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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823 Digital Workflow with Dr. Effrat “Effie” Habsha : Dentistry Uncensored with Howard Farran

823 Digital Workflow with Dr. Effrat “Effie” Habsha : Dentistry Uncensored with Howard Farran

8/25/2017 5:08:34 PM   |   Comments: 0   |   Views: 399

823 Digital Workflow with Dr. Effrat “Effie” Habsha : Dentistry Uncensored with Howard Farran

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823 Digital Workflow with Dr. Effrat “Effie” Habsha : Dentistry Uncensored with Howard Farran

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Dr. Effie Habsha is a Prosthodontist practicing in a multidisciplinary practice in Toronto, Canada.  She earned her DDS degree from the University of Toronto.  Upon graduation, she completed a one year General Practice Residency at Mount Sinai Hospital in Toronto, ON.  Dr. Habsha received her Diploma in Prosthodontics and Master of Science degree, both from the University of Toronto.  Dr. Habsha is an Adjunct Assistant Professor at the Department of Dentistry, Eastman Institute for Oral Health at the University of Rochester Medical Center. She has served as an Assistant Professor at the University of Toronto and currently instructs both at the undergraduate and graduate level in Prosthodontics at U of T.  Dr. Habsha is a Professor at George Brown College of Applied Arts and Technology and is the On-staff Prosthodontist at MedCan clinic in Toronto. She holds an appointment as Staff Prosthodontist at Mount Sinai Hospital where she instructs the dental residents and is involved in various clinical research projects. Dr. Habsha is a Fellow of the Royal College of Dentists of Canada (RCDC) and is an examiner and Section Head for the Oral Examination in Prosthodontics for the RCDC. She is an Associate Fellow of the Academy of Prosthodontics and a  Fellow of The Pierre Fauchard Academy and holds memberships in numerous Prosthodontic organizations and societies.  She lectures both nationally and internationally on various Prosthodontic topics and maintains a private practice limited to Prosthodontics and Implant Dentistry in midtown Toronto.

Howard: It is just a huge, huge honor for me to have Dr. Effie Habsha come by my house today. I mean, how lucky am I? She’s a prosthodontist practicing in a multidisciplinary practice in Toronto, Canada. She earned her DDS from the University of Toronto. Upon graduation, she completed a one year General Practice Residency in Mount Sinai Hospital in Toronto, Ontario. Dr. Habsha received her Diploma in Prosthodontics and a Master’s of Science degree both from the University of Toronto. She’s an adjunct Assistant Professor to Department of Dentistry Eastman Institute for Oral Health at the University of Rochester Medical Center. She has served as an Assistant Professor at the University of Toronto and currently instructs both as the undergraduate and graduate level on Prosthodontics at the U.T. Dr. Habsha is Professor at George Brown College of Applied Arts and Technology; is on Staff Prosthodontist at MedCan clinic in Toronto; she’s also been appointed as Staff Prosthodontist at Mount Sinai Hospital where she instructs the dental residents and is involved in various clinical research projects. She is a fellow at the Royal College of Dentists of Canada and is examiner and section head for the oral examination in prosthodontics for the RCDC; she’s an Associate Fellow of the Academy of Prosthodontics and a Fellow of the Pierre Fauchard Academy and holds memberships at numerous prosthodontics organization societies; she lectures both nationally and internationally on various prosthodontics topics and maintains a Private Practice limited to Prostho and Implant Dentistry midtown Toronto.

My God, what do you do? Do you ever sleep or what?

Effie: Barely. Barely.

Howard: Are you just on amphetamines all day long trying to get all this done?

Effie: Pretty much.

Howard: So what’s the point of Dentistry in Canada when your favorite sport is hockey and just knocking all the teeth out?

Effie: It’s good for business. It makes for good business, that’s where to practice.

Howard: I want to get you on for so many reasons, but you’re an expert and lecturer on the world on Digital Dentistry, and where is the Digital Dentistry? And I want to say it in the context of– a lot of these kids are scared because they come out of school like three hundred and fifty, $500,000 debt. Phoenix, Arizona has two dental schools– one is AZ still at Mesa Private, the other one is Midwestern Glendale Private. These kids are paying the bank and they come out of school and they say, “I want to be an amazing Prosthodontist like you.” So what where does the technology fit on bleeding edge to expensive to leading edge to it’s a return on investment?

Effie: It’s a really good question. I think that in order to kind of keep up with the times, you’ve got to adapt digital technology because the key is it’s going to make you more productive, it’s going to keep you one step ahead of your competition and allow you to do stuff that you can’t really do efficiently in conventional dentistry. So, I think it’s a wonderful adjunct in all levels of dentistry. We’ve certainly incorporated it in our practice as well— from implant surgery all the way to digital impressions, digital laboratory workflows so it’s really been an adjunct in what we do.

Howard: What I enjoyed the most about digital dentistry is just always the magnification. I’ll never forget when I took my first oral scan impression—

Effie: It’s a humbling experience—

Howard:  I thought Stevie Wonder cut the prep and my assistant said, ‘No, it’s probably Ray Charles’ I forgot. I don’t think I ever looked at a prep scanned where you don’t go back and touch it again.

Effie: Yeah. I mean, as I said, it’s a very humbling experience to look at that, see your prep on a massive screen so, I think it makes you a better dentist as well. So, using that part of digital dentistry, the digital impression per se, it allows you to I think be a better clinician and a whole host of other benefits, to your patients and to the practice workflow. So, yeah when I started doing my digital impressions quite a few years back, I would go back and go, “Okay or maybe we can get a bit more clearings here and refine the margins that you tend to obsess. And certainly when you’re designing, if you’re doing any chairside milling, the same thing holds true, you kind of want to make your margins perfect and everything perfect and the technology is there that you can do that now, it’s no longer hocus pocus.

Howard: Yeah, and even the lab said that most labs say that their average impression material dentist is running at 6% remake and their average digital dentist is at 1% remake.

Effie: Right. Well, because you can see it as you go. I’m doing full arch reconstructions, full mouth rehabilitations using digital impressions and the nice thing about it is that you can go and make your impression kind of stitched along so that it’s not just a one-time deal where you make that full arch impression and cross your fingers and hope that it works, you can see it as it goes with the digital impression.

Howard: My, my. You have the longest resume in all of dentistry, the longest.

Effie: I don’t know about that.

Howard: So, just name brands. A lot of time that you’ve been on the show, you say, “Yeah.” But you didn’t say which impression. Any name brands you like more?

Effie: Well, we have, I mean, I’m lucky to be part of a large multidisciplinary practice so we actually start it off with the E4D scanner Impressiona System, and then we have the True Definition because we weren’t getting exactly what we needed with that generation of scanner. So, we have the True Definition scanner by 3M and now, well, we also have the Omnicam by Cerec so we can do some chairside work which is really exciting as—

Howard: Man, you have all the big boys.

Effie: We do.

Howard: E4D in Dallas was bought by Plan Mata, a monster company and where they had it, in Denmark or, I know they’re in Finland, somewhere—

Effie: Yes, so it was really revolutionary in terms of doing chair side milling but it’s gone through as many iterations and now being the planscan, it’s a lot different. I don’t have that system now but it was good for us as an entry point but then we’ve shifted into other scanners as well.

Howard: Which one do you like the most, the True Definition—

Effie: I don’t think it’s a matter of liking the most or not liking the most, I think they offer different things. Look, it used to be with digital impressions that each company was kind of closed in their own little world but I think manufacturers and industries gotten smart where it’s more of an open system where they have STL files that can be sent to labs. So, all of the scanners are doing a lot of the same things and have various open platforms. Some have strengths that others don’t, I think from a chair side milling, having the opportunity to mill a Buckman chair side, I think that’s really exciting and that’s something that I think the Omnicam and the Cerec system does really well, but I’ve been very happy with the True Definition scanners who have done lot of large cases using that scanner. So, I think it’s a matter of what makes sense in your hands, what relationships you have, what your lab works with, and really I think in North America there are pretty much six major players and we have two in our office— the 3M scanner, the Itero, and a few others. Planscan, Trios is another popular one, 3 Shape, that’s right–

Howard: One of the complaints I didn’t like about the 3M is some people say, we had to use powder. And I always cringe at that because I imagine myself getting a bypass and I remember the gold standard of bonding was a blue phosphoric action as a primer, it’s a bonding agent and then, but it always had to get faster and faster and then you came out like Prompt-o-pop, and I just thought, “When I get a bypass, I don’t want the doctors saying, “I’m using a Prompt-o-pump.”” And one extra step of spraying powder, I’d rather just have the doctor– I just really want the best and it seems like a lot of people in dentistry they just are so fast to just cut one little step that I mean, if spraying a little powder gives you a rocking hot better impression, I hope they spray little powder when they’re looking for my prostate cancer. You know what I mean? Or—

Effie: Yeah, I mean, if you’re dead set against using powder for whatever reason, then that’s not the scanner for you. For me, it hasn’t been a big deal. Certainly, the Cerec system needed powder originally, now you don’t. So, it’s one of those things that it’s really not a game changer for me and for thousands and thousands of other people, it still delivers a very good product at the end of the day, that’s what you want. You don’t want to ever compromise the integrity of your work and so, it doesn’t—

Howard: You have a very unique practice. To describe your practice, you have multi-disciplinary, and you have your own lab, your own digital workflow lab—

Effie: Yeah, we do. We’ve sort of expanded over the years. We’ve got a number of prosthodontists, some other specialists like endodontists, a couple of periodontists, but what really makes our practice really amazing is just is the people and sort of the workflow that– We build the practice with the idea of having the patient in mind. Where used to be that patients would run in and see this specialist and that specialist and go here for your CT and there for your surgery and there for your Prosthodontist, etcetera. So now, it’s all under one roof where we can see a patient, a patient comes in, we have a CBCT in our office as well. They can come in, have their scan, have their implant surgery, all the prosthodontic work and all of the lab work in the same facility. And I think that that’s sort of a trend that we’re seeing and we’re very lucky to be able to do that and to really have all the tools at our disposal that makes us be the best that we can be. It’s a good place to work.

Howard: I would kill to get an online CE course from you. We started online CE in 2004, millennials love watching online CE instead of driving to the building and we’ve got four hundred and forty courses coming up on a million views but I am, just you talking about that. I would love to see that because there’s three things that everybody is talking about now— one’s digital, one’s implants, one’s in design, and those seem to be the newest, biggest, hottest things when we measure clicks and views.

Effie: Yeah. Well, I mean, the digital technology kind of starts for the patient experience before they even come into our office. I mean, online presence, social media, all of that starts before they even step foot in your office and so, it doesn’t just occupy one facet, just from the administrative level to the clinical, the laboratory level, and education. I mean, you mentioned education in CE, we built as part of our practice a CE. center. So, we have an education center at the facility—

Howard: What kind of (inaudible 0:11:10)

Effie: We try to stay a step above the competition. I mean, I think when we started off, it was more kind of lecture-basic-classroom style stuff but then we saw, let’s do something different and more advanced. So now, we really focused on hands-on programs, we‘re doing digital programs, veneer courses, implant courses, really everything and we have the capability of– Because it’s all in a clinic setting as well, we have a couple of large operatories in our office that we stream and it allows us to see the procedure and the clinic directed into our education center.

Howard: Your online CE would be the best marketing for that because what a lot of these institutes do, they a three or four day course. They put a one hour course to kind of go from just seeing it in a flyer to get to see it for an hour to getting on air for—

Effie: All our courses are recorded and so they’re available, you have access to it through our website, so—

Howard: And what is your website?

Effie: and the education is

Howard: Can you send me So, what do my homies find on

Effie: That’s our office website so sort of shows—

Howard: So, is your private office and what’s the online CE?

Effie: And then So, that’s Prosthodontic Associate Center for Excellence.

Howard: P.A.C.E Prosthodontic Associate Center for Excellence because the P.A.C.E. is also the approval for ADA or AGD, one of them behind that P.A.C.E.

Effie: It cuts both ways.

Howard: It cuts both ways, that’s a great name. So, these kids come out of school and they want to be great but they can’t learn everything overnight and they’re bombarded by messages. Some say, “You should learn invisalign.” Some say, “You should place implants and bones grafts.” Some say, “Sleep apnoea.” Some say, “Be a cosmetic dentist.” And she’s sitting there, she’s twenty five years old, she’s driving to Aspen Dental for her job, and where do you think she should begin especially if she’s trying to pay back $350,000 of student loans?

Effie: First of all, I like how you say ‘she’ because as you know, in our dental school, I mean, the majority of the graduating class is female so, nice on you to say she. So typically, you’re going to see a lot more female dentists but we’ll get to that later. I guess I can just draw from my own experience. When I graduated, I wanted to specialize and I’ve spoken to some people, but I was very passionate about pros and I had the opportunity to—

Howard: Where did that come from? Was it your Dad, or Mom, or Uncle?

Effie: Oh no, I’m the first immigrant family to Toronto—

Howard: And where did you guys emigrate from?

Effie: From Tel Aviv, from Israel.

Howard: Nice.

Effie: Yeah. So, I worked at a hardware store so I’m used to screws and drills and all that stuff so now I do a little of miniature screws and stuff but I’ve always been good with my hands and my passion really was from my mentor, George Zarb. So, he was—

Howard: George Zarb, from the University of Toronto?

Effie: That’s right. He pretty much, along with Professor Branemark, put implant dentistry on the map in North America but that’s a whole other story. So, he was my mentor. I worked for him in the summers and just really was passionate about prosthodontics so when it came time for me to decide my career path, I said, “You know, even though pros is a little bit competitive, I mean, every general dentist does cosmetic dentistry if you will, but I said, “You know what, screw that. I want to do what I’m passionate about so I’m going to go with the specialty that I enjoy rather than something that could make me quick money.” And so that was my journey and I have no regrets. I think you need to just be passionate about what you do and prosthodontics really offers so much in dentistry, really cutting edge and that’s what we’ve sort of built.

Howard: So, you can find all that at If they type in .com, does it ever redirect?

Effie: I don’t know. Try it.

Howard: You should redirect on that because that’s—

Effie: Note to self. Okay.

Howard: Yeah. So .ca or get a .co So, they can find out all the information to P.A.C.E. at I can tell you my one hardware store though which reminds me of your office. There’s only like two thousand and twenty billionaires and most of them did something really, really simple and I love reading autobiographies of billionaires and one was Thomas Watson, Jr. of IBM and he learned everything from a hardware store. He grew up in a small town and there were three hardware stores and two of them had one clerk and one of them had two, and whenever he goes to one of the stores that had one clerk, he jumped on his bicycle and ride across to the store with two clerks and he realized that market share had to do with, not number of locations but by number of reps and services. So when he inherited IBM from his daddy, he said, “I don’t know anything about computers.” He basically flunk out of college, he was drunk through his whole college and he said, “All I know is this, if 70% of all the salesmen in the world worked for IBM, we’ll have 70% of the market.” Because nobody does what a computer does, no one knows how it works, so if seven out of every ten people are saying, “Buy this one, you get that one.” And I see that with corporate dentistry where they just have better hours, they have their better chance of seeing you that day. So if you’re all that in the bag of chips but you can’t get me in for three days or four days or next week, and then I called these corporates, or you have a large multi-specialty practice, it’s more patients-centered than doctor-centered. I mean, when you’re in a group practice you’re covering– like look at retail. The business model of retail going all the way back to New York three hundred years ago is that, you had a little garage and lived above it and you’re a banker by next generation who got two garages wide and then next generation went four or five. So, to kill scarcity they just kept building bigger boxes until there’s no scarcity. And so, you have far more products and services to sell by having periodontists, prosthodontists—

Effie: Right. I think it’s about the experience and I mean, people are busy and you want to have a good experience, an excellent experience and the customer service that you want to have, the work, and the efficiencies. So I mean, coming to practice where I’d like to think patients are treated really well from the moment they contact us and being able to have everything done under one roof, I think is a real benefit. So, there’s that boutique feel to the practice with the ability to kind of offer anything a patient might need, so that’s what kind of sets us above and plus our individual need to constantly improve what we do. We’re all very driven, just wanting to continue to learn, we’re heavily involved in education and both educating ourselves as well as educating others, so it just somehow all falls together.

Howard: Now, do you place implants or do you restore?

Effie: Yeah.

Howard: There’s a lot of them! A lot of prosthodontists will tell you that they are afraid to place because they get so many referrals from oral surgeons and periodontists, and they’re afraid that if they start placing, they’ll only get referrals from general dentists.

Effie: You know, It’s funny you say that because that’s our dilemma because we didn’t place when I graduated. I wasn’t placing my own implants but then overtime, we sort of started to see this need for patients getting annoyed of having to go to multiple practices and then we thought, “You know, what if we started, we brought in a periodontist or we place implants ourselves?” and that was really a dilemma. So yes, we did lose our surgical referrals but what we gained completely surpassed that. So, on a personal level, it allowed me to kind of challenge myself because I get bored. Every few years, I get bored professionally so I need to do more stuff and so, it allows me to broaden my horizons, allows me to kind of challenge myself, be better at what I do. So, that’s a personal fulfillment but then the patients’ as well, they have the benefit of again, having everything done in one facility. So—

Howard: So, this is dentistry uncensored and we don’t like talking about anything that anyone agrees on so let’s just start going to hard-hitting below the belt controversies on Dentaltown. To screw or cement your implant— there seems to be a war going on in Dentaltown about whether—

Effie: Oh I think our screw team people are winning that battle. It used to be historically that prosthodontists, everything was screw-based dentistry but then industry got involved and said, “Well, we’re going to teach every Joe how to place implants and how to restore implants.” I should say, and the whole shift towards cementation was primarily industry driven and where, “Hey, your surgeon can’t even put the abutment. Just prep it like a tooth and just cement it.” That was kind of the idea behind that but we’ve seen a lot of problems with cement-based restorations and so the pendulum has swung back to primarily screw-retention. And not that you don’t cement routine if you have to and we’re not going to get into the details as to when you cement and screw, but if I have my choice, if I have my preference and I think most prosthodontists you would speak with would probably recommend a screw retention. And you’re also seeing industry also falling in that with the A.S.C., the angulated screw chip, the ability to go in with the screws in situations which conventionally would have been cement routine, so I think industry is also catching on.

Howard: I can prove statistically that this next question is the most controversial in implant dentistry. It seems like everyone on Earth who has placed over a thousand implants, says that a surgical guy is like training wheels— grow up, learn how to make a flap, you need to see the bone, do it right, be a surgeon or go home. And then everyone who has done under a hundred says, “Oh no, no, no, no. You want a surgical guy, surgical guy.” So there’s these two camps and it seems like everyone is in a thousand, five thousand, ten thousand thinks it’s training rules grow up to be a surgeon and everybody, a hundred under is like, “No, I just want to make it soft and pretty and bleaching bonding veneers surgical guide, I don’t want to see blood.” Where do put a surgical guide? If you placed a hundred first molars, if you placed one hundred mandibular first molars, what percent of the time would you use a surgical guide?

Effie: I use a surgical guide almost all the time and I’ll tell you why, because I think that the precision that you can’t get otherwise so I know exactly where I am surgically and I think that again, the patient experience is so much better. If you’re placing multiple implants, six implants, would you rather have it done in a flat less guided fashion or have a flat raised from ear to ear and the whole postoperative issues with that? So, I think you have to believe in digital technology and believe in the accuracy of it to feel comfortable doing it and we’ve placed thousands of implants in a guided surgical fashion. I’ll tell you in the beginning, we’ve started with the original Nobel guide over ten years ago and those guides didn’t fit that well at the time, we had a lot of adjustments so you kind of would wonder about the detail and the accuracy and if you’re using this, how accurate is it. But again, the technology has improved so much that now these guides fit beautifully—

Howard: Which guide are you using now?

Effie: So, we use NobelClinician, we use Simplant with the materials that makes a guide but now, primarily, NobelClinician, We’ve got multiple systems in our office as well.

Howard: Yeah, are you mostly placing Nobel implants?

Effie: Nobel, we’ve placed a Zimmer Biomet as well, we’re placing Southern implants as well which are really neat, so—

Howard: Southern?

Effie: Southern. Yeah.

Howard: Man, it’s like every month I hear of a new implant company.

Effie: Well, they’re an interesting company because they have an interesting product where there’s an implant called a co-axis implant just as an example, where the body of the implants has a different access, what kind of like a psychosomatic implant but there’s an angled head so it allows you to do a screw routine restorations in situations where you’d normally have to be cemented because of the design on the implant. Anyway, they’ve got some nice products: fat, big implants, wide implants for immediate implants in molar sites. So, it’s not like we just select these implants just cause, it’s because they offer different solutions for different situations, so yeah.

Howard: So, what I think is amusing is so many kids are afraid to place an implant, but they’re doing procedures that I think require more surgery like removing a wisdom tooth.

Effie: Well, yeah.

Howard: Do you agree that anybody that can remove an impacted wisdom tooth can place an implant, or?

Effie: I think with the proper training, I mean, surgically, we’re trained to do that. I think if you have the proper training not just a fly-by-night course, we can wear your course and you do it, I think if you have proper mentors, proper training then you have the clinical skills to do it. We place little tiny posts in teeth as well so, I mean, we have the precision, we have the skills, why can’t you place an implant in a massive amount of—

Howard: Are you teaching hands-on, over-the-shoulder implant placement in Toronto?

Effie: Yeah, we have programs that do hands-on—

Howard: What do you actually mean by digital workflow? What is digital workflow? Does that mean it’s going to be digital scan, a CAD/CAM mill? What CAD camera are you using? Are you going to chairside mill that or are you going to have— how many laboratory technicians you have in your office?

Effie: We have ten lab techs, yeah.

Howard: Wow! Ten lab techs, that’s a huge facility.

Effie: Our lab also has also sort of expanded, so again, moving away or— it’s just about keeping up with the latest and keeping up with the times, really. So, the conventional way of doing things, I think we found that if you’re going to keep up with the times, I mean, digital is the way to go. I think we’ve seen that with labs in the U.S. and in Canada, the little mom and pop shops have closed down or were bought out by larger labs because you can’t keep up with that, with the technology. So again, I think the lab has been well ahead of us, of the clinical dentists for many years. I mean, they’ve been doing things in a digital fashion— milling crowns and what not for quite a long time and now, only now, dentists are getting more into the digital workflow. So, in our office, when I say, “The digital workflow,” it really encompasses everything we do. So, at the administrative level, we’re not even going to worry about that, the diagnostic level having digital radiography, CBCT on hand, digital occlusal analysis system, like really we incorporated almost routinely and then if any patient that’s going to have implant surgery as well, we have as I said, a CBCT in our office so we can scan them. Our surgeries are done in a guided fashion most of the time, and then our prosthodontic work as well. So, digital impressions, I will tell you that I’m not doing a digital scan for every single patient that comes in, but there has been a shift for me. I mean, I’ve been doing it for quite a few years that now, if I’m doing a single unit implant restoration, I don’t want to have it, an impression. Just stick a scan body on there and make an impression, it’s just digital impression. It’s so much cleaner, so much neater. So, to answer your question, what do we do in our office, I think pretty much every aspect of dentistry that we offer and then that also extends into the lab. So, once a case is sent to the lab, we’re milling crowns, we’re milling full arch restorations, implant-based restorations, a single unit– both tooth born and implant-based. So, it’s really part of our workflow and then of course, we have our laboratory technicians that will refine things or if need be.

Howard: I think in my thirty years, from ‘87 to 2017, of the nine specialists, the one that changed the most is periodontics. I saw little changes in endo, pedo, but periodontics, I mean, it went from all these surgeries trying to save all these teeth and vocations to just curing everything with titanium, just pulling everything out of him. But it’s tough for these little kids because you’re podcasting to millennials and their oral surgeon is saying, “Yank it out and put titanium.” The periodontist is saying, “Save it to do a molar surgery.” And then the epidemiologist are saying that all these implant companies’ say they have like a 99.999999% of success rate and they’re showing 20% peri-implantitis at sixty months, at five years. So, there’s a lot of misinformation. So, how do you treat or plan her to pull or save the molar and then how do you tell a patient that has a 99% success rate when the periodontist are seeing a 20% peri-implantitis rate?

Effie: I think it’s a very good question; it’s a very good point. I think you have to be a good diagnostician and figure out the effectiveness of a particular treatment. So, if you’re going to look at a single molar just for example, so if you have a case where in order to save the tooth, the patient would require crown lengthening, endo, and a crown, and a post and quarter crown. By the time you add up all those costs, you’re way more cost-effective and more predictable in my opinion, placing an implant. So, I think every case is very specific and of course not every compromised tooth, I mean, we still try to save teeth absolutely, we know there are certain definitely benefits even from a soft cosmetic standpoint where it’s advantageous to do that. So, I think it’s really a case by case basis, but I think that the days of saying that, “Implant dentistry is an implant. Once it’s placed, it’s placed for life” which is what we kind of used to say, I don’t think you can really say that anymore because, of course, depending on how old the patient is, but I think we are seeing some challenges with peri-implantitis, etcetera. So, it’s kind of a balance that you have to strike but I think the key of it is just good diagnosis and having the capability of not placing implants in compromised sites or having the knowledge to understand if there is insufficient bone volume to generate the bone before you do it. So, I think that’s where people run into problems, where you want to be the cowboy and like, take a tooth out, put an implant in, not having a regard for biology. It’s quite industry-driven sometimes, I hate to say. I think, we sometimes need to take a step back and say, “Okay, is what I’m doing making sense?” And just to give you an example, immediate load. I mean, you can talk about that and it absolutely works and it works really well in the right application. So, if you have a case where you place an implant and the patient wants a restoration right away, you can’t do that for every patient and sometimes, you go in with the best intentions, but if the biology doesn’t permit it, then don’t do it and I think that that’s where people may run into problems– where you just don’t respect the biology enough, I think.

Howard: I think the hardest lesson every single morning after listening, we have to learn the hard way is they don’t want to do something and grandpa talks her into doing it and she has this pit in her stomach the whole time, she does it anyway then it fails like she knew it would and then she drives on her home all morning, “Why did I do that?” And old people have a way of manipulating young people to get what they want done and every time I ever really screwed up is some grandpa with liver spots talked him to doing something that I shouldn’t have done.

Effie: That’s true, you do have a point.  I mean, it’s hard to say no sometimes especially when the patient dictates, and I had a case like this just yesterday. I had her over last week, a dentist referred a patient to me, she said to the patient that the patient would require crown lengthening before placing the crowns and the patient didn’t want anything to hear any of it, she said, “Effie, please help me out.” She’s really pressuring me, she doesn’t want to do the crown lengthening, and I basically said to her, I’m happy to see her but if the case needs crown lengthening, she’s going have crown lengthening. It’s not up for discussion. So, I can see this is a much younger dentist that didn’t have as much experience or confidence I guess, and I can see your point, but you just have to stand your ground and go with your gut basically.

Howard: So, every periodontist has told me for thirty years that if he has twenty five people that referred to him, five people send him 90% of his crown lengthening procedures and the other twenty are 5%. Why do you think that’s so like that? Why do you think some dentists have a small minority, probably eighty twenty year old, why do you think 20% of the dentists do 80% of the crown lengthening?

Effie: Students loans? I don’t know. I mean, taking on more than they can chew, is that what you’re referring to?

Howard: For all thirty years, every periodontist I know says, “Almost all my crown lengthening patients referred to me for crown lengthening come from like three or four or five dentists and the other twenty never send me one ever.” They’re just always saying that for a decade after decade after decade.

Effie: I guess people want to keep things in-house. I can’t speak to that, but as a prosthodontist, our referral patterns, I mean, we have some good referrals but what we find is that we get single referrals from a lot of people kind of thing. There isn’t that consistency because the truth of the matter is its economy. A lot of people want to keep stuff in-house especially with something like prosthodontics. Why would I send it to a prosthodontist?

Howard: I want to tell you the biggest prosthodontic complaint and in the CE market, the continued education market, the labs say that ninety six out of a hundred crown are selling in one unit at a time. And then when you go to all the major meetings of the CDA in the Atlanta, New York, and Toronto, and all the big ones, to all the prosthodontic cases that are all on for full mouth rehab, and all my millennials are like, “Dude, I’ve never done a full mouth rehab in my life. I’m trying to learn my basics; I’m trying to learn how to do a filling and a crown.” So, how could you step it down and just give her some tips on just a first molar crown? And when you look at insurance data in the states, you look like a hundred million claims; you look at the thirty two teeth, all the dentists respite on those four six-year molars. I mean, they get all the root canals, fillings, crowns, extractions, replacement. So, can you give her any tips on just a single unit first molar crown to be a better clinician?

Effie: The tips would be isolation, respect the soft tissue, use the appropriate burs, and I mean, I’d like to think by in dentistry or in dental school; one would be quite proficient in doing a single unit crown. I think the challenge is more of the large cases that you see where people bite off more than they can chew and get really lost in restoring vertical dimension or opening up the vertical without really knowing what they’re doing. So, I think that’s where people have to really be careful and take the appropriate courses and do kind of the due diligence before you embark on something that’s too extensive, but—

Howard: Now, I want to ask you a religious question. My friends in Phoenix that are ear, nose, and throats, some of them are called Rhinologists, they see patients that are thought to have allergies for ten, twenty years and it’s a leaking root canal into the first molar, it’s a leaking sinus. Some may get a bone pact, a sinus lift, and when I talk to my rhinologist homies, “Hey dude, you had an elephant tusk, bicuspid in front of it and a molar behind it, stay on your teeth, filed a new enamel.” See, we’re dentists so we worship the god of odontology, so we don’t blink at doing a sinus lift and throw in a grenade and dead bone and titanium and paper clips and anything we got. And back to that CBCT, those rhinologists are telling me that anybody who has a sinus infection or allergies because of root canal and going into the sinus, it needs to be examined by a CBCT or a skull of something because it just see so many misdiagnosis because once you take that nerve out, you don’t feel pain so it just leaked in there for twenty years. So, do you think if you were a rhinologist, you would worship the god of sinus and file down the two teeth or do you think you’re biased since you went to Stone Mythology School that you’re going to save the teeth no matter how–

Effie: That’s a good point. I mean, I still prefer—

Howard: Because I feel teeth were shamed when they need three new bridges. I feel people in lecture halls, I mean, they’re literally shamed, it’s like you’re a bad person. We’re filing down the tooth.

Effie: Yeah. No, I mean, I think in certain situations, of course, you know, if it makes sense then of course, conventional crown or bridge. I had one, a case a couple of weeks ago where we’re looking at a redo a patient’s full mouth rehabilitation and one of the sites she had a six unit anterior, six unit bridge and she had some missing molars, so we scanned her because the idea was if we can place implants in the anterior maxilla and then just have independent units and restore her that way, that maybe would make more sense but after looking at the scan, the amount of grafting we would have to do, it would just obliterate any sort of aesthetic soft tissue response so we said, “No. This is not an implant case, we’re going to keep the prep teeth and keep it a conventional case.” So, to your point of if there’s a sinus lift situation where it’s riskier, if there’s a contraindication to sinus, I don’t do sinuses myself, I refer that to my oral surgeon, the periodontist but you have to know what the contraindications are. If it’s someone that’s potentially suffers or has sinus issues, maybe you avoid it in that patient and do your 3 interbridge if that makes sense, but I will have to say that I do try to preserve my teeth and if I can keep teeth, if I can avoid a three interbridge if I have to then that’s my preference of course, but it’s not absolute—

Howard: It’s very different treatment planting on a short, fat, bald grandpa like me than a beautiful woman like you. What would be more predictable for replacing an anterior tooth on a beautiful woman who shows her dimples when she smiles: a three interbridge or an implant and a crown?

Effie: I think it depends on what your starting point. I think that if you have a beautiful foundation or if you build up your foundation to an appropriate one, then I would like to see an implant there because over time, the bridge isn’t going to stand the test of time, but you have to see where your starting point is. And again, the key is to be able to diagnose the treatment plan properly and that’s where looking at the pink not just the white, looking at your gingival contours, looking at the aesthetics of the patient, looking at the smile line, all of that falls into play when making the decision so I think it really depends on what you’re starting with.

Howard: Okay. And what is your go-to crown on central incisor first molar?

Effie: Conventional in terms of material. I like lifting basilica, I like my E-max crowns still on the anterior. Molars we’re going with full contours, zirconia crowns with some buckle puck cut back if we need it just for aesthetics, but the zirconias are so beautiful these days, they are getting, I shouldn’t say, so beautiful but we can use them in a lot more applications than—

Howard: And what would you cement or bond each of those with?

Effie: The resin cement so we use 3M products in our practice, use Kerr products but 3M resin cement works well.

Howard: When you walked out dental school, did you think you’d witness the extinction of the PFM? I mean, I want to wait, I didn’t see it coming.

Effie: No, I mean, it really has and I looked at my own practice, I mean, not that there’s anything wrong with the PFM, but we have such beautiful materials these days that work, so, yeah, it’s a constant evolution and as I always say, “The only constant in life and in dentistry is change, really.” I mean, you got to keep up with the times.

Howard: So, another question I’m going to ask is, do you pack a cord or do you trench with the laser?

Effie: Another very good question. So, I’ve evolved as well in my practice and some of it has to do with digital dentistry. So, I started off doing from impressions to double cord technique and then I moved to retraction paste for a number of reasons and retraction paste works really, really well, something like Expasyl. We threw away retraction cord for quite a few years and then when I came back to making digital impressions, when I started doing that I thought, well, I kind of need to push that margin out again because you don’t have the good impression material, the compression of the tissues so it all has to be visual or visualized. So, I’ve gone back to using cord and now I’m kind of in-between so I’ll use cord, maybe cord with a layer of paste on top of it as well and of course a laser if you need it. So, I think I’m using more cord now than I did when I was doing just conventional impressions but the pendulum has sort of swung for me as well so I think both and depending on the situation but retraction cord works, sorry, retraction paste works really well in my hands as well.

Howard: If you did a hundred incisors and a hundred molars, what percent of those would be same day crowns?

Effie: I’ll be honest, not that many yet. I’d be more inclined in a molar crown, I haven’t yet mastered, kind of getting ideal and aesthetics, it’s not to say it can’t be done but I’ll tell like it is. So, I still have my lab making my anterior crowns.

Howard: Do you, as a prosthodontist, a highly decorated prosthodontist, is there any room left for the (inaudible 00:44:59) bridge or is that just another dinosaur?

Effie: Yeah, no, there absolutely is if you have no room for an implant or if the cost of getting an implant, not financial, but building up bone to do an implant is too great or it’s too invasive then a resin-bonded bridge works quite well.

Howard: Are there any differences do you think practicing in Canada than in United States?

Effie: I don’t know. I haven’t practiced in the United States.

Howard: I just assume you guys are like sitting up there in the loft looking down at all of the hillbillies who live down here and thinking, “Oh my God! What a crazy country.”

Effie: No, I mean, I think we’re so similar. I think there are so many similarities— our meetings are combined, we attend your meetings and you come to ours, and I think to me, it seems pretty similar.

Howard: It does seem like there are much more nicer and cordial and insightful. I mean—

Effie: I don’t know, you’re pretty nice, so—

Howard: Why are we in Kansas? That’s what actually gets us. Back to shaming, okay? Because there are, I mean, a lot of people they feel bad on Dentaltown fees so they did the three abridge and people call him a “Hack”. Hack down two teeth and they like, “Dude, you threw a grenade in the sinus with a dead cow.” I mean, there’s religions that are even against that. Same thing with the triple tray, you know that it’s just too easy and too short to take your work, when can she get by on a triple tray and when does she have to do full arch and further, when does she need at face full transplant?

Effie: I love my triple tray, if it makes sense to use it so I usually like to have posterior stops, so if I’m doing a first molar, hell, I’ll use a triple tray for sure. I mean, it is just the same way as a digital impression as well, you don’t have to do a whole arch, you could just do the quadrants. So, yes, I do use a triple tray. I think there are a lot of benefits in terms of using it in certain cases where you’ve got one or two units; I have no hesitation using a triple tray.

Howard: But you want a posterior spot?

Effie: I generally like to have that so there’s—

Howard: So there’s two molars, and no one’s—

Effie: No, you can still do it. We use a very stiff impression material, I like to use a polyether so it’s quite rigid—

Howard: Impregum?

Effie: Yeah Impregum. We use it for everything: crown a bridge, implant dentistry, like in everything so it’s nice and stiff as well. So, I will use it for two units as long as I have enough, so, if I have a first and second molar, I could generally use it. It’s ideal to have a posterior stop as well. A face full transfer? Any time I’m reestablishing the occlusal vertical dimensions, so strictly not for my one or two unit cases or where I have a stable occlusion where I’m not really altering the vertical dimension, of course any complete denture case as well and this is when I’d use a face full transfer.

Howard: What I do on dentures is I hire a limo to drive them to the denture clinic. So, you just won a free limo ride all the way to denture world. I’d rather just give my license and work that. That’s reason I got an implant—

Effie: I love my dentures.

Howard: Do you really love your dentures?

Effie: I love making dentures. Sure, I’m a prosthodontist. Yeah, but we’re seeing a lot less complete denture making because implant-based dentistry is so prevalent — In Canada, we have denturists.

Howard: Actually, that’s an interesting stand. I just saw some good deal online. When I got out of school thirty years ago, they had estimated the disappearance of the denture and it is been growing robustly and it’s been growing. People don’t talk about this because it sounds racist, but because of immigration. And I say to you, it’s one million legal immigrants a year and probably that many illegal, but my last denture patient, it was a family stuck in from Bosnia, the one before that was from I think (inaudible 0:49:06) So actually, the total units of dentures keeps going up.

Effie: Absolutely, yeah. And if you read statistics, like even the prosthodontic journals etcetera, we are seeing an increase in the rate of the edentulism and that’s even though people are hanging onto their teeth longer, the demographic, the aging population is increasing so, just by sheer volume of patients you’re going to see a lot of the edentulous patients. The reason I said we don’t see a lot of complete dentures is that in Toronto or in Ontario, we have denturists that are making conventional dentures.  But we still see our complete denture patients absolutely or the edentulous patients and I think the young dentists out there shouldn’t be afraid of complete dentures because they are going to be seeing them so, edentulism is not going away.

Howard: Yeah. And there’s some of the best full mouth before and after pictures I’ve ever seen are of dentures. I mean, little girls that don’t have any money who lost all their teeth for meth or drugs or decay and they—

Effie: They have the flexibility for sure to transform lives for sure.

Howard: Is corporate dentistry having a big impact in Canada?

Effie: I think so, to be honest, I’m not that well-versed in the topic. I think it’s probably a little bit bigger in the U.S. but we do have our dental corporations that are buying out the smaller ones. Not so much that on a specialty level, but it is changing the face of dentistry for sure.

Howard: It’s amazing because as Clearchoice spreads around the country, they do so much amazing advertising on all on 4, I can’t believe the first one that opened here in Phoenix. The questions that grandma started asking me about all on 4, just went to the roof. My buddy, Tom, he quadrupled how many he was placing himself. It’s amazing how when a big player like that comes out and—

Effie: It’s great for business because they do all the advertising and the patients come to ask and ask these questions so, it’s great. It puts the awareness out there.

Howard: I want to ask you, you’re so sweet to be spending so much time with me, i only have you for five more minutes. One of the biggest questions they ask on Dentaltown is, they always come out of school, every generation since the Flintstones, they didn’t learn enough in dental school, they didn’t learn implant and all, and I can’t imagine being a Dean taking a hundred kids off the playground and turning them loose with a license. I get that all schools have a (inaudible 0:51:54) but when they’re trying to go learn occlusion, they say that if they want to learn about pediatric dentistry, they can go to any course. They want to learn about endodontics, then go to any endo course. So, when you start studying occlusion, it’s almost saying you had a pick a camp or religion first and they’re like do you have to pick the religion first and quite specifically, it’s like neuromuscular or CR or things like that. What do they supposed to think about?

Effie: With occlusion, you’re right. I mean, I chose the safe road; I became a prosthodontist so I had my training in dental school. There’s a lot of kind of mystique around occlusion and the way I was trained and George Zarb didn’t have this philosophy on one camp versus another Pankey or whatever institute so, I’m not really very well-versed in what they offer, but for me, it comes into play when you establish your occlusion, if you’re starting from scratch and doing a full mouth rehabilitation using your face full transfer, doing a proper diagnostic wax up transferring that to your provisional restorations and allowing the patient to function with it and if you have, if you’re restoring both arches then you can plan it either in group function or in canine guidance and then using your provisionals as your template for the basis of your restorations. So, you’re speaking to the wrong person about a religion of occlusion which camped to go to personally. So—

Howard: And that’s my tip for young kids when they’re doing a single unit crown or bridge. I mean, when the labs send you back reduction coping, you know what that means? It means you took the final impression before you did your temporary work, everything, all temporary. If you can’t get it proper yet, make it temporary. If you can’t see the margin on the temporary, it doesn’t exist on the tooth and when you’re adjusting your temporary and you need all the way through it, you need to do more reduction and so—

Effie: And use your existing occlusal scheme if you’re not restoring your vertical dimensions, you use the existing occlusal scheme.

Howard: Last question. How would you recommend she ramps herself up as a leader? She’s going into a practice, she gets out of school twenty five, she’s in there working with a bunch of ladies who have been there, they‘re all grandmas, the doctor is seventy years old and she wants to buy that practice in two years. How did you ramp up your leadership? Did you do that reading, how did you become a faster leader at a younger age?

Effie: I think you have to look at the people. Surround yourself with good people. And I’ve always been fortunate to have really good people, really good mentors in my professional career. And so, I’ve had good mentors– I have good mentors, I continue to learn from them. And I think that for a young clinician, go out and find someone that you admire, that you can relate to somehow, that’s why I founded women in dentistry study group because for so many young women coming out of dental school, it’s a bit intimidating going to these meetings where you see a bunch of middle aged—

Howard: Website on that. Is there website on that, women?

Effie: We’re actually, believe it or not, that’s on my agenda to-do. So, my group is PA’s, women in dentistry, we do have a website, we have a domain name, we just have to populate it. So, we founded it about seven years ago, I have a really nice group of women— we have this, an annual symposium, we have a quarterly newsletter, and the idea behind it is really to mentor the younger female, or not even younger ones, but just, as women, we have some commonalities but it’s not fluffy. It’s still about the best education, the best that we can offer our patients but learning, networking with people that you’re similar with. So, with other women that challenge, have the challenges of life and children and work and whatever, I look to my mentors but, unfortunately, there weren’t that many female mentors for me to look for and I think that establishing something like the Women in Dentistry is really nice for the younger women that do graduate because they see other people in the same sort of a life circumstances and aspire to maybe be like that. I might have had, it’s the biggest compliment and the biggest honor to have some of my younger, my residence in grad pros. who are incidentally, I think all female with the exception of one who just graduated, the male, but it’s nice to kind of see them and they’ll say, “Oh, Dr. Habsha, I want to be like you one day.” It’s very flattering, it’s very humbling, but it’s nice that they can see what the potential is. It’s still a male dominated world, but we’re slowly chipping away and I think it just has to be with merit, I don’t want to achieve anything just because I am a female. I want to achieve it, and by the way, I’m a female. And if I can impart a little bit of wisdom on a younger grad then I’m happy to do so.

Howard: They do have so many challenges, I mean, I had one in this room crying because she came out and set-up a nice dental office for ten years, her husband made half as much money, they got transferred to another city. He said, “Come on, pack up, we’re going.” His ego, and he told me that it bothered him that his wife made twice as much money as he did. And I say, well, just don’t think about that while you’re packing.

Effie: He needs to get over it.

Howard: Yeah. I know and I saw with my own mother, I mean, I love my mom to death, but she’s put my sisters in dresses and they couldn’t go in the river and she put me in blue jeans and I can go swim, We live right next to the Arkansas River and the river was at least as wide as a four-lane street. And they weren’t allowed to go ten feet to the edge and I could swim across it.  I couldn’t figure that one out when I was ten.

Effie: Times are changing for sure. I mean, we see women in leadership position. I mean, there’s so much— I’m so lucky to be living in a day and age where really, the sky is the limit for me personally. And I won’t let anything stop me, if I want to achieve something and I don’t think gender really has to— I think we have a lot more obstacles sometimes. I think chauvinism is still– you still see it, but you know, do the best you can, be the best that you can be and that’s my piece of advice.

Howard: Last question and I’ll let you go. You’ve been so sweet to come by and she flies into Phoenix for more important business and stops by here first. Last question, I see this debate, it sounds silly but it’s true—back to that leadership image, some of them think that they should be wearing a dress with a lab coat, other ones, like blood and guts and just want to wear scrubs and Asics tennis shoes and mix it up.

Effie: You mean practicing dentistry?

Howard: Yeah, practicing. I mean, some women want to be in tennis shoes—

Effie: Like sexy when you practice?

Howard: Well, no. Wearing tennis shoes, planted in scrubs and just feel like you’re going to the gym but then other women think, “Well, If I’m going to carry myself and present this treatment to implant case—“ I should come in wearing a dress, high heels, and a lab coat.

Effie: Hell, no. I mean, for me, I mean, I am who I am. I go to work in my scrubs, in my ponytail, and get in there. I don’t want patients’ stuff on my clothes so I wear scrubs and what I have to say comes across more as the way I appear to patients. I think the confidence that you carry is more than your outfit, and then when I go to conferences, I dress like a girl. So, it’s all good. But you do raise a good point. I mean, I have a conversation, a friend of mine who’s a prosthodontist who wears a suit and tie or a shirt and tie in a lab coat, and I said, “You know, get over of it, put on scrubs, it’s a lot of infections, he goes, “No, no, no.” He practices in West Palms so, it’s more like, “No, no, I’m wearing a suit, wearing a tie.” And that’s great but I mean, I’m all for, I wear scrubs.

Howard: It’s true. You only see that, it was Palm Day and they probably retired from New York, New Jersey. The only restaurants I’d ever been kicked out of, I’m not entering in my life, they are all Manhattan. “I’m sorry sir, those shoes.” Like, are you out of your mind? Really, my shoes? And they’re like, “No! Go home and change them.” I go, “There’s nothing I can change into.”

Effie: I do have nice shoes but I wear sneakers to the office. It’s all about comfort and—

Howard: And it’s such a different culture like you’re in Arizona it’s like a hundred and eighteen degrees, people don’t—it’s a very different dress code than Connecticut or New Hampshire. Hey, I’m your biggest fan, I was so honored you came by.

Effie: I’m so honored and humbled to be speaking to the Howard Farran, it’s pretty amazing and to your homies, is that?

Howard: Oh my God! I hope you make this an online CE course, I really do.

Effie: Let’s talk. Have your people talk to my people.

Howard: Alright. We’ll do it.

Effie: We’ll make it happen.

Howard: Effie, thank you so much for coming by.

Effie: Thank you so much. I appreciate it.

Howard: Alright.

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