Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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1009 No Bull with Gordon J. Christensen, DDS, MSD, PhD : Dentistry Uncensored with Howard Farran

1009 No Bull with Gordon J. Christensen, DDS, MSD, PhD : Dentistry Uncensored with Howard Farran

5/7/2018 7:51:53 AM   |   Comments: 1   |   Views: 1000

1009 No Bull with Gordon J. Christensen, DDS, MSD, PhD : Dentistry Uncensored with Howard Farran

Gordon J. Christensen is Founder and CEO of Practical Clinical Courses (PCC)and Co-Founder and CEO for Clinicians Report Foundation (CR) and a practicing prosthodontst in Provo, Utah. PCC is an international continuing education organization that provides courses and videos for all dental professionals. CR offers unbiased research on thousands of dental products.

Dr. Christensen has presented over 45,000 hours of continuing education throughout the world and has published many articles and books.

Gordon and Dr. Rella Christensen are co-founders of the non-profit Gordon J. Christensen CLINICIANS REPORT (previously CRA), which Rella directed for many years. Since 1976, they have conducted research in all areas of dentistry and published the findings to the profession in the well-known CRA Newsletter now called CLINICIANS REPORT.

Gordon's degrees include: DDS, University of Southern California; MSD, University of Washington; PhD, University of Denver; an Honorary Doctor of Science from Utah State University, and an honorary Doctor of Dental Education and Research from Utah Valley University.

Early in his career, Gordon helped initiate the University of Kentucky and University of Colorado Dental Schools and taught at the University of Washington.

Gordon is a practicing prosthodontist in Provo, Utah. Gordon and Rella's sons are both dentists. William is a prosthodontist, and Michael is a general dentist. Their daughter, Carlene, is a teacher.

VIDEO - DUwHF #1009 - Gordon Christensen

AUDIO - DUwHF #1009 - Gordon Christensen

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1009 No Bull with Gordon J. Christensen, DDS, MSD, PhD : Dentistry Uncensored with Howard Farran

Howard: Hey, we are live at Townie meeting 2018 Orlando, Florida. I'm sitting here with the God of dentistry and I mean that sincerely. I think the only thing you'll remember from the 1700's was Pierre Versace, the 1800's GB Black. The only thing they'll talk about this century a thousand years from now is you and I'm sitting next to the editor of Dentaltown magazine, Tom Giacobbi. We've been working together since the year 2000.


Tom: That's right, yes.

Howard: And, my gosh, he's the front man with a suit, tie, polished, smart. 

Gordon: Just like you.


Howard: I'm the guy they always try to keep in the basement. They're just, gosh darn, did he really say that, put a sock in his mouth and hide him. But Gordon, dentistry is under hard times. We got dental insurance in 1948 to sort out the Longshoreman's Club, but it was a $1000 max. That thousand would be five thousand a day for [inaudible 00:00:49]]. It's still a thousand.

Gordon: Right, it is. 

Howard: They come out of school $350,000 in debt. There's a dentist on every corner. They're told to be a good dentist like you, you got to have $150,000, chairside milling machine. Their patients want them to sign up for every PPO.

Gordon: Yes.

Howard: It's tough. 

Gordon: And they've got a gross revenue that equals 1997 levels with more overhead and a net revenue that is pathetic right now. A new guy right out of MBA program makes as much so it's a bit of a problem.

Howard: So what can they do? How do they navigate this mind [inaudible 00:01:46]. Well, let me ask you some civil, the higher dollar the question, the more focus. Do they need to buy a $150,000 chairside milling machine to be a good dentist? 

Gordon: No, that will help and it will stimulate them. I had an old guy tell me a while ago, it was just like marrying a seventeen-year-old, turned him on and it's desirable and it keeps them stimulated. As you know the burn out for dentists is somewhere around twenty years. By the time they've been pressing along doing the same thing, same old, same old, same old, they get frustrated. So ...

Howard: Twenty years you say is the burnout.

Gordon: Give or take. Hygienists, about five years, unless well, the orientation of the program you guys had me on today was using motivated, stimulated, educated staff, and expanding the functions of staff, which is about the only way to answer your question, to get around the miserable net revenue they now have. Because they got two hands and the average American dentist has one point, seven dental assistants. Half of them don't even have a  hygienist, can you believe that? If they expand the functions of the current staff, what do they do? Just what I gave this morning, they will double their net revenue, they're double it. 

Howard: They'll double their net revenue if they do what?

Gordon: If they expand the function of hygienists beyond nitpicking, picking, picking, picking. We have twenty functions for hygienists, not just one. Every day they're in there they'll do at least one diagnostic appointment during the staple [policies? 00:03:30].  They can do occlusal splints and it turns the hygienists on and they don't burn it out. I had one that lasted with me forty years. She's now teaching. She got to the point where she felt like she needed to not pick all the time so she's teaching now here in Preston. So they need to expand what the staff is doing because you can't change their title unless we have a total evolution you know that and that is imminent. There are a lot of people including you that would like to blast out of there. Oh, where are we? The lethargy, you've been with me to ADA a few times and I love ADA, they're my parents. I can't kick them out, but I would like to see action, action. It's like a big battleship that's going along. We need to change course, change course. We're too small, we can't change course. We need a PT boat, whereas they change course. We need to get with a third party. We need to tell them collectively, look, we're the doctors, you're the facilitators. You're not supposed to tell us what to do, we're the doctors, you're the helpers. Until we do that, we're locked. I don't see a way to jump out of it. I honestly don't see a way to jump out unless [inaudible 00:04:51].

Tom: When you have long standing staff that are performing those expanded functions, what is that impact on the overhead for the practice with labor being the largest cost? And get to the point where that hygienist has been with you so long that her salary ultimately has to reach the ceiling.

Gordon: Yeah, you get to a ceiling point, so we bonus them. The more expanded functions they do and this is very interpretable, [inaudible 00:05:17] bottom line, by salary [inaudible 00:05:17]. Let's says, well, the hygienists I mentioned that was with us forty years. She did thousands of occlusal splints for about five hundred bucks a piece and it's not hard to figure out there's very little overhead on it.

Tom: It will be a procedural bonus.

Gordon: Yeah, the more expanded functions they do the higher the salary is. I don't care whether they're an assistant or a hygienist as long as you do it. Some of my assistants over the years have made more than the hygienist has. The hygienist who wants to just pick teeth obviously they're profitable, but they soon burn out. 

Tom: That's right. 

Gordon: The hygienist who will get into occlusal splints, [inaudible 00:06:12] appliances, diagnostic appointments, preventive appointments, and maybe half of the day is in hygiene and the rest is these other functions. 

Tom: Keeps them energized.

Gordon: Yeah, oh yeah, it does and the revenue goes up.


Tom: Do you differentiate between what assistants will do as expanded functions and what hygienists will do? It seems well educated they could both do most of the things you mentioned.

Gordon: Absolutely. Legally we got to look at that. The hygienists can, but cannot legally scale a tooth so we got to stay within that spectrum. But beyond that, they can be pulled into situations Yeah. You get, as an example, I have one hygienist assistant, she's both, who she's a CDA and RDH and she does our cone beams stuff so that's her thing so any [clumping? 00:06:53] she's in there. We have others who are full arch temporary assistants or hygienists and you know what a full arch temporary, how long that takes and how well it's got to be. I had one who was [inaudible 00:07:11] she had to go on with her sick dad and in doing so I had to do the temporary's, the full arch, and although I taught her, she's much better than I am because she does it every day.

Tom: Yeah.

Howard: So Gordon it seems like what Tom asks is there a ceiling on this deal.

Gordon: For salary.

Howard: For salary, it's so bizarre that the insurance companies can all talk amongst themselves to set our fees, but we can't talk about ourselves. It seems like a power grab because the dental insurance isn't trying to help someone because they're not saying, "Hey, I'll give you a $50 benefit to get your teeth cleaned. You go wherever you want." They're saying you can only charge $50 for a clean.

Tom: Sometimes I think they don't even pay for it.

Howard: Yeah and the government does the same thing. They didn't go to the poor people and say here's a $30,000 housing allowance so they could go buy a trailer home and live in their own property. They said no. No, we want to control. You have to live in government housing and not only is a cleaning only $50, but you can only charge. It's always about under the disguise of helping someone they're trying to control someone.

Gordon: In their way, yeah.

Howard: It's not a subsidy for housing and clothing where you say, here's $1,500 to help you get along. No, no it's food stamps. It can only be used this place. You got to live in government housing. Delta Dental, a nonprofit, "a nonprofit," , some of the highest paid people I know work for a nonprofit and it just seems to me that dentists should be able to stand united and say, "Look, if you want to help these people with a subsidy, that's fine, but don't be controlling me and telling me what my fees are even for things you don't even cover."

Tom: That's right. 

Gordon: It doesn't matter whether it's an A-plus quality or a C minus it's the same fee, I mean the same payment you know that as well I. Yeah.

Howard: But the consumer they make complicate decisions all-time between houses, cars, all kinds of different cars, houses, boats. They make sophisticated decisions all the time on price so if you give me $50 for a cleaning, I may say, "Well, I want to go to this guy because he subsides payment in full. Or you know what I want to go to this guy because I think he's better, but I'm going to have to pay ten more dollars out of pocket". But they're controlling everybody to the same fee. What if that was done in cars in America? What if the government did that in housing, every house had to be a $100,000 house. Every car had to be a $20,000 car. 

Gordon: There's those that would like to do that.

Howard: That's what they're doing in dental insurance. 

Gordon: Yeah, so how do we bail out of it?

Howard: And the government, like Medicaid, like California, they had so too low participation in dentist for insurance Medicaid so they raised the payment. They were shocked that more people signed up and they're so ignorant to realize that if it was just a subsidy, a 100% would take it. The reason they'll take it because you say, well we're only giving you forty for cleaning, but you can only charge forty for cleaning, so now you lost almost all the providers. 

Tom: Well, I think there's also the notion that the insurance companies may start to pay attention to the quality of the provider which you kind of touched on a little bit there. Would Delta reimburse provider A? 

Gordon: That's pretty delicate as you know because someone would have to make a judgment.

Tom: But they're starting to track outcomes, right?


Gordon: Yeah, oh yeah outcomes. They can look at outcomes.

Tom: So if they see that one dentist their fillings don't last ...

Gordon: Yes, the others they do.

Howard: I want to change something just completely [inaudible 00:10:58]. We've noticed some of the largest implant companies in the world like Straumann are buying all ceramic implant systems and there's a lot of Periodontists on Dentaltown saying that they don't think that titanium is as inert as everybody says it is.

Gordon: It isn't. 

Howard: And they're saying that at five years, 20% of implants have peri-implantitis. 

Gordon: You know what the real number is?

Howard: What?

Gordon: 46% latest study out of Gothenburg, Sweden done by dentists right in the heart of where implants started, Gothenburg. 46% moderate to severe peri-implantitis after nine years. Think that over.

Howard: Do you think that ceramic implants will have less peri-implantitis than titanium. Is there something about titanium we haven't figured out yet.

Gordon: Titanium, as you know, is, almost of them, 90% titanium, 10% vanadium and aluminum. Now you go and look at the electromotive chairs and go onto, oh, here's a website, one that is basically looking at leukocyte damage and you will see titanium has two or 3% [inaudible 00:12:18]. Vanadium's got a little bit. Aluminum has got a lot they're part of consistency or constituency of implants. I feel quite strongly that it's not just microorganism. Rella, my wife, was asked to look at the organisms that relate to peri-implantitis. She got in there and found they were so variable and a lot of other factors were negative. Diabetes was negative, smoking was negative, blah blah, blah, blah, blah. And she denied going after it because they would have tried to blame it on microorganisms. It isn't just microorganisms. There's metal allergies, it's oral hygiene, it's systemic conditions that titanium is working, well, it used to be many years ago I started doing implant placement thirty-two years ago where this is a godsend. Rip all the teeth output implants in. Now I'm just about the reverse, save the tooth at all costs, that's what I know now.

Howard: Save a tooth at all cost?

Gordon: Yeah and I'm seeing it at the All on 4 clinics, some of them, they're taking teeth out.

Howard: You know what I always call that ... 

Tom: Would zirconia implants be any better?

Gordon: We don't know that. I'm treating a patient right now who had All on 4, they put eight zirconia implants in. They're all out now, that was $60,000. Then they turned around and put all within, pardon me, all titanium ones in and now they're starting to fail. Is it immune response? What is it that's making them fail? There's nothing like a tooth I'll stand on that much.

Howard: Well, you know what I call boloney with dentists, if you study every major religion they don't have a city, place, person name, nothing in common in every major religion except for the one phrase, the golden rule. Treat other people like you want to be treated. I noticed a lot of these dentists who always lecture on veneers when their daughter needed veneers it was orthodontics and bleaching. When they say pull that tooth or do an implant on their wife, it was retreat the root canal, redo the crown and maybe a Periodontist does the surgery. And it's the same thing I see with natural paths, One of the biggest slams on Dentaltown is that if you're a holistic dentist or a natural path you're a wacko, but then every time that dentist gets told, well you need to go on a high blood pressure pill and you need to take a Statham and you need to take an ED pill. They're like, "No, I'm not going to do the [polymer? 00:15:06]. I'm going to lose weight, start acting ..." And I'm like, "Oh, well what are you, one of these holistic, wacko, natural paths." I mean you know ...

Gordon: You're right, Howard, you're right. No, I feel strongly that we've got to be preserving teeth for as long as we can because there is less problem with a natural tooth. It moves, an implant doesn't move. We were just doing a study of premolar implants. You put a premolar implant in and within months you lose your [contractual? 00:15:34]. What happened? The teeth are moving mesial so you can't move the implant so you wait a few months or years you got an open contact mesial. We can't deny it, the teeth are moving forward. Lots of challenges, but the main thing is peri-implantitis and we're seeing that now at an unbelievable level.

Howard:    So, Gordon, when you look at a hundred million insurance claims processed, all the activities on the six-year molars, it's just flat line boom, boom. 

Gordon: Yeah, that's right.

Howard: So the tooth most likely to get a filling first molar. Tooth most likely to be working out, first molar. Crown, first molar, implant, everything's a first molar. 

Gordon: That's right.

Howard: Podcasters are young. They're 25% of them are still in dental school, the rest are all in their thirty. Let's just go to dental kindergarten, first molars only. What would be your go-to full coverage on a first molar?

Gordon: You mean the crown?

Howard: Yeah.

Gordon: The crown.

Howard: Would it be gold ...

Gordon: On a first molar?

Howard: Yeah, first molar.

Gordon: Okay, you know both of you just as well as I do that you have some alternatives. 73% of [inaudible 00:16:46] who are the biggest lab in the country, 73% of their gross revenue last year was zirconia crowns so I don't have to tell you what's being done. What's being done is zirconia and we're finding almost every dentist doing zirconia routinely has had some of them come off in service. Whereas, in previous years with the old zinc phosphate almost nothing came off. Zinc phosphate and glass ionomers almost never came off. Now they're popping off, so zirconia is working and I just understand your course in there telling them how to make them stay on. There's ways to make them stay on, but they're not ready to say no and what's going to last the longest? Is there any reservation, Casco. Casco, yeah, same here, same thing. Casco even done poorly, well, I have casco that's been in fifty years and every single one was done by students at USC, not a single one of whom had any idea what they were doing. So then there it was zinc phosphate cement and they're still there. Yet we look at some of the newer cements, the companies are pushing us for resin. Resin is cariogenic, resin cement.

Howard: Resin's are what?

Gordon: Resin's are cariogenic, resin cement.

Howard: Yeah.

Gordon: If they go resin-modified glass ionomer they got a little cariostatic, but a gold crown, and I hate to say it because nobody wants to do it, but I just had one done on me, gold crown second molar. Now I asked the aesthetic academy last year, what would you have in your own mouth on various situations?  And I'll just say it because it will be interesting to the listeners. Second molars aesthetic academy, gold, second molars. First molars, lower gold. First molars upper, now they wheezeled it. Aesthetic Academy, now they said, not gold because it's going to show that PFN because we got sixty-five years of research on it. Pre-molars [inaudible 00:18:33], anterior ...

Howard: Emax.

Gordon: Yeah, you're looking [inaudible 00:19:02] at Emax. Anterior now most of them agreed looking at silicon right now. However, we're seeing changes come in zirconia. We're seeing changes come in layered zirconia and I asked them what about a three-unit bridge anterior. You can't do an implant for some reason, what you going to do? They came out by brand name lava layered zirconia from 3M because they've mastered the [cleverage? 00:19:20] of expansion of the outside and the inside. So Rella and I and you guys listening, Rella is my wife, Dr. Rella more knowledge on zirconia and crowns in any human and I asked her the other day, what if we had to go back to 1975 and we both agreed we'd probably be better from a functional standpoint. We would be worse from an aesthetic standpoint, but functional, yeah. Functional was better.

Tom: On the topic of materials. What are your thoughts on this growing area of the bioactive materials?

Gordon: Now, okay, Tom...

Howard: Great question, Tom. Great question.

Gordon: You have an unbelievable question. Now. I'm going to go back to the mid-1800's dental cosmos, the pre [inaudible 00:20:22] to the ADA Journal. They would take an English sparrow and go ooh, the poop that came out in the hand was used in the [inaudible 00:20:29] and that was one of the first bioactive materials. You take dycal, which everybody's used almost and dycal builds a dental bridge. It was bioactive. The only thing new about bioactive materials is the damn name. They've been around since the mid-1800's, but they decided to make a new name to make it look attractive, so resin-modified glass ionomers is bioactive, glass ionomers is bioactive. How long they been there, twenty-five, thirty years, so nothing really new. What we're finding is the word bioactive in dentistry means formation of a form of hydroxyapatite in other words what a tooth is made of and that's been around forever. So the products saying we're going to fill the margin with phosphorus and calcium we're finding no transfer at all on some of those materials. We have more fluoride than resin-modified glass ionomer, we're finding some advertising had no fluoride coming out of them. We looked at seven hundred and seventeen new products last year and one out of five met their plan, one out of five, [90% 00:21:34]

Howard: I know and a lot of these dentists are conservatives who believe in economics. They say, well, free trade is the best, free trade because I see four chickens and you see a pig and we're going to make a trade. And I see it's fair because we're both on top of it. Well, that doesn't play into effect the billion dollars a day spent on advertising to make this trade being blurred with misinformation and so when people talk about free trade, I believe in free trade if you back out advertising, but advertising is so much misinformation. I think of Adam Smith was alive today he'd be appalled. Why don't we settle it on another dispute because ...

Gordon: Okay.

Howard: 90% of dentists are taught and believe that amalgam fractures teeth and then they're going to need root canals and crowns and that composites glue the walls together and make the tooth stronger.

Gordon: That's a joke, total joke.

Howard: And then when you tell him that amalgams last longer than composites. 

Gordon: Twice as long.

Howard: They don't believe you, so she believes that she should take out everyone's amalgams and replace them with composites because she's doing the patient a favor. What would you say to her? 

Gordon: I would say very clearly the international data, not some isolated study done by somebody in academics, but if an overall view shows amalgams will last twice as long, but and yes there's the occasional fracture because amalgam in [inaudible 00:23:22] can expand slightly. But all composites literally all shrink 3% so around the margin of every composite you and I ever did was the Grand Canyon looking down into the [inaudible 00:23:46]] and that's one of the reasons why there's no caries there. Other reasons why they're coming out is that that bond situation, I'll say very candidly the word bond probably got to be eliminated from dentistry. I'll explain that a little bit if we put any one of the good bonding agents on there I don't care which brand. You put it on dental you got fifty megapascals today. Then they go out and they're drinking a hot cup of coffee, cold ice cream [inaudible 00:24:18]. Try it six months later its half, try it a year later there's no bond. Now you put it on enamel and you get about forty megapascals today. Let's send in our six months so that's already megapascal. Why? Because you've got an interdigitation of all those [inaudible 00:24:36] regularities like bricks on the wall that hangs on. There is no bond. The bond is gone. It's the interdigitation, it's the bricks on the wall so when we say we're going to bond, in your dreams and then you look at things like MDP primers it's supposed to bonds zirconia, the bond is miserably low eight megapascals. I can blow that off with my breath, but yet they can advertise they got a bond. The bond, word bond is false. You got to be eliminated and bonding dentin to dentin with a layer of cement in between this resin, total joke after six months. The bonds gone. It's the actual irregularities, that's one way to keep a zirconia crown on. You have to go on the inside of the crown and in the course, I just gave them to raise generations in zirconia, only the first generation and that would be [inaudible 00:25:36] can you do this too? You go on the inside and make scratches on the inside of that smooth crown. You know how slippery they are, how smooth they are. Now you got irregularities, then you go on the outside of the prep and you make diamond scratches. I got an interdigitation [inaudible 00:25:50]. If I go [inaudible 00:25:50] zirconia and a smooth crown prep, they're off. I don't care what kind of cement, most of them are coming up. 

Howard: Okay same question, sorry, I don't mean [inaudible 00:26:05]. Back to those engine graphs, you see a hundred million claims based on the thirty-two teeth and it's just four huge spikes on three, fourteen, nineteen, thirty. So same question with dental sealants. She's six years old, those four teeth are going to rot and they're going to be the most likely to have anything ever done to them. [inaudible 00:26:28], crowns. Sealants, aren't you just bonding resin to pits and fissures filled with plaque and cheese sticks and Oreo's?

Gordon: Yeah, and I did hit that in the course minutes ago. If they blast out now, I'm going to get irritable relative to what was originally taught and what has continued to be taught because it was wrong. The thought was that if you seal the bugs inside that crack that you're going to stop caries. That is so false. Dr. Rella has shown very clearly that decay goes faster. Their bugs are sealed off. They get more fluoride from the toothpaste and they just sit there eating one another and eating the tooth.

Howard: Does making it an anaerobic environment help them too.

Gordon: Nope. They go for an aerobic to anaerobic in hours, the bugs do. They just decide I'm not getting any oxygen, okay we'll turn it off and they're into anaerobic. So the point I made in the [twelve? 00:27:21]  course was they have to blast out the crack in the …

Howard:    What would you blast it out with? Would you use a burrow, a laser?

Gordon: Well, if the dentist is doing it, you've got $150 restoration. If the staff does it, we got a $50 sealant so the staff blasts it out with sodium bicarbonate. It starts out as a big rock the water gets hot and it gets smaller and smaller and smaller it'll go right to the bottom of the groove.


Howard: And what would you blast it out with?

Gordon: Pardon me? 

Gordon: What would you blast it out with?

Gordon: Well, [inaudible 00:28:04] there are a dozen out there and that's all staph. So staph can blast it, get the crap out. Then they've got to put ...

Howard: No, it's not staph, it's streptococcus mutants, it's not Staph.

Gordon: Crap. 

Howard: Is that where staff is named after staph bacteria. Staph infection.

Gordon: Rella's studies have now shown over almost a hundred organisms. We do a DNA analysis of over a hundred organisms are in caries and Staph, pardon me, streptococcus mutants is not even in a lot of the caries even though that's what you were taught I was taught. It's not even in it. [inaudible 00:28:44] 

Howard: It's an oversimplification to think that streptococcus mutants causes cavities. I mean that is so ...

Tom: And even sealing with a filled local resin. What about sealing with the glass ionomer based material as well? 

Gordon: Glass ionomer, the one that releases the most fluoride, Tom, like any material we know is a materal called triage MGC, but you have to keep replacing, replacing, replacing.


Tom: Because it wears out.

Gordon: Yeah, wears out. Yeah, that's the most cariostatic thing in dentistry by far, the most cariostatic. 


Tom: When you're cementing crowns on implants when it's necessary for cement. We know screw it in retainer's preferred.

Gordon: More popular, yeah.

Tom: What are you using for cement? You want something reversible or you're not worried about that and what about [radiopaque? 00:29:33] 

Gordon: Excellent question. I asked the aesthetic academy a couple of years ago, I give a paper a year for the last hundred years practically, not quite, but a lot of years.

Tom: Close enough.

Gordon: And I asked what percent dentists and these are all mostly mature people. What percent of your crowns cemented over implant abutments, not screwed cemented over implant abutments, what percent have you had come off? Just guess over your whole career? We got a number, [inaudible 00:30:05] 15%. In other words in a hundred crowns cemented you'd have fifteen of them come off. Okay, obviously we're trying to screw through it now. If the implant is perpendicular to the occlusion plane, you can put a screw in it. If it's not, if it's facial, we got to make a hole and therefore it goes back to cement it. Okay, but to answer your question, typical cement that would be considered quote "permanent", and this is a bad word would be resin-modified glass ionomers or resin [inaudible 00:30:38]. If that comes loose, in other words the screw holding the abutment comes loose, you're dead, you're dead. Now you're going to go through the occlusal. If it's lithium [disilicate? 00:30:50], you broke it. If it's zirconia you're having a hard time even finding the screw hole so you're pretty well [inaudible 00:30:55]. If you've cemented with a reasonably [retentive? 00:30:55] that you could whop off material, I feel you're much better off. In our studies two products come up, one is Telio implant cement that's from Ivoclar and the other one is the newest version of premier implants cement where they put [radiopaque? 00:31:20] in. Now it comes loose and the patient says a little bit loose. I usually tell them that's like a little bit pregnant, something's got to happen. So we'll take a wire, the smallest diameter orthodontic wire you can get, let's say it's a central. Go through one side, wrap it around the lingual, come through the other side, take a pair of pliers, twist it, twist it, twist it, twist it. Where's it going to go? It can only go up [inaudible 00:31:48] It'll go right to the septa [inaudible 00:31:48] Then what do you do? Now you take a van deep or one of the whopper off's and hook it in that wire and pop it off. Now I'm into that without screwing them up or if they've used the final cement you’re dead meat, but Telio and premier implant cement are the two choices and they're both, well Telio is very radiopaque. Premier is not so radiopaque, but adequate.

Howard: You know what my doctor tells me I am three screws loose. He says there's nothing he can do. So you never told us what cement you would cement that [bridges? 00:32:24] with. 

Gordon: Oh, the [bridges? 00:32:33]. Okay, now I'll quote some of those research. We have cemented nine hundred units of three unit bridges and they've been in now fourteen years and this is done through one hundred different, hundred and six I think she's got, different dentists. So it isn't just one dude doing everything, which is a terrible study that's [inaudible 00:32:56]  the right one. I like hundred because now I got bad guys, good guys. So we got hundred in this study, [inaudible? 00:33:01] and it's fourteen years, in the three-unit bridges we've had 4% de-bond. Now when we, I hate the word de-bond, we've had 4% come off and [inaudible 00:33:01], or the other, now we have to beat it off, so what cement did we use? We didn't have any idea what was the best because everybody was using resin-modified glass ionomer. 40% of their cementations according to the survey are resin-modified glass ionomers right now, 40%. So we use Relyx luting from 3M. Relyx luting was remarkably good with 4% de-bond. That's good even with zinc phosphate. 

Tom: Absolutely.

Gordon: Now we've got close to nine years of research on single unit zirconia crowns done in the way I mentioned. No de-bonding with resin-modified glass ionomers.

Howard: What's your favorite brand on that?

Gordon: Relyx luting 3M.

Howard: Relyx luting. That used to be the old Vitremer bond.

Gordon: Pardon me.

Howard: They used to call that Vitremer.

Gordon: Used to call it Vitremer, yeah. Or you could also go to Fuji plus from GC or  [inaudible 00:34:10] got a resin-modified glass ionomer, yeah almost everybody. Cruz got one now.

Howard: And they just moved their headquarters from Tokyo to Switzerland. 

Gordon: Yeah, I know …

Howard: Is that just for taxes?

Gordon: Well, I'm not sure. Mr. McCow who's the owner of the company.

Howard: Does he still live in Tokyo? 

Gordon: No, he's ...

Howard: He moved to Switzerland?

Gordon: He's moved to Europe, yeah, a very ethical company. One of the few.

Howard: So it's more than just taxes. 

Gordon: I think so. Well, we work with three thousand companies and some of them we trust completely and others, I'll be candid, we don't. 

Howard: Yeah, but Fuji’s one that you can trust completely.

Gordon: Fuji is one we trust completely.

Howard: What are some of the other [inaudible 00:35:08] companies you trust completely.

Gordon: That we trust, okay, 3M, Ultradent. Ultradent just got an award for, last year, I'm going to call it right, but something like the most honest company [inaudible 00:35:20] Ultradent, Centrix, I could name ...

Howard: Centrix, that's Bob …

Gordon: That originally was Bill Dragon.

Howard: Bill Dragon.

Gordon: Bill Dragon.

Howard: It's still Bill Dragon isn't it.

Gordon: Well yeah, he's my age and he's pretty crippled, but he's still involved with it.

Howard: He was in a car wreck or something, never recovered.

Gordon: I don't know. He's got a cane and ...

Howard: Yeah, I think he was in an auto accident. 

Gordon: There are quite a few companies ...

Howard: So Centrix, Ultradent, 3M, Fuji.

Gordon: Ivoclar.

Howard: Ivoclar, makes the list.

Gordon: Ivoclar. I was just in Lichtenstein looking at the problem I expressed in the course and that is the more [inaudible 00:35:58] the more it breaks. These guys got on that fast because their cash cow has been emax and emax is being beat up somewhat by these other crowns so ...  

Tom: Yeah, because they've come out with there zirconia.

Gordon: So they know they've got to have zirconia and they're really working to see should it be, three wire works, seven-wire is failing. [inaudible 00:36:16] so now they and others are trying five, 6%. What's the right percent to get better aesthetics ...? 

Howard: I want to go back to implants because when these kids come out of dental kindergarten a lot of them have three hundred and fifty, $400,000 in debt and a lot of them are told that you see this peri-implantitis, but the best way to treat that is to go with Lanap, which can be anywhere from eighty-seven to $135,000 package depending on how much training you get with your deal. She's already $350,000 student loans, then Sirona is telling her she needs a $150,000 chairside milling. The implant companies telling she needs a $100,000 CBCT. Does she need an eighty-seven to $135,000 millennial laser Lanap to treat peri-implantitis? 

Gordon:    Do you? Now Lanap if you're listening to this, you know what we've proven, so don't whine. Rella did a five and a half year study on this very concept with not just Lanap, which they did not want us to test, but we were able to test some others that have used that. We used CO2, erbium, MB [inaudible 00:37:40], we went across the board and it was a highly controlled study. There were in periodontist offices, general dentists offices, this was the track division of [dentists? 00:37:56] report, which Rella coordinates. They take a team into the office, they'll stay three or four days, it's a really expensive kind of study and there were several factors in this study. One was scaling root planing alone, one was laser, various plans, alone. One was a combination of the two. Do I really want to say what we found because these people get mad at me. Scaling and root planing was the best with laser was used with it there was a very slight positive difference. When laser was used alone, not much. Now as good as anything that laser did was just the lavage from a ultrasonic cleaner, just dooshing the inside with that powerful hose of water, the  solution was adequate. So and I know Lanap gets excited this paper was delivered at the American Academy of Implant Dentistry if somebody wants to look it up and it caused quite an uprising because some of the claims on laser are so extravagant, it's absolutely absurd I say it. Well, you take diode, diode laser isn't a laser. Well, it emits light, but does it emit like, no. You have to put some black thing on the end of it, which does what, stops the light? Light turns to what? Heat. So what you guys [inaudible 00:39:34] elective surgery. That's all you got. Cutting a three quarter millimeter wide diameter cut when you can go down to even the elective surgery, make a point on it which is now available in several of the companies and cut a tenth of a millimeter cut and I'm going to pay $800 for that versus five thousand for the diode. There's a lot of hype out there.

Howard: So you like the elective surge better than the diode?

Gordon: I use both. If I'm doing say scanning and there's a little piece of meat that keeps coming up over the margin, it's very easy to go into it with a diode and just barbecue that little piece. If I go with elective surgery, I'm going to cook more meat so ... 

Howard: I can't let you leave without asking you to weigh in on the single largest, if not only controversy in pediatric dentistry, 10 minutes. So as you know Tom and I are both in Arizona. We just had another child die during ...

Tom: Sedation.

Howard: Sedation during [inaudible 00:40:46]. We have pediatric dentists in Arizona, like Jeanette McClain who's saying, first of all, this two-year-old, you could have put silver diamine fluoride killed all the bugs, reapplied it every six months until the space it was more manageable. A lot of the pediatric dentists say, no, we've got to take this kid to OR. It seems like almost every quarter on social media, some little kid dies somewhere doesn't survive the general sedation.

Gordon: Oh yeah, no question in my mind.

Howard: So what are your thoughts of silver diamine fluoride? 

Gordon: Oh, you don't want to go to sedation or general. Let me hit that first.

Howard: Well, yeah.

Gordon: We just did one of our [dentists? 00:41:25] report. By the way, if you want to go to our website, so I'll see say it right now, tcc, Paul, Charlie, Charlie,, or clinicians just like it sounds, and you'll get a lot of this information. Anyway, we just had one of our articles on that very topic. What about sedation and general anesthetic for fairly routine things and we found the percentage of death and it was high, but on the other hand it doesn't even partially represent where they die because they only record death when they go to ... where they're going to go if they're in trouble. Go to the hospital, where do they die? Hospital. They really died in the dental office, but it's recorded in the hospital. So the deaths are far higher than we would ever expect because they're record it as a hospital death. The kid came still alive, died in the hospital or adult too and now you want to get me into silver diamine fluoride. It's a highly controversial subject. It's been around about a hundred years although the company only claims about fifty years. This is one where it got an ADA code faster than any ADA code I've ever seen because there's a lot of bucks pushing this. There big federal grants and company grants coming in to push the public health orientation silver diamine fluoride. I'm positive and I'm negative. If I want to detect the initial caries in a molar which you've talked about a couple of times,  one drip of silver diamine fluoride, it goes down into that overall atomic bomb dipped upside down and it's black. If it stays black when you wash it, cut it that's caries. So that's one of the easiest [inaudible 00:43:20] caries identification we got, just one drip of silver diamine fluoride, but they're charging over two hundred bucks for that miserable little bottle, so there's a little something happening there. What is it good for? Their advertising is partially correct. Does it kill the bug? No. It kills a few of them. Rella, she got commission to study that It kills some bugs, but the bugs are still working there. The caries are still active. Does it crust over and make the tooth hard? Yeah. Does it make it beautiful? No, it makes it ugly as sin. You know it's black, black black. Is the caries stopped underneath? No. You've got a black layer, billions of organisms, then you got a cream layer, thousands of lurking organisms. Then you got a tooth-colored layer, hundreds of organisms still there so all the way down you got a lot of organisms still living. Should you put glass ionomer over the top which some are doing, that's stupid. You got to doosh it again several times. If you don't then the stuff goes inactive again. So what do I feel it's good for? Last one caries [identification? 00:44:34], nursing homes, areas of poverty where they're going to have something better than nothing. Third world countries, locations where there are a lot of senile people living ...

Howard: Third world countries, are you talking about Mesa or Phoenix?

Gordon: No, Los Angeles.

Tom: I have an implant question.

Gordon: Yes, yes.

Tom: In the case of what's commonly referred to as the All on 4's. You got multiple implants, a denture-less patient, there's really a couple of main options. One is a fully retained implant retained hybrid denture or one is a bar that the denture clips onto. Do you have as a Prosthodontist, a preference of one versus the other or a time when you would choose one versus the other? 

Gordon: I certainly do. Right now I'm treating several people who have had All on 4's done by a very competent dentist and I don't have to tell either one of you or viewers if you're listening that the face sinks in because if I fill up [inaudible 00:45:39] lips out where they were, they can't clean under it. As we did surveys of thousands of All on 4 users, we found the most common complaint was there second last Thanksgiving dinner out and their breath stinks. If they do it all in one day, in other words, jerk and screw same day there's spaces in some of these a quarter of an inch. They can pack their lunch in and suck it out every fifteen minutes. Bottom line is pretty clear. Let's say you got four implants, now if you're going to do All on 4 you're going up into the zygoma, most of the time. If I do All on 4 and leave it anterior to the metal frame and anterior to the sinus I can put four locators on their make a palette less denture, both the lips are right where they want it. They can pop it out and wash it in a minute. It's one fourth the cost of All on 4 screw in and they look like a normal human. If something breaks fifteen minutes it's fixed. It's not taking it out and doing all the shenanigans you have to do. If I were an [inaudible 00:46:47] which praise the Lord I'm not, I would prefer, sorry you guys, I would prefer [inaudible 00:46:51].

Howard: Absolutely.

Gordon: Because I can clean it. I still got the power of indent, I've got total full contour. I've got any shape of teeth I want. I'm not [pusting? 00:47:02] around with the thing breaking. I'm not got some major twenty to $40,000 surgery. 

Howard: It's the same reason I went with a wig instead of the hair transplants.

Tom: Yeah, the magnetic wig, yeah.

Howard: I wanted it removable. Do you have one more question?

Tom: I do.

Howard: Okay.

Tom: Have you spent any time, while we're on the prosto topic, have you spent any time with digital denture in that category?

Gordon: Oh yeah, yeah. We spent time and I'm going to be positive about digital dentures, but I'm going to be negative about dentists. One study we did was Lith [inaudible 00:47:27] and ...

Howard: Out of Scottsdale.

Gordon: Well, yeah. Now I'm biased, so I'll say that to start with because I've done thousands of dentures, so we picked some patients. I did conventional and I did digital and they were pretty equal. Then you look at it in the field. Now I'm on dentists. They're getting out of dental school some of them having watched a denture being made. Never done one.

Tom: [inaudible 00:48:10]

Gordon: So when you do a digital denture, at least at this stage, the digital denture has to digitize what, the cast and if the final precedent is no good, how good is the denture, useless.

Tom: Useless.

Gordon: So the problem is not just digital dentures, it's all dentures. Dentists as a general rule cannot make a denture impression.

Howard: Gordon, I just met two dentists who just graduated middle school one did not do a root canal. The other did one. Final question, you got a taxi to catch. You've got two minutes to answer this question. The most controversial thing in dentistry, pew research is pushing dental therapists all around the country. What do you think of pew research and what do you think …

Gordon: You're going to get my blood pressure high right now. I'll say it in the vernacular. It sucks and I'll say it very strongly that there is no place and I've sent this to states [considerary?  00:49:47] Minnesota's got med levels, have you got it? You're trying to get it. 

Howard: They're voting on it now.

Gordon: Pew's saying it, several of the organizations are saying this is the way dentists should go. I talk to veterinarians fairly often. I mentioned that this morning and they always ask us how come dentists can get patients to come in on the average 70% are coming in once per year. We can't get our dogs or cats to come in more than when they're sick. Physicians treat people with a broken arm or they're bleeding or they're in a car wreck. How did you dentists do it? And I said we have a team and everyone of them takes their job seriously. Assistants, hygienists, technicians, general dentists, specialists, front desk people, and where is a place to stick some obscure unknown creature. They're not hygienists, they're not an assistant, they're not a dentist. They're going to go to areas of need - in your freaking dreams. They're not going to areas of need. I asked the Minnesota people, where they going? Northern Minnesota, no. St Paul, they're going to St Paul, they're going to Minneapolis. Some of them were flunking the board. There is in my very strong and quite considered opinion, there is no place, no place literally for mid-level practitioners and I would stand behind that. 

Howard: So who is pew research and why are they pushing it?

Gordon: They're looking at the New Zealand nurse. They're looking at the Alaskan, and that's fine. It's a confined area. There's a lot of government funding, blah, blah, blah, but you put that into a private practice. They're going to make some money and I see absolutely no purpose for it. Expand as we did today, expand the functions of hygienists and assistants with a quarterback. There's no quarterback with these people. They're going to do simple dentistry.

Howard: You got a plane to catch. I'm going to kick you off my own show. I just want to tell you. Thank you for all that you've done for dentistry.

Gordon: Thank you. 

Howard: When I got out of school you were the one, you were my idol, my God. 

Gordon: Thank you, thank you.

Howard: [inaudible 00:51:14] you took dentistry to a whole new level, we never looked back.

Gordon: I appreciate it. Well, let me tell you about him. He's a rebel rouser. He has stimulated ADA, we tried to do together a few times, I love ADA, but I hate ADA because we need more action. It's apparent you can't kill them. So Howard has challenged them. I had challenged them. I went right before the board of trustees with 20 crisis in 2011. Do I have to say if anything's happened, I'll let you figure it out? Bottom line is we need you young people to get on this immediately. Third party, mid level, I could name twenty off the top of my head because if you don't nobody …

Howard: And also you decided this year, Tom Giacobbi has been the editor of Dentaltown magazine since the year 2000 and he's incredible and you decided to write us four columns this year.

Gordon: Yeah.

Howard: Right, was it four?

Tom: Yes.

Gordon: Yeah, yeah.

Tom: Very excited. 

Howard: Thank you. You used to publish a column in the ADA and we both knew no one ever read it. 

Gordon: Oh yeah.

Howard: So now at least you're going to a magazine that people read.

Gordon: Well, you're all too true.

Howard: And I really liked you a lot, but really thank you so much.

Gordon: Thank you, Howard.

Howard: So much for being a contributor to [inaudible 00:52:36] Dental Magazine.

Gordon: And Tom, thank you.

Tom: Thank you so much for your time.

Gordon: It's been my pleasure. Thank you, thank you.

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