speaker-0: Welcome back to your all in, all on X podcast. I'm your host, Dr. Adam Hogan. We are here for a very special live one-on-one podcast with my good friend ⁓ Dr. Vishy Bruman, Dr. Vishtab Bruman. ⁓ I love it that we got to be in in ⁓ in person today, man. Welcome. Welcome to the show.

speaker-1: I know, imagine being here both at the same time. That's awesome.

speaker-0: That's great. Little update, you know, we ⁓ usually I'm remote because I'm in Virginia Beach and it's tough to get people in person, but I was trying to hook up with this guy right here, this incredibly good looking gentleman on my left. And ⁓ he says, I'm gonna be in Vegas next week and I'm like, I'm gonna be in Vegas too. So we took the show on the road. I got like all the equipment up here and ⁓ first time first time going remote.

speaker-1: Worked out perfect, man. Yeah, I actually ⁓ made sure that our hotel was less than a block away from you, so when I found out where you're staying, I like, Okay, we gotta stay close by That's how it worked out.

speaker-0: That's great. That's great. So here we are in beautiful Las Vegas, Nevada. You can't this is our my ⁓ hotel suite right now. so apologize for the background, but it's good to have you in person. So ⁓ we've been here, we've been chatting for an hour, we've got a lot of topics we want to talk about. but ⁓ before we do that, I think I should probably give you an introduction. Welcome back to the All In, All On X podcast. Where we take you behind the scenes of full arch dentistry, innovation, and the people who are redefining what's possible. Here we go beyond the procedures and into the lives of people shaping full arch dentistry. This isn't just about implants or workflows. It's about the lives we build, the decisions we make under pressure, and the leaders who push this profession forward when no one's watching. Get your head straight, because we're about to go all in. The all in all in XPod is brought to you by JB Dental Labs, the elite lab, trusted by full arch surgeons. Prosidonis and digital forward practices internationally. JB specializes in precision full arch restorations, zirconia, PMMA, photogrammetry workflows, and fast turnaround times that don't sacrifice quality. JB delivers a truly digital workflow powered by their proprietary online portal for easy case uploads, real-time tracking, and fast streamlined communication. If you're looking for a lab that understands immediate load, Passive fit and the demands of modern all on X dentistry. Learn more at JBdentalab.com. Tell them that the all in, all on X pod sent you. ⁓ a man that I feel really needs no introduction. but I printed up some notes here about you, man. ⁓ founder of the owner of Desert Ridge Oral Surgery Institute, Oral Maxwellfacial Surgeon, Phoenix, Scottsdale, Arizona. you've got a tremendous ⁓

speaker-1: Way too comment.

speaker-0: resume. Hospital training. I know you trained down in Miami under Bob Marks. ⁓ did a little ⁓ residency, mini residency at Portsmouth Daveville Hospital where I was in two thousand three, four. ⁓ yeah. ⁓ so we kinda go way back. But why don't you g give the listeners just a brief ⁓ minute or two of your history so they can know who they're listening to and who they're talking to. ⁓ yeah.

speaker-1: Well, thanks for having me again, Adam. I I l I love being here. This is a real pleasure and honor to be here with you. ⁓ so I went to dental school, University of Florida, and ⁓ afterwards went to Miami to do my oral surgery training because everyone talked about Bob Marks back in the day. Everyone said, Well, Mark says this, Marks said that. I'm like, you know what? I wanna go train with this guy. Yeah. And they said, Well, they don't take anyone a fresh out of dental school. You gotta do a an internship and this and that. I was like, you what? I'm gonna take my chances. So I went down there when I was a dental student, fourth year, third year. Did a one month ⁓ externship and I took call every other night. So imagine for thirty days as a dental student I was there fifteen nights. So that impressed everyone. Luckily I got in, so I went to Miami for a residency right at dental school and afterwards I did a year private practice right there locally in South Florida. But I got bored pretty quick because I just you know, back then ⁓ you had to work for practices in South Florida. I took every insurance, you just took out lots of teeth, and I wasn't placing implants, it was just teeth teeth teeth. And I called Up Marx and I Hey Dr. Marks, I want to come back for your fellowship. Luckily, it worked out because it was a few-year waiting period. It worked out where I was able to get in because one of the guys that was coming from Saudi had visa issues. So I I didn't have to wait three years. I got in the following year, did Marx's ⁓ head and neck cancer reconstruction fellowship, which really cemented my training. It was the best year of my training. I got to spend ⁓ you know a year, day and night with my mentor, and we did so many cases. He was writing his second edition of his book, so I was operating like crazy. But that fellowship was amazing. And then I stayed on as faculty for a little while, was getting ready to go to New Orleans. A lot of people don't know this. I was gonna go be faculty. I was destined to be in academics for life. I was gonna go to LSU New Orleans. And then ⁓ Marks and I were actually at the International Association of Rural Surgery Meeting in Vienna that summer after I finished my fellowship. I was listening to Malo lecture on the all on four techniques, and I I remember I was like, this guy's a lunatic. Four implants for a full arch. I'm like, this is never gonna work. And he's presenting his research, a thousand arches, only three failed. I'm like, and Marks and I were like, This is crazy. Yeah. So we go back to our hotel and then he calls me up. He goes, Did you see Hurricane Katrina just hit New Orleans? What are you gonna do now? You're gonna be unemployed. And sure enough, the levee's broken. I didn't have a job. So ⁓ as a result of that, I came back to the States and I was like, now what do I do? So I had to go look for another job. It was a week before I was starting in New Orleans. So I found a six-man practice in Daytona Beach with a couple of guides that I had trained with. One was my chief resident, one was a year below me. It was a full scope practice, and they said, hey, anything that you were going to do at LSU, full scope, cancer, reconstruction, you can do here because none of the other colleagues in the community want to do it. So I went to Daytona Beach for about four years and I had an amazing practice. But you know, I was part of a practice that was fifty staff members, six docs. Imagine being s married to six people. That was the hardest part was I got along with everyone, but none of the guys got along with each other. Right. So ⁓ you know after about five years I was got tired of being the middleman and I was a full partner but I was not making any money because her overhead was about eighty percent. True wow. And that practice still exists but the overhead is still about eighty percent. So I called up Dr. Marks, I'm like, hey I'm ready to come back and be full time academic. So I went back to teach. ⁓ I was teaching for about ⁓ three to four years and I met my my wife and ⁓ she's like hey I have two offices in Arizona and looks like ⁓ I can't sell ⁓ 'cause the real estate market had crashed in, you back then in two thousand eight it was awful. I I lost my shirt on my house. But ⁓ so I told Dr. Marks I was gonna go out there and he goes, ⁓ they got a j young program there. So ⁓ I went there and they said, Hey, you're overqualified for what we do. I'm like, Well, what does that mean? They said, Well, we're not gonna do the kind of stuff you do.

speaker-0: Doesn't

speaker-1: do teeth and I said, Well, why don't we do it? Yeah. But they ⁓ they weren't really interested the program at the time at Banner. So I just opened my private practice and ⁓ I continued doing what I was doing in in my academic setting in private practice and but you know I I I was already doing a lot of full arch and so it was nice. I mean so I ended up in Arizona and you know a Miami guy in Arizona a little culture shock for me. ⁓ the weather was a little different but man it's been it's been awesome. It's been a great ride for ten years in there in in Arizona and ⁓ ⁓ never look back.

speaker-0: Yeah. To me, I mean, what a tremendous ⁓ story and the way that ⁓ God kind of puts things into our lap or steers us in a certain direction, you know, with Katrina, the way that the way that that affected you. we got my wife sneaking out. Yeah. Busted. Two cappuccinos here, please. Thank you. Do you want more than a dream? You want a coffee?

speaker-1: I'll take a double espresso. I'll be gonna it's quick as ⁓ how are you? Look good? You know, like I said, I did a podcast yesterday in the hallway ⁓ in the lobby of my hotel and it was it was kinda Yeah. It was good 'cause I the ⁓ you know the AirPods. AirPods but

speaker-0: AirP you didn't have the boom mics and all the lights? No, nothing like this. This is awesome. I didn't want to get I don't want to get kicked out of the public spaces. Anyway, real life folks. This is ⁓ Allie and I are here in Las Vegas enjoying ourselves. We're gonna go to the Kenny Chesney concert tonight and we're gonna see UFC McGregor tomorrow night. Are you coming to UFC?

speaker-1: I'm gonna see UFC? No, not UFC, just ⁓ Katie and Chassidy. Okay. And obviously Wizard of Oz. We might stick around for that. Okay. My kids would love to see ⁓ a UFC fight. ⁓ who do you think is gonna take that one?

speaker-0: I I hope McGregor 'cause that's I mean I want

speaker-1: fighting five years ago.

speaker-0: Right. I want to see him go out on a high note. He was injured last time. He a lot of people don't know that. You know, he got injured in training and then he didn't do well in his bout at all. And then he had legal problems and things it took a while to get back. I just want to see him go out on a high note. Yeah, yeah. You know, I mean nobody wants to see you like retire like at the bottom of your game. Nope. You know, so I hope he and I hope if he does win, I hope he stays retired. Absolutely. Yeah. So anyway. So yeah, it's good to be here in Vegas with you. But again, going back to your your resume, ⁓ Katrina hits, you don't go there and And turns into this whirlwind, you try private practice, you see you learn a lot from that 80% overhead, and you learn why that doesn't work. A group practice with five people in it, very hard to run. I mean, you're basically married to five spouses. For sure. And you know, you have enough trouble in one marriage. I mean, you know, when you're married to one person, it's enough to deal with. Absolutely. You know. So it's it taught you a lot.

speaker-1: I mean 'cause there was six of us. One guy did nothing but facial cosmetics. One guy did nothing but orthomatics and joints. And one guy did tons of exodontia. I was the head of the cancer guy. There went there was a full arch guy. And I was really intrigued by what he did because he was doing twenty arches a month back then.

speaker-0: Well that's crazy.

speaker-1: it was ⁓ John Akers, great guy, tweam to South Carolina and I thought to myself, I wanna learn what he does but is, you know, obviously every doctor 'cause we had three offices in all in ⁓ in, you know, what we call now Volusha County, in Daytona Beach, Palm Coast, Nishamurna Beach and everybody sent the patients to him and I became known as a cancer guy. ⁓ but he taught me a lot. Mm I learned a lot from him. It was great for me because I was a left handed surgeon. Okay. And any time it was a big case in the hospital they're like, hey, this you come along, you Left side, we do the right. So I learned about ortho nactics from from Dick Gaines, who's ⁓ an amazing friend and mentor. He's passed away now, but he's Miami trained as well. But he was the first graduate in class from Miami, like back in the 70s. Yeah. Like we missed each other by 30 years. But ⁓ you know, ⁓ it was it was a great experience. But you're right, overhead was massive. And ⁓ I learned how to keep it small. And now in my practice, it's just me and ⁓ ten staff members. But ⁓ you know, I have ⁓ you I learned a lot from that.

speaker-0: I could ⁓ I could say a lot about, you know, practicing by yourself. We say twenty arches a month back then. ⁓ who was doing the prosthetic support and rehabilitation for him? Was it just the referring dentists that were sending up? Okay.

speaker-1: all done by referrals. We had some great referrals and they did all the we had a lab that would come and do the conversion. Yeah. ⁓ but they ⁓ they sometimes did it themselves. Yeah. And ⁓ it took a while but you know they did a good job.

speaker-0: It makes more sense 'cause when I was trying to do all on X from two thousand six, seven up through like seventeen before the digital age really started catching on, I was doing almost twenty arches a month by myself, but doing surgery and pros, you can imagine splitting my time in the clinic between surgery and pros. Analog pros. I was in over my head. I almost quit. But you say you had I mean, so your office had fifteen or twenty doctors restoring those twenty arches, not just one. ⁓ yeah I I'll tell the I'll tell the audience, if you're doing an analog, that's nearly impossible. I found it to be impossible. ⁓ for sure. To really keep up with.

speaker-1: It's it's tough.

speaker-0: It's a lot it's a lot of work. But you talk about Palomalo, you know, what they were talking about is crazy. ⁓ my roots go back to two thousand three, Portsmouth Naval Hospital. ⁓ Commander Alfano, who retired a captain, maxwell facial prostodontist. I'm not sure if you have the pleasure of of remembering Commander Alfred. You know that name. So he comes to me and he says, Your table clinic's gonna be on the all-on four procedure. And I'm like, I'm learning how to do composite fillings at the time, you know. So I got involved with the program up there and did our first all on four. And what a tremendous debacle that was actually to be honest with you. ⁓ I still have the poster board presentation in my institute back home. ⁓ that's awesome. I found it it s it survived my divorce. But it didn't get thrown away. But I kind of met you there. You know you were just a face in the hallway but you were trading time between Miami and Portsmouth. Tell me about that. What was that that trade like

speaker-1: So it was great because, you know, the the Miami program was known as the knife and gun club. We did lots of facial trauma. So the armed forces back in the day, it was initially just the ⁓ the navy. So all three of the Navy oral surgery programs sent their residents to Miami ⁓ for facial trauma. So they would come spend one to three months, depending on where they were from, with us. And in return we would go to the mothership. I mean obviously San Diego was the mothership, but to us Portsmouth was mothership because it was directly above us up the coast. So we would go to Virginia Beach ⁓ and stay there or stay ⁓ somewhere down close to the base. So we would go to Portsmouth, Virginia and spend one to three months there sure learning orthanathics and facial cosmetics. Man, I learned how to do hair transplants there. Because if people were a hundred percent service connected, guess what? Sky was a living. Yeah. So I learned so much about orthanathics, facial cosmetics and ⁓ you know, just

speaker-0: That's right.

speaker-1: Or oral surgery overall, 'cause the navy guys were just ⁓ amazing.

speaker-0: Well well well trained, well studied for sure. ⁓ you know, but w the the innate problem between b behind ⁓ the naval bases is ⁓ you know, you're behind a gate. So you don't get the trauma. don't get the ambulances pulling up. So so they kind of make their money and their training in in orthocs, which I think is great. Which it was a tremendous benefit for me. I didn't even realize how much orthognathics would come into all on four training. Okay. Just setting vertical dimensions, condyler C R. Like when I look back at my success, I don't even think I realized this until about three or four years ago that

speaker-1: That's amazing.

speaker-0: My success in prosthetic goes back to the orthophic surgery training days at Portsmouth Naval Hospital. Yeah. It's it I mean I I remember seeing, you know, cases that had stability long term, some that did not, looking at the philosophies of the treating surgeon and prost team, how they did it, you know, some balanced condyles more than others, you know, that kind of thing. And I I find that ⁓ you know, there's a lot of a lot of c similarities between all on four and orthoathic surgery.

speaker-1: Most definitely. Most definitely. I mean a lot and think about it. When in orthodonathics the first thing we do is facial analysis, right? Right. The facial thirds, the facial fifths. Right. But in in all on four, that's rarely done. And it's so important to perform a facial analysis. I do it all the time. And you know it's interesting. When I lecture in Europe, I notice that they really harp on that. Facial analysis, jaw relations, joint positions.

speaker-0: Right. Amen.

speaker-1: But you know, here in the US you see a lot of cases and of course Instagram and Facebook university, people just show the teeth, right? They don't show the whole face oftentimes. So people are like, Man, look at my case, it looks gorgeous. You're like, Yeah, that those set of teeth look beautiful, but I want to see the whole face. Right. So that's often overlooked. And ⁓ so that's one of the things that I think it's so important to educate people on, ⁓ is is correct facial.

speaker-0: Yeah, I was we chatted for about an hour before we started this pod, but I briefly told you about a textbook I'm writing and a huge part of it is on facial analysis and how I I I couldn't agree with you more. I'm I'm happy to hear that in Europe they're doing it correctly. I feel like in the United States we're just so focused on what's between the lips or between the lower third. And ⁓ there's really no thought process put into the rest of the prosthetics. ⁓ Yo would you say what what creates more of a complication or a failure? Is it your surgical ⁓ inadequacies or your prosthetic inadequacies?

speaker-1: I you know honestly I I always say this, I think it's the prosthetics. I mean surgeries you get failures early on, but you know, with prosthetics, man, I all the failures I see now are from poor poorly done prosthetics. Yeah. You know, it's really I always tell people and I remember when Malo said this at my the lecture ⁓ back in ⁓ two thousand and six in Vienna, mm-hmm, he said this is a a prosthetic procedure with a surgical component.

speaker-0: Agree. Amen.

speaker-1: And ⁓ it truly is. Yeah. You know, I it's I'm I'm so glad you're writing a book and and you know, we need more books on prosthetics because this just not done. I I recently became the editor for the clinics and the Atlas of Oral Surgery and we did three volumes on, you know, ⁓ graftless solutions, solutions with grafting, but the very first one which I thought was the most important one was on ⁓ digital workflows. Right. And and w I had a great chapter on there written by ⁓ a good paradonist, ⁓ Ernie Arfanos, on facial analysis. And ⁓ that chapter, I mean, to me it was so important. I I first saw him lecture at a Nobel symposium in Miami Beach ⁓ like twelve, thirteen years ago, and he talked about facial analysis in full arch and a lot of people thought, well, what's the relevance? ⁓ my god. But it's ⁓ so relevant. But you're right, prosthetics is the is the key and it's often overlooked by so many people.

speaker-0: ⁓ yeah, every time I you know, we c we look we can move into revisions. I mean I see a lot of revisions coming, you know, failures coming into my console room. Mm-hmm. You see you certainly have pretty much built a business. I how much of your practice would you say is on redoing all on I figured it was high. Yeah.

speaker-1: I'd say about eighty five percent. It's very high. Yeah. I don't get those slam dunk cases at all anymore. I mean I don't I don't think I've had a slam dunk virgin full arch case. Yeah. Where I'm taking out the teeth and just doing conventional full arch. I love that. Yeah. But I don't I just don't get ⁓ anymore.

speaker-0: Are you like me like I'm always calling my referral base. ⁓ proud to say I have a good referral base. I mean periodonists are in there, oral surgeons are in there, a few a few of each. I've even got a couple of prostodontists that are sending me revisions. And they but they and the general dentists too, they never send me the easy ones. I always get the ones that have failed somewhere else that I have to fix. And I'm like, Well, where are the layups? Well, they're keeping their relationship going with the periodonist oral surgeons and you know they get they get the easy ones and it it can be frustrating. But yeah, would you

speaker-1: I mean it's good for you. You have that reputation. I mean you do the hard cases.

speaker-0: Yeah, well, ⁓ humbly, you know, each one one at a time, you know, but y you don't look forward to them, do you? Yeah, I mean it's it's

speaker-1: You know, I I look forward to the final result and and giving the patient the that, you know, we call ⁓ the reveal, like man, look in the mirror, look what I did for you. Yeah. But the steps that you go through sometimes you're like, ⁓ man, it's all this is a this I hope this is not as tough as the last one. Yeah. But you know what's nice, Adam, is you learn throughout your your journey and even now I'm still learning. Yeah. We're still learning. So I don't look forward to the cases that have ⁓ that

speaker-0: ⁓ yes.

speaker-1: have been the most challenging ones. Right. But I'm telling you man, the prosthetics is always the most challenging part with some of these cases.

speaker-0: Yeah, I really enjoy the prosthetics. But going you know, and get into that in a second, you know, when you get it when I get a revision case, I sort of look at it like like a football game. You know, I'm a big I'm a big sports guy, I'm a big sure athlete. You know, it's like the other quarterback got to play three and a half quarters of the game and they're handing you the ball and you're down by twelve. You know, and it's like, Okay, there's three minutes left, we're down by twelve, see what you can do. And it's ⁓ you're you're very much these patients last, last results

speaker-1: It really is.

speaker-0: And so I wanna talk about what happens after the all on four. 'Cause I know that you are on the forefront of pioneering some custom implants, cause patient specific implants, which we've known forever to be the subperiosteal implant. It goes back to nineteen forty eight, nineteen fifty two. ⁓ it's nothing new. ⁓ take me down, you know, what got you into the custom patient specific implant let's talk about that. Let's talk about the what happens after the game, after you've lost the game. What it what do we do now?

speaker-1: Absolutely. So, you know, it w it's actually very interesting. What got me into it was a couple of my own patients that had had ⁓ massive facial injuries. And ⁓ you know, we went through bone grafting and reconstruction, and ⁓ the bone grafting wasn't really done properly. It was done by different colleagues who didn't understand occlusion. ⁓ they were done by, you know, really good guys, well-meaning ⁓ plastic surgeons and ENTs who did a fibula on a gunshot wound or on a cancer patient, and the fibula was about a centimeter out in Crossbite, and I thought to myself, well, how do I fix this? Right. And right at that time, some of these plating companies were coming out with subperiosteal or they call them patient-specific implant individualized patient solutions. And I thought, you know, I should be able to take advantage of this. And you know, I knew in Europe they were already doing some of these ⁓ custom subs with multi-un abutments, but they weren't removable MUAs that were fixed, makes it challenging. Right. So a couple of those challenging ⁓ you know, gunshot wounds ⁓ cases or or cancer cases. Got me into the subperiosteal realm where I was like, you early, it was probably like 2020 where I had to there was no other option because I couldn't put implants, conventional implants, because of the poor positioning of the bones. Sure. And that's how I got started. And then I got introduced to mm so many other systems out there, and they all have their own nuances. ⁓ I have yet to find a perfect system, right? Right. Either cost is too high or quality is too low. I mean, some of the I mean

speaker-0: Make sense.

speaker-1: I'm doing revisions on some of these cases that were done elsewhere. Now I'm even doing some of my own revisions. So that's one of the things you learn from them. And ⁓ I I wish there was a perfect system out there, ⁓ but there really isn't yet. They're still working on it. KLS is the only FDA-approved one in the U.S. It's a great system, it works well. But design is so key. So the most important thing with any of the subperiosteols is having good design. And I learned a lot about that from our good friend Sam Jerry. Right. Yeah. My very first case. that I did, w I I asked Sam for his help and Sam and I actually wrote an a chapter together on this on ⁓ virtual surgical planning for PSIs. Man, it's so much that goes into the prosthetics. I mean my very first failure happened because of prosthetics.

speaker-0: Yeah, you see it all the time. I think you said it earlier. If it's a surgical failure, you're gonna see it in the first six or twelve months, typically. I mean there's the positioning issues that make prosthetics difficult. Yes, I get it. But by and large, when you see something failing three and five years later, it's the occlusion. It's it's the condyles, it's the occlusion. ⁓ yeah, Sam is a tremendous asset with ⁓ he did a pod w pod with us. I've known him for years. You know, his mentor and my mentor were best friends.

speaker-1: ⁓ I had no idea. Yeah.

speaker-0: Truman Truman Baxter, Joe Littlejohn Arc out in Arkansas. ⁓ they were doing impl slinging implants together in the seventies. And so we ⁓ it's funny, you know, I didn't really meet Sam s you know personally for twenty year fifteen years. ⁓ but our philosophies are so in in line because we learn from the same people, you know. So it was you gotta have mentors, right?

speaker-1: Yeah, and and I tell you what, Sam, you, ⁓ myself, what I you know, I you try to connect with guys that are all about patient care. Right. And you know, the thing is this, you you try to provide the best quality service for your for your patients. And ⁓ you know, and you know, you build a great reputation to do that. Sam has been doing this longer than you. So I mean, I see his work and sometimes he'll like, Hey, look at this follow up from twenty five years ago. I'm like, Man, yeah, that is a home run. ⁓ yeah. ⁓ so he's done some amazing work here. I consider him a friend and a mentor.

speaker-0: Yeah. These things work. I'm about to ⁓ I've I'm gathering data right now to publish a ⁓ 30-year-old subperiasteal implant just as a case study, just to show and prove that these things work and make it relevant. It was obviously done by my predecessor. My first subperiasteal implant was 2006. ⁓ she's still living, ⁓ still going well. So it's almost 20 years now. So ⁓ but 30 years about to publish a case study. I should probably publish both side by side.

speaker-1: ⁓ you definitely should. I mean listen, the biggest complication that we see with these subs yeah is ⁓ dehiscances. Sure. And so now we're doing ⁓ a study now with actually with Geis Lick where we are ⁓ patients that don't have the keratinized tissue or lacking soft tissue ⁓ because you don't want to those permucle struts to dehiss. No. We're going in early on doing connective tissue graphing. So we're staging a lot of our subs now. Yeah. So they get ⁓ you know, and obviously Geislik has fiber guide as a problem. product that thickens a tissue or mucograph. So I'm using that product quite a bit now and I'm hoping long term we get good results out of it.

speaker-0: So I'll I want to go go down this path for a second. There's so many things we could talk about. But you know, everyone's seeing out there this patient-specific implant, this subperacteal implant, and people, the young people and the new beginners, ⁓ they get the idea that all you have to be able to do is lay this on the bone. Just get it in there, and then the prostodonists will figure out the rest. You mentioned soft tissue. I'm a huge advocate of soft tissue, even you know, with conventional andoceous implants. I think the one thing, if there was one factor that would predict the success, the prognosis, the twenty, thirty year success rate of our implants and subperiosteal implants, I think it would be soft tissue. Would you agree?

speaker-1: I think so, yeah, because you know, ⁓ I have a good friend Bakley who is is become a good mentor, good friend, we lecture together and we've written together. He talks about the number one so does Oldie Jensen, ⁓ number one cause of implant failure in in their in their c scenarios and cases has been perimplantitis. Right. Other than occlusion. And perimplantitis is always due to lack of keratinized tissue.

speaker-0: I yeah, I think so. The number one factor I mean in fact I did a pod ⁓ or a webinar and and we had to defend our implant and talk about which one was best, you know, for preventing periimplantitis or whatever, and is it the bone or ⁓ i or the implant and I think it's really neither. I think it's really just that band of keratinized tissue. So they talk about two to three millimeters of keratinized tissue. I think that's great. I want to see four to six. Yeah. If I if I can

speaker-1: I want to see as much as I can. I mean the the more the better.

speaker-0: Yeah. So ⁓ I wanna get I wanna ask you a question. ⁓ this ⁓ isn't actually the question I thought I was going for, but a couple of questions I wanna ask you because ⁓ you've been practicing long enough to see implant dentistry evolve dramatically. Are there any are you seeing any differences, ⁓ fundamental differences in patients today versus the way they were twenty years ago?

speaker-1: Yeah. Most definitely. I mean, one of the things that I'm seeing now is their patient expectations. They're much higher than they were before. Right. ⁓ and I think you know, that's just ⁓ how we are as a product of our societies now, you know. Think about it. Twenty years ago you would tell a patient, Hey, we're gonna do a hip graph, we're gonna reconstruct your jaw, it's gonna be six to eight months before you can get implants, then you gotta be without teeth for a little bit longer. Yep. So patients had the expectation of, Hey, I'm gonna go without teeth for a while. Now everyone wants immediate seat. Think about it. It's not good enough just to order from Amazon, so you gotta do Amazon Prime Plus. Right. Or if you're a Clear member going to the airport, there's Clear Plus or TSA touchless now. So everyone's expectations are different now. And I find that with patients, ⁓ I I bring ⁓ to reality. I'm like, listen, I will do my best to get you immediate teeth. Right. But once in a while we're not gonna be able to do that. Especially with these PSI patients. Yeah. ⁓ like with a patient that has an atrophic mandible that's six millimeters and has no soft tissue, I tell ⁓ Hey, we're gonna do a connective tissue graft. You may not have teeth for a for a couple of months, but we will get you there. And I'll make it where you have something that lasts for a while, not just for a little bit. Yeah. ⁓ so ⁓ I think yeah, expectations are much higher. That's what it is.

speaker-0: Think we sorta sort of did this to ourselves in many respects with social media, right? ⁓ yeah.

speaker-1: I mean listen, it's ⁓ it's I mean nobody posts ⁓ their disaster cases on social media. I try to ⁓ show dis you know complications where hey this is what we need to avoid and that's why you know interestingly the last couple years I've been lecturing a lot on complications of full arch and now complications of of patient-specific implants. There's plenty out there and you know we're seeing more. Like for example, at Jay Newgarden invited me to lecture at the Full Arch Complication Symposium. in New York City last year at Complexities, which is a great meeting. And you know, one of the things we're seeing now with zygomatic implants is six to seven years out, we're seeing these cutaneous fistules not at the apex of the implant, mid shaft.

speaker-0: ⁓ no kidding. Yeah.

speaker-1: And and I've seen a couple of my own patients that I did zygos on ten years ago and now they have a cutaneous fistula not where the apex of the implant is at the zygoma, they're in the middle, right where the implant enters the alveolus or exits the alveolus. So what's happening is some of these cases that we saw that were we thought were slam dunks. Like I saw a patient that ⁓ you know, she thought she had a dermatologic lesion, went to have a biopsy, and they They said, ⁓ this is unusual to have here. Yeah. But that's one of the things we're seeing. So, you know, we're seeing complications that we weren't aware of and we're we're finding new yeah, obviously there's new techniques, new modalities, new implant systems all out there. But everyone claims to have the best and the latest and greatest, but time will tell.

speaker-0: Very scary. The number of simply the number of implants that are placed. You know, even if they even if you were to assume that everybody, every surgeon was competent and every prostodontist, every d general dentist was competent doing assuming that they were all perfectly placed, we're still gonna have a high degree of periimplantitis. George Giorgio Kasakis ⁓ just did a pod with us talking about periimplantitis and I th the millions and millions of ev of cases every year that are surfacing. Now you're telling me about a mid shaft on a zygomatic and I really wish you wouldn't have told me that because as soon as somebody tells me about that I I go back to my office on Monday morning and there's one in my waiting. I'm gonna call you. I'm gonna call you. I'm gonna refer that because that patient's your fault now. But that's that's ⁓ unbelievable. You know, so there's a lot that we don't even know yet that's coming, right? Definitely. And we're gonna have to be prepared prepared to have to deal with that.

speaker-1: Most of the Definitely. I mean I you know, ⁓ a couple of months ago I lectured at the Pico Symposium. He had the first Global Three Sixty Complication Symposium. And man, let me tell you, it was an eye opener because everyone there was just showing cases gone wrong, not cases that were perfect. Right. And one of the biggest things that I certainly don't condone is medical tourism, right? Right. Medical tourism is huge. Right. There was a surgeon there at ⁓ was showing cases and I have friends that practice all over the world, you know. On Europe And ⁓ some of the people that go overseas to get work done, buyer beware because you're getting what you pay for oftentimes. Yeah. And the complications that we see from some of these medical tourism cases gone wrong are outrageous.

speaker-0: And I tell my patients that have you know had a consultation in what whatever country, XYZ country, ⁓ you know, I tell them these consults E even if you assume that they're doing perfect work for that half price, third of the price, even if you assume it's amazing, they're still gonna have some degree percentage of complications. And there's benefit in having your practitioners be local so that they can handle it. Absolutely. And they can identify it or they can follow up with it, right? It's so dangerous really. ⁓ does it scare you when somebody calls you from

speaker-1: It really is. ⁓

speaker-0: New York, Washington State, Florida and says, I want to come to Phoenix and be treated there? Does that concern you at all?

speaker-1: know that's the bulk of my practice now, right? It's the bulk of my practice now is cases gone wrong. They're not all just local. I just make sure before I accept a case that they have a local referring doctor that can handle the surgical complications and the prosthetic complication, right? So I have I make sure that any out of state patient that's coming has someone that's gonna restore their case back at home. Yeah. Because I need to make sure they are seen in a timely fashion.

speaker-0: Yeah. Are we entering a dangerous era where, you know, like you said, patients want everything right away. And you're in Phoenix, Arizona, where I'm told there's an all-on-force center, you know, on every corner, on every major intersection. Right? Tremendous amount of complication ⁓ competition out there. You and I are established enough to say, look, patient, we first need to do some, you know, Extract your back teeth, get this infection under control before we go all in for it. We first need to do ⁓ carotinized tissue graphs and wait a few months before we do this procedure. ⁓ because if you want me to do it, I'm sure you're like me. You're like, You came to me, I'm gonna do it right, that's the only way I'm gonna do it. But what you know, what kind of dangers out there? How do these young doctors that are having to compete with three other doctors on their intersection that are gonna deliver they can go across the street and get the teeth today? How do they get find the confidence and the wherewithal to to address their patients that way and you know command that that consultation room? You know, how do we convince them to do the right thing and stop being the one the office that just treats everybody under the sun with all on four right away? You know, what do we tell these young doctors that are trying to learn this?

speaker-1: I think we just have to show them what happens when things go wrong. Because a lot of times the problem is you don't know what you don't know. Right. So if you don't know about the complications that can happen from a pterygoid bleed or from an implant in the infratemporal fossa or from a cutaneous fistula or implant the orbit, you'll just cavalierly do a lot of these cases without having the proper training. So I think the most important thing is education, education, education. That way 'cause I never I never tell someone, Hey, you don't know what you're doing I just say have you considered what will happen if this doesn't work out? Then they look at me like well what could what could go wrong? And then I explained that to them. So I think the most important thing is to educate people properly. ⁓ but a lot of these full arch courses that are out there, they don't go over complications. Right. They don't even cover them.

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speaker-1: And so what's scary is you have guys that are now new grads ⁓ going into these courses and getting all this courage without knowing the complications. And when something goes wrong, they call us. That's why my practice, man, I'm busier than ever. I and the complications are just crawling out of the water. I mean, every time I see one, I'm like, I hope this is not worse than the last one I saw. And man, I'm seeing everything. Mandible fractures, cutaneous fistulas, ⁓ cases That are just disasters. And the doctors are well-meaning. No one ever means to have a complication like that, but we're just seeing them on, and it's increasing at an alarming rate. And I think the best thing to do is tell these young guys: say, make sure you don't just learn about the procedure, learn about how to handle the complications. And if you can't handle the complications, find someone that will take care of it for you and refer them out early. Because, you know, listen, it happens in medicine too. People will have complications. but you don't just hold on to those complications praying that they'll go away because they don't.

speaker-0: And you don't want them f landing in someone else's office or in the hospital to deal with because, God forbid, you know, when you get a radiology report on your zygomatic implants from a hospital, you know, it looks like you nearly intentionally try to kill ⁓ you know, when you read that report. You want to be able to keep ⁓ in office, you know, handle your own mistakes, that kind of thing. Of course, go out and get help when you need to get help. Obviously don't don't work outside your scope or comfort level. But ⁓ I agree with you about the education. In fact, twenty twenty seven we're at adding a module on complication weekend, ⁓ just because ⁓ We we try to cover it in each module, just w an hour or two of, you know, these are the things that can go wrong, but I don't think it's enough. I think we could sit there and talk about it for three days and barely barely cover the tip of the iceberg. So I I agree with you about the education. ⁓ it's all it's just this ever expanding, you know, we started out with one weekend on full arch and then it was obviously not enough. You know, it turned into five weekends on full arch and now we're adding complications. So six weekends on full arch. But we're basically trying to ⁓ trying to give people a r what they missed in residency. ⁓ absolutely and you're just not gonna get it in two days.

speaker-1: No, I mean we're just starting to see symposiums on complications. Right. But I mean this is new. I mean we've been doing full arch what for twenty years. Right. And now we're just starting to see complications symposiums.

speaker-0: Yeah, I w you know, why do you think it took so long? ⁓

speaker-1: I think it's our arrogance because a as practitioners and I don't mean in a bad way, we all thought, ⁓ man, there's nothing that can't be fixed. Right. And now we're starting to see cases that are like, Whoa, fixing this is gonna take ⁓ an act of God and it's gonna be challenging. I mean, when I was at the Pico symposium this last time, I did a podcast with our our good friend Doctor Mike Picos. I love that man.

speaker-0: I watched your podcast, but it was very good.

speaker-1: I also did one with Bruce Huberman and ⁓ he's a great guy, oral surgery out of New York. And we did a podcast there. I've been you know, and it's funny, every one is different. Because I I talk about I cause I used to be work with residents at the University of Miami, and everyone is different. I mean, it's so unique ⁓ when you start talking about ⁓ the world of oral surgery and full arts. But I tell you what, with with Mike we were talking about complications. And you know, one of the questions that ⁓ Mike asked me was Like, okay, you get a patient, and this is a great question. He goes, You get a zygo 4 patient. What's your go-to? Is it going to be zygomatic implants or a PSI? And you know, you ask 20 practitioners out there, you're gonna get a different answer. That's right. And guess what? The it all depends on your your comfort level, your training. But in my hands, I still would rather go to a quad zygoma if I have to do a case like that. Yeah, where because the PSIs have their own set of complications, right? Zygos do too. Don't get Me wrong. I mean, I see some of my own zygote complications now, like the cutaneous fissure that's happened eight years out. And you know, I at first I was dumbfounded. I was like, how is this possible? Eight years later, yeah, and then I look at the patient's CT scan, the wear patterns of the maxilla are up and back, right? So I'm thinking, ⁓ my god, I look at her maxilla from eight years ago, and she's continued to resorb. Even her nasal spine has moved back. So you're gonna see things that ⁓ you're not. expecting yeah and I think that's why ⁓ you know I you gotta stay humble and I think it's because of our arrogance not just me you anyone else it's just as as a a dentist that we're like ⁓ man this can't happen this is this this full arch is gonna work for everyone it doesn't

speaker-0: Well agree with you on the quad zygo before the PSI because the P there is no bailout for the PSI except the denture. At le conceptually a quad zygo could have a PSI bailout. Sure. Correct? So there's still one more step to go. You know, ⁓ knife, you know, talks about the fifth, fourth, or fifth dentition ⁓ you know, as the you know, that's why you go to the F P one. You do you do the PSI, now you got a sixth dentition. So it's it's ⁓ you you just basically the the moral is the lesson learned is you always want to have a bailout. Well what if this doesn't work? You know, and what are we gonna do after the PSI though, after the denture? I mean, what's next? Are we let me ask you this. What we're doing right now in implant dentistry, does it not look painfully similar and not too far advanced from ancient Egyptians? I mean, have we evolved very much in 2,000 years?

speaker-1: Well, mean I think we've definitely come a long way. Sure. But it's funny, I I thought you were gonna describe it to plastic ⁓ compared to plastic surgery. Yeah. ⁓ And you're like, ⁓ my god, these people just don't know when to stop. Right. And that's because of the arrogance of some of our medical colleagues who think, ⁓ I can do better. Yeah. And when you get a lot of scar tissue, you think that failed quad zygo, now you got no blood supply, you got terrible you know right blood supply and soft tissue, you Put a PSI in there and that thing dehisses. That happened to me. So actually, I have a failed PSI case that I told the patient, I'm like, we're gonna take this out and let you heal for at least one year. Then I'm gonna go back and do connective tissue grafting. At that point, we'll consider the options. But I can't promise you anything. And that's the thing. Our arrogance gets in the way of like, I think I could do this. Because even ⁓ you know, after all these years of experience, some once in a while I'll take a look back, I'm like. Can I do this? Mm-hmm. Because you just don't want to be the guy where like, ⁓ man, I tried my best but it didn't work. 'Cause I I just want patients to leave my office better off than when they came in.

speaker-0: I it's a very humbling ⁓ I mean I think I mean I've got a case, you know Peridonist did an all on six, not no pterygoids, by the way, all on six Maxilla ⁓ that failed. And then that went out of state and got quad zygomas and two failed on the other side and then they came to see me and I thought, well, I'll rectify this. I'll put in two pterygoids and a and one more zygo. And ⁓ guess what? That side, the pterygoid, and the zygote didn't take. I think the patient, by the way, has very poor p proto ⁓ plasm, you know, just doesn't not a good healer, by the way. But you know, you're coming in the third person in eight years. And you got all that scar tissue. I'm beating myself up, but now I I'm stuck. Now I have the patient. Right? Now they're mine. And I'm like, w you know, I've got two zygos on this side. By the way, not very good prosthetically placed very well. They're not at all. You know, they're in the middle of her palate. She's not concerned about it. But definitely interferes with their phonetics. But we a pterygoid, two zygos on one side and really nothing on the other. And here we are. Like what are we gonna I mean, I might be sending her to Phoenix for a patient sp unilateral no, I don't I don't agree with unilateral patient specific implants. Yeah, what do you well up three

speaker-1: Well you I've done a couple and they've worked out well, but now. But these were patients that had failed zygos. Okay. And you know, it's interesting you said it. I was against it myself. And I told the patient, I said, I've never done this before. Right. There's hardly anything in the literature. You have two failed zygos. And ⁓ if I can close this orantral fistula, then the only other option now is a PSI, or you just wear a unilateral denture, because we can't do an all on two two implants. So we we were able to close the fistulas, went back and did in ⁓ unilateral psi, but not purely unilateral because I extended it across and did screws on both sides and a palate. So I'm utilizing the full arch, the full maxilla, but you only have a buttons on one side. So it's not a true unilateral one, but the soft tissue is the issue. Soft tissue is beautiful on both these cases, so I've had great results. And guess what? I see those patients every three months. Yeah sure. Just because I want to make sure I don't lose track, lose sight and end up with a complication.

speaker-0: Do you take it out every three months or have someone take it out? I yeah.

speaker-1: Yeah, absolutely. I unscrew it. I want to look at the soft tissue because the the PSIs that I've had fail weren't surgical failures. They were prosthetic failures that led to the PSI failing. You know, you've got to be careful, not have too much pressure on the tissue. Sure. You won't have good tissue there. You know, one of the best, like I said, your best teacher is your failures. Sure. ⁓ and I've learned a lot from Mike Picos and Sam Jericho about PSIs and subs, but my best teacher has been, ⁓ man, I shouldn't have done this.

speaker-0: Yeah, there there's ⁓ there is quite an education in failure, obviously. It's a hundred X over top of the course you take, right? 'Cause

speaker-1: Like you were saying, your patient had bad protoplasm. We we ⁓ we ⁓ Dr. Marks, my mentor, coined a term PPP. This patient has piss pore protoplasm. And ⁓ anytime we had a patient with PPP, like we'd circle using this may not be a surgical candidate. Yes. I mean sometimes for for us it's important to realize we can't help everyone. Right.

speaker-0: I guess I I mean there is there is su such a thing as the cluster failure. You know, the recurring failures just of standard endosseous implants in the same patient. You know, when I came into this twenty years ago, plus years ago, it was, well, just because one implant fails doesn't mean the next one's gonna fail. It's a mutually independent event. That's what we told them twenty some years ago. Now I'm telling them, No, your chances of a failure are higher. You've already rejected one implant. Your body has already not taken to one implant. We know statistically you're more likely to reject more.

speaker-1: ⁓ yeah.

speaker-0: So I think that that that needs to be said.

speaker-1: I mean think about it. Now we're seeing you know, ⁓ funny enough, my daughter di I did a ⁓ my I'm gonna publish something with my daughter who's only in in eighth grade, but she did a study at her school and looked at the effects of antidepressants on plant failure. It's significantly higher. But guess what? A lot of practitioners ignore that. Sure. And like they ignore the fact that p some patients are smokers or uncontrolled diabetics. I have heart I I have heart stops. ⁓ you're a smoker, you don't get zygos, you don't get PSIs. ⁓ your hemoglobin A1C is above seven point five. No, you're not getting zygos. Yeah. You're not getting a PSI because that elevation, you know, the the lack of control ⁓ you know is a big setup for failure. So we just have to know that not everyone is going to be a candidate. Yeah.

speaker-0: Well, I think proper screening of patients is probably the most critical error that most dentists make, especially the general practitioner. Especially the general practitioner going into this. And as a general practitioner, you know, I I'll say this I say this every time I am a general practitioner, even though I get confused with you know, some people think but I'll I'll clearly state that. So as a general practitioner, I'll say the place where we fail the most is in selecting our patients, doing a quality medical review on our patients, and informing the patients of their level of risk in undertaking a procedure. ⁓ I think I can guess your answer, but you know, to what extent would you agree with that?

speaker-1: ⁓ I hundred percent agree. A hundred percent agree with you. And you know, I think whether you're a general dentist and ⁓ oral surgeon and periodentist, it all stems back a lot of it to your dental education. I mean you and I ⁓ we had amazing dental education. Obviously, you were in the military and I was at the University of Miami with a a great guy. But nowadays what I'm seeing is some of the dental graduates, they're basic they're lacking basic foundational knowledge. You know, I've had so many people reach out to me and said, Hey, this Patient had radiation to their jaws, and I'm gonna do dental implants, but the radiation was 20 years ago, so the effects of it are gone by now, right? I'm like, no, right, it's actually far worse now, 20 years later, than it was a year out. So these are things that I don't know if they're not teaching in dental school or they're not, ⁓ they're just overlooked. And you know, and you know, I think as a general rule, ⁓ you know, dental education has changed, you know, and I I'm not trying to harp on education. educators or students, but my faculty were hard on me. Right. And dental school and residency. Man, they didn't let things slide by. Right. They were hard on us. So I think you have to be hard on yourself and not and take like, you know, it's funny, we talk about Sam China all the time. Yeah. Sam is a C E junkie. Right. And we talk about

speaker-0: I don't think he practices. I think he just goes course to course to course.

speaker-1: has to yeah. I've talked to him. He goes, Well, I gotta t talk to my wife because I've taken too many C courses this month. I gotta practice a little bit too. Yeah. But like you have to do that. If you are whether you're an oral surgeon or general dentist, you have to take as many courses out there as possible because you learn something from all of them. And what we have to do is make up for what's lacking in some of our dental school. I mean, I you know, you know how it is. In dental school, some of the guys that are teaching, ⁓ they only have one hour to cover a big topic. Sure. So it's often only So I think that's important to keep in mind. ⁓

speaker-0: So if dental school and again not to harp on our educators, because they're doing a they're doing a great job and the best job they can with the resources that they have, obviously. But we always say that, you know, dental school basically gives you a license to be a dentist but doesn't teach you to be a dentist yet, right? Correct. So could you say the same thing about oral surgery training program? I mean, do they give you the license to be a surgeon? Or do they come out any better or worse? Is it similar to dental school?

speaker-1: Absolutely the same. So, you know, just because you're an oral surgeon doesn't mean you're gonna know how to do orthodonatics, trauma, wisdom teeth, or any of it, you know, joints. You just basically, you know, your oral surgery certificate gives you the alphabet. Right.

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speaker-1: When I was when I was in medical school, same thing happened. ⁓ you know, 'cause throughout my program we did our medical school after dental school. So I remember I was sitting in my cardiology class, she goes, All you guys are graduating, do you think you're gonna be this top hot physicians? You're not. Right. Your medical degree or your dental degree, or in our case, will give you the alphabet. It will give you the means to know where to look things up, 'cause that's really what it is. Right. And what you do with that is up to you. That's why some guys are so much better than others. You know, there's there's obviously statistically we know that there's the top ten percent of any ⁓ group of you know physicians, dentists or specialists that you go to that you try to find that have actually gone the extra distance, the extra mile to become better and better and better. Like just like you like it's like athletes. Not everyone becomes like ⁓ you know like look at last year OKC had Jalen Williams I the best at and that's why they won the NBA championship, right? So we all become kinda like like athletes. Everyone becomes a quarterback. Like not every quarterback in the NFL is the same, right? Right. So the same thing with us. Oral surgeons are definitely oral surgeons too because guess what? Out of my top referrals are oral surgeons and periodonists. That some of them are like, you know what, I wanna stick to what I do best. Right, which is Exodontia, which is I admire them because they're like, I don't want to dabble in this stuff. Right. And I think that's important to realize if you're not doing it on a regular basis you probably shouldn't be doing it.

speaker-0: Yeah, I agree. I mean I think the the number one way to stay at the top of your game is to practice it every day, day in and day out, obviously. You know, and for my role surgeons that refer to me, they'd say the same thing. They're like, you what, I just ⁓ I want I know well, part of it is they know the referring dentists don't really have good control of the prosthetics and they don't want to see those patients come back later. But they also know they haven't really delved into pteroboids and the zygomatics, things like that and they're just you know what, you do it every day, it's better off in your hands and they just wanna stick to their exodonti their ortho mathics, so I get it. But ⁓ so for surgeons coming out of their programs, I mean you stated your vast amount of experience going private practice back to academia, back to you know, private practice out in Arizona. I mean, it does it really just boil down to reps and ⁓ your fixing your own mistakes?

speaker-1: Sometimes, yes, but oftentimes, you know, you also some I find that some of the younger surgeons aren't taking advantage of the training available to them. Just like you said, we have our educators that are doing their best with the limited resources they have, but you also have some residents and some dental students that aren't taking advantage of what's available to them. You know, and I can say this wholeheartedly because I'm an educator and I work with Roll Surgery residents and I talk to all my friends around the country that are all program directors or chairmen. Twenty-five percent Of our graduating oral surgery residents are at the top of their game. They have taken advantage of every case that was available to them. Right. And but the other ones just kind of not that they just want to coast, they want to have that work-life balance. They have a life outside of oral surgery. I'm not saying you shouldn't. Yeah. Because look at me. I'm here in Vegas on vacation, but we're doing a podcast. Because guess what? This is right. I am passionate. You know, you and I are passionate about what we do. Right. But ⁓ some people aren't as passionate about it. So I think what's happening with the younger guys is if you get out and you're like, man, I didn't take advantage of what was available to me in residency and now all of a sudden I want to do it, man, you gotta go out there and bust it out, do as many CE courses, live surgery courses, cadaver courses, mentorships, like your institute. And l what I say is don't limit yourself to just one training course. Right. Go to as many as possible.

speaker-0: Amen.

speaker-1: And that way you get to see how peop different people are doing it and you get to learn how to do it the best way that that works for you. Because remember what works for you that may not work for me, but it wor we get the same results.

speaker-0: Yeah, and you know, w you you said it Perfectly eloquently about putting the effort into the program every single day. You know, I'll never forget when I went to University of Michigan Dental School, a mentor of mine, I believe it was Dr. Verizer, he said to us, he said, at the end of these four years, some people are gonna leave here thinking that they got the worst experience in the world, and some people are gonna think they got the best experience in the world. But it really, you know, and some people are gonna really benefit from all the knowledge they gain and some people aren't. But it really comes down, it's not the program, it's you. It's what you put into the program. And those words resonated to me because the first day I got in the Marine Corps, I heard the same thing about the Marine Corps. They say some of you are going to get out of you're going be agitated about the Marine Corps. You're going to think, ⁓ it wasn't that great or this and that. And then some of you are going to be like, Marine Corps is the best thing that ever happened to me. I'm going to love it for the rest of my life, as do I. But it's really going to boil down to what you put into this program. Because nobody can make you learn and nobody can make you participate. Right? I love that about that. And that, and that the ⁓ Education doesn't stop when you graduate your surgery program, right? ⁓ it never it never really stops.

speaker-1: Listen, I'm still learning. Every day I'm still reading, and actually my kids they're like, ⁓ you just finished writing three books. What's next? I'm like, I'm gonna take a little break, but I'm gonna write another one because yeah, guess what? I think it's our duty as guys that have done enough of it is to educate the future generations. Because you know, look at look at Malo, he's still lecturing and still teaching. Yeah. I finally got to meet him and we lectured together in ⁓ in Dubai. Yeah. And and he it's interesting because he's like Like, you know, what I'm teaching you today would have been considered heresy twenty years ago. I would have considered it heresy. Yeah, twenty years ago. Yeah. And he goes, When I first came up with the all on four, what I was doing then, I wouldn't do now. Right. So we can t we have to constit cu constantly evolve and adapt and embrace new ideas, new technology, because things will change.

speaker-0: Yeah. Yeah, you know, and I love that about ⁓ what Mollow said right there. You know, because if you're not and I've heard it said before in numerous arenas, business and dentistry and otherwise, but if you're not embarrassed ⁓ If you're not embarrassed by your early work, you probably, you know, launched too late or never launched at all. I'm embarrassed by my early work. Sometimes I have cases come back from five or ten years ago and I'm go and I go, Hey, ⁓ mind if I redo this? You know, like mind if I set this up again? ⁓ because you should be embarrassed by because we're constantly evolving and learning new things. Absolutely. And so, yeah, a lot of a lot of beauty in that. And speaking of Dubai, speaking of you traveling all the time, I want to talk about that. Sure. Okay, 'cause you practice by yourself. I know you lose lose a ton of revenue and opportunity in your office when you travel, yet every other weekend I think, I think I is that safe to say? Twenty-six weeks out of the year, I see you talking somewhere, maybe twenty at least.

speaker-1: I did for sure in twenty twenty four and twenty twenty five. In twenty twenty six I think I kind of put the brakes on it about a month ago, but it's gonna start up again in a couple months. I think summertime is always s it slows down. Yeah. But yeah, I have been lecturing a lot and traveling a lot. But I tell you what, it's been tremendous for my practice because almost every time I lecture and I don't lecture because I'm gonna get referrals, but every time I go lecture somewhere, someone out of the Audience goes, hey, I have this case that I want to send to you. Right. And so it it never fails. Almost every symposium I lecture at, someone gets referred to the permit. So yes, I am gone, but like my schedule is full for three months with consultants and surgeries. But ⁓ could I do more? Sure. But you know, you and I, I don't think I could just sit there and operate every day because I love the interaction with amazing like-minded colleagues like yourself. And when we go to the meeting. Man, it's amazing when you get up there and lecture, you're like, hey, this guy does it the same way I do. Yeah. Or ⁓ I could do that and I might get a better result. So, yes, when you're gone, you do lose revenue. And you know, I tried having an associate once, and like you said, it's if you don't have like-minded individuals working with you, it's not gonna work. And my associate was a great guy, but ⁓ you know, it just we didn't have the same mentality for for building a practice. So ⁓ you know, I think it's hard to clone yourself. Right. And I have a lot of guys that say, Hey, I want to be, what does it take to be the next you? I've actually had a couple younger guys at your Wall Surgeon say, Hey, what can I do to be like you being speaking on the national podiums? ⁓ you know, I'm speaking at Amos, at DIC, and now international association meetings. what will it take? I'm like a lot of hard work, yeah, a lot of sacrifice, and a lot of dedication. I said, I'm not necessarily any smarter than you or anyone else. I said, I just made a lot of sacrifices. Right. Are you willing to do that? Yeah, because that's what it takes.

speaker-0: How do you ⁓ I agree completely? ⁓ how do you balance so I see you speaking out a lot for a lot of different companies, right? And you know, I know that with with a lot of companies, some of the things that I've gotten personally are like, well, if you're gonna speak for someone else, you're not gonna represent us. You know, how does ⁓ Vishtab Ruman get up get up around that? How do you keep on getting invited to, you know, this week you're talking for Neodent, next week for JD, you know, JD. How do you do that? I mean, how do you

speaker-1: I know it it's so they all and I I buy Horizons and ⁓ at ⁓ so many symposiums and because they know that my work represents ⁓ it's honest, it's academic. I think you have to have academic integrity and and you have to have non-biased data. So I think the way I get around it, I tell them I say I'm doing what's best for my patient. I'm not married to any implant company. And you know, I have friends and colleagues who are now on payrolls for different implant companies.

speaker-0: Yeah, yeah.

speaker-1: Companies and they you know it that works for them. For me, I don't want to ever be owned by the company. I don't want to ever have anyone but my wife and kids tell me what to do. And my staff, of course. My staff were always like, hey, you're running behind, you gotta do this, you gotta do that. But I don't want to ever have corporate America tell me what to do. Yeah. Because I learned early on from Dr. Marks ⁓ when I was at the University of Miami that the corporations, no matter how How much they tell you, hey man, we love you. Right. At the end of the day, it's not about you. It's about them. So I will if someone doesn't want to invite me because I don't use their product, fine by me. But when they invite me, I'm like, hey, I'm not gonna necessarily use your product at my lecture. They're like, we don't care. Because you are gonna show what works. We want you to talk about the science behind it. So I think what I do is at these at these symposiums and lectures, I talk about the ABCs, the

speaker-0: Okay.

speaker-1: the basics and I talk about what works for me. I don't come out and say, ⁓ this zygoma is better than that one. I talk about all of them. Like hey, I show a case with Nobel, with Neodent, with Bio Horizons, ⁓ with Norris, all the systems that I've used. And I'll talk about, you know, because if someone gets up there and says, ⁓ this is the best system out there, you know for sure. Right. That's not true. Right. Because there is no one best printer, there's no one best form of photogrammetry or or that I'll Implant and you just have to be honest with your audience, and I think people pick up on that. Yeah, that's how I manage it. Because yeah, some implant companies won't invite me, and that's fine. I I don't necessarily need to work with them. Yeah, but that's what I've done is and you know, at the national symposiums, like you know, when we lecture at some of our national meetings, they flat out tell you that if you are are are a hired gun from one of these implant companies, we're not putting you up on the podium. So, and that's how people know, because if you're on the national podium. people know that you're impartial. So I think it's important to maintain that impartial aspect to your lectures and to your research and to your publications. And that's how you become the better clinician, better educator. Right.

speaker-0: Tremendous amount of respect for you with that you know, ⁓ for that because ⁓ y people out there really have to watch the education programs they're going ⁓ and listening to the educators and looking behind the scenes and going, Okay, well, are they getting their pockets lined, are they getting their pockets filled by this company or not? You know, one thing I always say is that with my companies, I'm I have not been paid really by I mean I get paid to lecture. Right. But I don't my institute hasn't taken a big grant from anybody or anything like that because I don't wanna be, you know, giving an opinion that is biased. I would I w I'm so I'm very much I have a great great amount respect for you. In fact one of the reasons I left my last KOL relationship was that I was told not to speak about other implants. So I was like, well, that's kind of a that's kind of a no. You know, I can't be told what not to do. Sure. Right? So yeah, big big deal on that. You know, li but KOL, you ⁓ you seem I don't think I haven't found that the life of a KOL is very glamorous. Not like I thought it would be, but you seem to make it look glamorous, my friend. I

speaker-1: You I I try to like I said, I I just maintain my impartial ⁓ you know, character and I just tell them I say, Hey listen, I don't just use you, I use whatever works best for my patient. Yeah. And like sometimes I'll have a quad zygoma with three different implant systems on that patient. Yeah. Because in certain areas one worked better than the other. But yeah, it it it's not easy sometimes dealing with some of the companies.

speaker-0: I think the less there's a lesson in that for the listeners is that if you're if you're I don't want to say this. If you're an accomplished clinician, surgeon, whatever, prostodontist, doctor practicing surgery, you can make most any implant work in your hands, you know, especially given the reps and the experience, right? So it's not it's not always of course there are in my People have been in my courses know that I'm a big believer in engineering on implants and there are systems that I would say I do not recommend. Sure. For sure. You you might say the same.

speaker-1: Absolutely. ⁓ yeah, for most definitely. I mean if something is n doesn't work twenty years ago it's not gonna work now.

speaker-0: Yeah. Have you ever had a very like open disagreement with a company or ⁓ yeah.

speaker-1: Yeah, absolutely. I mean listen, I mean, I I've ⁓ never been a big fan of surface coated zygomatic implants from Apex all the way to the top. Right. And you know, I try to tell them, Hey guys, ⁓ why do you think sinusitis is so much higher with your implant system? ⁓ well You're the only one complaining about that. And you know, a lot of times implant companies will cover up their failures. You know, we learned that long ago with ⁓ with the the three eye nano tapered osteotite implant and which is really what got me into psychobatic implants. I don't know if you remember that implant. ⁓ you know, I was a big Nobel user out of ⁓ you know, when I first started out and you know, a lot of times you have a rep that you like comes in and says, Hey, use our product, right? So we in my practice in Daytona we switched briefly

speaker-0: No.

speaker-1: from Nobel to the three I and the we had the osteotite and there were great implants and they're like, ⁓ we have this new thing, the nano tapered, it's osteotype, nano tapered and nanotechnology, and then in big words, you're like, ⁓ man, this looks yes. So what happened is we did some our failure rate went from two percent to eighteen to twenty percent in a matter of years. And we weren't having cases fail next day. They were failing a year later.

speaker-0: Yeah. Yeah, ooh, that's even worse.

speaker-1: And that's even worse 'cause prosthetics in hand. Yeah. And ⁓ that's how I got into zygos 'cause I had one of my own patients that was radiated. His full arch failed, ⁓ failed and and he sent me a picture. I back then I had a palm pilot, not an iPhone yet. And I was like, ⁓ wow, that doesn't look good. That's how I got into zygos.

speaker-0: The old palm pilot. We've come a long way in many industries.

speaker-1: The Blackberry. My kids will never know what a Blackberry is. They think it's something you eat. Yeah, yeah. I mean listen, I mean we've come a long we've come a long way in dental implants. ⁓ just like anything else. Technology is is your best friend at times, but it can be your worst enemy. Yeah.

speaker-0: Yeah, yeah. You remind me of a story, ⁓ just a little quick one. Had my kit, my oldest down at Disney World, Epcot Center, you know, twenty years ago when he was like six years old. And ⁓ he we're looking at the red booth in in England and he goes, What is that? I go, it's a phone booth. He goes, What? I go, it's a phone booth. He goes, What? There's I go, there's a phone in there. He goes in there, he picks the phone up off the wall and he goes, he goes, Dad, why is there a cord on the phone? ⁓ Yeah. Unbelievable. Absolutely. We've come so far in this in this lifetime, I swear. Yeah, we sure have. Where's the future gonna be then? I mean where you know, what what are we looking at? I mean we got bi I where do you wanna go down this road? Between AI and biologics, that's where my mind first goes. Where where does your mind go?

speaker-1: I think both. I think AI is obviously ⁓ playing a huge role in dentistry, implant dentistry for sure. I mean it already has in my practice we've ⁓ we've converted all of our EMR to AI. So obviously AI is listening to everything and transcribes for me. But at the same time, you know, what's interesting is like for example, we're both going to see Kenny Chesney tonight, right? I guarantee you when I walk out of here and I look at my phone, there'll be Kenny Chesney ads on my on my phone trying to sell me stuff. So yeah, I think ⁓ we just have to be careful with it that at the end of the day, not forget that there's a human on the other side of the patient we're treating. Right. So AI can only do so much for you. The biologics can I mean listen, we've come so far. I mean look at bone. We used to now we use PRF, we use BMP, we have so many products. There's Gem21 out there, so many products that but at the end of the day, nothing can replace good technique.

speaker-0: Amen. Yeah. I knew you were gonna say that word right before you said it. Good to

speaker-1: I mean because guess what? If we don't do it right, it's all

speaker-0: There is no magic like fairy dust. You just sprinkle over it, like even the person fresh out of dental school can like no, you gotta actually apply it correctly. You know, even go back to things like a socket preservation. I mean, I see so many failed socket preservations. People just think it's so easy, take take out the tooth, drop this bone in there, come back. I get referred the case drop the implant in, it's just mush. Yep. Right? But there's a there's a technique, there's a hand, you know, and I always tell them it's like pot.

speaker-1: Just practice.

speaker-0: A plant. Well, first of all, you gotta get the bone to bleed. But then you know it's like potting a plant. You don't want to crush it in there, you don't want to smash it in there, but you don't want to have air pockets. You know, people people go, What's potting a plant? Like I'm like, go grow up grow a plant and then try to grow bone first. Like let's let's start there. There's gotta be this hand technique and everything you yeah, I I agree. So biologics, AI, what about navigation? What about robotics?

speaker-1: the hardest things we do is growing bone. So, you know, obviously I think that that has come far far already, very far. So we published on that on on the haptic robotic navigation and of course on the you know ⁓ dynamic navigation and the clinics. You know, in my practice, obviously I I'm a one man show. ⁓ for me, I firmly believe if you can't do it freehand, don't do it guided because sometimes guides will fail whether it's a static guide or dynamic, right? They can fail. ⁓ You better be prepared to be able to do it. Like, for example, one there was a case where we were I have a navy dent in my practice, right? Well, if your wireless is out, guess what? Things don't work. You can't the CT scan can't talk to your to your machine. Or you know, if you can't upload your your Trios 5, whatever you use, I use the Trios 5 in my practice. And if we can't upload my data to JB Labs that I work with, guess what? We're gonna have to do a conventional conversion. Yeah, and we've done that. The last time I did a conventional conversion was the wireless was out in my office and we couldn't upload any files. Right. So my laptop's like I just do a conventional conversion now.

speaker-0: Yeah. You gotta get yourself a Chevy. Yeah. So I what I mean by that is we got the Trios five and you know connectivity is an issue. The Wi Fi will be out sometimes or the Update Dang updates. Like they'll come in, they'll fire up the system at O seven hundred and it works and we're going to take a scan at O nine hundred and it's updating. Yeah. You know, and so we learned we got an Allied star and it's just like plug and play, never needs an update, not wireless, just thumb drive, this, that upload. And so like we always can work around Wi-Fi. ⁓ but yeah, so that I call that Ally Star the Chevy. It just never fails. Yeah.

speaker-1: Right. Well listen, it doesn't. But even though when navigation works, it works really well. Yeah. But you have to be prepared to have a backup. So I I know that some people think that ⁓ you know, like especially in Europe, there's a guy like Al you know, Alessandro Posey talks about hey, if you're doing a pterygoid without navigation, you're in the wrong. Well, guess what? Not everyone can afford it. Yeah. You know, and that's the thing too. You know, ⁓ it's affordability. I mean, ⁓ d some of those machines are fifty to a couple hundred thousand dollars.

speaker-0: Yeah, but you know, I I might this might be the f only time I maybe disagree with you, not a hard disagreement, but I think we can afford it. So XNA, I'm using XNAV now. Sure. And one of the things that got me into XNav is after being in teaching for a few years and students they'll send me you know, embarrassing, if not dangerous, you know, complications. Like they Where they put the implant is in not s not so good, you know. They put it in the you know, greater Palatine Framen or something like that, and they had a bleed or something like that. And so, you know, they make mistakes. And so XNav was reaching out to me constantly and I said, Let me see your product, bring it down here. Because I the main reason I brought it in was I said if it works, it can help my students stay out of trouble. Right? So when they're doing a pterygoid, they can if they use the machine correctly and they align it correctly, they can actually see where the tip of their drill is if they know anatomy on a C B C T. Right. So it keeps them out of trouble and now you know I'll proudly say that I love using XNAB even though I've been free handing for twenty two years before that. You know, if I had had it twenty years ago, I think I would have been a much I I would have been in five years where I was in fifteen. ⁓ you know, on the learning curve. Right. So I'm proud to use it, but you can't use it all the time. I was doing, you know, I got referred a a cleft patient.

speaker-1: Well that

speaker-0: had no premaxilla whatsoever. Well guess what? I put the tracker arm, you know, in the anterior nasal spine in the floor of the nose in the palatine bone right there, but they had no palatine bone there. So I had to do a quadzagobacase freehand. So you gotta know when to back up. And actually it was not a quad, it was single zygos, had pterygoids, had posterior tilts, but it had anterior pterygo anterior zygos and just navigation was not gonna be possible because guess what? We didn't have a place to suitably ⁓ fix the the aligning device. Sure. And that's gonna happen. It doesn't happen often, two, three percent of the time. But you gotta you gotta know when you can't c trust your technology.

speaker-1: And I and I think remember with with that your staff training is is a key as well. Right. You know, so but I I listen, I ⁓ sometimes I see cases that are done with navigation and they couldn't have been done without navigation. Right. Those are the cases that you're like, wow, I wish I had this twenty years.

speaker-0: Well it doesn't take the ⁓ it doesn't take the place of good training. And I didn't finish my point about the affordability, by the way. You know, fifty thousand dollars you finance that for a thousand bucks a month. Everyone can afford a thousand, but that's not you're you're gonna pay it off probably in six months anyway. Mostly but it's affordable. But yeah, the robotic the robotics, there's ⁓ a doc in my hometown who's ⁓ a robotics user and I routinely get his cases because well, one, he doesn't know where to put the implants in. So he's programming in where to put the implants, but they're in one hundred percent the wrong.

speaker-1: I see what you mean, yeah.

speaker-0: And then he can't do prosthetics. So it's like just because you have this technology does not make you an automatic proficient

speaker-1: Doesn't know where to place it. Yep, you're right about that. I like that.

speaker-0: Yeah, it's ⁓ it's something that you see that's very, very common. Digital technology, would you say it's become dangerous ⁓ making it seemingly so easy? You know, back in the days of analog, if you couldn't pick up your implants, you knew right away that y they were in poor positioning.

speaker-1: Right. Right. ⁓ well it's it's very true. So it's interesting 'cause some people say, you know, when I was at the J D meeting a couple of weeks ago in Italy, they were talking about how ⁓ photogrammetry ⁓ that everyone thought it was fail safe, right? But it's not true. Right. And there are errors that happen and th you know, the you have to try to make sure that you utilize digital workflows, but at the same time be prepared to accept the shortcomings. 'Cause digital is great. Great, but it's not a hundred percent perfect. Right. That's a myth. If you think it's perfect, it's not true.

speaker-0: Yeah, I agree. All right, Mr. NASCAR. Tell me what's going on on your chest. I've been waiting to ask you the whole look at YouTube, look at this shirt.

speaker-1: So I I you know, I got involved with ⁓ initially was major league baseball. Okay. ⁓ you know, one of the actually it was at that time one of the ⁓ was the Boston Red Sox. They went town for spring training and one of their pitchers got hit in the face with a fastball, fractured his jaw. So the team dentist for the Phoenix Suns called me up. He goes, Hey, listen, you know, we don't have an oral surgeon. Yeah and ⁓ I've seen some of your stuff. Social media can be your good friend and good referral. He goes and can you see this guy? Sure enough, man. And his dad was a major big time ⁓ pitcher from ⁓ you know the seventies this guy. So I was like ⁓ my god yeah I'd love to. So I got involved with Major League Baseball first, ⁓ fixing some broken jaws. And then they said, Do you want to be involved in the NBA as well? I was like, sure, I'd love that too. So with the with the base basketball players, I don't see as many facial injuries. But ⁓ after that became ⁓ soccer. So and the WMBA. So I became the official oral surgeon for ⁓ all the Arizona teams, but now I get referrals from ⁓ other teams. So it's nice I'm getting referrals from UFC, I'm getting referrals from other NBA teams who don't necessarily have a d a guy. So it's great because like this week is the the summer league and ⁓ you know, last week we we had some athletes and my kids idolized some of these guys. Yeah. And it's it's it's interesting. Some of these younger athletes are the nicest guys. And as some of them as they get older they stay humble and some of them don't. Just like clinicians, right? Mm-hmm. But I I love working with the s with the athletes ⁓ because they're ⁓ it's just it just ⁓ you know, I I'm a big sports fan just like yourself. And when you take care of these guys, ⁓ you just realize how you know, you see how human right they are. Yeah. And ⁓ I just love it though. My kids are so impressed, like, ⁓ can we meet so and so? I'm like, you can come sit in my office, I'll see how it goes. Yeah. ⁓ but yeah, last week I got to take pictures with a couple of NBA players and they they were in heaven. ⁓ but no it's it's nice to be involved with sports. Yeah. ⁓ because you know, these guys have to be able to go back to function the next day. None of them I've never done a full arch on an athlete yet, but on family members for sure.

speaker-0: That's great. ⁓ yeah. One of the great intangible benefits of of ⁓ your experience and just kind of being known as the guy and also your reputation doing good work. I mean anybody can kind of seemingly have a good reputation for three or five years, no? It takes you you really gotta love your patience to have a great reputation for twenty years.

speaker-1: Right. Yes. And you know what I do? What I've done is I've learned to admit when I have a complication. I will tell my patient, hey, this happened, this went wrong, ⁓ but we will fix we can fix this.

speaker-0: Yes. First thing when when one of my mentees calls me and says, Hey, I had this complication in the office, how would you handle it? First thing I say, Well, does a patient know about it yet? Have you addressed it with the patient? And have you owned it? You know, I think, you know, ⁓ we we're kinda running out of time, but you know, talking about medical legal malpractice and w and suits and things like that, I find that one of the common denominators is doctors that don't readily admit the mistake and offer to fix it. I mean, have you come across that in your experience?

speaker-1: Yeah, all the time unfortunately. And what happens is they they're hoping it gets better on its own. Right. So you just have to make sure that when something goes wrong, talk to the patient and if you can't manage it, send it out to someone who can. I see a I do a lot of nerve repair and sadly it's ⁓ it's from implant placement or from thirds, obviously. I'm seeing more and more of it from implant placement these days. Right. And it's poor planning ⁓ and I see more more of it with itinerant doctors. Yeah. I mean just imagine you and I have our C T scan, you have your X nav, I have my Navi dent. You can't travel with those things. So you go into some office and you s meet the patient for the first time that day, you place an implant. Oops, I went a little too deep. Now what? Right. Now you gotta fix it.

speaker-0: One of the dangers of the ⁓ traveling surgeon too is not having a rapport or relationship with the patient. You know when you get in there if something goes wrong, you're not treating a friend, it's just a body in the chair, right?

speaker-1: Most definitely.

speaker-0: Would you say ⁓ a question I want to ask, go back to we were talking about maintenance follow-up care. Can you do really good, reputable work and not offer, you know, a a maintenance program or is is it possible to do that? You know, in your case you're you're you're reliant, you're making sure that the referring doctor is doing it, right? But what do you what do you have to say for, you know, some of these offices, do you have an opinion where they like go in, they get it done and then they go, okay, we're done now, you got your final teeth in three days or three months or something. six months but now go find someone. Right? Is that can that be an elite service or is it missing something?

speaker-1: I think it's definitely missing something. You know, I I I have patients, local patients, that the restorative doctors don't want to deal with the restoration. Right. I make sure I find someone for the patients to maintain that. Because listen, patients old habits die hard. Right. And they don't know. They think they paid forty, fifty thousand dollars for this thing, it's gonna last forever. Nothing lasts forever. And that's one thing I tell people you have to maintain it. Yeah. ⁓ so it's like a car, you gotta you gotta change the oil, you gotta rotate the tires. Yeah. And ⁓ with patients that are not getting that from their referrals, man, you're you're you're doing a disservice to your patients.

speaker-0: Yeah. I want to close on ⁓ mentorship. Okay, we have a mutual friend. You know Sarah? Yes. Yeah. Sarah, she worked for you for a long time, everyone knows. She was on the podcast. You gotta check out her podcast, by the way. She had really nice things to say about you. You shouldn't be surprised.

speaker-1: That's awesome. I love Sarah. ⁓ no, listen, Sarah and I worked together. Man, I'd say I don't want to date us now, but ⁓ dating back like ⁓ my god, we worked together tw maybe twenty years ago. Twenty years ago. Has it been that long? ⁓ my god. It's scary. But yeah, I remember ⁓ her kids were little. Yeah. So I remember what Sarah I didn't have kids yet, I wasn't even married yet. I was I was working like a I worked seven days a week back then. Sure. And she would tell me, she goes, You work like crazy. I'm like, I love it. ⁓ and I had I have lots of hobbies too, but I loved oral surgery. But I remember she had a little one who's now almost 13. Her youngest is the my oldest age, but her oldest is like in their twenties now. Yeah. ⁓ Sarah's awesome. ⁓ she's I mean, I'm sure like she is a huge part of of you know anyone's success she works with because she gives it a hundred percent. A hundred and two hundred percent

speaker-0: ⁓ she really does. Absolutely. She is ⁓ passionate about this. She's not just a rep out there in the fi you know, it w working for a corporate company who's just doing her job and c punching the clock. She loves this and she loves training. So hats off to Sarah, but I asked Sarah, and I kinda wanna I might finish on this. But I asked her why she what did I ask her? Sort of why she held you in such high regard. Why what she looked up to the most in you. And she told me, and this is beautiful, man, she said, because you love, you genuinely love to sh to teach, mentor, and share knowledge. And she respects that about you. And that's what I've seen about you across the globe, going, traveling, doing all this. I know we don't do it for money. We can make far more money in our practices.

speaker-1: Definitely.

speaker-0: But she said you were an excellent mentor and that you genuinely gave that from your heart.

speaker-1: Yeah, I mean listen, it it does come from more I actually had one of my residents tell me that the other day, a a first year resident. He goes, You know, I learn more from you than I do from all my other attendees collectively and I said, I just love to educate, love to teach and it makes me happy. And you're you're right. You you don't make money by educating people, going to lecture at different places and courses. 'Cause you could do more in your practice. But at the same time, you know, ⁓ it you have to do all of it. It brings it together. And that's why I can practice until I'm that's why Mike Pico's practice is even now, you know, he's a a little bit older than me and you. Right. But he can easily continue doing it because he's he's so satisfied. It gives you so much satisfaction and gratification knowing that you are making a difference and an imprint in the future generation. Right. ⁓ that's Sarah's nice. I have to thank her for that.

speaker-0: I love that about yeah, listen to her, listen to her. She's very, very kind and I think she's a very honest person. You've person of high integrity yourself. ⁓ it's an honor to have you on this pod. do you have any anything else we want to talk about or any final words or

speaker-1: No man, listen l we should do this again. I you we we should collaborate more. This is awesome. I mean the fact that we did the first podcast in person, right? Is this the first one in person?

speaker-0: Not the first one in person. In v on the road. The first time I took all my gear on the road. ⁓ I p I packed that pelican case for you, my friend. All right. Yeah.

speaker-1: No, I I I just think like in closing, I just have to say this is the one thing that I will tell you that isn't said enough. You know, I I I look in the mirror today and I see the same person I saw thirty years ago. And I saw a picture of me and my mom who unfortunately passed away a year ago from cancer. I saw a picture of us, ⁓ f nineteen eighty eight. Yeah. Almost it'll be thirty eight years. And I had I'm trying to think, I had just got into UF for for undergrad. Right. Okay. And I had a picture of me holding my acceptance letter, and I had this grin on my face. And I the happiness that I had, the joy that I got from that ⁓ moment, I was like, you know, I never knew I was gonna go sore to the top. And I'm not saying I'm on the top, but a lot of people come up to me and say, Hey, can I get a picture with you at the meetings? And you know, I I I I always humbly say, Are you sure you want a picture with me? You have the right guy. Right. And so So the the thing I've learned the most important thing is, and unfortunately some of my colleagues and my mentors aren't like this, but you have to be really nice to everyone on your way to the top. That's right. Because someday you'll be on your way down. Amen. And guess what? The same people that you were nice to on the way to the top will be nice to you on the way down because it's people never forget your kindness. Right. But they will always remember that you were a jerk to them. Yeah, always. Right? ⁓ it's like that basketball player.

speaker-0: Yeah.

speaker-1: like hey can I get a picture with you? No man, can't do it. Right. But you always remember the ones that were jerks. Right. And you always remember the ones that were super kind. So be nice to everyone on your way to the top. Yeah because it you won't always be to

speaker-0: Be nice to the waiter, people. Be nice to the janitor. Yeah, everybody. Everybody. The people who clean your floors, do your bug work. I mean, I'll tell you what. I agree with that 100%. I mean, we're all just people. Maybe we're here by happenstance. You're not more important than the people that are pushing the broom. Yeah, it's been my absolute pleasure.

speaker-1: No, wait a minute. Thanks for having me on there. My pleasure too. Yeah.

speaker-0: Great conversation. Thanks, brother. Hey, if you guys are listening and you enjoy this podcast, I'm just gonna ask you to please subscribe. Subscribe on YouTube, on Apple, on Spotify, subscribe on all three, keep us going. ⁓ keep sending your questions in. ⁓ if you have guests that you'd like to see on the show, I'd love to hear about it. But ⁓ yeah, stay engaged and remember, I mean, you gotta do this every day. You gotta go all in, all on X, right, brother. That's right. All right, let's go enjoy some Vegas.

speaker-1: Practice makes perfect. Thanks again. All right, Boss. Thanks, bud. Yes, sir. Appreciate you.

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