Dentistry Uncensored with Howard Farran
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717 Disciplines of Dental Implants with Stacey D. Vlachos, DDS : Dentistry Uncensored with Howard Farran

717 Disciplines of Dental Implants with Stacey D. Vlachos, DDS : Dentistry Uncensored with Howard Farran

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VIDEO - DUwHF #717 - Stacey Vlachos


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AUDIO - DUwHF #717 - Stacey Vlachos


Dr. Stacey Vlachos is a graduate of Michigan State University in East Lansing, Michigan. He graduated with a B.S. with honors in 1976. He then went on to attend the University Michigan Dental School and graduated in 1982. Following his graduation, he practiced with the World-renowned Dr. Carl Misch in his private and hospital practice for several years, working side by side with him, to learn the field of implantology. He graduated from the 20-month Course thru he Misch International Institute where he was invited to join the staff as a lecturer, prosthetic, and surgical instructor. He holds dental Licenses with several states and has practiced for 35 years. He became a diplomate in 1992 of the American Board of Oral Implantology, and a diplomate in 1994 of the International Congress of Implantology. He also became a Diplomate of the American Society of Osteointegration, and American College of Oral Implantology. Dr. Vlachos is a fellow of the ICOI, American Society of Osteointegration, American College of Oral Implantology and American Board of Oral Implantology. Dr. Vlachos has earned a national reputation for his clinical experience and technical expertise. He has helped to develop the field by participating in ground breaking procedures which resulted in implantology becoming the fastest growing field in Dentistry. Dr. Vlachos currently practices in Naples, Florida. He is the founder of the One and One Surgical Implant Training Program. This is an individualized surgical program designed for inexperienced Dentists to perform surgical procedures, on their own patients with Dr. Vlachos and his staff assisting them and working together side by side. Dr. Vlachos can be reached at 239-560-7365 and at drvlachos@gmail.com

Howard Farran: It is just huge honor for me today to be podcast interviewing Dr. Stacey D. Vlachos all the way from the most beautiful area in America: Naples, Florida. I love that place. He's currently making an online CE course for us that I hope he talks about today called One on One. Dr. Stacey Vlachos is a graduate of Michigan State University in East Lansing, Michigan. Does that mean you're a Wolverine?

Dr. Vlachos: No. That's a Sparty. 

Howard Farran: Oh, so you're a Sparta?

Dr. Vlachos: Well I also went to Michigan so I'm a little of both. 

Howard Farran: You're half Wolverine and half Sparta?

Dr. Vlachos: That's right.

Howard Farran: I just love Michigan the most because Grand Rapids, Michigan was the first city on the planet to adjust the fluoride in the water to one part per million back in ... What was it? January 1, 19-

Dr. Vlachos: Geez. 

Howard Farran: 45?

Dr. Vlachos: I thought '46, but you're probably correct. 

Howard Farran: And he graduated with a BS with honors in 1976 and then went on to dental school. I love the water ... Did you ever hear the story about when they started ... They turned it on? 

Dr. Vlachos: I don't recall, no. 

Howard Farran: Oh my gosh. It's a classic story. This is a chemist in the water department, and he knew that ... He thought this out ahead of time. He announced he was turning it on and that they started, and he called a press conference that we now have fluoridated water. Then he walked away. For the following week, all these people were having allergic reactions and a lot of increase to the emergency rooms and all that. They kept asking them to come back and talk it. He kept waiting and waiting. Finally, they demanded because all of this crazy illness and everything. He walks back out there and he says "Well I actually haven't turned it on yet. I knew this was going to happen, and we haven't even started it yet. So tell me when you guys are all done pretending and having drama and being crazy, and then we'll turn it on." I mean how genius was that?

Dr. Vlachos: That's pretty good. I like that. 

Howard Farran: I mean you can't make that plot up in Hollywood. I mean that was just ... Oh my gosh. I just love that story because remember back then with Joseph McCarthy and they were calling it a Communist plot, and McCarthy was a US Senator telling everybody that if you drink that there's an area in your brain that, when exposed to fluoridated water, will make you more sympathetic to Communist ideology. I mean god, what some wacko times back then. 

How would you get interested One on One? Talk us through your journey of how you got into this.

Dr. Vlachos: How I got into the implant field?

Howard Farran: Yeah. 

Dr. Vlachos: Well-

Howard Farran: And your ideology. Your course is called One on One because One on One means one instructor for one student. 

Dr. Vlachos: Right. My history goes back to when I was starting practicing with Dr. Misch back in the early '80s. We had a practice together and a hospital practice together and the Misch Institute. I've taught on and off for 30 years, and right now I think that everybody's getting away from the general principles of treatment planning. Everybody says they want to do four-on-fours, four-on-six or whatever. I think that ... I thought I should get into the field again, teach some people some safe, predictable ways to practice implant dentistry. I think it's getting too commercialized so that's when I decided to do the course. Basically, we're going to treat implant from the prosthetics forward and okay the cases, bring the guys in, and do the surgeries together with them and proceed from them and then carry on to fruition with the prothesis. That way we can follow the whole case through. 

Howard Farran: So this will be at your dental office in Naples, Florida?

Dr. Vlachos: Correct. 

Howard Farran: When are you starting these over-the-shoulders?

Dr. Vlachos: End of July. 

Howard Farran: End of July? How will my homies listening to you right now ... How will they contact you? How will they find you? 

Dr. Vlachos: Basically, they will just send me an email: drvlachos@gmail.com. 

Howard Farran: And Vlachos is spelled V-L-A-C-H-O-S. Whenever there's a V and a L together that means it has to be Greek, right?

Dr. Vlachos: That's right. 

Howard Farran: Well what is Vladimir? Is that spelled V-L-A-D-I-M-I-R? That's Russian, isn't it?

Dr. Vlachos: That's Russian. That's Russian. 

Howard Farran: So Russians and Greeks have the VL thing going, huh?

Dr. Vlachos: I guess so. I think it'll be real helpful for young guys that revert back to treatment planning. I think everybody is getting away from it. Everybody's like "Okay." I get calls like "Hey, Stacey. Can you help me with four-on-the-floor? A patient wants it." I'll say "Well what's opposing it?" "I don't know." "What's the arch shape? What's the density of the bone? What's the projection? Does he have any parafunctional habits?" They just say "No, but the patient wants it." Well they'll get in a little trouble down the road if they practice like that. 

Howard Farran: Well old guys like you and me, we read books and go to courses. These young millennials are the ones doing all the podcasts, the online [inaudible 00:05:33]. I think they're asking the wrong questions because you want to talk about how the prosthetics determines the implant treatment-

Dr. Vlachos: Right. 

Howard Farran: And that dental implantology is a prosthetic discipline with a surgical component. They're always asking first "Well which implant system should I buy?" I think one of the reasons they ask that is because in the US market most of the implant continuing education is sponsored by the implant manufacturer so they almost feel like "Well before I go get training, don't I have to pick the system because the system I buy is going to determine all my training?" Do you agree with that assessment or not?

Dr. Vlachos: No. I mean you're right in one aspect that they have the commercial and the power to do that, but if you really want to be a practitioner longterm and not have any major events in your life, you would take continuing education and survey the field, talk to the people that have been in it a long time, and get their input. I mean they're selling a product. Okay? I'm trying to sell you a way to protect yourself and a way to practice predictably for a number of years. 

Howard Farran: So what is the ... Talk me through the dynamics of this course. Is this like a two-day course, a weekend course? Is it like-

Dr. Vlachos: It's a big course. 

Howard Farran: One course or four weekends? Talk about the curriculum. 

Dr. Vlachos: Well basically it's a two-day course, but in advance they will submit their cases. They will basically treatment plan the cases, the student and I, over the phone or over the Skype. We'll okay the case. Then when they come in, it will be a very little lecture. I don't want to sit there and show them these huge cases if they're not going to be applicable for their practice. We're just going to sit down and do the surgeries. Then we do the after the surgeries. Then we'll follow it up after that. 

Howard Farran: So they're going to fly the patient ... They're going to come to your office with the patient?

Dr. Vlachos: With their own patient, correct. They can actually pay for their course with their own patient. 

Howard Farran: Well unfortunately, most of these patients are family members so you have to take your cousin Eddie, fix his teeth up for free, and put him up in a hotel. You know what I love about your course the most? These people go to these courses out in the middle of Mexico or the Caribbean or whatever. They place all these implants, but then they never see the patient again. 

Dr. Vlachos: Right.

Howard Farran: Some of them might get a lot of false sense of security because there's some pretty clear research that says your failure rate for your first 100 implants placed is twice that of number 101 to 200. 

Dr. Vlachos: Exactly.

Howard Farran: If you can't see what you did a year ago ... It's kind of like young dentists when they start doing endo. They say "I've never had a failure." Well yeah, you've only been doing them for a year. Come talk to me in 10 years.

Dr. Vlachos: I agree. Well that's ... I agree 100% with that because they're doing it backwards. They're just putting implants and fly away. Then they don't know what the anatomy. They don't know ... A lot of these courses, they don't teach them any anatomy, and they can't follow the case. They go back to their practice and then they have a problem. They're going to say "Oh, okay. Where are those people now?" You know what I'm saying? Whereas my course, it's just in Florida and Michigan, by the way. I will follow all the cases and all the students and help them out. I'm here to educate them. I'm not here just to teach them how to put [inaudible 00:09:11]. 

Howard Farran: So you live in the winters in Naples and in the summers in Michigan?

Dr. Vlachos: Basically. 

Howard Farran: Where in Michigan?

Dr. Vlachos: It's Plymouth, Michigan. 

Howard Farran: Plymouth? I take it's that where they started the Plymouth car. 

Dr. Vlachos: I don't know about that. I don't think there was much in Plymouth for a long time. It was a rural community, but now it's built.

Howard Farran: So are you doing these over-the-shoulders in Naples and Plymouth?

Dr. Vlachos: Eventually, I'm going to do them in Plymouth. Correct. Right now I'm just getting off the ground, and I want to see what the response is. I'm totally funding it myself. I'm not going with ... No implant company is backing me. Nobody's backing me. Everything's me. We'll see how it goes. 

Howard Farran: This will be good marketing. Your online course will be great marketing. Have you started posting cases on Dentaltown under implantology? In your signature box, you can put your name, your website, your logo, the whole nine yards. A lot of these people who teach, instruct, and lecture, they're always answering questions in their field, helping, sharing, non-commercial. But in their signature, you can realize ... You can say "If you like to hear me speak, come here. Here's my website. Whatever." 

I would go on Dentaltown and subscribe to the implantology forum. There's 50 forums: root canals, fillings, crowns, implants. Subscribe to the implant forum, and when anybody asks a question, they'll forward that to your email, drvlachos - V-L-A-C-H-O-S - @gmail.com. Then you'll see that question, and then you just hit reply and answer it like you were just sitting there having lunch with them. Then that really massively builds up your brand, your name. They see your website, your links, your online C-course, all that stuff.

Dr. Vlachos: I have sent you some cases that I thought were very interesting. I haven't heard back yet, but I'll follow up on it. 

Howard Farran: You sent who cases?

Dr. Vlachos: Your organization some cases. 

Howard Farran: Who was it? Howard Goldstein?

Dr. Vlachos: Who did we send that to? Was it Goldstein?

Speaker 3: I think so, yes.

Dr. Vlachos: Yeah, I believe so. Yeah. 

Howard Farran: yeah.

Dr. Vlachos: I spoke with him two or three months ago, I believe. 

Howard Farran: Yeah. 

Dr. Vlachos: One of my really good teaching case, I sent him, for implants. Every aspect of implant dentistry in it. It's an unusual case. 

Howard Farran: Wow. I can't wait to see that. 

Dr. Vlachos: It's unusual. 

Howard Farran: So you talk about the basic treatment planning components are being ignored with the treatment plans being improperly designed as one-fits-all like, example, all-on-four. What do you mean by that?

Dr. Vlachos: Well exactly. They think all-on-four. They never take into account, say, the arch form, the parafunctional habits, the crown to root ratio. I mean these are things that make cases fail in three or four years. If you have a square arch form and you cantilever it back to the spine, it's going to fail. They've commercialized it to the fact the patients' come in and say "I want an all-on-four." Well it doesn't fit that way. It doesn't work that way. But the younger students are like "Oh, well they see it on television. They hear about it." I'm like "Okay. You want that, we'll do it." Then what's going to happen in four or five or six years if they're practicing for 35 years? They have to live with these people. When you're doing implant dentistry, [inaudible 00:12:43] for life. 

Howard Farran: It's the same thing with Invisalign. I mean when you talk to all the orthodontists, they say it's about 20% of the practice, but when you look at that marketing, I mean I have people talking to me with some of the most crowded gnarly teeth in the world. It's like "I really don't want to do that with a removable clear aligner. I'd really like to get into there and band that up and use metal and do it." Yeah, a lot of this stuff. And they do it with prescription pills. Everyone is watching these commercials during TV, and then they decide they're going to go take a pill for something. 

Dr. Vlachos: Yes. Well I mean it's the same thing too with a sinus. There's a million ways now to avoid the sinus, and it's one of the most predictable areas of the mouth to drill bone. That's where you have most of the force in your mouth, but everybody's cantilevering over the sinus. They're putting short implants in. Why? It's not that difficult. It's not the right treatment plan longterm especially if you're doing fixed work. There's a lot going on. 

Howard Farran: One of the things that bothers me on the continuing education especially for millennials is that when ... I love looking at the insurance data. When you look at tooth numbers one through 32, and then you look at insurance claims made per tooth. You have these four monstrous spikes on the four first molars, and then it just falls off to almost nothing on either side. It's that first molar that's always going to need a filling, a crown, a root canal, extraction, implant. It's always the first molar, but when you go to these big national meetings, it's always all-on-four and somebody that got ... Looks like they're being treated for a titanium deficiency. They got like 20 implants in their head. Then this kid's sitting there thinking "Well I got to go from zero to one, and you're talking about this massive crazy case."

Then I look at the market for paying back their student loans. They got $350 thousand in student loans. When you look at the crown sent into the labs, it's like 94% of all crowns sent in are one at a time. 

Dr. Vlachos: Right.

Howard Farran: But then you go to the dental conventions and all the courses are full mouth rehabs-

Dr. Vlachos: Right.

Howard Farran: And veneers and all this stuff. My question to you is: how can you take ... Okay. She's commuting to work right now. She's 25 years old. She's mad that she didn't get to place an implant in dental school, and she just wants to go from zero to one. Talk to that girl right now. How do you go from zero to one? How many implants do you think you've placed?

Dr. Vlachos: Myself?

Howard Farran: Yeah.

Dr. Vlachos: Oh, over 10 thousand. 

Howard Farran: Okay. So you did 10 thousand so 10 thousand and one probably won't be that much stressful for you. How do you go from zero to one? That'd be you going from 10 thousand to 20 thousand. 

Dr. Vlachos: I think ... The first thing is your first implant, you should have a mentor or a program that is accredited and that is not commercially driven by the implant manufacturer. There are some good programs out there in various parts of the country, but you should have somebody that sits down with you like I'm proposing and show you the pros and cons, show you where to start, and honestly showing you that it's not always right what you see being promoted. Right now everybody says "Let's do an immediate implant. Let's do an immediate [inaudible 00:16:12]. Let's do this." It's very popular, but if you're a beginning person in implant dentistry, your first 50 implants you should bury. Okay? You broke the anatomy, you've been successful. If a person has a problem with their first 50 implants, they're not going to keep practicing implant dentistry. It's a matter of continuing education and finding a mentor that is willing to help you through that learning curve. If not, it's very difficult to get to where you're placing implants and you're comfortable with it basically. 

That's one thing about the profession now. It's very specialty oriented. You're telling the kid out of school "Hey, I'm an oral surgeon. I'll take you to dinner. I do implants. You shouldn't do implants." Well the general dentist should be placing implants. He knows the prosthetics. The oral surgeon, the periodontist, they went to specialty school because they didn't want to do prosthetics. Prosthetics runs implant dentistry. There's a lot of currents going on and it's run by a lot of money. 

Howard Farran: Well one thing about specialists is that they seem to be the highest percentage of people who volunteered at all the state dental meetings because they want to be at a place where they can meet the general dentists who refer. Then they end up being all the upper senior management.

Dr. Vlachos: Right.

Howard Farran: When you go into the other countries that don't have nine specialties, they might have anywhere from three to zero. Three out of four general dentists placed an implant last month. Then you come over here to the United States of America that has nine specialties. What percent of kids graduate from dental school and never placed a single implant?

Dr. Vlachos: Yeah.

Howard Farran: What percent? What percent would you say?

Dr. Vlachos: That never placed an implant? Probably 90% never placed an implant.

Howard Farran: Yeah, yeah. Where were those implant cases going? To the grad programs and oral surgery and perio and now endo. So they get out of school and never placed one, and then the endodontist is saying, the oral surgeon is saying "Well if you want to do that, I'll place it and you can put the crown on."

Dr. Vlachos: Right.

Howard Farran: It's a complicated-

Dr. Vlachos: It is. 

Howard Farran: What I don't like about the whole education part is that the rural America is half in 19 thousand towns and the other half of America lives in 147 metros. When you're in a small town and you're two hours from an airport and you graduated from a state-funded dental school and you don't know how to do ortho and implants-

Dr. Vlachos: [inaudible 00:18:56].

Howard Farran: I mean you're not ... Those schools are not serving their people. The deans finally got ... You know what the deans are telling me? They kept thinking that if they increase the supply of dentists that they would push dentists out into the rural, but now their data is clearly showing them that the only way you can get dentists to go out into the rural is you got to accept kids from the rural. Now there's a concentrated push that if they got two identical applicants and you're from Detroit and the other kid's from Eloy, Arizona, they'll take the kid from Eloy because you got to be a small town boy to want to go back to a small town. 

Dr. Vlachos: Right. You're right. Dental schools aren't ... They're failing in my eyes in educating the general dentist. It's all driven by the specialty [inaudible 00:19:49]. I mean we try to start start our own specialty in implants, and I decided I didn't want any part of it because I want the general dentist to place the implants. I mean it's frustrating. The poor dentist comes out of school with all this debt, and thank god for programs like yours because they can go online and get continuing education and learn some things without going broke. That's why I just started this course. I figured I'd help the guy out. Hopefully he'll bring a patient in that ... He'll pay for the course because I have to get everything in line and help him get to that next step, help him learn to do implants and integrate it into their practice. It's-

Howard Farran: How much is ... Now just a single two-day course?

Dr. Vlachos: Yes. 

Howard Farran: And it's just one dentist at a time?

Dr. Vlachos: Mm-hmm (affirmative). 

Howard Farran: So that's purely one-on-one. So one dentist going to come to Naples with a patient and just you and that doc for two days. 

Dr. Vlachos: I have a group of my friends that are all general dentists that have been in implant dentistry for 30 years. They all volunteered to come down so if we have five or 10 people, we'll have five or 10 instructors. 

Howard Farran: Oh, okay. How much will that course cost?

Dr. Vlachos: For two days, it's $5900. 

Howard Farran: $5900?

Dr. Vlachos: Mm-hmm (affirmative).

Howard Farran: Why'd you go $5900 and not $6000?

Dr. Vlachos: I don't know. They asked me off the cuff, and I'm pretty spur of the moment. I came up with $5900. I should have said $6000 I guess. I don't know. 

Howard Farran: No. I've said it before on this show, I think, two or three times. I think it's funny. When they first started out with cash registers, they weren't electronic. When you're trying to control internal control over peculation, embezzlement, stealing, whatever, one of the factors you need to know is how many transactions you've had. What they would do is instead of charging something $1, they made everything 99 cents. They'd go in there in the morning and they'd break open a roll of pennies, dump it in there, and say "Okay, there's 50 pennies." Then at the end of the night when they're counting out the drawer and you only have 10 pennies, now they know you had 40 transactions. That was ... It's folklore that they sold it for 99 cents because it sounded better than $1, but it was actually an accounting technique-

Dr. Vlachos: [inaudible 00:22:06].

Howard Farran: For embezzlement and actuarial stuff. Now you know when she calls you up to go to this course or she emails you, you know one of her ... What are her top five most likely questions? I assume she's going to say "Do I need to buy an implant system before I join? Do I need to ... Do I bring my stuff or do I use your drill?"

Dr. Vlachos: The beauty of it is I'm not connected to any ... I'm not bought or paid for by an implant company. I'll have people there. They can purchase the implants there, different systems. They can ... They don't have to bring anything. Basically just the patient. 

Howard Farran: So they can buy the implant system at your course?

Dr. Vlachos: They don't even have to buy the system. They can just buy the implants. 

Howard Farran: So what if she just asks you ... You know she's going to say "Well what do you use?"

Dr. Vlachos: Yeah. [crosstalk 00:23:01].

Howard Farran: She's going to say that every time.

Dr. Vlachos: Yeah. I use quite a few implant systems. I use Biohorizons. I use Implant Direct. I use AnyRidge which is one I'm using quite a bit lately. 

Howard Farran: That's Megagen?

Dr. Vlachos: Yeah. Yup. 

Howard Farran: AnyRidge?

Dr. Vlachos: Benco is ... Is it Benco?

Speaker 3: Mm-hmm (affirmative). 

Dr. Vlachos: Is it Benco? Yeah, I'm sure it is. 

Speaker 3: It is.

Dr. Vlachos: Benco is ... They're promoting this course for me. That's the only ... That's about it. Benco.

Howard Farran: Have you talked to the brothers, Chuck and Rick Cohen? He two brothers that run it? What are they ... Are they selling an implant system these days?

Dr. Vlachos: Far as I know, I know they do ... Benco does AnyRidge, correct? I'm asking my associate here. 

Speaker 3: Yes.

Dr. Vlachos: I think that's the only one, but I'm not sure. [crosstalk 00:23:50].

Howard Farran: So Benco is a distributor for Megagen's implants?

Dr. Vlachos: Correct. Correct. 

Howard Farran: That was interesting because Straumann initially was going to bought them, but it never closed. It fell out of closing. 

Dr. Vlachos: I think they bought 50% or something like that. They bought a percentage of-

Howard Farran: They did, but then when the deadline came up, the bill fell through.

Dr. Vlachos: Oh, really? I don't know. I mean I don't-

Howard Farran: Yeah, that's what I heard. So Benco is sponsoring Megagen's AnyRidge. So you like Biohorizons. Was that started by Carl Misch?

Dr. Vlachos: Yeah, definitely. 

Howard Farran: Yeah. Then Implants Direct was [Gerry Niznick 00:24:30]?

Dr. Vlachos: Right. Niznick. Correct. 

Howard Farran: Then Megagen was Dr. Park in Seoul, Korea?

Dr. Vlachos: Correct. 

Howard Farran: Any other systems you like? Are those the main three?

Dr. Vlachos: Those pretty much cover what I need. You know what I'm saying?

Howard Farran: Right. By the way, after you guys listen to this, I podcasted all three of those guys: Carl Misch, Implants Direct Gerry Niznick, Dr. Park of Megagen. That's pretty cool that you like three systems and I podcasted all three of them. 

Dr. Vlachos: Well Carl is ... We sort of grew up together. You know that, Carl and I.

Howard Farran: Right. 

Dr. Vlachos: For [inaudible 00:25:06] years. You know he passed. He always said the profession needs this. It needs somebody to sit down with a dentist and do the surgeries. That's basically what I'm trying to do, trying to get-

Howard Farran: What do you think ... Some people say when you go to an implant course, it'd be like going to a course learning how to drive a car and that nobody really goes and buys the same car they used during driver's ed. That it's basically not the car they use in driver's ed, it's the principles of driving a car. If you go to an implant course, it's not all these little parts of the product and all the little features, it's the concepts of placing an implant. 

Dr. Vlachos: Right.

Howard Farran: Once you learn the concepts, it really wouldn't matter what implant system you're using. 

Dr. Vlachos: I agree. I couldn't agree more.

Howard Farran: So when you look at these kids, these dentists that are young enough to be our children, what do you think the top mistakes they're making when they're placing implants?

Dr. Vlachos: When they're placing implants?

Howard Farran: Yeah. I can ask it another way. In the US market and what you see, what are like the top three or four or five reasons implants fail? 

Dr. Vlachos: Oh, okay. First of all, immediate load. Everybody puts on these nice little [Youtube 00:26:28] things and they blow out the buckle plate and they take [inaudible 00:26:32] they cover it. Then they stretch the tissue and then they immediately load the case. That's great on film, but if it's in your private practice, it's not good. I don't like immediate load. It just increases your failure rate. Okay? That is one. 

Immediate placement, I don't have too much trouble with as long as we have bone, but that's another problem. If you present to your patients - I will tell the students this - the advantages of immediate load versus if I bury it for a while, your success rate is 98%. Now it's commercially ... Everybody wants immediate load. You know what I'm saying? I think that definitely contributes to failure rate. Not knowing reclusion, definitely. The parafunctional habits, the treatment planning, things [inaudible 00:27:21], cantilevering back to the spine. This type of stuff because they don't even know the arch forms. Is it square? Is it tapered? Is it ovaling? These thins all contribute because, like you say, it's not just placing the implant. It's knowing the forces in the mouth, the prosthetic forces in the mouth that make you successful longterm. 

Howard Farran: Right. Yeah. I think it's funny when they have these concepts of one size fits all. When you go to your practice, you have everything from a 90-year-old 100 pound Italian woman to a 6'8" 280 pound man, and one's grinding their teeth and has abfractions. The other one doesn't. Some have 28 teeth, and some have that whole load and they only got 20 teeth. I mean there's so many variables at hand-

Dr. Vlachos: Yeah.

Howard Farran: That when you hear someone say "I always immediate load," it's like "Well you can't always do anything in dentistry." 

Dr. Vlachos: I think it ... What'd they say? Parafunctional grinders and clenchers that immediately load lose 70% of the implants. Okay? It just doesn't work that well. 

Howard Farran: But parafunction, aclusion, bruxism, abfraction, that's responsible for 70% of implant failures or immediate loaded implant failures?

Dr. Vlachos: Immediately loaded implants.

Howard Farran: Immediately loaded? Yeah, that makes sense. 

Dr. Vlachos: Yeah, because if people grind their teeth off, believe me, they can generate a thousand pounds per square inch and you're going to immediately load an implant?

Howard Farran: Did you notice that all those people grinding their teeth were married?

Dr. Vlachos: Or going through a divorce. 

Howard Farran: I've noticed that. 

Dr. Vlachos: Yeah. Well we won't go into that right now. I mean it's just ... Implant dentistry, if you're in it long enough, things go in and out of favor. I remember ... I'm bad with years. It was 15 years ago and they were saying "Well you bury the implant three millimeters below [inaudible 00:29:17]. You have a great emergent profile." Well yeah, but we couldn't keep it clean. All of a sudden, all that literature disappeared. We'll see what happens with fads, I call them, because-

Howard Farran: Fads?

Dr. Vlachos: You know what I mean? If you don't stick to the basics - the bone density, the stress on the implant, things like that - you're going to get in trouble, and the manufacturer doesn't care. He wants to sell implants. Treatment planning is everything with prosthetics. 

Howard Farran: I see ... What I ... This is dentistry uncensored so I don't want to talk about anything everyone agrees on. I like to ... I'm on the all-time boards everyday since 1998. I like to talk about what is polarizing, what people are arguing about. There are dentists that draw blood and spin platelets and PRP and bone graft-

Dr. Vlachos: Sure. 

Howard Farran: Basically every implant they do. Then there's other dentists that say "Dude, I've never even done that one time." Where's the true? Where's the 50 shades of gray on this?

Dr. Vlachos: Well I mean I've been spinning blood for sciences for 25 years. Okay? I think that if there was that many factors in blood then we would have bone in our arteries. Correct? I mean it's helpful. Okay? I mean it's not a cure all. It's a fad. It does help. It does help when you're making sticky bone to place it, but if you want to get the growth factors, you take some autogenous bone. There's more growth factors in autogenous piece of bone than you're going to get from spinning blood.

Howard Farran: So you just do it for sinus lifts?

Dr. Vlachos: Correct. 

Howard Farran: No other indications are you spinning blood?

Dr. Vlachos: Not really. I mean if I do ... I do a lot of block grafting, I do [ramuses 00:31:14] and chin grafts. I don't really have to ... It has a cortical plate. You know what I'm saying? It's more predictable in my hands. If I'm doing grafting, I don't need to spin it, but the sinus, I've been doing it for years.

Howard Farran: I wanted to ask you another polarizing question. 

Dr. Vlachos: Sure.

Howard Farran: There's a lot of dentists that every single time they extract any single tooth ever for whatever reason always recommend a bone graft after the extraction. Other dentists, again, they've never done it one time. Where is the truth in the middle? Where is the indications? When do you want to extract a tooth and use a bone graft and when is it just noise?

Dr. Vlachos: Well it depends ... If there's infection in the area ... You want to do a bone graft when you're first starting out in implant dentistry. Okay? You can stabilize the arch so everything's stable so when you place the implant there's no remodeling going on. Okay? The ... I think that ... I like getting the arch stable before I do anything. I like grafting. I'm not opposed to grafting. I'm really not. I mean some guys that have never grafted, well I'd like to see their patients in six years. 

Howard Farran: Okay. 

Dr. Vlachos: Addressing your point to [crosstalk 00:32:37].

Howard Farran: Here's another polarizing one. There's guys like you who have placed 10 thousand implants who never use a surgical guide one time in their life, and then there's other people who use one on every single case. Where's the truth out in the middle? Where do you sit with surgical guides?

Dr. Vlachos: Well I obviously don't use them. I mean I ...

Howard Farran: You've done 10 thousand. You've never used one, and yet there's an entire industry showing you how you need a surgical guide. Then what's even sillier is that most of the implants are replacing, again, a first molar. 

Dr. Vlachos: Right.

Howard Farran: So we've got a second bi in front of it, a second molar behind it. You got the patient's head in your lap at 12 o'clock. I mean Stevie Wonder could almost drop that implant. 

Dr. Vlachos: Well the number [inaudible 00:33:29] I'll give you a classic story. I'm in this practice and I'm doing six implants on the lower. I ask the younger dentist that's replacing implants and she said yes. I said "Well let me see your case." She had number five, and she had a stent for it. I'm like "Well you're only missing number five. There's only kind of like one place to put it, right?" She says "Yeah, but I don't want to jeopardize my license." I'm like "Well how are you jeopardizing your license?" "Because I'm not using the stent." "So you know more about this than I do?"

I don't understand the stent thing. I really don't. Okay? So you're going to do between the foramen on the mandible. We have so much bone and so much area to put those implants in, right? That's where implants going to go. They got to be parallel. Why would I need a stent? Then they put stents through soft tissue. I don't understand that either. I mean there's long drills and they drill right through the soft tissue. How do they know what they're doing? I don't get it. It's fine in some instances, I guess, if you're doing ... If you don't have enough confidence, I guess, they're okay. I don't think they ... I think they're oversold. Let's put it that way. Definitely oversold. 

Howard Farran: Okay. We're going to keep ... We're going to keep on going down. Again, I like to talk about the single crown and the single implant replacing a first molar because I know my homies listening to this are most likely under 30, and that's where they're at. They don't need to be ... They don't even care what you think about how to place an all-on-four or any tips of all-on-fours. That's another decade down the road for these guys. But when you're doing a single implant-

Dr. Vlachos: Sure. 

Howard Farran: For a first molar, do you cement or screw?

Dr. Vlachos: I've always cemented for 35 years. Why would I screw it in? You don't screw in your bridges. When you have a ... That's another thing. I used to lecture for labs. So what do you do? Say you put an implant in three and you put it in crown vault and they give you the pulse with the implant. Correct? Okay. I usually go back. Okay. Now everybody tries to do a pickup impression and send it to the lab, get it analyzed, and spend all this money on the implant. Where's the dentist making any money? He's not. Why don't you just place [inaudible 00:35:55], prep it, and take an impression. It'll work farther ahead than ... I don't understand that. I've done hundreds and hundreds of cases and I've prepped everything. So did Dr. Misch. We did them all the time. 

Howard Farran: What brand of cement do you use?

Dr. Vlachos: Whatever. It really doesn't matter. I mean you're not trying to prevent decay. The people over ... They say the cement gets bound in there. Well they put too much in. Put a little bit. Then if you screw something in, you got the screw hole. That throws of your aclusion. It looks ugly. Why? So you can take it off? Why would you want to take the crown off? I don't know. To look at it? I don't get it. 

Howard Farran: Now I'm going to ask you a question that you obviously have a bias towards one side, but I trust you that - you've done this 35 years - you could be objective. Some people feel shamed when they saw a patient's missing a first molar and they file down a second bicuspid and a second molar and do a three in a bridge. But I think it's kind of funny how really you kind of get trash talked by your peers like "Well why did you file down two virgin teeth?" Well I could say the same thing. Why did you blow up a virgin sinus? That sinus was a virgin. It had never had sex. It'd never been laid. Then you go in there [crosstalk 00:37:26]. Titanium and cow bone and all this. So why is it against our dental religion of odontology to file down two "virgin" teeth but it's totally okay to put a used car in the sinus to save the enamel? Why is enamel on two teeth more sacred than a sinus? 

Dr. Vlachos: Well I don't look at it quite that way. Good presentation though. I mean I think it's ... I mean you've got to give the patient the option obviously. Okay? If you place an implant, obviously it's going to stimulate the bone and it's going to be easier to maintain. I don't think the people ... A three in a bridge has been around for a long time. It's a perfectly acceptable prostheses, but you have to let the patient know that it's a limited [inaudible 00:38:21]: a three in a bridge versus an implant. As long as you keep the patient informed, I don't think that they're doing a disservice. As long as you let them choose and inform the patient, it's fine. 

Howard Farran: Yeah. That is the perfect answer because sometimes they're on Dentaltown and they're deciding should this maxillary first molar with periodontal disease, bone loss, and all that ... Should it have periodontal surgery or should I just treat it with forceps and place titanium? The correct answer is present both to the patient because some people, especially women, can get very emotional about an extraction whereas grandpa doesn't give a rat's ass. So grandma might go from here to Kathmandu to save her "natural" teeth because she wants her natural teeth. Natural like tornadoes, hurricanes, viruses, black holes. Where do you sit on the fence of periodontal surgery on a maxillary three rooted first molar with furcation involvement or extract and go to titanium?

Dr. Vlachos: Well basically I want to know what the patient wants. I mean I'll say "Hey, we can send you over to the periodontist and he can masturbate your gums, and we'll see how that works out for you."

Howard Farran: He can what your gums?

Dr. Vlachos: I shouldn't say that. Masturbate. 

Howard Farran: No, that was hilarious. He can masturbate ... Did you say masturbate your gums? I've never heard that one. I have never heard that one. That is hilarious. 

Dr. Vlachos: That's an old Carl joke, but anyways-

Howard Farran: Is that a Carl Misch joke?

Dr. Vlachos: Oh, yeah. Him and I used to kick it around all the time.

Howard Farran: Oh my god. That is hilarious. 

Dr. Vlachos: [inaudible 00:40:02] because I'll get killed. But anyways ... I mean I always give the patient the option. If you don't then you're doing a disservice. Okay? But you have to know the options. That's the whole thing. "This could be treated periodontally. Go and see the periodontist. What's his success rate? Or this is your other option. I can give you the success rate on that. What would you like to do?" You've got to have ... You have to present the option. I never tell people what to do. It's their choice. It's their mouth. 

Howard Farran: You mentioned Carl Misch a couple times. I want to ask you a question on a disagreement he has with his brother Craig.

Dr. Vlachos: Oh, my. Really?

Howard Farran: Carl will place implants in smokers; Craig won't. A lot of times these kids go to these courses and then when they review the health history-

Dr. Vlachos: Right.

Howard Farran: For the ideal patient, they're sitting there in [inaudible 00:40:54] saying "Well dude, the people that are missing teeth, those aren't your yoga instructors. They're smoking, drinking, working the railroad."

Dr. Vlachos: Right.

Howard Farran: "You're saying only do it on Mr. Rogers." What's your view on smokers and implants?

Dr. Vlachos: It's the same thing I tell them. I say "Listen. You smoke. I'm not going to tell you to quit smoking. Okay? You've been smoking for years. The success rate goes down a little bit. Okay?" Everybody smokes and they do implants. I mean I give the patient the choice. I give him the choice. I'll tell him "Hey, I'm happy to do it. I'd like you to quit smoking for two weeks, but that's up to you. I'm not going to go home with you. Okay?" I treat smokers. 

Howard Farran: You treat smokers? Have you been to China? In America, it's all no smoking.

Dr. Vlachos: Yeah.

Howard Farran: You know they have the smoking and the non-smoking section. In China, they have the chain smoking section and then just the regular smoking section. 

Dr. Vlachos: I know. I know. When I go to Greece, believe me. Believe me. Everybody's smoking. They hand me a cigarette and look at me strange when I don't smoke it. You know? It's weird. 

Howard Farran: So you're Greek and you went to Greece. Was that to see family or just lecturing? Do you still have family in Greece?

Dr. Vlachos: Oh, yeah. Well they've since passed, but I used to go there quite regularly. Yeah.

Howard Farran: Man, that is one beautiful ... You know the most interesting thing I always think about Greece and Albania? If you look at the land prices on the Mediterranean especially up in northern Greece and Albania, it's like nothing. Then you just get a boat and go across on the other side of Italy, and all that land's a million dollars a square acre. 

Dr. Vlachos: Yeah. 

Howard Farran: I mean that is got to be the best longterm real estate because you know there's going to be an equilibrium. I mean how long does it take a yacht or a boat to go ... When you go on those beaches of Greece and Albania, I mean they are just ... They're to die for. Basically they ... It's cheaper to buy beachfront property there than it is any property in Phoenix. 

Dr. Vlachos: Oh, yeah. Yeah. But it's beautiful too. It's stunning. I agree with you. I love going there. Yeah. You're making me homesick. 

Howard Farran: Yeah. Yeah, I love that place. That is an amazing city. I want to ask you another question. Go ahead. What?

Dr. Vlachos: A controversial question. What do you got?

Howard Farran: Okay. My oldest sister's a cloistered Carmelite monk, and she knows Greek and Arabic and everything. She speaks like seven languages. She's always telling me how that when you study all the books of the major religions, there's only one sentence that's in common in every major book, and that is "Treat other people like you want to be treated." She goes "There's no other person, place, city, thing." She goes "It's so ... It translates so hard that it's like pure plagiarism" which is her philosophy that all religions are talking to the same god because it's treat other people like you want to be treated. 

When I think of myself ... Let's say I need a surgery. Let's say I need to have a whatever ... Prostate surgery. I wouldn't want to go to somebody who does it every one time every three months. A lot of these guys, when I tell them they're learning a procedure, I always tell them that if you don't do this procedure one time a week, you don't do it 50 times a year ... I don't care if it's placing an implant or Invisalign. I personally believe you'll never make money on it. You'll never get good at it, and you should really probably tell that patient "You know what? You should probably go find someone better to do it because why would you want to spend all this money on an implant if I haven't done one in the month of May?"

Dr. Vlachos: Right.

Howard Farran: So do you believe there's ... Do you believe that one procedure a week is the critical mass?

Dr. Vlachos: I believe ... I know what you're saying. I agree with you. You have to do the procedure over and over and over. That's why I believe that you should start with an implant in the posterior area, definitely not in the anterior, and get comfortable with that. Bury the implant, get your hands lose, look at the bone, see that you have a millimeter of bone on each side, progressively get there and see if you enjoy it. If you enjoy it and you're comfortable with it then you can proceed on, but you still need to continue education to know what you're doing. I mean a lot of guys graduate from dental school and they've never taken a class. The only time they take it it's on the computer. I mean I've taken thousands of hours of continuing ed before it was ever popular, I guess, or demanded. I shouldn't say popular. Yeah, you have to do the procedure. [crosstalk 00:45:48]

Howard Farran: I did mine ... I probably shouldn't say this on here, but you know who my first sinus lift was on? You do? Yeah. When I was going through the missions, doing my fellowship at the Misch [inaudible 00:46:02] and all that stuff, my first ... I couldn't afford to buy like Rhesus monkeys or gorillas or chimpanzees so I just used all my uncles and aunts and grandparents. They were the lowest priced research monkeys you could get. Then I really was biased towards old men, grandpas with liver spots because ... I mean if you were ever doing a root canal on one of those guys and it just wasn't going to work and you said "Man, I'm sorry. This is not going to work. I think we need to extract," he's like "Well I told you that before we started. You're the one that wanted to save it." So people with really low expectations.

Dr. Vlachos: Right.

Howard Farran: Then you got that beautiful girl and it's a visible tooth and she's got makeup on and she's looking all fine. It's like just run. 

Dr. Vlachos: Yeah.

Howard Farran: That's got to be at least implant 100 plus. Maybe 200 plus. How many implants do you think they'd have to do before you sunk a cental incisor on a beautiful woman?

Dr. Vlachos: With a high smile no doubt, right?

Howard Farran: Yeah. 

Dr. Vlachos: Well how many? I would say they'd have to do at least, at least, 100 to 150 implants. 

Howard Farran: Yeah.

Dr. Vlachos: At least because-

Howard Farran: So-

Dr. Vlachos: I mean the soft tissue ... It's all wound up and the presentation has to be spot on because it's not that predictable. 

Howard Farran: So you've been doing them ... How many years did you say? 35?

Dr. Vlachos: Yup.

Howard Farran: So there's dentists who've been placing them for 35 years at these kids' study clubs, and they're saying "Look, I've never done a surgical guide and I've only used a pan. I don't need your surgical guide, and I don't need your $100 thousand 3D CBCT." Agree with that or disagree?

Dr. Vlachos: Well I mean of course I practice with a [pano x 00:47:58] for years and years and years. 

Howard Farran: How many years did you only use a pano 2D?

Dr. Vlachos: I mean my memory isn't what it should be. Probably 20 years. 

Howard Farran: Right. So obviously it can be done?

Dr. Vlachos: Oh, definitely can be done. There's ... It makes life easier if you a CT. It can pan out. You can see the width of the bone, the height, the trajectory, and it makes a quicker surgery. Okay? Otherwise before if you had a one dimensional picture, you had 20 implants and you're "Okay, this fits." You reflect down ... You can reflect down to the mental foramen and measure and do it that way. There's a lot of ways you can do it. You don't have to spend $150 thousand on a CAT-scan. There's devices where you can put on your digital x-ray and figure out your distortion. Yeah, I mean you don't need it. It makes life easier. Believe me, it does. 

Howard Farran: Yeah.

Dr. Vlachos: Yeah. Not a big stent guy. 

Howard Farran: Not a big stent? Back to that CT. Do you think that ... Do you agree with this analogy or not? I never saw a cellphone til I think I was 35 years old, but anyway ... You start off with that Motorola flip phone, and then it went to Nokia. Now it's a damn iPhone. Do you think buying $100 thousand 3D CT scan today that five years later you're going to be like wishing you didn't own this Motorola flip phone and wishing you could get the new Samsung or iPhone ... Do you think the technology is moving so fast that it's better to send it out and let someone else take it so you're not on the line for 100 grand and you're not going to be living with an outdated iPhone?

Dr. Vlachos: Well I mean I think that if you're placing implants, a significant number of implants-

Howard Farran: One a week?

Dr. Vlachos: Yeah, one a week. Twenty a month, something like that. More than ... It's a very wise investment. Also it's good for endodontic treatments. I mean I like the pano x. I think it's a worthwhile investment if you can afford it. I mean for surgical if you're doing wisdom teeth, you know where the nerve is. I think you have to have it today if you're going to progress. I think we'll need more technology coming along, but if you don't get this technology you'll miss the next technology. I really like the CAT-scan. I'm spoiled. I think-

Howard Farran: Yeah. Which one did you get?

Dr. Vlachos: Well I have the ... I have like three of them. Okay? But I don't want to promote one over the other to be honest with you. 

Howard Farran: But you gave us three names on implants. You gave us Biohorizons' Carl Misch, Implants Direct's Gerry Niznick, Megagen's AnyRidge by Dr. Park.

Dr. Vlachos: Gendex is one of them. 

Howard Farran: Okay. Gendex?

Dr. Vlachos: Yeah, Gendex. I'm trying to think. What's the other one? I can see it, but I'm having a senior moment right now. 

Howard Farran: Is it iTero?

Dr. Vlachos: iTero. Yeah, I have one of those. I have like four offices I work ... Five offices I work with that have CTs. 

Howard Farran: So do you ... You have one office but then you go into other offices?

Dr. Vlachos: Yes, I do. I've been doing that for 20 years.

Howard Farran: Well I want to talk about that. In fact, I was thinking about writing a column about that. If the customer comes first-

Dr. Vlachos: Correct.

Howard Farran: Then the specialist should go ... It should be one shop stop. 

Dr. Vlachos: Right. 

Howard Farran: I question the ... These young specialists come out of school and they come to Phoenix and San Fran and LA, and they just say "It's so crowded. It's going to be so hard to get these referrals." Yet they commit to buying land, buying a building. They're already ... If they're specialists, they're 350 in debt at a dental school, but by the time they get out of specialty school they're 600 in debt. Then they go buy land, building, equipment which costs another million, another million six. I always think to myself "Well if the pace ... If the customer came first and everything's crowded, why wouldn't you just go and find the five most rocking hot offices in Mr. Big City and do Monday, Tuesday, Wednesday, Thursday, Friday? If you're young and you're single and you don't have kids, you could work six days a week and pay that loan off. You'd have no debt."

Dr. Vlachos: Right.

Howard Farran: What do you think of ... Because it's a really nasty message when oral surgeons and orthodontists and endodontists are hearing me say that. They're like ... It's like a violation of their turf and their property and their identity. But you've said you've done it for years.

Dr. Vlachos: Right. Exactly. It gives the patient a better service. They don't have to leave the office. You can ... You don't call the oral surgeon up. You sit right down and talk to the dentist. The treatment plan's right there. It flows well. I do IV sedation. I mean so everything's done in-house, one spot. 

Howard Farran: And then you don't have any overhead on those locations?

Dr. Vlachos: Well I have ... I bring everything with me: all the equipment, the implants, everything else.

Howard Farran: Yeah, but you're not paying the land, building, rent?

Dr. Vlachos: No, I agree. [crosstalk 00:53:18].

Howard Farran: What about staff? Do you bring a surgical assistant with you?

Dr. Vlachos: No, I just ... I just use ... They can retract back and do the surgery. I don't-

Howard Farran: Damn. Do you mind sharing ... Do all five of them have the same percentage split with you? I mean is it 50/50?

Dr. Vlachos: No, they all have the same split, but I don't want to let that out. 

Howard Farran: Okay. They're listening on iTunes. They're not watching on Youtube or Facebook so just put up your hands. 

Dr. Vlachos: Certain things you can't get out of me. 

Howard Farran: Just put up your fingers. But you know ... I mean I've seen so much research. There's a lot more research with MDs than dentists because there's over one million MDs in the United States. There's only 211 thousand dentists. The MDs, I mean they do research where 100 grandpas come in and they say "Well you need to go to this doctor and get it checked. You need to go to this doctor." They'll give them three referrals. When he walks out that door, grandpa ... A third of the grandpas just throw them away right there. 

Dr. Vlachos: Sure. 

Howard Farran: I mean it's the same with even filling the prescription which is so dumb because they write the prescription in Latin. Grandpa is 70, and he's looking at this thing in Latin. He don't even remember what it was for. 

Dr. Vlachos: Right. I believe you.

Howard Farran: It's like if giving him his medication was so damn important and you knew that the chance that he won't fill the script is so high, then why ... Why wouldn't the MD just say "Hey, here's a bottle of blue pills. You need to take one every day or you're going to have a stroke and be paralyzed on the right side and you're not going to walk again." The specialists ... If his diabetes or whatever ... I mean why couldn't he just say "Come back here Tuesday. That's a day the diabetes guy is in here or the prostate guy."

Dr. Vlachos: Exactly.

Howard Farran: Do you think it's headed towards that?

Dr. Vlachos: I hope so. It should be. I agree with you because, like you say, I work with a lot of older people and, believe me, you hit it right on the head. They just throw it away. "I'm not going to do that. I'm not going to go here." It's the same with what I do. How many times do they send them for an implant at Mr. Oral Surgeon? They never go. Or Mr. Periodontist? Now you say endodontist. I didn't know that. It works out fabulous, and you're right. 

Howard Farran: It's the same in rural America. There's just a significant portion of rural America that just detests driving an hour away into the big city. 

Dr. Vlachos: Exactly. Exactly. 

Howard Farran: And they get freaked out on the interstates and the freeways and it's lost. They have no concept of the layout. When you refer, there's so many instances that when you refer you have a doctor-centered practice, not a patient-centered practice. If you're doing something that you know a significant portion of your patients are not going to comply then it's all about you and it's not about the patient. I really think a patient-centered practice should have the specialist [inaudible 00:56:16]. 

The other thing I don't understand about corporate is there's 35 corporations that have more than 50 locations and they employ 12% of the dentists, but they're actually doing 19% of the dentistry. I look at how they're spending so much money training these young kids and sending them to all these programs. Again, I sit there and say "Okay, well you're going to drop a lot of money on this kid to teach him how to place implants. Why the hell don't you just go find some periodontist that's already sunk $10 thousand and rotate him through there? Because it would be better, faster, predictable." I don't want you to talk about predictable because a lot of times they don't realize in the price of the margin if you do something for a $1 and you only make 25 cents and one out of every four of your cases fail, you're never going to make a penny on implants. I mean your failures eat so much of the ... What do you think the ... How many ... What do you think the average number of cases you have to do profitably to eat one failed case?

Dr. Vlachos: I think it was five. 

Howard Farran: Five to one? 

Dr. Vlachos: Yeah.

Howard Farran: Yeah.

Dr. Vlachos: Yeah, yeah. 

Howard Farran: I don't see how corporate has that idea. 

Dr. Vlachos: They don't. That's the whole thing. I mean you have to be predictable. In Michigan, I had 40 referral doctors. I can't have 40 headaches. Okay? So you have to be predictable, and you have to start from the right side and that's the prosthesis. Once you do that and you progress and you know the forces in the mouth, you will be predictable. But if you just go drill a hole in the bone, anybody can do that. You know? Or cantilever off an implant or make a six unit bridge up two implants. I mean the young kid's going to get in trouble. I'm out there to help him. I really am. 

Howard Farran: I am very ... I'm going to ask you another-

Dr. Vlachos: Okay.

Howard Farran: Very controversial question. Dentaltown has a quarter million dentists on there.

Dr. Vlachos: Okay.

Howard Farran: 50 thousand have downloaded the app, but under implants, we had to separate implants from mini implants because when anybody placed a mini implant, all these other guys go on there and start telling them how you shouldn't have placed a mini and all that. We had to separate them just like two kids in a sandbox. We had to do the same with a CAD/CAM: the CEREC boys versus the E4D boys. I mean every time some poor E4D guy post a case, the standard CEREC people would come on and say "Well you should have bought a CEREC machine." We're like "Look, they're past that. They already bought an E4D." My question is: why did I have to separate implants from mini implants? Why is this such a polarizing hot button in dentistry?

Dr. Vlachos: Well what do you mean by exactly mini implants? Are you talking about a little thin implants? Is that what you're-

Howard Farran: Well by definition, it's anything under three millimeter diameter. There was three. There was IMTEC. Who's the guy in New York or upstate New York? Who's the guy in upstate New York, that place that teaches minis?

Dr. Vlachos: I don't know. I mean minis is not ... I have done zero minis. I talk to the patient. It depends on what's opposing and where you're placing it. I mean I guess there's a certain market for that, but, again, if you don't take the forces into account, you're going to lose a lot of minis. You're mounting 12 teeth on minis. That's a tough situation. Surface area dictates support. You know that. 

Howard Farran: Stress equals force over area. 

Dr. Vlachos: Yeah, that's right. Exactly.

Howard Farran: How many times did Carl say that in his lifetime?

Dr. Vlachos: About a million. 

Howard Farran: So we did ... We put him on the cover when he passed away. We put him on the cover. I thought we did a very nice tribute. 

Dr. Vlachos: You did a very nice-

Howard Farran: I just think that that guy ... He reminds me of when you watch the Rock and Roll Hall of Fame. It's my favorite show of the year. It's about this time. It's about the end of April. It's two or three hours long. I just love that because these are the people who rose to the very top of their profession.

Dr. Vlachos: Right.

Howard Farran: I was wondering when ... Like Cheap Trick got inducted last year. 

Dr. Vlachos: Oh, really?

Howard Farran: And the day that they were accepting the Rock and Roll Hall of Fame, they had three cities they were touring on that week. They never stopped touring. That's what you can say about Carl. The guy was touring around the world til the day he died. 

Dr. Vlachos: He did. He was teaching. 

Howard Farran: That guy lived in an airplane for what? 40 years? 

Dr. Vlachos: Yeah. My favorite saying to Carl was ... We're practicing together and he'd fly off to Hawaii, Japan, around the globe, and come back and walk in with his slide cases. You know the old slide cases? I sat down with him. I'd say "Carl, you know the profession needs somebody like you. Thank god it isn't me." Because that man worked nonstop seven days a week, and that's all he thought about. He was phenomenal. He was a lot of fun. 

Howard Farran: Yeah, I thought he was a blast. I thought he was amazing. What I loved about him is so many dentists and physicians and lawyers have the biggest egos in the world, and that guy should have have the biggest ego in the world.

Dr. Vlachos: No.

Howard Farran: You'd sit down there with him, drank with him at a bar, and he would just like ... It was just like your high school buddy. Yeah, just one of the boys. All-on-four. Here's another ... I know you promised me an hour and I've already taken my whole hour, but can I go into overtime for a couple-

Dr. Vlachos: Sure.

Howard Farran: At least one more?

Dr. Vlachos: That's fine. 

Howard Farran: On Dentaltown, sometimes whenever someone says all-on-four they get a reply "You mean none-on-three" meaning that if one implant fails, you lost the case. What do you think of that comment? All-on-four or is it none-on-three?

Dr. Vlachos: Well you know what? All-on-four, like I said ... So you're falling into this same thing. It's just ... It's not really dentistry. It's a sales pitch. Okay? If they do put all-on-four and they lose one and the screws comes out on the acrylic whatever they call it then the other implants fail. I just can't bring myself to say that that's really a treatment plan unless I know more about it. I think it's a commercialized effort to sell implants. 

Howard Farran: Well you definitely ... You definitely can't think of Homo sapiens as like a standard iPhone. I mean the variants of them is between height and weight and age and health history. There's so many damn variables. 

Dr. Vlachos: Of course there's ... Arch form. What about ... If they were so good maybe God would have made us with four teeth. 

Howard Farran: Yeah. [crosstalk 01:03:24]

Dr. Vlachos: You know? It's just not ... It's a good marketing tool. They're marketing the hell out of it, but I mean you can't make it work in every situation. In some situations where you're posing a 90-year-old woman with an upper denture, sure. It'll work.

Howard Farran: So here's what I want to tell the kids listening because you're talking to a lot of kids right now. So the course is $6000. You could email drvlachos@gmail.com. Now $6000 is probably going to be what? Two cases, implant, build up crown? What are you charging for an implant? $1500 or $2500? Let's say you just charge $2000 for an implant and crown so you'd have to replace three [inaudible 01:04:06]. But here's the point I'm trying to make to you is that a lot of dentists start thinking "Well maybe I should learn sleep apnea or Invisalign or snore guards or place implants." What you need to do is you need to look at what's in your office right now. What is the demand right now? If you got three people missing a molar and you just charge only a $1000 for an implant and $1000 for a crown, three cases and you've already dug yourself out. You went $6000 under; three cases, you break even and then you're ready to start storing. 

My final question to you, Stacey-

Dr. Vlachos: Let me interject one thing. Not only is it the surgery, but when we plan out the case, I want to go over treatment planning with him. We're going to do mostly treatment planning from the prosthetics. It's going to be not just see him at the course. I'm going to be communicating with them quite a bit and have to present the case and I'm going to have to okay it so they'll learn a lot just with treatment planning with me. 

Howard Farran: So my final question to you is this: what would be ... If there had to ... What is the most no-brainer easiest case that she should be looking for in her practice? Obviously not number eight on a beautiful woman. What's the least amount of trouble single implant case you can place?

Dr. Vlachos: Number four. 

Howard Farran: Second bicuspid?

Dr. Vlachos: Mm-hmm (affirmative). [crosstalk 01:05:33]. Yup. 

Howard Farran: Or 13?

Dr. Vlachos: 13. You have a lot of bone, access is easy. You don't have to worry about the nerve. The bone is soft so you're going to have an easy osteotomy. You're not going to burn the bone. Okay? And it'll be a good learning curve. It's out of the aesthetic zone. 

Howard Farran: Okay. Well let me give you a second ... This is last question 2.0. 

Dr. Vlachos: Okay. 

Howard Farran: Since the most likely tooth missing is always going to be a first molar-

Dr. Vlachos: Right.

Howard Farran: If you had to pick a first molar, would you pick upper or lower?

Dr. Vlachos: Upper.

Howard Farran: Upper and why?

Dr. Vlachos: Most people get nervous about the nerve when they first begin. They're always thinking they're going to go into the canal. How much damage can you do? I mean really if you perforate the sinus and you can't place the implant then you take it out and you let it heal. You take out a tooth and you perforate the sinus, you know how to treat it. Right?

Howard Farran: Right. 

Dr. Vlachos: You go into the nerve, we might have a little bit of a problem there. 

Howard Farran: Usually if I perf the sinus, the way I treat it is right after work I go to the bar and just start drinking. Did I do it right? Is that ... Did I do everything right?

Dr. Vlachos: Everybody is scared of a sinus. It's not-

Howard Farran: Well I've read papers that said that as many as ... Some people predict 80% of all sinus perforations, the dentist didn't even know what happened. 

Dr. Vlachos: Exactly. Exactly. In the old days when we just had the pano x, I'm sure we perfed the sinus hundreds of times. Hundreds of times. Everything worked. I mean everybody's so scared of the sinus, they need a hydraulic pump and pump it up or something. You know what I mean? It's not that difficult of a procedure, and it's the most predictable place to grow bone and they should utilize it. That's where you have your first molar. That's where you do your chewing. You know. That's where all the force is. 

Howard Farran: All right. Well look for his course coming up on Dentaltown: One on One. He's D-R-V-L-A-C-H-O-S, drvlachos@gmail.com. He's all Greek and if you sign up today, he will send you a case of Windex. 

Dr. Vlachos: Yes. [crosstalk 01:07:52].

Howard Farran: Watch the comedy My Big Fat Greek Wedding. Truthfully, have you ever used Windex on an implant case?

Dr. Vlachos: No, I can't say I have. 

Howard Farran: Okay. So now we know he's not really Greek. 

Dr. Vlachos: Oh, that's true. Okay.

Howard Farran: Hey. Thanks so much for coming on my show today and spend our hour with my homies. I thought you were amazing. Thank you so much for all that you've done for dentistry. 

Dr. Vlachos: I appreciate it. Nice seeing you, Howard. 

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