Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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878 Perio, Implants, and Chairside Manner with Ancy Verdier, DMD : Dentistry Uncensored with Howard Farran

878 Perio, Implants, and Chairside Manner with Ancy Verdier, DMD : Dentistry Uncensored with Howard Farran

11/6/2017 3:08:59 PM   |   Comments: 0   |   Views: 285

878 Perio, Implants, and Chairside Manner with Ancy Verdier, DMD : Dentistry Uncensored with Howard Farran

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878 Perio, Implants, and Chairside Manner with Ancy Verdier, DMD : Dentistry Uncensored with Howard Farran

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VIDEO - DUwHF #878 - Ancy Verdier

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AUDIO - DUwHF #878 - Ancy Verdier

Dr. Ancy Verdier is the founder of Worcester Periodontics, a periodontal dental practice located in Worcester , MA where he practices periodontology and implant dentistry.  He earned his B.A. in Psychology from Tufts University, where he served as Student Body President and was the winner of the coveted Wendell Phillips Award (sole student speaker at graduation). Following his graduation, Dr. Verdier completed the post baccalaureate program at Harvard University then matriculated at Tufts University’s School of Dental Medicine.  After receiving his Doctor of Dental Medicine, Dr. Verdier completed a prestigious three-year residency program in Periodontology at Tufts University School of Dental Medicine after which he was awarded Diplomate status by the American Academy of Periodontology.  He also was featured in the magazine Incisal Edge Top 40 Dentist under 40. In October 2017, Dr. Verdier will be inducted as a fellow in the International College of Dentists in Atlanta. 

Dr. Verdier is a former teacher at NYU School of Dentistry, Lincoln Hospital GPR Program and Interfaith Hospital GPR program.  He is a frequent speaker at national dental meetings and oral health seminars.  Currently, Dr. Verdier is the Director of The Seattle Study Club of Central New England. He is serves on the Tufts University Dental School Alumni Association, Eastern Dental Insurance Association Agency, and a Trustee of Evidence, a Dance Company.  He is also a regular contributor to Tufts Practice Based Research Network.

Howard: And it's just a huge honor for me today to be sitting in my home with on Ancy Verdier, DMD, Periodontist all the way from central Massachusetts. Thank you so much for coming by the house today.

Dr. Ancy Verdier is the founder of Worcestor Peridontics, a periodontal dental practice located in Worcester Massachusetts where he practices periodontology and implant dentistry. He earned his B.A. in psychology from Tufts University, where he served as student body president, was winner of the coveted Wendell Phillips Award, sole student speaker at graduation. Following his graduation, Dr. Verdier completed the post bachelor program at Harvard University, then matriculated at Tufts University School of Dental Medicine. After receiving his doctor of Dental Medicine, Dr. Verdier completed a prestigious three year residency program in periodontology at Tufts University School of Dental Medicine after which he was awarded diplomatic status by the American Academy of periodontology. He also was featured in the magazine Incisal Edge, top 40 dentists under 40. Congratulations on that!

Ancy: Thank you.

Howard: In October 2017, Dr. Verdier will be inducted as a fellow in the International Congress of Dentists in Atlanta. He's a former teacher at NYU School of Dentistry, which by the way is the biggest dental school in the United States. In fact, seven percent of all the dentists in America graduated from NYU. Now, I don't I don't think anybody else has 5 percent of that. So that's 7 percent are NYU grads. And Lincoln Hospital GPR program and Interfaith Hospital GPR program. He's a frequent speaker at national dental meetings and oral health seminars. Currently Dr. Verdier is a director of the Seattle study club of central New-England. And we just podcasted the founder of that is --.

Ancy: Michael Cohen.

Howard: Michael Cohen, and we just podcast his son in Dallas Texas, love that kid. He serves on Tufts University Dental School Alumni Association, Eastern Dental Insurance Association AMC, and a trustee of Evidence, A dance company. He is also a regular contributor to Tufts practice based research network. I have to tell you the only dentist I ever met in my life who had a last name of Verdier when we were in Paris, France. So you must be French.

Ancy: With French origin. My parents are from Haiti originally, so I was born here in the States but --.

Howard: There is a few French islands down there.

Ancy: Yeah there's a couple: St. Martin is down there, you know there's Guadaloupe, but really nice, beautiful countries. But unfortunately not a lot of access to care.

Howard: But what's the island where the airplane runway is right over the beach?

Ancy: I think it's St. Martin.

Howard: That's a French Island, right?.

Ancy: Yea that's a French Island. They have a dutch side and French side.

Howard: And my gosh that was -- Ryan do you remember that when we took you there to that French island? You lay there on the beach and these 747s -- you think you're going to die. You think it's going to land right on you. And it goes right over your head, it's so cool. So I look at the nine specialties, and I got out 30 years ago in 87. I'd say of all the specialties, perio has gone through more changes than pediatric dentistry, endodontics, oral surgery. I mean that profession's really changed in the last 30 years. Do you agree or disagree?

Ancy: Yeah. I totally agree. So let me tell you my story. So I graduated in 2006 from my perio residency. Went to school in Massachusetts, left there, went back to New York. I thought I'd never come back to Massachusett, right? I started, I was working at like seven different practices at one point. I was doing perio, working, working, like most residents when you come out. And then I went out on my own and I started practice from scratch. And then I did that for about nine years. Then I said to myself, I looked at myself. I got married, had a daughter and I was out in the Hamptons, I was out in the Hamptons in New York City. Like, you always talk about podcasts like: where do you start your practice? I went right in the middle of the hardest stuff, right? Where all the rich folks live. Right. The highest zip code, the highest in terms of income. That's where I started my practice. And then after a while I started thinking about, what do I really want? What's going to make me passionate? And I said I can either grow this practice more or do something different. And I saw where dentistry was going, it was a little bit different. I got together with one of my buddies, we were in Costa Rica for a friend's bachelor party, and we were talking. And he's like you know why don't you come to Massachusetts? I said, "No, no I left that place I'm not coming back." So we joined forces. He's a prosthodontist I'm a periodontist and between us we have about six practices with us.

Howard: do you mean six practices? So you guys now have six practices?.

Ancy: Yea, six practices.

Howard: Holy moly. In central Massachusetts?.

Ancy: Central Mass, right? Some are Roland's right. He's a partner with me in the perio practice but he has his own practice prosto. But then we have all the general dentists that are there. But I get outside referrals and I also get referrals from the dentists that work in our group. So think of it like a DMO, right. But a DMO with a different --

Howard: And what does DMO stand for?.

Ancy: Dental management organization.

Howard: And then there's also, which is really the same with D.S.O.,.

Ancy: DSO, same thing.

Howard: Dental services organization.

Ancy: So you talked about that, you've had Rick Workman talking here. You had Steven Thorne I think, from Pacific, and you have some really big companies that are really starting to merge these mom and pop, smaller practices. Right. And so for me I always like to work in a group. So when I talked to my buddy, His name is Abhay Bedi. He's my partner. So he taught at Tufts, we've known each other for about 14, 15 years. And you know partnerships, it's like marriage. So you have to really know somebody before you say. Because I sold my practice and moved. I from like the beach to central mass. So people are like, "What are you crazy?" And that's when we had the big snowstorm; the biggest snow ever. My wife looked at me and said, "Are you crazy, what are we doing?" But I was --.

Howard: Oh so you moved North then?.

Ancy: Yeah, North.

Howard: To Hamptons, Boston that's -- so how many miles north did you go?

Ancy: o, it was --

Howard: miles?.

Ancy: Yeah, at least, I think so yeah. It was the heart of Massachusetts, right in New England.

Howard: And when does Boston have their yearly Yankee meeting?.

Ancy: They have it in January, February.

Howard: Is it January or February?.

Ancy: End of January, beginning of February.

Howard: Are they out of their mind?

Ancy: But people don't --.

Howard: That is the most beautiful city in April, May. Chicago midwinter. The only month you would never want to go to Boston, London, Chicago. It's their best idea to have their meeting. And I ask every year, every time I lecture in Chicago, I said, "Why?" You know what they say? "We been doing it this weekend every year since 1850."It's like okay so you made a bad decision for a century and a half. But anyway, sorry.

Ancy: People like routine. That's why I think they always do that. Right. So for me, I wanted to break the routine right. The biggest thing I hear from folks right, like my dad is eighty one. I said, "What's the biggest thing, you know, if you have to do it over again?" He was like, "I'd take more risks." I said, "Okay. Let me take a risk." You know, but you don't want to take too many risks. You have a family now. So with me I said, "All right, let me do this. Let me go to Massachusetts." My partner and I talked about a vision, about teaching people how to do comprehensive care dentistry, but also appealing to the emotional side of our patients.

Howard: So how old is your daughter?.

Ancy: My daughter is five years old.

Howard: Is that why you're a trustee of evidence a dance contest.

Ancy: So I did that when I was --.

Howard: Are you a dancer or is she a dancer?.

Ancy: No I'm not. I appreciate dance. So I always think that you got to have balance in your life: culture, arts, politics, whatever your thing is right. And dentistry. So dentistry is one aspect of my life but you have to be well-rounded. Health and Fitness, whatever it is. And that was part of it that I saw this dance company, it's an African-American dance company, and it was -- I became enamored with it and I said --.

Howard: Where are they based out of?.

Ancy: In Brooklyn, New York.

Howard: Well, you know, they have the most amazing fit bodies you've ever seen and you go to -- the one thing when you go to Broadway or you see ballet or whatever. I mean it's like it's got to be the most amazing exercise. you know when I look at the boys and their time working out. I'd say, well look at this form of your body, I mean you want to look like Arnold Schwarzenegger winning a deal and they thought that was too much and gross. Wrestlers, weightlifters, but I always thought it would either be -- the most amazing body would be the people in the 100 meter Olympics or in dance. So that's got to be the best exercise.

Ancy: Yeah, they take care of their bodies, right. They really do and their bodies are their tools. Same thing with dentists right. We still have to take care of ourselves.

Howard: And for dentistry, I think the number one sport is yoga. When I look at all the old guys, I meet their, necks are jacked, their lower back -- how many dentist do you know that are 50, 60 and had their vertebraes fused at both ends. And then I can name, on Dental Town alone, just hundreds of dentists who got into hot bikram yoga and unwounded all that crap.

Ancy: It makes a big difference. If you want to practice for as long, and live a healthy life, it's all about living well right. For a long period of time. So yeah, for me, it was lifestyle had to make sense, schooling had to make sense. New England offered a lot of that for me. And then vision had to make sense. If you're not passionate about what you do every day when you walk into work, why are you going to work? Right. If you can't talk to your patients in a way that's engaging, why are you doing what you're doing?

Howard: Well look, this is Dentistry Uncensored, let's get right to the brutal stuff. When I get out 30 years ago, I mean, these these young millennials don't realize that when I was in dental school the people that were -- the early placers of implants, ramus frames up here, they were called butchers. They were called quacks. My dental school faculty would openly trash talk the oral surgeon in our school, placing these implants back in the 80s some of these guys -- the first time a sub or ramus frame failed, the local state board would take their license away. And all of periodontics was flap surgery, quadrant surgery, was all these heroic surgeries for a case development. Then over the next decade or two it got to be: forget all that stuff, now the implants you've gone from being a quack to that standard of care and how do you treat a [00:10:54] forcash evolvement? [0.1] You extract and place an implant. Now, 30 years later, looks like the pendulum is coming back when you start seeing that, at 60 months 20 percent of the implants have peri-implantitis. So these millennials: she's 25, she's driving to work and she's getting mixed signals. The oral surgeon says pull that and do an implant. The periodontist is saying, "Well I think we should do a flap surgery." There are so many one liners and memes, you know, I'd treat that with titanium. How is she supposed to know at 25 years old, when would you try to save a natural tooth and when would you say that it's not worth the return on investment, extract it and treat it with titanium and forceps?

Ancy: So I think the most important thing, right. Everybody falls into categories. And you have to look at the patient, right? At the end of the day it's really the patient that makes a big difference. Are you looking at someone who's 25 years of age or are you looking at someone who's 67 years of age? And you have to -- so what we teach our dentists, and this is why I brought you this book, is that -- it's called "The Way of the Superior Dentist" Adrian Wilkins, it's one of the consulting guys that I work with and our group works with. And he's been one of those people that -- you know one of those people that you meet, that's kind of instrumental to changing the way that you think?.

Howard: Well you got to get him on the show.

Ancy: Yeah I will, I will.

Howard: The Way of the Superior Dentist, Adrian Wilkins, is he out of Central Mass?.

Ancy: He's in Central Mass. Yes. So he's consulting. When you talk about whether to do an implant on a patient, whether to do guided tissue regeneration on a patient, whether to do lanap on a patient, these are all the different modalities that we have available for our patients nowadays. But you have to sit down -- I think when you sit down and you talk to the patients at the front end, not just say, "Okay, you have furcation involvement, here's your treatment plan. Boom, it's going to cost $5000 to do that." That's like somebody coming into your house and looking at your roof and saying, "Hey, Howard, you've got a big hole in your roof. You're going to have to replace the whole roof, it's going to cost you 5000 or 10000 dollars." Until you can explain, until you can understand where the patient is coming from, what they want to do long term is this a patient who wants to keep their tooth? Maybe they had a trauma back in the day where they didn't like teeth to be extracted, so they don't want any kind of extraction, so they'll try to do anything to try to keep that tooth. When you can give them the different modalities that we have, and there's a lot of different things that work with different patients. Is it a patient who smokes a pack a day? Is this a patient who bruxes? You know, all these different things you have to take into consideration before you make the treatment. The treatment is the last thing that happens. Understanding the patient from the beginning is where you should spend most of the time. Then you're not feeling like you're grabbing the patient and saying, "Hey listen, you got to do this treatment, you got to do this treatment." That's where people lose their patients and they run. That's the problem.

Howard: Are you doing LANAP?.

Ancy: Yeah.

Howard: I want you to talk about LANAP, because I got to do a big shout out to one of my periodontists I refer to in town, Allen Honigman.

Ancy: Yes Allen.

Howard: You know Allen? I have to tell you this is 2017. He started doing LANAP, what, 20 year, when did that come out? 20 years ago?

Ancy: 20 years ago Allen taught me.

Howard: And every single periodontist in the valley, behind Allen's back saying, "That's crazy, that doesn't work." And now, 20 years later, every periodontist within 10 miles of my office is using LANAP. So big shout out to Allen Honigman for holding his ground. And you know dentistry, when you climb up the pole the furthest, dogs bark at things they don't understand.

Ancy: That's right.

Howard: So everybody was barking at him and now he turns out -- and then we did another one. Allen was on 399 and we did another one on 275, with Terry [00:14:29] Sunguis, [0.3] same thing, talking about LANAP, she's a hygienist, in fact she came on the show before Allen Honigman. Actually, she got Allen on my show, but so talk about LANAP and why did it go from very controversial to where now.

Ancy: So I didn't learn LANAP on my perio program.

Howard: At Tufts?.

Ancy: At Tufts. We didn't learn it. We heard about it, but we didn't know enough about it. Because think about it, it's $100,000 machine. When you come out of practice, or you're dropping for a [00:14:57] serac, [0.7] a LANAP, and all these different machines that you're going to buy, so the evidence had to be there for me to actually do something.

Howard: So a LANAP right now is a hundred grand? Or is it more?.

Ancy: About a hundred grand for the machine. About 80 to 100000 thousand for the machine. And then there is --.

Howard: That's a chunk of change.

Ancy: Yeah, it is. But I think that for certain patients it works really well. Again, think of it -- so I play golf -- I think of it as another -- I have different -- I have my putter, I have my irons, I have my woods. For each situation you're going to pull out a different club. It's the same thing with dentistry and perio. For LANAP, if the patient is not a grinder or the patient doesn't smoke a pack a day, has vertical defects is not horizontal, I think you can do a lot of great things. Peri-implantitis works really well. Or patients -- so I bought a practice that's been there for about 30 years. I bought an existing practice when I went to Worcester Massachusetts. So I went from working in different practices, starting my practice from scratch, to buying an existing practice. And the existing practice had a lot of perio patients that had been treated with traditional osseous surgery, and those patients did not want to go through osseous surgery again. So when I talked to them about LANAP, and Luckily the guy who I bought the practice from was doing it at the time, and people were saying the same thing. Like, "Are you crazy? You're not going to be able to do all that stuff." We saw the results, and even Allen, when I went to the course and I showed him, I was like, "OKay." I think when you you live in a place of abundance, you really start to see there's different possibilities. Another controversy is mini implants right? Another controversy? People are like, "Oh, no mini implants don't work." I think that you have to, for certain situations, you have to use the right treatment, but you have to understand the patient first. And that's a lot more work. It's a harder way of practicing.

Howard: I remember a priest one time at Bishop Carroll used me as an example about something and he said, "Howard, come up here." And I was wrestling, freshman sophomore year high school Russell varsity 98, junior I wrestled varsity 119. But the other guy was Gary Locks, and he was our heavyweight. He was like 350. He'd say, "Howard, Gary, come up here." And here's little me, you know, 98, and here's Gary Locs 350. And he says, "Look at the variance of size." And when people start talking about mini implants, I mean, there's little old ladies that are five foot tall, there's big boys that are 7 foot tall. So you have to find the right implant for the right patient. And sometimes a mini implant is almost too big on some people that are so small. But you said you're a golfer, so I got to tell you my two stupid golf jokes. A lion would never drive drunk. But a Tiger Wood. Get it, Tiger Woods.

Ancy: Tiger Woods.

Howard: When you're playing golf in a lightning storm, you always switch to a one iron. Why? Because not even God could hit a one iron.

Ancy: Got it.

Howard: My two bad golf jokes. So you like LANAP. Here's another problem we have. Help her out: she's 25, she's got a job as associate, Grandpa comes in, he's got peri-implantitis, he doesn't feel any pain. He can go to eat corn on the cob through a chain link fence. He loves his implant, he loves his teeth. It's got peri-implantitis. I totally believe at 2017 that I don't even think America has a protocol for peri-implantitis -- when does this need to be extracted? Would you treat it with laser? Would you flap it? Talk about the 20 percent of implants with peri-implantitis at 60 months.

Ancy: Well, a lot of people are placing implants, right. S before, you remember, we talked about this earlier. Where all surgeons were the only ones that were placing them, and they only let oral surgeons place it. Now it became the periodontist, and now the general dentist, and now endodontist. So as you start to see more people placing it and they have so many different systems out there. We know that implants work. So now, what's on top of that? Is there cement that's causing this? The bugs that cause people to lose their teeth in the first place, those don't go away when you place titanium there. You might not get decay --

Howard: I always wondered about that, because when I use -- a lot of peri-implants I see, they lost a first molar. They had gum disease and pocketing all around the mouth and they placed an implant there it's got peri-implantitis. But I always wondered, when you're doing like an all on 4, if you completely extracted all the teeth, put them on a round of antibiotics, let them all heal up, then place the all on 4. It just seems so intuitive that you'd have to have less peri-implantitis if you --I mean, some people will say, "Well, there's still [00:20:04] peaching value [0.5] in the tonsils or tissue, it'll still be found.

Ancy: Yeah, it still resides in the tissue. So, just because you take out the teeth and replace implants, doesn't mean OK all the care has to be taken away. Patients still need to come back for routine maintenance. Right. And if you lose one implant, the joke is you know, all on 4,none on three. So it's -- [00:20:25] Karl Mitch [0.1] talks about over-engineering cases. It makes sense, because what happens is that now we're taking into account now we're seeing a lot more people who grind and brux. So in the presence of inflammation and the bacteria that causes bone loss around teeth or implants, if you don't take into account occlusion, then you're going to get failures. So the person who takes a course and says OK great I'm going to replace one single tooth implant over here, but you're not looking at the whole mouth. That's comprehensive care. Look at the person as a whole. See what kind of habits that patient has. If you put all on 4 and the patient smokes a pack a day, is there more likelihood for success, or are you going to have failure?Those are the statistics that are still out there. So I would tell you that peri-implantitis is treatable. There's different ways to do it depending on -- so I'll give you an example. Remember back in the day everything used to be screw retained. Then we went to cement retained. Now we're going back to screw retained, because we found that some of the cement that people were putting in there was getting underneath.

Howard: This is butter too. We went from butter to margarine, and now we're back to butter.

Ancy: Things work right? You can see implants that people have had in their mouth, the external hex implants that have been in their mouth for 30, 40 years. There's a reason why those things were lasting. Why is it? So that's where we have to start looking at the patient as a whole and saying OK what's going on with this patient that's causing this implant to fail. Maybe you had a bad implant, maybe when you were placing that implant and you're overheating the bone that's what caused that to happen too. Listen, if I told you that no implants failed from the ones I placed I'd be lying to you. I knock on wood. Luckily I haven't had that, as many. And when it does, I try to figure out what happened.

Howard: So you, being a periodontist, you're getting referred every implant system from A to Z. And she's trying to decide -- she wants to buy one. What would you tell her? How many implant systems have you had to work with?

Ancy: So I've worked with I think four or five different implant systems.

Howard: And if she was trying to pick one system, what would you tell her.

Ancy: So I would tell you find one -- I think you talked about this in your other podcast. If the person driving for that hour commute is thinking about placing implants or thinking about restoring them. Find a mentor. That's the best thing that you can do. If somebody -- if you can go in their office -- I invite general dentists to come into my office, see how I do it. I don't care if you're placing implants. I want to show you: this is how we do it here. These are the complications that we might have.

Howard: So that's where you need to find someone in abundance, because you're afraid that if you ask an orthodontist well how do you do Invisalign, he's going to say well I'm not going to show you, you send it to me. That's a guy in fear and scarcity. Be glad you met him so you can cross him off your list. Then go to the other orthodontist. Find one you think is in hope growth and abundancy. Because I'll tell you one thing in ortho: every dentist I know at my age who got into ortho, realize that they don't want to see a patient every month for two years later. So they got out of it, but the one orthodontist that helped him now gets all those referrals. I don't know anybody who ever learned how to place an implant from the periodontist up the street, that didn't to this day still refer out 80 percent of their implants to that guy up the street. They might take a single unit, but 80 percent of the time they they don't want to do the case, they want to restore the case.

Ancy: My business partner, he's a prosthodontist, he places implants. He does bone grafting. It doesn't matter. We talk about cases all the time. That's good. I want to do the complicated cases with them, even that dentist that will refer into our group, into our group and they're having a complicated case, I'll sit down with the general dentist, maybe a young dentist and say, "Listen. My partner is a prosthodontist, let's sit down and do the case together. He'll hold your hand." See this is the problem: when you go to cases, like I love coming out here to Spear, it's great, but who's going to hold your hand when you go back home. Who's going to be there when --.

Howard: You tell Spear you go to their class. [00:24:20] Quince [0.1] has been on my show, Peter Dawson's been on my show, [00:24:26] Carl Mace, [0.7] has been on my show. He's right up the street as -- [00:24:30] Samir Perry's [0.6] been on the show. Tell Frank he's the only guy from that building -- [00:24:38] Flam [0.1] has been on the show. Tell him I'm waiting for --

Ancy: Waiting for him.

Howard: Tell him I'll drive up there. So, shout out to Spear. When are you don here going to Spear?.

Ancy: So I believe there's not one way of doing something. You can go to Dawson, you can go to LVI, you can go to Kois, you can go to Spear --

Howard: Had everyone on the show. Bill Dickerson, LVI.

Ancy: There's so many different places out there for people to get information. Why am I going to just stay with one philosophy. I don't believe that. I think that the more things that you can learn and the more things I can bring back to Central Mass, to my group. So if I learn something, a pearl that I can bring back, or if I see someone speak -- not everybody can come out to Scottsdale. I'm blessed that I have the time that I can come out here and do that stuff. But I believe in education.

Howard: Do you bring your wife and daughter?.

Ancy: I bring my wife and daughter.

Howard: And you stay at the Fairmount?.

Ancy: I stay at the Fairmount.

Howard: So they're sitting at the swimming pool while you're on dentistry uncensored?.

Ancy: I'm lucky.

Howard: Life could not better.

Ancy: My wife comes from a family of dentists. So I married up.

Howard: Is she a dentist too?.

Ancy: No she's not, she's a nurse.

Howard: But her family is --.

Ancy: My father in law's an endodontist.

Howard: Wow, in Central Mass?.

Ancy: He lives in Southern Arizona right now. He's retired.

Howard: Really, where in Arizona?.

Ancy: Right by the border there. Further south.

Howard: Yuma?.

Ancy: Yeah. Right around there I think so. Near V.A. hospital. I think is right around there.

Howard: But he's retired.

Ancy: He's retired. And then her aunt is a general dentist. Her uncle is another endodontist in Long Island. So you know, I think it was easy meeting them, they were happy. I think they weren't too sad when a periodontist came into their life. So it worked out really well. So she's very supportive of the things that I do. And it's it's a team right. If you don't --.

Howard: Well, endodontists are getting into implants, because I love insurance today because dentists just -- all humans have that condition. They just believe things because they want to believe it. I mean, you see it in politics, you see it in religion, they just believe stuff because they just want to believe it even though the data says it's just not true. And the the insurance says that if you do a million molar root canals, a general dentist does them, in just 60 months, 10 percent have been extracted. And if you're an endodontist, 5% have been extracted. And from everybody I'm talking to, the email saying that 5 percent that tooth was probably fractured when they did it, and for the general dentist, which says twice the failure rate, they're doing a root canal and they're not doing the final restoration, the whole thing gets reinfect -- if they can't afford the root canal and the crown, then they should just extract the tooth and spend the money elsewhere. But to do a root canal and [00:27:26] cavit, [0.3] and turn them loose, the patient shows back up two years, later three years later, it's all rotted out. But these endodontists are now, when that's fractured, they're extracting the tooth and placing an implant.

Ancy: So, I'll tell you, I have an endodontist in my practice, he comes in twice a week. He's great. I learned so much from him. When you can work side by side with another specialist and we can look at things together, and I look inside that microscope and you're right. Why is that endodontists have better success rates? Because they take the time. He sees four patients and he's taking the time to really clean out those canals and really get it filled nicely and his results are really good.

Howard: And he has a microscope.

Ancy: He has a microscope.

Howard: And what magnification does he use on that microscope?.

Ancy: I'm not sure the magnification, he has a Zeiss one, so it's really --.

Howard: The German one? Most of them are telling me that they're using eight. And that is the lowest hanging fruit on how to be better. Take your human eye to loops and see two, three, four times better. Use magnification, digital impressing. When you take that impression with digital you see your prep 40 times bigger. Any time a human can magnify what they see they're just higher quality.

Ancy: Well you know, so, when you came out of school I'm not saying that you're old, but when you came out of school --.

Howard: I'm old. I own it.

Ancy: People, magnification was -- now you have hygienists using magnification. Digital impression wasn't there at the time. So there's so many things that have changed in dentistry and it's still changing. But it doesn't mean you have to -- if you don't know the nuts and bolts, if you don't know the bread and butter of dentistry -- so, if you're a young dentist and you're looking to say, "Okay, I want to jump into something bigger and I want to get CEREC machine." You know, if you don't understand the basics, then I don't think it's worth it to start to jump into those kind of things. If you're doing endo, and you're buying a $60,000 $70,000 microscope, that's a big investment for a practice. It's not so easy to do. So I think you do it and you do it well. And I talk to students at Tufts all the time. Every year we have this student alumni relations thing. And the biggest thing they say, I see the hands go up. "So what questions should I ask when I'm applying for a job position?" I say, "Listen, I had one guy who said I can take any dentist and teach them things. But the communication piece is the hardest part. If you can't sit with someone like having coffee, like this, to your patient, then you're never going to get case acceptance. You're never going to do the root canal. You're never going to do the implant because I'm not going to trust you. It's like brand identification, like Mayo Clinic. You go to Mayo Clinic and you know you're at the best. So when you take your time to really understand your patient and then really do it the right way and explain to them why you're using magnification, they'll appreciate you. So no matter if the dental insurance changes, it's brand verification. They say. "OK no I'm sticking with Dr. Verdier. I'm sticking with Doctor Farran. Because you know what? He treated me well. He really listened to me and I know he was using really the best materials around.".

Howard: You know the Mayo Clinic is right by Spear.

Ancy: I know, I saw it when I was driving and I was like --.

Howard: And I will tell you, that's the one thing I don't understand dentistry. So we have 35 corporate chains that have 50 or more locations and they've all gone after the cheaper coupon, take your insurance, extended hours, whatever. But no one's really gone after -- I mean the Mayo Clinic the Scripps in San Diego, the Houston Clinic and the Cleveland Clinic, the Sloan Kettering in New York: these these high end places where they build the brand that this office was started to do the best dentistry possible. And so many have taken the strategy of: I want to be -- which is fine -- to be the Southwest Airlines, the Ikea, the Walmart, the Costco. But I want to say one thing about that Zeiss microscope. I can say for a fact, you don't even know what a pair of binoculars are until you buy the Zeiss binoculars. I mean, so many times you've been at a sporting event, someone's got a pair of binoculars, you look, it's a little bigger it's fuzzy. Oh my God. You get the Zeiss -- and they'll get mad if I say this but if you're going to buy a Zeiss microscope you should negotiate. I'll do it if you throw in a pair of Zeiss binoculars. I bought a pair for one of my friends, a dentist in Albuquerque, Craig Steichen, you remember that? Yeah. And he's an outdoorsy guy and I knew he would love them and I bought him a pair and sent it to him. And he says, that was like 20 years ago, he still says it's the greatest gift anyone's ever given. I mean those Zeiss -- you could be at a rock concert with the worst seats in the house and you look at that thing, you think you're standing on the stage. And when you go out and your outdoors guys, and the sun's coming up and it's still pretty dark, any microscope, it's all dark. That Zeiss, it's so amazing that, it's still dark, the sun's barely coming up and it's light out. I mean they're freakishly freaky microscopes.

Ancy: But they know what they're doing.

Howard: So if you're going to a bunch of dance recitals with your little girl and you ever thinking about buying a microscope, just buy the Zeiss, you'll never use another microscope.

Ancy: Right now she's five, so I can get her close enough that she's happy.

Howard: But those endodontists tell me that they just do it routinely, right before they operate, they'll pull down the Zeiss microscope. Some use the global microscope out of St. Louis, and just, it might only have one in ten times but they see, oh my god I missed a canal, we're not talking to MB2, they saw that it might not be MB3. Or it might be wow, that dorsal canal still has sludge on the lingual side of it and the magnification is amazing.

Ancy: And going back to what you said with, most of these larger corporations, they're based on price and convenience right. But when you change that model to be based on comprehensive care and also patient communication, it's much more technique sensitive. I would tell you it's a lot harder to replicate, because the other one is scalable. You can make that and that can work well. So I think there's two ways of operating as a young dentist. You can go to work, you can do your drill and fill and you'll make good money. But then after that, what's the fulfillment that you get? It's a way of living that you have to start to think about, saying "OK do I just tell the patient every time they come in that they have decay over here, decay over here, decay over there?" And then when do I really tell them everything that's going on? When I go to my physician, I want them to tell me everything. Tell me I got a heart problem, tell me I got a cholesterol problem, tell me I've got all this stuff. Then we can fix it together, at least we have a plan. So you can have all the tools possible, but if .

Howard: So you taught at NYU, largest dental school in the world, in Manhattan, with the most dentists of any city. And you went to school and Tufts. What would you say to a young kid who is going to NYU and going to Tufts? Do you really think -- NYU is incredibly expensive. Tufts is incredibly expensive. Do you really think you can walk out of NYU and set up in Manhattan? Do you really think you can come out of Tufts and set up in Boston? Because a lot of D2s and D3s and D4s are listening to this show, and they're kind of in a lot of debt. Or will you say, "Look dude. Tufts is in Boston, NYUs in Manhattan, get out of those towns." Can you make it in those towns or do you need to get out into Central Mass. like you are?

Ancy: Well it's difficult .

Howard: Would you consider yours kind of rural?

Ancy: Yes, I'm 45 minutes out. About 45 minutes to 50 minutes out from Boston. Worcester is one of the biggest cities in central New England, has a lot of biotech there.

Howard: How many people?

Ancy: It's the second largest city in New England. Worcester is.

Howard: In New England, you mean Massachusetts?

Ancy: In New England. Worcester's a big city.

Howard: I'm sorry I'm from Kansas. When you say New England, what states do you mean by New England?

Ancy: So we're talking about Maine, Vermont, Connecticut, Massachusetts, New Hampshire, that's New England.

Howard: So why does California only have two senators but Vermont has two, New Hampshire has two and Maine has two? What would you say to all the California dentists?

Ancy: I don't know.

Howard: California is like 10 percent of the state and they get two senators away for nothing.

Ancy: California's a different beast. You can go from northern California to southern California is be very different. But your same thing, you can go from Maine and you can go to Massachusetts, it's going to be different. So I would tell you --

Howard: I'm counting six senators for 14 people. And California's got almost 40 million people.

Ancy: We do things a little bit differently there in New England.

Howard: And Delaware, the vice president, the last vice president from Delaware. That's got to be one of the smallest state.

Ancy: It's tiny. You're in Rhode Island, right? Rhode Island is a tiny state.

Howard: Rhode Island. Oh my gosh. I'm a senator from Delaware. That's like being the mayor from Tucson. But anyway.

Ancy: But yes, starting off I would tell you that the best thing that you can do is ,if you can start of -- you always talk about this in your podcasts. If you had to start all over again you would set up shop at a rural place where there's not a dentist from a mile away around you and then you'll get a whole bunch of people. But it's quality of life that you have to start thinking about too. Everybody wants to be in the Bostons and the LAs and the New Yorks, but it's much more expensive to set up shop there. If you're going to do something like that then I would tell you to have some experience underneath your belt first. If I had to do it over again. Yes, I would buy an existing practice and start from scratch. I think that was the hardest thing to do.

Howard: You would buy an existing instead of starting from scratch?

Howard: So I did it all. I did from starting working in a group practice, working with a couple different practices, starting from scratch, and then also by existing practices. Looking at the whole spectrum of all the different things that I did, buying an existing practice, at least you have a certain patient flow already there. The trick that you get to with young dentists is that when they buy an existing practice, what are they actually buying. You're buying a lot of the goodwill from the dentist who's selling it. How long is that dentist going to be there? The best thing that you can find, I would tell you, I always tell the dentists this when I talk to them at Tufts: the best person I would pay money for is a mentor.

Howard: And when you buy a practice, here's the thing I don't like about today versus 30 years ago. Thirty years ago when you bought a practice, the owner carried. Well when you go to Kansas and buy a practice and old man McGregor sold it to you and it's a seven year note, the interest on that seven year note -- so let's say he sold you the practice for a dollar. Well if he financed at it 10 percent interest for 10 years, the dollar he sold the practice for, let's say it was 750. He'll make another 750000 interest because 10 percent on $750000 over 10 years is another 750. But what's cool about that, say 10 years is too long, say only do seven years. For seven years he's walking around in Parsons Kansas saying, "I'll tell you what, I could have sold to anybody but I sold to this young man because that's who I want to take care." And then when you have a patient, chairside manner problem and someone's mad at you or leaves you a bad review, you can call the seller and he's like, "Oh, I know Shirley, she's been in love, let me call her. Or I go to church with her, I see her at the grocery store." And now you've done that, you've got rid of that, and now you're having some big fortune 500 bank do the carry. And I'll tell you what, and I've seen some very unscrupulous dentists sell dentists a complete piece of garbage. We're talking about in my backyard in Phoenix and some dentist bought a hunk of crap and didn't even know it, and that owner would have never carried because he knew he was selling a sinking turd that needs to be flushed down the toilet. And I think the owner carried -- I know all old people think it was always better thirty years ago. You can't find a grandpa who doesn't think it was better. But I like the owner to carry, I agree buying a practice is one tenth the risk of doing a de novo starting from scratch. I think you should buy a practice and if that owner doesn't want to carry. He should at least carry half. And I know all the people that work at Bank of America and Wells Fargo, that they disagree with that because they want to finance the whole damn thing, because they only have a half of a percent failure rate. They get a 99.5 percent success rate, because usually the only time a dentist defaults is a personal issue and the number one is alcohol. Now when you talk about substance abuse the TV makes you think it's all opioids, it's actually alcohol. Eighty five percent of the time, opioids would be about 15 percent of the time and cocaine just like barely a rounding error. But the dentist knows is not going to default so have them carry so he'll be .

Ancy: Yea dental businesses don't fail. They really do, just like you said before. So when you get into something you're going to have enough support where you'll do well. But then, what do you have to do when you're in there? Now, are you going to change your systems over? Now you have to be a leader. And unfortunately dental school, it's great, they have to teach you a lot of stuff. Like where does leadership come into that play? Where do they teach you about leadership skills? So I went from an office with two or three employees to one with 14. Holy cow. Talk about take your diapers off and pull up your big boy pants, you got to do something now. So I had to learn really quickly what I could do and what I couldn't.

Howard: What advice would you give to learn leadership. What would you tell a 25 year old kid, how could they fast forward their leadership skills without going through the school of hard knocks for 20 years?

Ancy: So I think you got to know your numbers right. So you put out the dental MBA, and it's free, it's online. I listened to that. That was the first thing. Understand what the numbers are in your practice, so you can understand -- you need to know what people are doing in your practice. Then also know the communication aspect is very key. So I used to download -- Every time I was driving I'd look up every communication thing that I could read on. Now my wife might tell you something different. She says I'm not the best communicator. But I'll tell you, it's something that's a work in progress, and if people see that you're working on it and you really take a special interest in what they're doing, they'll go above and beyond for you. My staff, like my my team is amazing. They do things for me that I'm just like, I kind of take a step back and think wow.

Howard: You know I feel sorry for you. I had boys. You got a five year old girl, I got a five year old granddaughter. I couldn't imagine telling my granddaughter no. If she was mine, she'd have to be the most spoiled rotten woman that ever lived. It was very easy to tell four boys no. And my boy was telling me the other day, he was going Dad you ran a strict house. And I was sitting there thinking, my god, that's because I had four boys.

Ancy: Grandparents have it great! That's what my grandparents -- I'm telling you, they send the kids back afterwards, so I've got to make sure that all the great things that I've had, I want to give the same thing to my daughter.

Howard: So what's her name?

Ancy: Hazel.

Howard: Hazel.

Ancy: Yeah.

Howard: So is she already the most spoiled rotten little princess on earth?

Ancy: We've been to Disney plenty of times. And I got to thank you. You moved the townie meeting from Vegas to Orlando. Thank you. I think that's really .

Howard: So how many times can you watch frozen so far?

Ancy: I think I got that thing over and over. And it's a balance right? So you have the dentist who's driving to work right now and they have to balance. "Okay, I'm going to have to go to work. I have to see my spouse, and I also have to go to this CE course. How do I do it all in one day?" And that's the biggest challenge that I have in running my study club, is that I tell dentists, "Hey listen, this is an investment in your future and what you're going to be doing." And you can't sell that to somebody. They have to see it.

Howard: So more controversies. I like controversy. Some people they work as an associate. And it's just protocol that any pocket over five millimeters is going to put a chip in there: arrestin, some minocycline, something, because there's an insurance code for it. Some dentists are wondering, "Okay I get it. That you want me to put it in there because there's an insurance code, but if there wasn't an insurance code, do you recommend these chips? What are some of the names of the chips?

Ancy: So arestin, periochip .

Howard: And what's the difference between arrestin and periochip?

Ancy: So arrestin is Minocycline. And then periochip is doxycycline.

Howard: And there are -- I mean, if you go to Dental Town and you do a search for those words, there's a lot of corporate chains where they recommend you put a chip in every pocket. What are your thoughts on that?

Ancy: Again, you have to look at the risk assessment of each person. What we do in our practice is now we use cell varied testing. Oral DNA. They're based in the Midwest, right where you went to dental schools --

Howard: Midwest. Yeah. And what is it, Wisconsin or Minnesota?

Ancy: I think Minnesota yeah. So oral DNA, and they're great, you take the patient's salivary and then they give you a whole, they give you a whole printout of what kind of bacteria that patient has in their mouth. P Gingivalis, AA, T4 tricentis, all the pathological bacteria that are going to cause periodontal disease. And from there you can assess that this patient is going to get the proper treatment by using an antimicrobial and also scaling and root planing. So, I was lucky, I went to school up at Tufts and right there they did a lot of the groundwork testing on those antimicrobials, through foresight. And they published a lot of articles that said, "Hey listen, we find that giving this patient a combination of amoxicillin, metronidazole, with scaling and root planing, you can get the same results with arrestin and periochip. So I don't know in every case that you need to do it. I think in certain places I think it's appropriate, but not for every case. And this is, for me as a periodontist, talking and looking at the literature, something has to be evidence based. So we see it so over three or four months, that works really well and then what happens after three or four months? The pocket comes back.

Howard: And that's why I'm still old school. I still believe that in these corporate dental chains, I still believe they should all have to be owned by a dentist. Because these kids, I mean, I feel sorry for them, they work at some place and some office manager who's not a hygienist, not a dentist, is back there telling these kids. "You know we like to see 35 percent of our new patients have perio." I mean, could you go to a physician, say "I'd like to see 35 percent of your new patients have gonorrhea?" I mean don't you only treat gonorrhea if they have gonorrhea? I mean, how do I have a quota that one third of my patients have heart disease? It doesn't make any sense.

Ancy: There are so many patients that are out there, people, I'm not scared about the patients who come to see, me I'm worried about patients who I don't see: the patients who are walking around out there with uncontrolled diabetes, hypertension, those are the patients that I get worried about. And at the end of the day, again, it goes back to the communication piece and saying, "Hey listen, what can we do to educate our patients a little bit better about what's going on in their mouth?" Because it's their mouth at the end of the day. They have to own it. And if they don't own it, then how are you ever going to get them committed to doing any kind of treatment with you.

Howard: And another thing about the implants and peri-implantitis. I mean, obviously, if it was a, say an all on 4. If you could snap out the removable, you could clean it, it'd be so much better. But the patient doesn't want to snap it, they weren't fixed. Do you think dentists should be really trying to sell implant retained removable as opposed to implant retained fixed? Or do you think that -- I see so many people with implant retained fixed that they don't even have a water pick, and they don't have a water pick or a water flosser because they just never got it. They come in, there's all kinds of crap underneath it. Do you think if everybody had implant retained removable, as opposed to implant retained fixed, there'd be less implant failure, less peri-implantitis?

Ancy: I think so. If you -- cleanseability is a big deal. So I think anybody who gets any of those fixed restorations should automatically get a water pick or flosser. Because if -- and also .

Howard: When you say a flosser, what --

Ancy: I think it's called an H2O flosser, it's the same thing.

Howard: H20 flosser, do you like that better than the water pick.

Ancy: I think it's a little less than the water pick, but it's the same. They both do the same thing.

Howard: I like the ones you can take in the shower.

Ancy: People love doing that.

Howard: Because I believe, seriously, that people are -- the old joke about divorce: why'd you divorce your spouse, because she left the cap off -- when you have something on your bathroom sink and you make a mess. People don't like messes. And maybe it doesn't bother you but then your spouse puts it under the can or throws it away. But where it's okay to make a mess is in the shower. And my favorite one is just the old shower floss. Have you seen that one?

Ancy: I've seen that, it comes right down .

Howard: YOu just unscrew the shower, put it on there, and my God, I mean if I had an implant retained fixed, that is just perfect. You don't have to add water, do anything.

Ancy: But you still got to get them back right. Because some of those parts, the O-rings and all that stuff, become worn over time so that they still got to come to your dental office to get checked up and all that stuff. So we tell our patients, "Hey listen, if you come and you make your appointments, and you come for your maintenance appointments, if something happens to that implant, we will replace it for you. But if I don't see you for five or six years, then yeah of course, now there's an added" -- it's like you buy a new car. I'm never going to change the oil, never going to do any maintenance on it. Are you kidding? Like, why would you do something -- why would you do that and not take care of your health. So something that you can take on and off. Yes it's easily cleansable, but also the maintenance part has to be incorporated into anything that the patient does.

Howard: Now I want to ask you the most controversial thing, which I can't believe is controversial, but it is. You go into dental offices. I mean, if you went into the 10 offices across the street from my house to the interstate, every single one of them sees grandma every three months for perio for the last 10 years, they've never seen her husband. Now if you saw her every three months for chlamydia, you eventually say, "I think Grandpa might be carrying" -- you get grandpa in. Can you treat someone every three months for perio and not see their lover who they're trading saliva with? The research I see, a standard kiss transfers 80 million microorganisms, bacteria fungi, and parasites. Human saliva has parasites. How can you kiss grandpa and share utensils in your kitchen and, "Oh taste this honey, try this." Eating on each other's food. I mean, so the bottom line is we know below the belt, STDs are communicable. Is periodontal disease communicable?

Ancy: Absolutely. So that's why salivary tests are great.

Howard: Absolutely. And on Dental Town half the townies think I'm full of it.

Ancy: No, absolutely. Take the salivary test, test the spouse. You know, I love doing test presentations with both the husband and the wife there, and they look at each other and they're like, "Do you need to see me too Dr.?" I said, "Hell yeah I do. What do you think your kids, and when you guys are spitting back and forth with each other, sharing everything, yeah.

Howard: Or bring a baby into the world. A baby is going to be born without any of these pathogens, and then mom and dad have these pathogens, and then they're going to have grandma come in and babysit and grandma hasn't been to the dentist in five years and got nine millimeter pockets kissing baby on the mouth. We have to start thinking of the herd diseases. Like if you talk to a vet, you tell them the species of the dog and he'll tell you all their diseases. And there's herd diseases. And these babies are being raised in a herd and when that lady's pregnant, who's going to be sharing utensils with this newborn baby? Who's going to be kissing this baby? Who's this baby living with cos she is going to pick up the whole herd disease.

Ancy: We know so much more. Remember when you said perio has changed so much in the last 30 years. We know so much more than what we knew 30 or 40 years ago. We didn't even know the species of bacteria that was causing the problems. Now we're seeing that it's connected to you know C-reactive protein, inflammation, beating the heart attack gene by --I think had Do Nin herre right? Bailin Donin, right? So that's a big thing. People are starting to understand like, Okay this person is very healthy and all of a sudden they get a heart attack. Why? Did anybody ever check their mouth, see what was going on?

Howard: So who is a candidate for oral DNA?

Ancy: So I usually do it on patients that have some kind of refractory periodontitis. Let's say we tried the traditional scale and route planing on this patient. It didn't work. If it's a simple -- this patient doesn't come in, doesn't brush their teeth, doesn't floss, you spend a little bit more time on the oral hygiene instructions. The patient that comes in is a smoker, is diabetic. There's so many things that we can find out now, as also something that a patient can actually take home with them and say, "Hey listen OK they showed the graphs about how much of the pathogenic bacteria that they have in their mouth." So you do the test right before and then you do the test afterwards and patients can actually see it. So if you engage your patient in the kind of treatment that goes on, they're more apt to be accountable for what happens. If they just think, "oh they just did --" Like I ask so many patients, "Oh, so what happened at the general dentist when you went there?" "Oh they cleaned my teeth." "What did they do? Did they scale your teeth? Did they do LANAP on you? What happened?" Many patients don't even understand that. They just know oh I'm going to get a cleaning. That's all they care about is the cleaning part. What happened during that profi that we talked about. It's not a cleaning, I'm not a cleaning person, prophylaxis. Let's start talking with the right terminology.

Howard: Being a periodontist -- so most of my homies listening right now are general dentists. When you're a periodontist, how much more a significant part of your practice is people with diabetes or smokers or whatever.

Ancy: I get so many. So we get a lot of patients, diabetics, patients are smokers, less smoking now because it's not so chic to do it as it was about 20 years ago.

Howard: Oh man when I was 10 years old, I can't remember any house on my block that you didn't go inside and there were ashtrays on every table.

Ancy: Well now it's e-cigarettes and marijuana. What do o we know about that? What do we know? And it's legal in Massachusetts. So I don't know.

Howard: Marijuana is legal? Like Colorado?

Ancy: Yeah.

Howard: Really! Was that just the last election?

Ancy: Last election.

Howard: Huh.

Ancy: Liberal area. So we don't know what that's going to entail. What's that going to do to the systemic bacteria in the patient's mouth. So patients that I see a lot of bruxes. So occlusion patients are just grinding on their teeth. So in the present inflammation in the grinding on their.

Howard: So what do you think would be the bigger risk in your practice: diabetes, smoking or bruxing?

Ancy: I think hypertension, diabetes, the big ones.

Howard: High blood pressure, than diabetes.

Ancy: How many patients did you come in and you look at their medical history and you see what kind of medications that they're on, high blood pressure, diabetes, statens. You know, so any of those medications, those are patients we know about the oral systemic connection. It's there. Some people can turn a blind eye to it. But patients understand it a little bit more than what we knew about 30 years ago.

Howard: So here's another thing that's confusing: she's trying a treatment plan, this case, and she just got out of dental school and they say, "Well these are the contraindications of placing an implant: that high blood pressure, diabetes, statens, a smoker." Then she gets in the real world and usually the people that need implants aren't the vegan yoga instructor who owns a dance studio. Usually it's over 50 pounds overweight, doesn't go to the doctor, he smokes, he chews tobacco, he's got a pipe. So it's kind of weird. I mean, most everybody who needs these implants does every single thing wrong. So where do you draw -- I remember with Carl Myss, and the only feud I ever saw him have with his brother Craig, was Craig won't put a implant in if you're a smoker and Carl would. Where do you draw the line?

Ancy: I would. I think that, so there's a lot of studies that came out of Europe and you know ,you go to Europe and people were smoking all over the place and those implants can still work. But in certain areas the maintenance was part of what those studies -- so they places the implant and every three months these patients are coming back for prophylaxis and scaling. That's why the results were so much better. If I place an implant on a patient and they disappear and I don't see them again, of course it's going to fail. Because the bacteria is what's causing the [00:56:56] bomos [0.1] around the teeth and around the implants. So until we can control the bacteria that are in there, plus the inflammation -- So yes I would love to get someone who's healthy, 18 year old, 20 year old with no systemic problems. But I don't get those kind of patients. I get the ones with the very thin ridge, they're smoking a pack a day. And those are the ones that say OK now I want some teeth. OK what are we going to do here. What options do we have. So either you have to cut back on your smoking, we have to get a little bit better. And when they can understand that, if they make a commitment to having -- it depends what they want. If they want to be able to chew their food they'll make some sacrifices. You'd be surprised.

Howard: Yeah I noticed -- I have heard over the years a dozen patients say well you know when I got my boob job or my tummy tuck or my face lift, he wouldn't do it unless I stopped smoking for two weeks before. And I'll say to them I said, "Well did you?" And they go, "Oh you know, because I really wanted the tummy tuck, I really wanted that. So yeah, I stopped for two weeks and I couldn't smoke for two weeks after and I did it as prescribed." And then I would say some of them they actually stopped smoking for that surgery and that was their catalyst to quit smoking, period. So it was amazing, I saw people from the Centers for Disease Control and they said just asking your patient to stop smoking was one of the most significant things. You come from a place of authority. When his wife is saying, "Harold, quit smoking!" "Oh you're just my nagging wife." Well, when the doctor said, "Buddy, come on you need to knock that, you need to stop smoking. I can't even do this surgery on the smoker." So just just coming from a place of authority and telling your patient, "Look, you've been getting away with murder for a long time buddy but you need to stop. I can tell by your gums what your heart would look like."

Ancy: So I would tell you on top of that patient engagement. So it's not enough them respecting you as a doctor because, yes, that's nice, but I'm dealing with Gen X, Gen Y millennials who are saying, "Well why do I need to change my lifestyle? What do I need to do that's different?" You know, if I get the guy who in their 60s or 70s, it's enough having the DMD behind my name and then they'll say, "Okay, yes, I'll listen to you Doc.". People want more research to say, "Okay why do I need to change what I'm doing?" And that's where the patient engagement comes in. Harvard Business Review just had something, and they talked about how a patient that you can make an emotional connection with and you can engage is two times more likely to go ahead and do treatment with you and to follow through than someone that you just have a casual transactional relationship with.

Howard: And it's a skill that goes everywhere in your life, whether it's to your spouse, your children, your staff, your patients are actually the least most important part of that skill. You'd think you'd want that skill mostly with your children, mostly with your family, mostly with your team members. Last question. I can't believe we've already gone over an hour. You know what smoking tobacco has done to gums. We all know that. But what's new is this -- smoking marijuana, at least it's out of the closet.

Ancy: And e-cigarettes.

Howard: And e-cigarettes. How would you compare -- if smoking on one to a hundred -- if smoking tobacco was the middle 50. Where would e-cigarettes and smoking pot be?

Ancy: We don't know enough, because it's so new. Howard we just don't know. And we had someone come in and talk about that. And they just don't have enough information. We have 40, 50 years of smoking tobacco and what that's done, even chewing tobacco we know what's happening. But with e-cigarettes they say, "Okay, well we've taken out the contaminants in it, it's a lot cleaner." What is that doing, so it's not the same thing as smoking cigarettes with all the contaminants in it. What does marijuana do? We don't know enough. We don't know enough.

Howard: Because if I try this new medical marijuana I want to know if I should start with an edible. Or should I start with this.

Ancy: We don't know that either!

Howard: I'll tell you the one thing that's weird about e-cigarettes is when you see em -- I mean, if you see someone out on the corner smoking a cigarette there's a little smoke coming out. You see someone with a e-cigarette, it's like a flipping -- I mean, it's like the smoke is the size of a basketball.

Ancy: I'm more worried about that thing exploding in your face than you smoking the e-cigarettes. Those are the things that I worry about. I show them pictures of that.

Howard: Yeah that's a lot of smoke. But hey, I tell these dentists that if I can wave a magic wand and give them one gift it would be the chairside manner, connecting with their patient, connecting with their team, connecting with their kids. You just reek of chairside suave. You just have that. And what's so sad is most of these dental students were only accepted into dental schools because they got A's in chemistry and calculus and physics, which is not a skill. In fact it's actually an anti-skill, because the guys that sat in the library till midnight every night getting A's in physics and calculus, usually weren't the fun guy that was out at the frat party on a date, the life of the party. And it's so sad when they think their knowledge of the periodic table and the Krebs cycle is going to translate into a victory in economics and practice devolvement. And it's not it's always the soft stuff, it's always are you a leader? Can you relate to your team? Some dentists could lead five ducks to a pond, but I'd rather have the skill of communicating with your kids, your family, your team and your patient than any other skill. And it's been really, really fun talking to you for an hour.

Ancy: Thank you. They say you are the sum of the of the five people around you, and that circle -- you just look around at your five friends and see who that circle is and that really determines about how you're going to be. And when you invited me to your house I said, "Wow this guy is opening up his house to me." And I just thought of it as truly an honor. So I really appreciate the time that you've taken to talk to me.

Howard: And you were saying that Ryan's room was the filthiest room you've ever seen in your entire life. Ryan, how does that make you feel? Alright buddy well have fun with that little girl.

Ancy: I will.

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