Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
How to perform dentistry faster, easier, higher in quality and lower in cost.
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767 Dental Excellence! with Dr. Ernest S. Orphanos, DDS : Dentistry Uncensored with Howard Farran

767 Dental Excellence! with Dr. Ernest S. Orphanos, DDS : Dentistry Uncensored with Howard Farran

7/11/2017 7:42:53 PM   |   Comments: 0   |   Views: 262

767 Dental Excellence! with Dr. Ernest S. Orphanos, DDS : Dentistry Uncensored with Howard Farran

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767 Dental Excellence! with Dr. Ernest S. Orphanos, DDS : Dentistry Uncensored with Howard Farran

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VIDEO - DUwHF #767 - Ernest Orphanos

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AUDIO - DUwHF #767 - Ernest Orphanos

Dr. Orphanos is a Board Certified Periodontist who has been practicing  in Boca Raton, Florida  since 1994. He limits his practice to dental implants and procedures associated with dental implants, such as extractions and bone grafts. He attended SUNY Stony Brook School of Dental Medicine and then pursued his Periodontal Specialty in Boston at Tufts University, where he was exposed to some of the founding fathers of interdisciplinary care. It was there that Dr. Orphanos understood the true appreciation of dental team members to achieve the highest quality of care. Currently, he is a visiting lecturer for the Post-Graduate Department of Periodontics at Tufts University.

Dr. Orphanos currently lectures nationally and internationally on the ALL on 4 procedure and has an interesting approach to his technique, which entails facial analysis and the reversal of facial aging. His passion is dentistry and he has a love for creating presentations with some amazing graphics entailing facial morphing. When he is not practicing dentistry or working on graphics for his next presentation he can be found traveling with his wife and son who he shares every free moment with. 

Howard : And it's just a huge honor for me today to be podcasting interviewing Ernest Orphanos DDS all the way from Boca Raton Florida. He is a board certified periodontist who's been practicing in Boca Raton Florida since 1994. He limits his practice to dental implants and procedures associated with dental implants such as extractions and bone grafts. He attended SUNY, is it sunny? S U N Y Stony Brook school of Dental Medicine? 

Dr. Orphanos : SUNY. State University.  

Howard : SUNY University. Then pursued his periodontal specialty in Boston at Tufts University where he was exposed to some of the founding fathers of interdisciplinary care. It was there that Dr. Orphanos understood the true appreciation of dental team members to achieve the highest quality of care. Currently he is the visiting lecturer for the post-graduate department of periodontics at Tufts. Dr. Orphanos currently lectures nationally and internationally on the all on four procedure and has an interesting approach to this technique. Which entails facial analysis and the reversal of facial aging. His passion is dentistry and he has a love for creating presentations with some amazing graphics entailing facial morphing. When he's not practicing dentistry or working on graphics for his next presentation, he can be found traveling with his wife and son who he shares every free moment with. So if someone asked you "Who invented all on four?" Would you say it was Halo Malo from Portugal. 

Dr. Orphanos : I'd probably say it was Palo Malo from Portugal. 

Howard : Palo Malo, so I pronounced it wrong. (laughs) 

Dr. Orphanos : Correct. 

Howard : Palo Malo from Portugal? 

Dr. Orphanos : Correct. 

Howard : And what do you think of that tech? I mean some people, obviously this is Dentistry Uncensored so we really don't want to talk about anything that anyone agrees with, we want to talk about everything that's controversial. Some people say all on four means none on three. What [inaudible 00:02:01] what do you think of that push back? 

Dr. Orphanos : Well, I don't know if you're even familiar with a trefoil which is coming out which is basically all on three. So all on four, nothing on three is really highly innacurate, and there's a plethora of reasons that we can go into on why it's innacurate, but by virtue of the fact of understanding the literature, we know that the longitudinal studies of all on four compared to all on six, immediate load, the laid loading has the same ten year success rate. That's number one, number two is if you do have a failed implant you can certainly put the implant in and you can weld to titanium. So you can, you don't have to create a new prosthesis. This is very simple. If that does happen. Number three is of course you're reducing the bone, and you're reducing this alveolar ridge getting down to the better basal bone. So you have less remodeling, you have thicker soft tissue, we can really go, it would take a full half hour to explain the benefits - 

Howard : I hope you make an online CE course for Dentaltown someday. We've put up 450 courses they've been viewed a million times, and it would be the biggest honor, if you ever created an on-line CE course for Dentaltown.

Dr. Orphanos : It would be my pleasure. 

Howard : Really? 

Dr. Orphanos : Absolutely. 

Howard : So I could tell my townies that you're gonna make an on-line CE course? 

Dr. Orphanos : Absolutely. 

Howard : These pod-casts are consumed by millennials. Guys your age and my age we read textbooks and go to conventions, and the millennials are consuming podcasts. When I look at the nine specialties that the American Dental Association recognizes, your specialty has changed the most. And they're so confused when they see a three rooted molar with periodontal disease and they're thinking, "Should I do periodontal surgery? Should I rip out the tooth and do an implant? I think your specialty, changed more in the last 30 years than the other eight specialties combined. Do you agree with that statement? 

Dr. Orphanos : I agree whole-heartedly with that statement. Not only did it change, it's become more all encompassing. When to extract a tooth is a very very challenging question to address. Now with the advent of LANAP surgery that brings in a whole other dynamic with respect to what we can do to save teeth. But we also have to know longitudinal studies, we just don't base it on our feeling, our opinions, our thoughts, our beliefs, it's really the literature the peer reviewed literature. What has been published prior to us and to when we encounter a clinical situation that dictates and governs our good clinical decision making abilities. 

Howard : So trying to help out, I mean how old are you? 

Dr. Orphanos : I'm 50. 

Howard : Okay, you're 50, I'm 54, most of the people listening to this are under 30. 20% are dental students. The other 80% are under 30. And they're sitting in the patient, it's a maxillary first molar, it's got a furcation involvement how is she supposed to wrap her mind around should I do the old school periodontal surgery or should I cure this with titanium? 

Dr. Orphanos : That's not such a question so easily answered. And I think you have to defer such a clinical question to a seasoned expert. Really, this is for a young clinician it's very challenging. And not just the old perio of yesteryear were we cut gums but we also have current techniques. As I said earlier, one of my partners limits his practice, we have an interesting periodontal practice I don't treat perio anymore. My partner does. And the kind of results he's getting with the LANAP one has to really defer to the experts of that field to really make the best clinical judgment for the patient. But there are other factors that come into play, age of a patient. I mean if I have a 20, 5, 30 year old patient I'm going to do what it takes to try to keep that tooth there for as long as possible. 

Howard : So age of a patient is huge. What else are you thinking about when you're deciding whether to do periodontal surgery or LANAP versus extraction and place an implant? 

Dr. Orphanos : Well root workthology furcation involvement or for the root trunk size, also considering the mobility and the imposing inclusion. So those are some critical factors that I look at when determining whether the patient needs titanium or a conventional periodont. 

Howard : So you're saying that all on four is moving towards all on three? 

Dr. Orphanos : No it's not moving towards, there's an additional protocol and it's not moving towards it's already coming out and it's been through a five year rigorous protocol, yes, and there will be a protocol where by it's all on three but the final definitive and just for the lower arch and the final definitive prosthesis is to be delivered the same day or the following day. It's unlike all on four where you're in provisionals for several months. And it's limited to the lower arch and yes, it's coming out. 

Howard : So all on three delivered on the same day with the final restoration? 

Dr. Orphanos : Correct and it's basically a treatment option available at our disposal for those patients who cannot afford the luxury of an all on four. 

Howard : So who does the most all on fours? Is it ClearChoice? 

Dr. Orphanos : I couldn't answer that question, I wouldn't know. 

Howard : But is this something that they're going to start doing also, I mean are they going to start doing all on threes? 

Dr. Orphanos : Well from what I understand ClearChoice is no longer the Nobel product. And this is very proprietary the parts. The parts are very proprietary, they're proprietary to Nobel, so [inaudible 00:08:23] that ClearChoice, if they are going to incorporate this into their clinics then they're going to have to use Nobel products. 

Howard : so obviously then you like the Novel products, you're not using others? 

Dr. Orphanos : No, presently I'm not, probably for the past 6, 7 years I've been using Nobel exclusively. 

Howard : And why is that? Try to help out these young dentists. They're 25 years old, they're walking out of school and they're all saying the same thing. They're saying, "we didn't place one dental implant in school." They say that from all 56 dental schools and then they go to the ADA convention and there's like 175 different dental implant companies. 

Dr. Orphanos : Correct. 

Howard : So you're all with Nobel Biocare so explain why and try to explain to a ... pretend your daughter just graduated from dental school and she just asked, "Dad what implant system should I use?" 

Dr. Orphanos : Okay, that's a very all encompassing question, that requires a very thorough answer. 

Howard : (laughs) 

Dr. Orphanos : So, first and foremost that's a tried and true implant system. We know that it's been around for more than 50 years. Number two would be the tolerance of parts, it's not difficult in this day in age to have implants integrate into bone. That's very easy. What's not easy is a high tolerance and a precision of parts to create a long predictable prosthetic result. That's the challenge then, and from my particular inclination, to use Nobel, I want to use an implant with an excellent implant surface. I want to use an implant that has an excellent primary stability because I do a lot of immediate loads and I think there're very few exceptions when in the anterior aesthetic zone I'm not doing immediate loads because the research shows you're going to preserve more of the ridge and more of the hard and soft tissue if you immediately load. So I need great primary stability, I need great tolerance of prosthetic components, I need a variety of prosthetic components, I need platform switching, in no uncertain terms. So these are just but a few criteria with the Nobel implant system that I'm afforded the luxury to deliver excellence on a regular basis. And last but not least is the support is excellent. 

Howard : So you think the extra money paid for Nobel biocare which is the Mercedes Benz of dentistry, you think it has value. [crosstalk 00:11:09] you would rather pay value added for Nobel Biocare than say the low cost for provider which is out of Brazil which is ... what's the one out of Brazil that's owned by Straumann?

Dr. Orphanos : I think it used to be called Neodent it's a - 

Howard : Neodent, so you ... now do you feel that the higher cost of Nobel biocare is worth the premium because you're in Boca Raton Florida? And the United States has 1 million attorneys and if you're ever put on a lawsuit Nobel biocare has 5, 10, 20 year research on every decision they make? Versus some low cost implant out of Russia? 

Dr. Orphanos : Well my response to you is lets assume you or a family member needed a heart valve replacement, and you were going to have a heart valve replaced and do you want the best product or do you want the low-cost product? These are medical devices inserted into human beings and those human beings happen to be my patients. And I take very good pride in my work, so as far as I'm concerned, I'm not saying you have to use Nobel, but I'm saying you should use a premium product whose research is there, whose product is tried and true, because if you want to build a good reputation and a good practice? Minimizing problems and maximizing the result is always the ultimate goal. So for my own personal benefit if I needed some prosthetic part in my body? For one I am 100% certain I want the best prosthetic part money can buy. 

Howard : That's interesting, most of everyone I know, who has placed a thousand, 10 thousand, 20 thousand, implants says the exact same thing. They want the very best, they want the Mercedes Benz, and they always go Nobel biocare because they say if I'm ever on the witness stand, I want all of Nobel biocares research proving everything I did. I want to ask you another, this is Dentistry Uncensored, we don't talk about anything that everyone agrees on, (laughs) we only talk about the controversies. I want to ask you the most controversial question. It seems that everyone who's placed a thousand implants or more, just does it surgically, and everybody whose placed under a hundred implants or more, wants a surgical guide. So my question to you, is do you use a surgical guide? Do you think every implant should be placed with a surgical guide? Or do you agree with the people that have placed 10 thousand implants that says, "Dude, take off the training wheels you're a surgeon, if you're gonna place an implant you gotta go scalpal to bone and look at what you have." Where do you sit on surgical guides? 

Dr. Orphanos : That's an excellent question. I think it pertains to the comfort level of the clinician placing the implant. Lets not remember that surgical guides as much as I like them they're not foolproof. There are inherent errors with surgical guides, and we talk rather liberally when it comes to dentistry. But very few people quote the literature. There's an article by a gentleman named Zhao, Z H A O I believe, out of China and he found upwards of ten degrees variation with surgical guides. Now in the dental surgical guide and the toothborne surgical guide are two completely different types of guides. Are you doing a full arch or are you doing a single tooth? Are you doing a posterior tooth or are you doing an anterior tooth? Where placement is critical. So I am a fan of surgical guides when the clinician is uncertain of him or herself, I am a fan of surgical guides in the aesthetic zone where placement is absolutely ideal, especially when aesthetics are of upmost importance, and we need the best aesthetic results. So I'm for surgical guides that's not to say that surgical guides do not come with some inherent problems but for the most part I'm an advocate of surgical guides. 

Howard : I'm a big fan of yours, I think your amazing, another thing that you're a big advocate of is, I think the easiest way to be a better dentis, if someone said to me, "How can I be a better dentis?" I would say, "Dude you're a homesapien, you need to see better." Loupes. Endodontists want microscopes, you use things to see better. You're a big fan that a homosapien should see better at 2.5, 3.5, 4.5 or 5.5 and that if a human can see more they're better. Do you think magnification is directly related to being a higher quality dentist? 

Dr. Orphanos : There is a direct correlation with higher magnification and quality of care. In no uncertain terms. The better the visibility the better the quality of care that can be rendered. We in our office, I've had prior to these omni optic loupes that I just did a beta test for, let me see if I can find them. They're thoracoscopic, prior to these omni optic loupes, I've had about three sets of loupes and we do a bunch of micro surgery so we have some microscopes in the office, and I have to tell you that the optics on these particular loupes are so fantastic, because they're magnetically held. They're easily removed. So these magnetic, these optics are removed and you can replaced them with varying magnifications such that you can go from 2.5 to 3.5 to 4.5 to 5.5 and here - 

Howard : Okay, but talk about that. When do you need to be at 2.5, 3.5, 4.5 and 5.5? I mean, what - 

Dr. Orphanos : That's an excellent question, I like to do my examinations, remember, the higher the magnification the narrower the depth of field and typically the narrower the width of field so width of field is also related to proximity of the eye so the closer the lens is to your eye the wider the width of field you have. With the higher magnification the depth of field gets narrower, so I like to do my initial examinations with the 2.5 it gives me a good view of the entire arch. I'm not a toothodontist I don't look at single teeth, I look at mouths. And I assess mouths. So I like a 2.5 loupe for evaluations for quadrant surgeries, I perhaps go with a 3.5 for a very single sight specific area, I would do a 4.5 and in the even I break a root tip off and I have to go an retrieve that root tip, I pop in the 5.5s and it just makes my life very easy. And it allows me the luxury that my microscope doesn't. 

Now I'm in Boca Raton most of my patients are elderly they can't always lie flat back, and I kind of sort of need that with the microscope. It's not that I couldn't work that way without the microscope but it's a little difficult a little bit cumbersome and with these loupes, it basically allows me to have almost the effects of a microscope without being relying on a patients fixed position. 

Howard : So what percent of those 80 year old women used to live in New Jersey or New York? In Boca Raton? 

Dr. Orphanos : 102%

Howard : (laughs) It's so funny because when New Yorkers retire in Arizona they always go to Scottsdale, they never go to Chandler, Mesa, Glendale, what is about Boca Raton and Scottsdale that New Yorkers feel at home about? 

Dr. Orphanos : Probably the mere fact that there are other New Yorkers here. 

Howard : Yeah. It's tribal. So how hard is it for you to switch from 2.5 to 3.5 to 4.5 to 5.5 I mean how difficult is the logistics of that? 

Dr. Orphanos : So here's is a 3.5. These are my 3.5 lenses, let me know if you can see these? Can you see them? 

Howard : Yep. 

Dr. Orphanos : I'm going to pop off the optics, it's magnetically held, takes less than a second to remove, and then there's a little groove that slides in, and it's magnetically in the 2.5 lens. So to change lenses out probably takes a second, 2 seconds at most, per lens. 

Howard : That is really, really nice. You know one of the [racist 00:20:16], or whatever you want to call it, I see is that I go into dental offices and the dentist is using scopes and he's bad mouthing the assistant for not cleaning off the excess cement, or the hygienist for not finding that [calculus 00:20:30] but the hygienist and assistant are all naked eyes. I mean I've always felt that anyone in the mouth, whether you're a doctor and all that and a bag of chips, or the assistant hygienist, you should all wear magnification. I mean what do you think about all the dentist listening to you today that use magnification but their assistant and their hygienist do not? 

Dr. Orphanos : Howard I couldn't agree with you more. We have optics for our microscope, we have the assistant side ops optics, so the assistants looking through the scope as we're working as well. So in no uncertain terms do I agree with you. Our hygiene department, she wears loupes, and then our assistants more often than not do not wear loupes, because I basically do everything. I'm kind of a little bit of a control freak, but I agree with you, loupes are cheap enough nowadays whereby if your using persistence you can do the pop up so that's a one size fits all as opposed to through the lens and we have ... we now have I think I'm around my fifth pair of loupes so pretty much everybody in the office for the most part wears loupes. I couldn't agree with you more. 

Howard : Yeah, and when I look at videos of like a bite pass or any other surgeries on youtube, the nurse assistants are always wearing magnification. 

Dr. Orphanos : Right. 

Howard : I mean they're isn't a ... you mentioned something that's extremely controversial, and this is Dentistry Uncensored, LANAP I mean that has got to be extremely controversial. And I want to say a shout out there was a periodontist on here 20 years ago, Allen Haughnegmen, he was thrown under a bus. After 10 years couple of my favorite periodontists joined LANAP and now after 20 years it seems like it's 50/50 but there's still a lot of controversy I mean I would say a lot of periodontists say, "no." And a lot of periodontists say, "yes." What are your thoughts on LANAP? 

Dr. Orphanos : Okay, I see results - 

Howard : Is that a controversial enough question for you? 

Dr. Orphanos : Yeah that's a great question. 

Howard : (laughs) 

Dr. Orphanos : My partner Dr. Craig Hescheles was the first periodontist to perform LANAP procedures in south Florida. He has over 10 years experience. He was the very first person to be performing LANAP so I'm always at odds because we see some of the most amazing results. I mean he should be on the podcast showing you unusual results, 8, 9 millimeters of vertical bone growth - 

Howard : Tell him he's invited to come on the podcast, I want to hear about this LANAP, we get a lot of questions on LANAP. 

Dr. Orphanos : He has a great presentation on LANAP. The people who pooh-pooh it, the periodontist or other health care providers in dentistry who pooh-pooh it, how can you pooh-pooh something if you've never done it? How can you pooh-pooh something if you have no formal training? So to me it's kind of silly. 

Howard : So are you pro-LANAP?

Dr. Orphanos : I'm very, yes, in my practice, I'm very pro-LANAP. I will tell you that we no longer perform resective gum surgery, osseuos-surgery in our practice, we haven't done osseous resective surgery in approximately 5 years. We will do pre-prosthetic surgery, but when treating a true periodontitis lesion, or disease entity, LANAP is the way to go for us. 

Howard : Okay, but I'm still going to hold your feet to the fire, you're a periodontist, you are all that and a bag of chips, I mean I called you to be on this show, you didn't call me, you are amazing and you're talking to a lot of 25 years old dentists who just walked out of dental school and they're looking at a patient with a maxillary molar with gum disease and they don't know if they should do LANAP, periodontal procedures, from periodontal procedures back in the day versus just extracting it and doing implant and they have so many mixed signals cause the oral surgeons don't treat periodontal disease, so they're just saying to this young girl, "just extract it and place an implant." I mean is it that black and white? How do you wrap your mind around doing old school periodontal procedures versus treating everything with a forcept? 

Dr. Orphanos : Right, that's a great question and only time and experience can give you that answer and I would suggest to all your young clinician viewers that they join a study club. They have to join the study club with seasoned veterans running that study club. And what they'll see is they'll be exposed to, hopefully they'll be exposed to great interdisciplinary care, they will have better decision making skills, and I would suggest the way I hold my study clubs is I provide my study club members with literature that substantiates the position of what it is that we're addressing. 

Howard : So a lot people are asking they come out of school, they have 350 thousand dollars in student loans, and it seems like there's a lot of noise about so many technologies because there's so many incentives to sell a hundred thousand dollar laser, a 150 thousand dollar CAD/CAM, a 100 thousand dollar CBCT, what technologies are you passionate about? And if your daughter just walked out of school, what technologies would you be saying, "hey honey you need to look at this technology."

Dr. Orphanos : Okay well that's very broad based. First and foremost, good loupes, cause if you can't see your dentistry you can't do your dentistry. So that's number one. Number two is I'm a big fan of 3D technology, we are on our third Cone Beam machine, over the past 11 years. It improves us as clinicians it improves our diagnostic abilities. Often times in a radio graph, an x-ray is suggestive of something, there's a haze around a tooth that suggests it so I'm a big fan of loupes, I'm a big fan of 3D technology I would say to a young clinician, "Stay away from, at this moment in time the intra oral scanners, cause they're only getting better. You know there'll be new intra oral scanners on the market that will be able to do full arch scanning that will be able to capture soft tissues so stay away from the scanners. You know the CAD/CAM is very expensive, and I'd say that put that on the back burner for now. The goal right now for young clinicians is diagnostics and carrying out good basic dental care and to put the brakes on slow down, get some time in the drivers seat before they start investing in some expensive technology. 

Howard : So you say no to the scanners, no to the CAD/CAM but yes to loupes and diagnostic. What other diagnostics other than loupes are you talking about? 

Dr. Orphanos : Well, geez, I would just from a clinical standpoint, as a periodontist, you know loupes and Cone Beam are essential I can't tell you how many times I diagnosed endontic lesions that have never been picked up. And the prevalence of missed mb2 canals I know these young clinicians want to treat these maxillary first molars with endo because it's a lucrative procedure and I understand that but if you don't have loupes and you don't have Cone Beam technology you're going to miss those mb2 canals which are present in about 90% of the time. 90%. That's a pretty high number. So those are really the technologies I mean keep it simple, they're coming out with a lot of debt, the last thing they need to do is put something additional debt on their back. Diagnostics and self and education, via podcasts, such as your fantastic Dentaltown, study clubs and read as much as you can until you establish a comfort level and then direct your career in the direction you'd like to have it go. 

Howard : What would you think, probably 20% of the people you're talking to right now are still in dental school and some of them are thinking, "maybe I want to be a periodontist." What would you say to a junior in dental school that wanted to ask you, "do you think that's a good idea to be a periodontist?" 

Dr. Orphanos : Well I love the profusion, I eat sleep and breath perio, I'm going to South America to lecture on Tuesday so it's a passion of mine, I think that when it comes to interdisciplinary care, of the specialties, if you're interested in interdisciplinary care, of the specialties we're the most involved interdisciplinary care. I work with some oral surgeons, very good friends of mine who are oral surgeons but they put an implant in they never see the patient again. They don't talk about hygiene and maintenance they often don't talk about soft tissue procedures around them. Endodontists, they treat a tooth and that's it, that's the extent of their interdisciplinary care. So as a periodontist, its very rewarding and exciting to work up these cases. I will tell you that I'm an unusual periodontist, Howard, I mount all my cases, I use Lucia jigs, I record the bites in centric and I mount every case with a face bow and an arch articulator, and my referring doctors are, now they're spoiled, but they were mesmerized. So - 

Howard : You are old school. I want to ask you the most controversial question in perio. 

Dr. Orphanos : Shoot. 

Howard : We know below the belt after HIV and AIDs the entire planet got religion on STDS, but you still see dental offices everyday, you walk into any dental offices and they're seeing grandma every three months for a perio recall, and they haven't seen grandpa in 10 years and then he shows up for a toothache and he's got gum disease, he's got a bummed out molar, and people still question whether this disease is communicable like gonorrhea or syphilis or chlamydia can you really treat grandma for periodontal disease every three months if every night she's kissing grandpa when she goes to bed? And grandpa's never been to the dentis and there's research that shows that a simple kiss can transmit 60 million organisms. What are your thoughts on that? 

Dr. Orphanos : Well I have to say thank goodness my wife brushes her teeth three times a day. 

Howard : (laughs)

Dr. Orphanos : No you're absolutely right, what we're doing is we are fighting an uphill battle. In no uncertain terms are we fighting an uphill battle. Now add insult to injury what if that spouse has an ill-fitting prosthesis that's plaque retentive. I mean you're just adding more insult to injury. So we are fighting, what we're trying to do is perhaps stave off the inevitable. Now there are other factors that come into to play in addressing this. Host immune response, how is grandma's host immune response going to hold up over the course of time? So of course it's multi-factorial but yes, you're absolutely right, that one of the ideologic or co-factors in the disease entity, can be your significant other. 

Howard : So it seems to me that you could just build every recall practice in America if you just went in there with certainty and said, "look I can't treat you every 3 months for gum disease without seeing the person you're kissing, and sharing breakfast utensils with, I need to see your husband or this isn't going to work." Would you say, could you say that with certainty to grandma? 

Dr. Orphanos : No. That's a utopian society, that's never going to happen. You know we strive for excellence, we strive for perfection, but dentistry is a little bit of art, a little bit of science, a little bit of materials, technique, dentistry is such an unusual and yet beautiful profusion but we're ... sometimes we're only as good as the patients will allow us to be, and that is a shortcoming of our profession not just periodontics, that's a shortcoming of our profession, and we just have to come to terms with it and accept it. 

Howard : Alright, yeah, it's definitely [inaudible 00:33:43] cause we know what we know and we know what we don't know but we don't know the unknown, unknowns. I read the first dentist ever was Pierre Fauchard I read his book from 200 years ago it's crazy, and then I read the first G.V.Black, I got on Ebay and bought the first three books, autographed and signed by G.V.Black, I paid like 10 grand for them, I read them and it's just like complete voodoo so I know a hundred years from now most everything we believe is going to look silly. I want to ask you another dentistry uncensored question, it seems like 10% of the dentists refer all the crown lengthening procedures to periodontists. I mean when I talk to periodontists they say, "okay I'm in the zip code 85044, and these five dentists referred all the crown lengthening procedures, and then the other 90 dentists never referred one. So what does that say about crown lengthening if 10% percent of the dentists see it as absolutely a religion, and 90% do not? And first of all do you agree with those numbers? Do you agree that 10% of the general dentist refer 90% of the crown lengthening? 

Dr. Orphanos : I do, not only do I agree, as you asked the other question what do I think, I'll tell you this without even looking at those clinical cases, cause I see them in my practice, those who refer the crown lengthening have the best prosthetic results when dealing with a good trained periodontist. In no uncertain terms. Tissue contour, tissue response, those who bury their margins in [inaudible 00:35:22] will always have a low grade inflammation, bleeding on probing, I think it is one of the most under utilized procedures in all of periodontics and I think it really becomes a mindset of we as a profusion, we set these you know we set these boundaries that patients will not go for it or I won't get the crown if they have to go for surgery, create these boundaries, but if you think about our own health, if you have to go through a procedure to achieve ideal health or circumnavigate it, what your mindset? In no uncertain terms the most successful clinicians I work with refer for crown lengthening, why? Cause they get the results back that they want, they get the soft tissue response, they have the architecture they have the prosthetics that allows beautiful results, so I don't know what it says. I understand why some of the clinicians don't refer. It's an issue of, "Am I going to lose the patient?" It's an issue of money. You know money and cents. Dollars and cents. 

Listen I can't convince everybody, it's not my intention to try to impose my belief system on the world but I can tell you this, the finest clinicians in the world many of whom I've worked with and many of whom I know always refer out failing crowns. 

Howard : I know I agree with you a hundred percent and I almost wanted to say, "keep ranting about it" because 90% of everyone listening on this podcast never, they must not understand, I don't know if they don't understand crown lengthening, I don't know, some people I'm a very [inaudible 00:37:11] but this is true, some dentists say that crown lengthening is done by the crown that if you place the crown, and the margins on the bone, that the human body automatically does a crown lengthening procedure and the bone will remodel 2 millimeters from the margin and that mother nature does crown lengthening by itself. What would you say to that guy? 

Dr. Orphanos : I think that's an embarrassment of a statement. I mean - 

Howard : (laughs) you think it's an embarrassment of a statement but I want to ask you this, how many dentists believe that? 

Dr. Orphanos : You know Howard I want to put my head in the sand because what they don't understand is what crown lengthening truly is, what they don't understand is not just vertically reducing the bone and the soft tissue it's also horizontally recontouring the tissue such that you have a nice scalloped contour and talk about crown margins today. How do you get a good crown margin if you can't see it? How do you seal that crown margin if you don't have a great impression? And how do you remove the cement? So that's just such a weak argument and from a biological standpoint it's so frighteningly wrong, I just put my head in the sand because I don't want to be around that conversation - 

Howard : So you're saying that it's the same discussion that fluoride in the water is a communist flood. 

Dr. Orphanos : Right, pardon my Bronx vernacular, it's stupid. 

Howard : (laughs) I want to ask you a couple other questions, there's a big, in your and my lifetime, you know when you and I got out of dental school when we went to college, you already had Colgate, Crest, Listerine, I think the biggest brand built since you and I got out of dental school was Invisalign, but in your specialty periodontics there's a couple of big brands building fast. We're already talking about LANAP but there's another one called pinhole technique another one is gumdrop technique, have you heard of the pinhole technique and the gumdrop technique, have you heard of these brands? 

Dr. Orphanos : I'm familiar with the pinhole, I'm not familiar with the gumdrop technique. 

Howard : The gumdrop is Delia Tuttle I think she's from Romania, but you're right the pinhole technique is a southern Cal dentist and he's really marketing a lot about it. Have you evaluated that? What are your thoughts if someone asked you, "what do you think of the pinhole technique by this southern Cal periodontist what would you say? 

Dr. Orphanos : You know I read his poster presentation before anyone even knew what it was about 6 years ago, in Boston at the Nevins Symposium the quintesent symposium in Boston about 6 years ago. And I thought it was very interesting and it's not a technique that a lot of periodontists haven't been already using. A tunnel technique, we've been doing a tunnel, he changed the position of the incision, he changed not so much the surgical technique but he uses those collagen strips, he has excellent instrumentation to not only elevate the tissue but to wrap around and to proximally and sometimes elevate the papilus cause sometimes papilus with recession get blunted. I think that he is a master at marketing. I think the procedure certainly has some fantastic merits to it. I know numerous colleagues of mine who employ the procedure on a frequent basis and I think that there's certainly a place in dentistry for the pinhole technique. Which basically is nothing more than a minimally invasive procedure. 

Howard : Again we're saying with Dentistry Uncensored we want to stay with the controversial stuff, you're an amazing periodontist you are all that and a bag of chips times 3, a lot of the young dentists that were working at these corporate dental chains, a lot of them are very stressed because they're told they have to place these chips into periodontal pockets because they bill like $15 a chip and some of these patients are coming in have like 9 or ten pockets that are 6 millimeter so you have to place 10 chips of [minocycline 00:41:48] or whatever. The question I want to ask you is as a periodontist do you believe, well that's value, placing an antibiotic in these pockets is value? Or do you see that as just an insurance scam? And some of the particular questions are well if it's tetracycline, instead of placing a $15 chip in 9 different pockets, I could write him a prescription for Tetracycline and it only costs the patient $3 if they went to Wal-Mart or I'm sorry, CVS or Walgreens or something like that. What would you say to that kid working in the clinic? 

Dr. Orphanos : Okay first of all I would say that he has to understand the science behind it, this is not just voodoo that we do in dentistry. A Lauren Gallop out of New York, a periodontist did most of the research on tetracycline doxycycline as an anti fibrinolytic. So it the fiberin from breaking down. Prevents the collagen from breaking down. That's the whole science behind it, so you're absolutely right, do we put these chips, do we inject, some magic yellow powder under the gums? If you read the research, if you pick up the articles, they were great articles written by Richard Boringer, Richard Boringer was trained out of Harvard, he did some fantastic studies, if you read it, you will see, I'm to going to name the product but you will see the improve - 

Howard : Name the product, name the product it's Dentistry Uncensored. Name the product. 

Dr. Orphanos : It's that yellow powder that you squirt underneath the tissue. 

Howard : Which is what? 

Dr. Orphanos : It's the yellow, it's a syringe, it's the Minocycline spheres. It's the ARESTIN. 

Howard : Okay, ARESTIN. 

Dr. Orphanos : The ARESTIN, I'm sorry, you know at 50 things start to escape my mind. 

Howard : (laughs) 

Dr. Orphanos : So, you will see point 2 millimeter improvement, well Howard, when's the last time with your fantastic microscopes and loupes you were able to measure point 2 millimeters? 

Howard : Not hardly. 

Dr. Orphanos : Right, so what they do is they take 3 pockets and lets say one pockets 2 millimeters and the other 2 pockets are 3 millimeters, so it's 2 millimeters, 3 millimeters, 3 millimeters. They take an average. So what's the average? 2.3. well that's not statistically significant enough. So then statistics it becomes 2.33 and if it's statistically significant enough they'll make it 2.333. These are products that are, I'm not saying they do any harm, I'm just saying they really, if you read the studies, they really don't provide much of a service. 

Howard : So you would say that you don't need ARESTIN. 

Dr. Orphanos : I would say that ARESTIN doesn't exist in my practice based on the research. 

Howard : Okay now I want to ask you a Dentistry Uncensored question which I don't trust you can answer because you are a dentist so you're biased for dentistry but I got to tell you that when I go to Lifetime fitness and I workout with ENT's I have three ENT's give me shit that I'm a dentist, I'm missing a tooth, first of all when you look at the 100 million insurance claims the huge spikes on anything, are the four six year molars. 3, 14, 19, 30, most likely to be treated with a root canal, crown, filling, MOD, extraction, whatever. And they tell me, "Dude, you have a second bicuspid behind it in from of it, a second molar behind it, do a damn 3 in a bridge." They see so many of these sinus bone implants sinusless implants, and they go in there with the scope and they say there's candidiases infection all over the root, they also say that they believe that probably 20% of all Americans who think they have allergies is because they have a leaking failed root canal into the sinus and these people come in and they say, "I have allergies." And they go in there with a scope and they see some root canal leaking bullcrap into the sinus for twenty years and they basically tell me, "look, you're a dentist you have a second bicuspid and a second molar do a damn bridge, stay out of my sinus. 

Now I know you're a dentist so you're from the religion of odontology so you want to worship to structure and you say, "screw the sinus, I mean we'll do a sinus lip pack it with cow bone, staples, whatever, but do you think the three in a bridge is underutilized? And that the ENT's, I mean they all tell me that so many people with sinus infections have leaking failing root canals and bone sinus lips and what is your religion of the sinus? 

Dr. Orphanos : Okay, religion of the sinus, fantastic question, fantastic question. The longitudinal studies of the three in a bridge in the posterior and the longitudinal study of a single tooth implant in the posterior, both show, they both show, almost the same success rates if you will. 

Howard : And what is that? Months or years? 

Dr. Orphanos : About 10 years. 

Howard : 10 years. Okay. 

Dr. Orphanos : 10 years. So there's a plethora of studies, so that's just a generalized statement. The problem we encounter, I've been a periodontist for 23 years. I've had 3 sinus post-op complications, during sinus surgery and the fault was my own. The fault was not getting an ENT clearance to check the drainage of the ostiomeatal complex. So what we're doing is first, back to the diagnosis, if we do not have proper Cone Beam technology to understand what it is we're looking at, we shouldn't be messing with the sinus. Number one. Number two is if we're messing with the sinus we should get clearance from an ENT because just the trauma to a sinus is going to cause inflammation, and that inflammation can block the ostiomeatal complex so you need to make sure you have a patent ostiomeatal complex. If you do these things your success rate for implants in the posterior will be through the roof. 

Now on the flip side of the coin, am I opposed to three in a bridges? Well I don't know, lets have us be more specific. Do any of those teeth have endodontics on them? Because if they do your success rate drops precipitously. And my partner's a root canal specialist he's an endodontist he does everything under a microscope and he's absolutely fantastic but I will tell you the studies say, because what we do is not based on how I feel today, it's not based on how much money the patient has, it's not based on warm fuzzies, we are a medical science. You unfortunately have to include art into that medical science, so we're in a very challenging but very rewarding profusion. So I would suggest to you that if there's endo on those teeth on an abuttment tooth? You might want to reconsider a three in a bridge. But, three in a bridges are tried and true. Doesn't need crown lengthening, doesn't need endo, doesn't need post and core, how stable are those teeth? What's the age of the patient? So all those things come into play there is a time and a place for an implant with a sinus procedure, and there's a time and a place for a three in a bridge. 

Howard : You know it's interesting the elite doctors, whether you're talking Mayo Clinic, or Cleveland Clinic, they're saying that when a male turns 50 they want a brain scan because most of the brain tumors that kill you in the 60's they can remove at 50 with the size of a pea. They want a colonoscopy. Same thing, they say these little things that are so small can be clipped out at 50 that kill you at 60, but there starting to say they want a CBCT of all molar root canals because so many of them are chronically infected releasing so many bacteria into the blood stream, and there's even a book called, "Beating the Heart Attack Gene" where these cardiovascular surgeons are saying that so many of these heart attacks are from failing root canals leaking these bacteria into the blood stream and these are the bacteria causing a significant portion of these heart attacks. Which when you and I were in school they said were all related to stress and all this stuff but some of these heart attacks are in the middle of the night. I mean grandpa's sleeping in bed, and he's having a heart attack and a lot of these cardiovascular surgeons are saying, "yeah he's had a root canal failing, leaking bacteria into the blood stream for 20 years." What do you think about that? Do you agree with that? Or do you think that's crazy? 

Dr. Orphanos : You know I'm an expert in what I'm an expert in and I don't have the data, and I can't cite the literature for that and if you have data and literature for me Howard, nothing would make me happier than to read it. But what I can tell you is each and every day in my clinical practice, remember it's limited to implants, extractions and bone grafts, that's my practice. Each and every day I probably take anywhere from 3 to 10 Cone Beam scans. Invariably everyday, everyday of my clinical practice I see leaking, failed endodontics on teeth that were not referred to me to evaluate. 

Howard : Right. 

Dr. Orphanos : And my partner the endodontist will just take a quadrant scan and I tell him he's doing the patient a disservice. I understand the ALARA rule, A L A R A when taking radiographs, as low as reasonably allowable. Or - 

Howard : A L A R A ALARA rule? 

Dr. Orphanos : Yeah? 

Howard : And what is the ALARA rule with radiographs? 

Dr. Orphanos : ALARA rule in the world of radiation is minimal exposure, that will give you the best result. So my partner and I always argue the fact I'm telling him he needs to take a scan of upper and lower arches even if he's told to look at tooth number 5. And I say, "The reason being is you know if a patient goes to see a physician, they just don't, you know they don't just evaluate the sore throat." They'll do a ... maybe they'll do a blood workup, they'll listen to your lungs, they'll look in your ears, they evaluate you as a patient and we in dentistry for some reason are so caught up on these limited evaluations we neglect the rest of the mouth. And with Cone Beam scans I always, always, always, I can't repeat this enough, on a daily basis, find failed, leaking, infected endodontics, that have nothing to do with what I'm evaluating. 

Howard : Yeah, I agree. Do you almost think that a 50 year old patient as they're entering the heart attack zone the standard of care is that they should be ... all their root canals should be evaluated by 3D? 

Dr. Orphanos : I really do. I really do and if you think about the root canals of yesteryear, when we went to school, Howard we're similar in age, you know I remember vividly, one of my instructors, one of my endodontic instructors telling us that the prevalence of an mb2 canal was about 10 to 12%. 

Howard : (laughs)

Dr. Orphanos : And now, you ask any endodontist with 3D Cone Beam scan technology and they'll say it's 80 to 90%. 

Howard : So I don't want to let you go, we only got four more minutes you promised an hour of your life but if I asked you what do you think, I mean you're an expert master on all on four, what do you think is the Dentistry Uncensored questions on all on four, what do you think that the homies listening to you right now understand the least on all on four? What could you ... what knowledge could you impart on all on four that you think they might not get? 

Dr. Orphanos : Okay, well there's a few things. All on four is not about teeth, at least my approach which is a very unique approach. There is ... my approach is about facial. Facial analysis, restoring face, you can go to my web-site you will see some really amazing facial transformations - 

Howard : And what is your web-site? 

Dr. Orphanos :

Howard : 

Dr. Orphanos : Yeah and it's number 4, numeric value 4. And if you go to the images, the gallery, and you go to the all on four section you will see that my all on four is not based on teeth, I diagnose from the face on in and not from the bone on out. I'll be lecturing at Nobel's Annual Symposium in August on my facial approach and it's very interesting. So - 

Howard : Where's that lecture going to be? 

Dr. Orphanos : That I believe this year it's in Miami. 

Howard : Miami, and you're in Boca Raton. Okay. By the way can I say one bad thing about your website? 

Dr. Orphanos : Sure. 

Howard : You have Facebook, google and youtube but you don't have twitter and I think the president of the United States would not be the president if he wasn't on twitter. I think you have to have a twitter now because when you make a post on Facebook they will only send out to a few of your followers cause they're pushing out sponsored content, advertisements, but when you make a post on twitter, it goes to all your people and Trump has 30 million followers, in a country of 300 million people. So when he gets up at 3 o'clock in the morning and makes a tweet, 10% of Americans read it, so you got to add twitter. 

Dr. Orphanos : I thank you, you know I'm starting to feel like an goat at 50, especially with technology, I have a not so full time three day a week IT guy who comes in and does some stuff for me, I agree with you. 

Howard : You really have a lot of great articles on center numeral 4, so it's center4smiles and the 4 is not F O U R it's 4, you got a lot of great content that I hope all my homies get on and read but you got to add a twitter so that when you put these blogs in there, I mean I've read some of your blogs, on LANAP, I've read some why should you choose implants, you got a lot of great stuff, but if you tweeted it out, it would be so much more powerful than facebooking it out. But anyway continue, sorry I interrupted you. 

Dr. Orphanos : So, that's okay, so it's all on four is about faces, it's not about teeth. It's certainly about faces. So that's number one, number 2 is all on four nothing on three, is the biggest lie I've ever heard. I have probably in excess of about 500 arches that I've done. 

Howard : Wow. That's a lot. 

Dr. Orphanos : Yeah, it's a lot, so I would tell you that come talk to me if any of you ... if anybody wants to e-mail me, grill me question me, I also have a training center where I train surgeons and dentist on the all on four approach, that's a whole different website. But you know that's all on four is probably one of the most misunderstood concepts and if you're not adequately trained you're going to get yourself into trouble. 

Howard : And I want, one last question. Where went an hour? We went into overtime, you're so sweet and adorable that you would get up on a Sunday morning and come on my show, to talk to my homies I really, really appreciate buddy. 

Dr. Orphanos : And Howard, I get dressed up for it too. To boot. 

Howard : And you wearing a tie and I'm wearing a shirt and I'm by the way I would give anything, I would fly out to Boca Raton and bring you roses if you'd make an online CE course. We put up 450 online CE courses, they've been viewed over a million times, you our age, we like to buy textbooks and go to lectures. But these millennials man if it's not on an i-phone, if they can throw it up on their big screen at home, you know if you have an i-phone you go to Dentaltown you watch the CE course if you have the apple TV you throw it up on a 60 inch screen. So we can just reach so many more of these kids if we do digital on-line TV like the University of Phoenix but I want to say this, let's say you just had a 25 year old, your own daughter, just walked out of dental school, and she said, "dad, how could I be a more excellent dentist?" What would you say to her? 

We just ... this is July 9th, we just had 6 thousand kids walk out of school and their thrown all these noises that they should learn, Invisalign, placing implants, sleep apnea, you know all this stuff, and she's saying, "dad, I've got $350 thousand dollars in student loans, they didn't teach me anything about LANAP, I didn't see one implant, I didn't do one Invisalign, I just want to be a great dentist like you." What would your commencement speech be to your own 25 year old daughter? 

Dr. Orphanos : My commencement speech would be keep it simple for starters. Establish a solid foundation in basic dentistry. And then once you establish that then venture off. Do not, what I see too many young dentists doing is reaching out and doing everything, they're learning sedation, they're learning LANAP, they're learning Invisalign, they're learning implants. There's too much being thrown at them. Guys such as yourself, guys such as us, we took 25 years to get to where we are, and it didn't come overnight. And we didn't have as much thrown at us coming out of school as these young clinicians and I think it's a great time to be in dentistry, it's a fantastic time. These clinicians are exposed to probably some of the best times dentistry has to offer, but I would say, "go slow, be careful, get a good foundation in general dentistry, and then when you pick up your next technology, technique, whatever it is, master that before you move on. One step at a time." 

Howard : We're ten minutes into overtime, I know it's Sunday, I know you're traveling out of the country, can I ask you two overtime questions? 

Dr. Orphanos : As long as you buy me a cup of coffee. 

Howard : (laughs) You have a lot of these young kids saying, do I need to be doing these oral DNA samples where you take a saliva and you send it to a lab? I mean can I really treat periodontal disease if I'm not doing these oral DNA lab samples showing what type of bacteria is in this patients mouth? 

Dr. Orphanos : I would say that if you have a recalcitrine case, a case that's really hard to get under control, that would warrant an oral DNA exam. I say by and large conventional periodontics resolves most of the periodontal problems that a patient would present with. But yes, I would say that if you have an unusual case, a very aggressive case, a case that doesn't respond well to initial therapy, then yes, you have to pursue and investigate further. 

Howard : Okay and this last question is not common at all in America, but this show is listened to all around the world, and in Asia and Africa and Latin America we continually get the question saying you have periodontal disease, I should treat this with an antibiotic. What would you say to a dentist in Malaysia, Cambodia, Indonesia, who's thinking, what you need is a prescription for antibiotics to kill all these gram negative anarobes, like P.Gingivallis and I can treat this with a prescription. What would you say to that kid in Cambodia? 

Dr. Orphanos : Gee now that's probably the toughest question you asked me all day today. 

Howard : (laughs) 

Dr. Orphanos : You're absolutely right. I tell my own patients who say, "hey, give me an antibiotic I have an infection." And I tell them you have to understand the source of the infection. You cannot fix the infection unless you get rid of the source of the infection. And the source of the infection is the infected tooth. And I would tell them that there's bacteria adherent to the tooth. And until we get that bacteria off the tooth by a surgical procedure or by an extraction, we cannot fully address the infection. And I explain to them, I explain to each and every one of my New York patients, if they're walking down a street in New York city and they're admiring a high rise that's going up and they trip and fall and get a rusty nail in their finger, they do not go to the emergency room and ask for antibiotics. They go the emergency room and ask to get that rusty nail removed. That rusty nail is your tooth, and it's not until you get rid of that, really what's causing the infection, the ideologic agent, until you get rid of what's causing it, antibiotics will not be effective in the long run. 

Howard : Great answer, can I ask you one last overtime question? 

Dr. Orphanos : Two cups of coffee. 

Howard : Two cups of coffee. So they walk into school and their instructor said these are the people you don't place implants on and the first thing is smokers. Then they come out to Phoenix Arizona, well who is the most likely person to lose all their teeth? Smoking, drinking, so everything they say that you shouldn't place an implant on, is all of their real world patients showing up in Phoenix, I mean you don't, periodontists don't lose all their teeth, dentists don't lose all their teeth, their smoking, drinking, Irish drunks. What would you say to this 25 year old lady who she sees this Irish drunk chain smoker and he needs an implant and everything in school said, "no you can't do that." And she's like all my implant cases are Irish, Russian, drinking, smoking, drunks and everything they told me in school is I can't do that. So my question exactly is, do you place implants in smoking, Irish, Russian, drunks who drink vodka in Phoenix? 

Dr. Orphanos : No, I only have cute little old Jewish ladies here in Boca Raton. 

Howard : (laughs) What do the Jewish ladies drink? Are they wine drinkers? Or what do Jewish ladies drink? 

Dr. Orphanos : Probably white wine spritzers. 

Howard : White wine spritzers. Well out here in Phoenix it's Irish, Russian, vodka drunks, chain smoking and the little girls say, "well my teacher told me you can't place an implant in a smoker." What would you say to her about that? Cause that's real world. Real world is you don't get these ideal patients who need an implant. Real world is you get a bunch of flawed humans that smoke and drink and eat Cheetos and Doritos and taco bell that need implants. What would you tell her? 

Dr. Orphanos : I would tell her that not everybody responds to smoking or the effect of smoking doesn't effect each patient the same. I'd say check the surrounding periodontia. Does it look like, you know if the entire dentition, if the entire mouth is failing then maybe that's case you want to pass on. But the tooth, if you have a smoker, and the patient has localized periodontitis, or a fractured tooth, or a non-restorable carious lesion, then I would say, "asses the remaining teeth, asses the rest of the condition of the mouth and if it's okay, then go ahead." You can also check what's called pack years. How much have you been smoking, how many packs for how many years? And that value can give you a gauge. I find that metabolic disorders are probably worse than smoking. Diabetes, alcoholics, most of my biggest post-op complications have always been on alcoholics. So I would say yes, you're right, they're going to come across smokers, they're going to come across diabetics, they're going to come across alcoholics, and play it by ear, also asses the patient. You know does this patient look like he or she is friendly and willing to work with you? Or are they grumpy? Cause if they're grumpy they might come after you if something goes awry. 

And I would also say, "Make sure your consents are thorough because the young pretty woman who brushes and flosses 10 times a day is not coming into your office for an implant. You're absolutely right. It's these patients who've neglected themselves for the majority of cases, who come in and need care. So proceed with caution, asses the other areas of the mouth to see how it responds to the insult the patient exposes them to, or the patient exposes themselves to, and get good consents. 

Howard : And what percent of these New York, New Jersey Jewish old ladies in Boca Raton would you guess are probably alcoholics? 

Dr. Orphanos : (laughs) you know, probably a very small percentage but I vividly recall three cases that went horribly awry, and the fault was mine. 

Howard : Cuase you know what my patients tell me? So I have patients that work the alcohol deal at the bar or whatever but they tell me that when they read all the press about alcoholics, you know it's always some guy getting a DUI or whatever. But they say that when they work in their business every morning when they open up, they have a hundred clients and they're all senior citizens who are buying a gallon a day of vodka or gin or whatever. They tell me that they really believe there's complete disconnect on what the public thinks is an alcoholic, a DUI, versus what really is an alcoholic and they say that they have no idea but they think a very high percentage of retired senior citizens just sit home and drink all day and then that patient shows up to your office and needs dental implants and I remember always smelling their breath and thinking they had some kidney disorder cause I could smell these ketones, and it took me several years to realize these aren't ketones from a kidney disfunction, these guys are all boozing all day. 

Dr. Orphanos : Right. 

Howard : And so one of my friends who sells the liquor at Walgreens who I have known for 30 years, I mean you go over to Walgreens, they open up at 6 am, and there's a hundred people outside their door and none of them are under 65. 

Dr. Orphanos : Right, and this is the real world that we live in. And these are realities. And I still think we don't have the statistics I have a very good friend who owns a DUI center, and you would think, and it's a DUI where they are able to get their drivers licenses back if they go through a DUI protocol. And you would think that these are all young kids and by and large, the class is not filled with all young people. 

Howard : Yeah I have another friend who's a dentist who's in this opiate treatment deal for Vicodin and Percodan abuse and all this kind of stuff and he tells me that the entire class is bankers, lawyers, dentists, physicians, there's no one in the class who has a tattoo, who you would think is a heroin addict ... 

Dr. Orphanos : Right. 

Howard : And it's amazing, so yeah, so these complications are more. But hey I want to tell you seriously, I can't believe you came on my show, I'm sure my homies loved it, Ernest if you'd ever write an article for Dentaltown magazine, the magazine's mailed to a 125 thousand dentists true, but there's 2 million dentists on earth, and more than that are emailed the magazine, so you would be writing an article for 125 thousand dentists, general dentists of the United States, but you would also be writing an article for about 150 thousand dentists in 220 countries, and to get a online CE course I would seriously fly to Boca Raton and bring your three cups of coffee because I know you're all that and a bag of chips. 

Dr. Orphanos : Well Howard, I need to thank you, on what you've done for the profession is immeasurable. I'm not sure if you are ever going to realize what you've done for the profession and especially for these young clinicians who are overwhelmed. And you're a mentor to them, you're a father figure, you're an educator, you're real and you have been absolutely fantastic for the profession it would be my pleasure to write an article and also do a CE course for you. 

Howard : Nice I would give anything if you did that, that would be so amazing cause if you're 30 and under, if you were born after 1980, you don't want to go to a bricks and mortar CDA convention, Chicago mid-winter meet. You want to sit in your home and watch on the big screen, so if you want to reach the next generation, you gotta do digital online CE. Cause they'll open it up on their Dentaltown app and then throw it up on their 60 inch screen and drink wine and eat Cheetos while they're watching you talk about all on four. But thank you so much I can't believe on a Sunday morning, I got you to get up in a suit and tie and talk to me on a Sunday when you should of been out at the Waffle house having a fun breakfast with your family. 

Dr. Orphanos : You got it 

Howard : Thank you so much. 

Dr. Orphanos : Well thank you for selecting me and sharing my little bit of knowledge with respect to my specialty, and once again, thank you for what you do for the profession. 

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