t contain yourself from not wanting to share it.

Howard: Look at this with this mini implants. This is just so cool what you can do with these. This guy broke this whole precision attachment partial. He is from a small west Texas town, he had driven three hours to our office, and what are we going to do? The thing about having a little time to ponder the greater truce I love the abstractness of it. I thought okay I’m going to do something with this. I mark it; cut those attachments off, place these implants, place these three of them right there. Just cut the hell off that old partial so I can get the housings on there. This is all in one appointment. Pick him up with a hard pick up material he wanted to bite into that so he didn’t get into his lower teeth. We work that thing. this guy I said,” how it?” He said,” I have a hard time getting it out.” They’re just handy, its tools. It’s a tool.

Steve: Well Howard I can believe the hour is up. That was the most amazing hour in the world. If you guys want to hear more of this go to www.centerforard. Center c-e-n-t-e-r for f-o-r ard that’s for the center for aesthetic restorative dentistry.

Howard: Here’s the phone number that bob just gave me.

Steve: Phone number …

Howard: 888-271-7774. 888-271-7774 will they be [inaudible 01:07:24] bob? You will get to talk to the bob.

Steve: What's bob’s … what's the email address for bob?

Howard: Email address for you.

Bob: This one.

Howard: Okay card its c-a-r-d 1611 at Gmail dot com [card1611@gmail.com]

Steve: What's the 1611 where did that come from?

Howard: That’s a… what is that? 1611.

Bob: My address.

Howard: Our address is 1613 okay 1611, oh yea that’s pour card address. Our office is 1613 the card address … get this the card address is 1611 Lake Success.

Steve: Seriously?

Howard: I’m serious.

Steve: Did you rename that street yourself?

Howard: No it was there when we moved in. it’s a little…

Steve: Go a head.

Howard: It’s a little backstreet you’ve got to be going there to get there.

Steve: What is the class size like? What is the…

Howard: Well we had ... It’s interesting because back in ’08 we’d had 50 in a class heading for 100. In ’09 I talked to bob and I said well how many do we have starting next month and he said six. I said sis what he said six. Something changed with the industry after ’08. Now we have about, we’d like to keep it to between 20 an d 15 a class because e my teaching faculty is assisting me with the hands on portion. Dentistry has changed since ’09. Our practice is better that it has ever been but I think with … I don’t really know Steve what the shift has been but something has changed since then have you seen it?

Steve: The only full time economist I know is the one that works for the president for the American Dental Association and he’s being doing this full time. He wrote an interesting article called lattés, what's was it? Dentists, lawyers, and lattes. Dentists, lawyers, and lattes. If you look at the data from 2008 the only people who have not recovered to 2008 level are dentists, lawyers, and coffee shops. I saw in 2008, 2009 about 85 dental offices go bankrupt in Phoenix Arizona. It’s an amazing …

Howard: Let me tell you, you can’t out cheat the corporate dental folks. You can’t out [inaudible 01:10:05] our practice has always been good but now it’s just killing them in a positive way because people are looking for places to go. Not to tip my own horn, there are other people who know how to do this that are going to get it right and not just process them. I think that dentists have fallen into that mentality of we have to get in to this manage care, all the cheapo, cheapo, cheapo. I reconstructed a guy who was head of a big dental insurance company. Do you have time for this story?

Steve: Yeah absolutely.

Howard: Every time he came in, he wrote a cheque and gave it to the front desk. He was from Plano, Texas, which is near Dallas. We never talked about the cost and we were doing a full mouth reconstruction he just peached a hell out of his teeth. Every time he’d come we’d go to dinner to lunch at aqua dams barbecue place and wake up. Best barbecue place in the country by the way. I said how does this manage care stuff work? He said, well we say that our competition is paying and we pay less. Then I say well don’t they pay less than you do. He says yes. I said then what actually do we pay less than them. I said eventually what happens? He said Howard dentists would sign up for these programs if we didn’t pay them anything. They would just own the program. That changed … I wasn’t cut out for that but that changed my feeling about those. They have no idea what it costs you to deliver a product. They are just trying to compete with the …

Steve: Hey if you download the …

Howard: Yeah I've gotten it.

Steve: Did you? Okay go ahead.

Howard: That’s it.

Steve: On your smart phone you can download the dental town app that somebody said is looking for a speaker and he goes. Someone goes on and writes you should consider Doctor Howardn Curtbirth who created the center for aesthetic restorative dentistry in Dallas. He has an introductory class where we [inaudible 01:12:15] group but they talk about you on those search bar. If you searched your name or the center for aesthetic restorative dentistry you can read whatever everyone is saying. Howard with 2500 ion that the best market you could ever do, you’ve got all those cases that you’ve been working on since you graduated in 1979. The more of those cases you put up the more Howardn Curtbirth will be a household name and you will fill your classes in Dallas.

Howard: We appreciate what you’ve done for dentistry. Thank you for having me on the show.

Steve: I can’t believe I just gave an endorsement to a cowboys fan.

Howard: I’m kind of... they’re going to get better.

Steve: They’re going to get better [inaudible 01:12:59] or that’s a one-man team. When Rome was there, they're undefeated when he’s out they can’t win a game.

Howard: Well when the quarterback Witten went to Houston he couldn’t win a game at Dallas, he’s won two in a row in Houston. How about a [inaudible 01:13:14] issue.

Steve: I want to seriously thank you for all that you have done for dentistry, for so many years. You've taught so many dentists, you have so many rating fans and seriously Howard thank you for all that you’ve done for dentistry.

Howard: Thank you Steve.

Steve: Okay have a rocking hot day and get a hold of Steve Goldsings, hogo@dentaltown.com.

Howard: Thanks a lot.

Steve: All right buddy.

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