Predictable Implant Dentistry

Predictable Implant Dentistry

Shaun Keating + Dr. Jerome Smith DDS

Practicing implant Dentistry for over 30 years, Dr. Jerome Smith DDS shares his passion for restorative implant dentistry. Jerome joins us this week to discuss how implant dentistry has evolved with technology, types of implant options, common mistakes when creating implant treatment plans, what to avoid, 3D-printed surgical guides, how to approach difficult cases, differences between the available denture attachment systems, and how to educate patients about the best treatment plan to avoid compromises and disappoint.

Learn more about the over-the-shoulder implant course Dr. Jerome Smith offers (next course November 10th):

Learn more about Latin World Ministries that Dr. Jerome volunteers his time to:

Full Transcript

Shaun Keating: Hey everybody, Shaun Keating here. I want to welcome you to this week’s episode of the Dental Lab Podcast brought to you by Keating Dental Lab here in beautiful Irvine, California. This week we have a very passionate implant specialist joining us to discuss different types of implants, 3D printed surgical guides for implant dentistry, how to deal with difficult cases and how a laboratory can improve your implant dentistry. Please welcome Doctor Jerome Smith, practicing all the way in Lafayette, Louisiana. Hey Jerome, what’s up baby?

Dr. Smith: Thank you, Shaun. Thanks. It’s good to hear from you. Good to hear from you.

Shaun Keating: Awe, dude. You’re the man. I mean you really know your stuff, dude. And I’ve known you probably like-

Dr. Smith: I’m old. I’m old. I’m getting old.

Shaun Keating: Nah. You’re still a puppy, dude. You look young. You look like that old Hollywood movie star type of guy. Man, you just, you look good. You’re just a good, real good heart. I remember meeting you. I met you a long time ago at a dental town meeting, I think it was.

Dr. Smith: First dental town meeting. The first one.

Shaun Keating: Yeah, and I think I introduced you. I remember I was all nervous that you were doing a speech or something. You had a big … You were one of the lecturers, and I was doing some work for you back then and somehow they said, “Hey, will you introduce Dr. Jerome Smith?” And I’m like, “Heck, yeah.” I remember I was with my wife, and I worked up a little speech. I was nervous because I never do that stuff.

Dr. Smith: That’s nice.

Shaun Keating: I met you and your wife and your family. Just great, dude. You just got the best respect out there in the industry.

Dr. Smith: Well, thank you. Thank you.

Shaun Keating: You know what, it just … Just are really awesome dude. You know what, hey, real quick, I know you’re out in Louisiana there. I always like to start off on sports. So tell me, man, you’re an LSU guy. I know you are.

Dr. Smith: Yes. Yes.

Shaun Keating: What about Coach O? Coach O, man. They took him from USC. Man, that guy, he got passed over for the head coaching job, and then he went back to his home town. I guess he’s from out there. What do you think of-

Dr. Smith: I really like him. I really like him.

Shaun Keating: Isn’t he great?

Dr. Smith: I can even talk like him a little bit.

Shaun Keating: He kinda … Awe, man. He kinda reminds me of the guy on the Water Boy a little bit. Remember the one-

Dr. Smith: Well, he’s from down in the bayou. He’s from Bayou Lafourche. He loves LSU, and we were ready for a little change. So far, knock on wood, things look good. But it remains to be seen.

Shaun Keating: Yeah, it’s tough in college football. Alabama is just so loaded with those five star recruits. It’s almost not fair, the way they get those guys out there. But I hope they get their butts spanked this year, and give it to somebody else.

Dr. Smith: Well, Saban is an exceptional … He’s exceptional. He really is.

Shaun Keating: He really is.

Dr. Smith: I hated to lose him because we hadn’t won a championship since 1958. He comes along and then we wind up beating Oklahoma. Then with some of his recruits, we wind up beating Ohio State a few years later. Won two championships. Really kinda of under his guys.

Shaun Keating: Absolutely.

Dr. Smith: He’s phenomenal. He really is.

Shaun Keating: He’s kind of like a Belichick. I mean, he just demands greatness. He doesn’t put up with squat.

Dr. Smith: He was Belichick’s understudy. Belichick was his coach.

Shaun Keating: Yeah.

Dr. Smith: He was an assistant coach to Belichick, so he had quite a mentor.

Shaun Keating: No kidding. Even too, when he got on … What cha call … Kiffin last year, he was like, I remember he answered one of them, “We heard you kind of getting on Coach Kiffin there.” And he goes, “No, that was a butt whipping,” or whatever he called it.

Dr. Smith: Right. Right. Right.

Shaun Keating: That was a verbal abuse, or whatever he said. It was like he didn’t mix it up or nothing. He just said, “No.” That was a tongue lashing he got. You know? It’s just kind of a … Yeah, he doesn’t mess around. But, you guys won last week. I think it was 27-nothing against BYU.

Dr. Smith: Yeah.

Shaun Keating: I guess it got moved from Houston because of that storm and went to New Orleans.

Dr. Smith: Right.

Shaun Keating: How did you guys fair with all that storm in Houston? Did that affect you guys at all, or?

Dr. Smith: I was in Alaska fly fishing, and I was … Fortunately, it didn’t really get to us, but our friends out in Beaumont, Texas and in Houston, Texas … If you think of it in these terms: Katrina was a big deal. Katrina had … There were 6.5 billion, trillion, gallons of water associated with that storm, and this last storm in Houston, Harvey, was almost three times that.

Shaun Keating: Oh my god.

Dr. Smith: Fifteen trillion gallons.

Shaun Keating: I couldn’t imagine. You’re kidding.

Dr. Smith: If you think about it, New Orleans is less than a million people. Houston is six million. There was no evacuation. When you compound all of those things together it’s a much bigger deal than Katrina ever was.

Shaun Keating: That’s crazy, dude. That’s just … I never … Even watching it-

Dr. Smith: Like I said, we were fishing. We were out in the wilderness, so I was just getting little bits and pieces of what was going on. I was just real happy that it didn’t come and affect us. I have a little camp on the Gulf Coast, and I was kind of sweating whether or not the boats were going to be okay and things like that. So we were all right.

Shaun Keating: No kidding.

Dr. Smith: Now we’ve got another one to worry about, Erma. We’ll see what happens with that.

Shaun Keating: Can you believe that? I think where we’re at, man, we always get the earthquakes and we have the smog and all this stuff, but, dude, I always worry about the thunderstorms and the tornadoes in parts of the U.S. Then you guys on the coast.

Dr. Smith: We hadn’t had anything in 12 years.

Shaun Keating: I know.

Dr. Smith: Been 12 years since we had a significant storm like this, you know.

Shaun Keating: And then now the one big one coming up through Florida, and all that. That’s on the side of you a little bit there. Doesn’t that …

Dr. Smith: Yeah. It looks like it’s going to turn east, but those things are unpredictable. You never know what’s going to happen.

Shaun Keating: God. And that little …

Dr. Smith: We’ll see.

Shaun Keating: That little hole in the middle, man. What the hell is that? Is that the eye of the storm? It’s like, holy moly. And it’s just-

Dr. Smith: Right. Right. Right.

Shaun Keating: Awe. So, dude, what a-

Dr. Smith: It’s a big one.

Shaun Keating: What about … Where’d you go fishing, man? What’d you get on there?

Dr. Smith: Well, we went up to this place called the Enchanted Lodge. We had 14 people there. Doctor Malone from Lafayette was with me and one of my classmates, Dr. Jimmy Iverstine, who practices in Ferriday, Louisiana and Natchez, Mississippi. He was with us. And every day we got on a sea plane and went to a different venue, and fishing was fantastic. It was really … It was surreal. It really was.

Shaun Keating: Unbelievable. Dude, that’s … Did you guys get any halibut or anything? What kind of fish?

Dr. Smith: No, no, because we were just fly fishing for rainbow trout. That’s all we were fishing for was rainbow trout. The trout down there get real big because they eat these salmon eggs. Salmon go up the stream and lay their eggs before they die during their life cycle, and these trout get real big. There’s nobody out there.

Shaun Keating: Oh my gosh.

Dr. Smith: We hardly saw anybody at all, the whole week, so it was really stepping off the grid completely.

Shaun Keating: That is so neat. I know you’ve been into fishing for a long time. I remember-

Dr. Smith: You like to fish as well, right?

Shaun Keating: I love it, man. But I’m just a salt water sea, deep sea fishing guy. I’ve never really done lakes, but … And I’m just a-

Dr. Smith: We fish a lot in the marshes off South Louisiana. Fish for speckle trout and red fish. Occasionally, we go offshore and catch a yellow fin tuna and amberjack, red snapper, things like that, but mostly what we like to do is fish in the marsh.

Shaun Keating: That’s what I would like to do, because I’m not a real big … I’ve got a nice boat and everything. I’ve got a Bertram ’54 and it’s a beast out in the water, but I got a weak stomach, man. I kind of like those marshes and lakes. It’s nice and calm. That side to side and up and down, you can’t see land. That gets on you a little mentally. It’s like-

Dr. Smith: You just have to douse yourself in OFF, because we’ve got a lot of mosquitoes and horseflies and all that stuff. If you’ve got a lot of repellent on you, you’re okay.

Shaun Keating: No kidding.

Dr. Smith: You don’t leave home without insect repellent.

Shaun Keating: Oh, I bet. My dermatologist, he hates me in the sun. I’m getting shit fried off my face and back. I’ve got the light, fair skin and blue eyes, and I built my dermatologist’s practice by how many times I go in there and how much money I’ve given him, man. Awe, it’s so crazy. Then my wife goes, “You came back, and did you put any sunscreen on?” I’m like, “Yes.” She goes, “Why is your face a tomato?” I go, “Well, the sun and probably the 12 beers, and probably I feel throw-upy because you know what, the damn boat, we’re hitting 10 foot swells out there.” I got this damn thing, it’s called a sea keeper. It’s a gyro. It helps about 60, 70% of the roll now. What a big difference that is. You get this big ole, it’s like a big gyro. You put it in the cock pit down there. We had to take a big gas tank out.

Dr. Smith: I know, I’ve heard of that.

Shaun Keating: Yeah. It’s called a sea keeper, and they have them, actually, in high rise skyscrapers, and it’s just like a counter balance, wherever it’s going it kind of straightens it out.

Dr. Smith: Wow.

Shaun Keating: It’s pretty amazing. I mean, I got a boat 60 tons, and it stops this thing like you wouldn’t believe. It’s pretty neat where you can just go and go on anchor by the kelp patties, and I’d be good for an hour or so, but now you can go three, four hours and it just like … It will go back and forth a little bit, but it won’t snap you and it just kind of keeps it … It’s a bit difference. For sissy boys like myself, it helps out quite a bit.

Dr. Smith: Right. Right. Right, right, right.

Shaun Keating: I’m actually going fishing tomorrow. There’s a bunch of yellowtail and bluefin tuna. We’ve got some marlins, and the waters up to like 73, 74. August, September is the time for us, you know. We don’t have to go down into Mexico. It’s just right here off Dana Point, four miles out, and there’s fish running right now. Kind of fun.

Dr. Smith: Wow. That’s close.

Shaun Keating: Yeah. It’s pretty neat.

Dr. Smith: When we go offshore to catch tuna we go 100 miles offshore.

Shaun Keating: Oh, dude. Yeah, we have this-

Dr. Smith: We fish all night.

Shaun Keating: Yeah. We have a place, it’s called the Hidden Bank, it’s out in Mexico. We’re right close to it where we’re at. It’s 90 miles out. For me that’s a good jog, but my captain and these guys, they go 900 miles on the boat down to Cabo, and I’m like, “No. I’m going to fly down there to this.”

Dr. Smith: Right. Right. Right.

Shaun Keating: It’s so freaking neat when you just pull on fish after fish. It’s just like … Sometimes you’re on dorado, you’re on yellowtail, yellow fin, blue fin. It’s just neat, but when you sit out there, and it’s called fishing and not catching, and a lot of times you’re not catching. I just hate-

Dr. Smith: It’s boring.

Shaun Keating: Yeah, it’s boring as hell. I mean, I’m in there watching the damn Kardashians on the TV and say, “Where the hell’s my fish?” Especially the marlin fishing, man. It’s like, dude, freaking trolling these lures for hours and hours. Even the marlin tournaments. I don’t even do them anymore. I have my team just do them.

Dr. Smith: That’s not for me. That’s not for me.

Shaun Keating: It’s like, dude, when you come to the docks with my marlins I’ll be in that picture, but I’m not going to be out there eight hours and get one hit on a lure. It’s just the freaking boringest thing in the world to look at these things waiting for something to come, and your teasers and kinda crazy, but …

Dr. Smith: Right. Right. Right.

Shaun Keating: Have you ever went down to Bisbee’s Black and Blue down in Cabo at all? That’s like the Super Bowl of marlin tournaments.

Dr. Smith: I’ve never been to Cabo. I have lots of friends that have been down there, but I’ve actually never been that way. We fish south of Cancun, bone fish down below Playa del Carmen, places like that. Most of what we do is fish off of the coast of Louisiana.

Shaun Keating: No kidding.

Dr. Smith: Venice, and then south of [inaudible 00:11:38], and the Bayou Dularge Cocodrea Area.

Shaun Keating: I bet it’s so beautiful. They got some of the best seafood in the world right out there.

Dr. Smith: Right.

Shaun Keating: Just even, too, all your crawfish. I’ve never been to Louisiana. I gotta get out there. I want to go … I’m an eater. I’m a foodie, dude. I just know I would fall in love out there.

Dr. Smith: We got that covered. We got that covered pretty good over here.

Shaun Keating: Get on down to that … What’s it called down there? In Louisiana, where all the partying is. Where they throw the beads and shit.

Dr. Smith: Mardi Gras.

Shaun Keating: Mardi Gras. I want to go to Mardi Gras.

Dr. Smith: Mardi Gras.

Shaun Keating: Heck, I-

Dr. Smith: Mardi Gras is a big deal.

Shaun Keating: Oh, I bet. You know. I’d be there … I heard they got these girls doing ping pong ball out their hoo-ha and stuff. Or whatever.

Dr. Smith: They do all kinds of things we can’t talk about on this broadcast.

Shaun Keating: Yeah, my wife won’t let me go there without her. So, I probably won’t be able to go there, but it’s just fun times. A lot of my buddies have been there. I guess the drink of choice out there is called a hurricane or something, right?

Dr. Smith: It’s one of them.

Shaun Keating: One of them.

Dr. Smith: Yeah. It’s one of them. From Pat O’Brien’s Bar in New Orleans.

Shaun Keating: Can you believe that?

Dr. Smith: A real famous drink. It’s been around forever.

Shaun Keating: Unbelievable. But I heard it’s just kind of like the Coliseum out in L.A. You go one block off the main strip and you’re gonna die. You know? It’s like you just

Dr. Smith: You gotta keep looking over your shoulder.

Shaun Keating: Yeah. You gotta be careful. But that’s anywhere in any city.

Dr. Smith: Yeah. Oh yeah.

Shaun Keating: You know? You just gotta watch where you go and keep your eyes open and stay with a group of people. Well hey, dude, let’s dental up a little bit now. So tell me, Doctor Smith, how and why did you get into dentistry? At what point did you know you wanted to be a dentist? Tell me how you got into it a little bit if you could.

Dr. Smith: My dad was a physician, and in those days we didn’t have guidance counselors and people to help you pick out a career and things like that. So, like a lot of our friends, I said, “Well, I think I’ll just go into medicine.” My dad was really against it because I think he had a premonition about what was going to happen with regard to socialized medicine. He really didn’t care for Medicare back then when it really wasn’t anything like it is now. He really encouraged me to go into dentistry, and you always do the opposite of what your parents want you to do. So I was determined to go to medical school, and then I wind up going to a fraternity formal in New Orleans, which was a Sigma Nu Fraternity. We had the White Rose Formal every year. I was staying with a friend of mine who was in dental school, and he said, “Do you want to take a tour of the school?” So, I said, “Yeah.”

So I went down to LSU dental school. It was a brand new school, state of the art, the most impressive thing I had ever seen, and I said, “You know, I think I’m going to jump ship. I think I’m going to apply to dentistry instead.” With really no idea what I was getting into, but I just began to see that medicine maybe … I couldn’t really figure out what, in medicine, was going to appeal to me. I thought neurosurgery would be cool, and my father kind of explained the facts of life about the fact that a lot of your patients don’t live and a lot of them can’t count to 10 after they have brain surgery. Things like that.

And then I looked at plastic surgery, and, of course, it wasn’t anything like … It was a lot more grotesque than I felt that I wanted to be involved with. So, I wind up in dental school, and one of the things was I had an opportunity to get out of college a year early. So, I applied to dental school, got into dental school after three years, and, by the grace of God, I said, “This is exactly what I want to do.”

Shaun Keating: That’s awesome.

Dr. Smith: I love doing lab work. I liked everything about it. The teachers there, they didn’t intimidate me at all. I figured, you know, those who can’t do, teach. Not to be facetious, but I just began to realize that I accidentally made the right choice. I enjoyed school as much as you can enjoy dental school, and so here we are 38 years later. I’m just so blown away by how much dentistry has changed in 38 years. I still feel like a young dentist, but I realize there was a time when we were doing composite resins where we would mix a base and a catalyst together and inject it into a hole and hold a Mylar strip on it for five minutes and wait for it to set up.

Shaun Keating: Oh no. Yep.

Dr. Smith: I started practicing before the lights came out. And then Nuvafill came out and we had a light, and that was cool. But back then, it was pretty much amalgams and gold crowns, occasionally porcelain infused metal crowns and partial dentures and dentures. That was dentistry.

Shaun Keating: Yeah.

Dr. Smith: You know, you look at it now and it’s just changed so much it’s mind boggling.

Shaun Keating: Oh, it’s just going so digital. Even too, with impression material, I remember back in the day, Impregum, you had to do that base and catalyst, and mix it on a little tray.

Dr. Smith: Right. Correct. We used rubber base, rubber base with a spatula.

Shaun Keating: That was the nastiest stuff.

Dr. Smith: You get it on and you look like poo poo, dog doo


Shaun Keating: Awe, that shit never comes off.

Dr. Smith: Yeah. Never. So look at what’s going on now. It’s just amazing just how much things have come along. I think about, I started doing implants in 1985, so that’s-

Shaun Keating: God, that’s when I started dentistry, ’84, but it’s just … You’ve been doing it so long. You’re just such a man in implants. You’ve been doing it 30 some odd years. That’s just crazy.

Dr. Smith: Right, but it’s so cool to see how much it’s evolved. And here we are now able to … We have a cat scan machine in the office, and then we’re able to digitize a model and stitch those together and create a surgical guide. I just got a Formlabs printer. Before that, my partner, Dr. [Gomang 00:17:06] and I, have these two Robox CEL printers and we decided we wanted to go from a Volkswagen to a BMW. So now I have the Forms 2 Lab printer. In fact, when I was talking to Eric the other day, getting ready for this podcast, he said, “I can hear your printer printing in the background.”

Shaun Keating: That is so cool. You’re so … You’re more advanced than I am, man, getting all those printers. I mean, I got a couple printers but, dude, that’s freaking huge, man. That’s so cool.

Dr. Smith: You know what, after eyeball implant placement after all these years, you feel a little reluctant to move up to the next level. But once you do it’s like I could never go back and do it the other way.

Shaun Keating: Oh, I bet.

Dr. Smith: Because it really cuts down on our time. Placement is just so much more accurate. It’s just a … It really … It’s slick. It really is slick.

Shaun Keating: That is so cool, dude. Now tell me a little bit about your practice. Where’s the location and stuff? Tell me about that. Is it the same one you’ve had all the time? And, tell me a little bit about that.

Dr. Smith: About seven years ago I decided to build a new office, and it was principally because I needed more room so that one day I could take in an associate and a partner and also be able to manage … I just kind of did it on a whim. I had an associate. She only had one operatory, and I thought, “There’s no future in this. I’m just going to have to get a bigger building.” So we built a 6,000 square foot office seven years ago. It’s really worked out well. Now my nephew, Dr. Gomang, has been with me for the last, I said three years, he said four. I think he’s right. It’s been about four years now. It really is working out really, really nice. He’s a great dentist and he’s a great guy. It’s neat to be able to practice with somebody that has kind of the same vision.

Shaun Keating: Absolutely, and you guys are crushing it. You guys are just so well respected in the area and nationally, too.

Dr. Smith: Thank you.

Shaun Keating: When I talk to different doctors, and I say, “Yeah, I’m working with Dr. Jerome Smith,” and they’re like, “What?” Because you do so much for all. Like a bunch of GPs, you teach so much implant dentistry and you’re a teacher. You do a lot yourself and you do a lot for everyone else, but you’re really making a difference out there. You’re just so … It’s kind of like Coach O in Louisiana. When they talk about dentistry, Dr. Jerry Smith is the man, and it’s just-

Dr. Smith: Thank you. Thanks.

Shaun Keating: You can’t teach it, dude. You just really have a passion for it. So, tell me a little bit on … You got any tips just for some dentists out there thinking of starting their own practice? What do you think for them as their best thing? Not buying all of the equipment or buying some stuff, get a comb beam or wait and get … What kind of advice would you give some of the younger guys that listen to me on this podcast?

Dr. Smith: Well, the best advice that I have is quit listening to all the negative crap out there about corporate dentistry and about debt and how am I going to pay this off and all that. Listen, every one of us, most of the guys that I know, when we got out of school we were broke, and we stayed broke for 10 years. That was just the way it was, and our expectations, perhaps, weren’t as high as maybe the millennial expectations are. I’m not really sure how to phrase that.

Shaun Keating: Yeah.

Dr. Smith: What I’m saying is, there was a time after four or five years in the practice when my wife said, “Am I going to have to work?” I said, “Well, yeah.” “How long?” “Probably forever.” We were just … We just winged it for 10 years, and at some point in time you start to develop enough of a following and you start developing enough business sense and efficiency, and all those things start to come together. And then some of that debt gets whittled down. And assuming that you don’t go out and buy brand new BMWs and a million dollar house and things like that, there’s a very, very right future for all the young dentists nowadays. They just need to know that it’s there. And what I find is the harder you work the luckier you get.

Shaun Keating: Absolutely.

Dr. Smith: It’s all this stuff about marketing and social media and ads and all this stuff, but sometimes it’s the exclusion of really good internal marketing, which includes being able to take photographs on patients and show them, in an effective fashion, what you can do. Raise the value for what’s available nowadays. A lot of times I find that young dentists, as well as people in my generation, will look at a patient and think, “Well, they don’t want that.” Or, “They just want two implants and an overdenture.” Don’t even offer them the opportunity to have what you and I would have, and that would be four to six implants and fixed bridgework. They won’t even offer them that because they feel like it’s going to be too expensive.

So, along those lines, what can we do to try to bring the cost down? One of the things we can do is quit being so damn inefficient at what we do. That’s why I think I have a passion, and so does my partner, Dr. Gomang, about doing guided surgery because it absolutely cuts a lot of time out of the procedure and it allows for more accurate placement. It allows for an easier restorative job. God knows it makes your job easier.

Shaun Keating: Oh, it does. We do so many different implants for different guys. When it comes with your practice, you’ve taught us so much in the past. And I’m still a dinosaur, you know? I’m an old school guy, and I don’t even … You work with Steve here and Bob and these guys, and they just rave about you. You make it easy.

Dr. Smith: One of the things that I think has happened is, what we see is we see the industry moving toward all on four, all on six and a full zirconia restoration that screws into place. I’m not saying there’s anything wrong with that. I’m saying that you’ve been in this business long enough to know that we kind of need to proceed with caution.

Shaun Keating: Yep.

Dr. Smith: When Howard Farran interviewed Carl Misch before Carl died, he really had some concerns about those types of restorations and those little bitty tiny screws that are holding in a full arch restoration on four implants or six implants. The mouth is a brutal environment. And everything … Like Paul Thorn is singing from Picayune, Mississippi says, “Everybody looks good at the starting line.” All this stuff looks fantastic the day you put it in. I want to see what it’s going to look like in 10 years.

Shaun Keating: Oh, yeah.

Dr. Smith: That’s my focus, because when this stuff comes back to you, and believe me after doing this for 30 years, this is like a repair shop over here.

Shaun Keating: Oh, I know.

Dr. Smith: Between my patients and patients from other practices and people that come in from out of town that move to this area, if they’ve got something broken or unscrewed or snapped off, they wind up over here. So we see it all. What you learn from that is we need to not under-engineer, we need to over-engineer a little bit, or at least air on that side … Be cautious on that side of the coin, and really start looking at these things in terms of durability and long term. That’s probably my greatest fear right now is that some of this stuff that’s being advocated and being done is going to wind up in litigation or it’s going to wind up with some unhappy dentists and patients.

Shaun Keating: Oh, I bet. A lot of them should be doing certain things. That brings me … Tell me, what the difference between the all-on-four implant screw retained versus custom abutments and conventional cemented crown and bridge work? What do you … Everyone’s different? Every patient is different? What do you like more than the other?

Dr. Smith: I just find that, maybe it’s because I’ve been in practice for so long, to me that if I’ve got four to six custom abutments in an arch, usually six, sometimes eight, and I’ve got custom abutments that have been designed by you guys using a computer, using the parameters of where the final restorations are going to be. These things come in and we screw them into place, and now we’ve got six or eight, it’ll look like beautifully prepped, parallel crowns, and we’re taking conventional crown and bridge impressions. And then we’re breaking the case up into components where maybe we’ve got two posterior three unit bridges and maybe two anterior three unit bridges or one anterior six unit bridge. If something happens to one of those legs we can deal with it and it doesn’t affect the entire prosthesis.

Shaun Keating: That’s so on the money, dude.

Dr. Smith: I’ll tell them myself, I have a patient right now who we placed four implants, and we did a full arch restoration, and low and behold she comes in one day and she’s got about 50% bone loss on number 19. I don’t know why. I really don’t know why, but there it is. So now, what we had to do was section the bridge at the distal of number 22 and take that implant out, and I’m going to have to go back and put one where 19 and 21 are and then make a three unit bridge. But, the whole restoration is tied together. And I just … It would have been a much better situation if it was more implants, and then broken down into separate sections.

Shaun Keating: It’s been my philosophy just with fixed prosthetics forever with … I’ve done so many roundies, just conventional PFMs through the years, and I’m always telling the guys, “Let’s break it up in two, three segments at least just so you’re not holding the bag at the end.” And they’re just-

Dr. Smith: Not only that, the longer the span the more leverage there is being transferred around.

Shaun Keating: Exactly. And so, so many guys-

Dr. Smith: I’ll tell ya, I saw a guy a month ago. He had five Branemark implants done at the Mayo Clinic in Rochester, Minnesota. Did a beautiful job. He had a full arch, fixed detachable, screw in hybrid type restoration. He comes in with the whole thing in his hand. It had broken screws in all five of those abutments. Had a little small one millimeter broken screw inside of them.

Shaun Keating: Damn.

Dr. Smith: Fortunately, we were able to get those abutments out and put new abutments in and retrofit it to his existing bridge, because Blusca Abayo has components that are compatible with Nobel BioCare. We were able to put it all back together, but it was like, “Man, this is scary to me.”

Shaun Keating: That’s it. It really is. You just, I’ve got some guys, in their top drawer of their toolbox, whatever implants they got they’re going to stick in and stuff. Just think this out a little bit, man. It just takes time though, and a mentor or someone good that can train these guys … I think once you get a sound system and the base, it’s kind of like your crown preps. I’ve got two burrs, three burrs and I do the same every time.

Dr. Smith: Right. Right.

Shaun Keating: The same thing on implants. If you can get a good sound foundation, and I’m not just saying take one weekend course and come back on Monday and pull flap back. But you can do some really good predictable implant dentistry if you get someone like a Jerome Smith or Carl Misch or some of the people that are out there. That you gotta put some time and effort in, but it is what the future is. Implant dentistry and removable and implant dentistry is the only thing that is really growing in my area. It’s hard to find dentists that are going to give us good stuff. Then we have to work with them, but it is because these baby boomers, and the ones beyond it, they’re only missing onesie, twosie teeth here and there and it’s implant dentistry buddy. Because a lot of these people now, you’re not going to cut down my virgin teeth. It’s a tough thing going forward because people are taking care of their teeth more and they’re not losing them all and everything.

Dr. Smith: Right. Right. Right.

Shaun Keating: Tell me a little bit about removable dentures and conventional attachment systems. What do you find there?

Dr. Smith: Well, it looks like the locator attachment really is the king right now.

Shaun Keating: Absolutely.

Dr. Smith: We went through a phase where we were doing bars with hader clips and then … I’m drawing a blank. The metal clips …

Shaun Keating: Sterniares and stuff or osso attachments?

Dr. Smith: All that stuff, O-attachments, O-ball attachments, things like that, then the locator comes along … And I don’t know if you know the story about Max Zest. Have you ever heard the story about him?

Shaun Keating: No, not at all.

Dr. Smith: He was the guy who developed it. He’s no longer alive. He passed away several years ago. Of course, his family now is running the company. But he had all of this teeth removed and had some Vitrix carbon implants done, because he couldn’t stand the dentures. He was a lab tech, like yourself. Couldn’t stand the dentures so he gets Vitrix carbon implants. Of course, those things had about 99% failure rate. Then, he comes back and has some Branemark implants, but he wasn’t happy with the attachments and the retention afforded by the O-rings, or whatever attachments were being used, ERAs, whatever it was back then.

So he developed the locator attachment. And of course, I’m sure it’s the most widely sold attachment on the planet now.

Shaun Keating: Absolutely.

Dr. Smith: That, basically, is mostly what we use. And we’ve had good success with it. We really monitor these patients. We have them come back in for recall. We will change out the attachments within the denture, as needed. Occasionally, some patients actually wear out the locator attachment itself. And the evidence to that is, when you see that anodized titanium nitrate coating worn away from the attachment, and sometimes you gotta take them out and replace those things in the mouth.

Shaun Keating: I know, it sounds like you do a lot, failing implants, elderly patients, medical compromised patients, older existing cases. You seem to get quite a few of those. It’s kind of like the guy, the master mechanic that gets these Ferraris and all these high-end cars that only the true experts can really work on them. I see you doing a lot of that. What do you find best with people? Is it a money thing? Or is it compromised, being older thing? What do you see on that? You see a lot of patients that come to you with problems. How do you deal with those?

Dr. Smith: First of all, one of the things that we try to do is educate them on what’s available. And it’s amazing how Fran used to say, “The average automobile …” And this is 15, 20 years ago. “The average person can afford a $20,000 automobile.” But when it comes to their mouth, we always kind of minimize the affordability, and second guess what a patient can afford.

And one of the things that I see about my nephew is, he presents ideal treatment to patients. He said, “Look, you have these options. Here’s the whole menu, or part of the menu, and we’re gonna try and explain all this as best as we can to get you to be able to visualize what’s available, and then you can decide.”

So, along those lines, what you don’t wanna do is something that we all, at some point, at some stage in the game, we always, all of us do, some still do, and that is, you offer a patient some compromised treatment. And they’re not happy with it, and you’re not happy with it, and nobody’s happy.

Shaun Keating: Exactly.

Dr. Smith: For instance, if somebody needs to lose their lower teeth, it’s like, “Look, we’re gonna put in four implants and we’re gonna make a prosthesis that’s gonna snap in. If it’s not affordable, then I’m gonna discount the fee somewhat, because this is what you need to add.” Otherwise, they’re not gonna be happy. If we put in two, the denture’s gonna rock around on it, you’re gonna wear the attachments out, you’re not gonna be happy. All you’re gonna remember is how much you spent. And all I’m gonna remember is, “We should have done it right, instead of compromised the treatment plan.”

Shaun Keating: Absolutely. You know, it’s tough, it’s tough with the chairside manner, what you have to do with the patients. And I think you almost gotta tell them, “This is the way it should be done. We can do this, but it’s just something-“

Dr. Smith: Well, Shaun, along those lines, one of the things that’s helped me a lot is, I have a dental assistant named Tammy that does all the new patient exams and does all the treatment presentations. And so, if you wanna tip new dentists out there, if you want a tip. That something to work toward. Because this girl doesn’t have invested interest in whether or not the patient goes through with these treatment recommendations. And they trust what she has to say.

Sometimes she says some things that don’t even make sense. I’m listening outside the door, something about the facial nerves. Like, “Wait a minute. You don’t deal with facial nerves.” Something about the inferior alveolar nerve. But the patients, they love her, they trust her. She’s passionate about what we do, and she sees the results. So she’s bought into it. With that kind of setup, I think it really does make a difference.

Shaun Keating: It really does. And I think that’s across the line from doctors and medicine, and dentistry. And all the top people that I know, they have a real go-getter that is her treatment planner that really … And they’re really down to earth, but they’re really knowledgeable. And the people get it. It’s not like a sales thing, it’s like this is what it is, and this is what you need, and then the doctor comes in and it’s really what you need. So invest in your staff, for sure. And get that one person, or a few of them, that can really go through it with the patient so you’re not doing all eight things that it takes to get a patient to get in the door and this and that. But that is so important, for sure.

Dr. Smith: And the interesting thing is, if you do this, your case acceptance goes up, which is kind of humbling when you think about it. But I have a tendency to start talking about implant surfaces and things that patients, they’re not even interested in. When your guy comes over to work on your computer, he starts telling you about what’s wrong with it, and you’re like staring at the sun. You don’t wanna know all that. You know what I mean?

Shaun Keating: Exactly.

Dr. Smith: You want, “Hey, can you just fix it? What do we gotta do? How much is it gonna cost?” And it’s just worked better for me having someone else go through that.

Shaun Keating: Oh, absolutely. And I bet it would for a lot of guys that are trying to do it on themselves, that they could pass that on, because that might not be their strong point. And I’m not saying that’s a strong point, but just people know when people are talking to you and they have a passion about it, and they really know what they’re talking about. Not that the dentist wouldn’t, but it’s just something they can get through it a lot better, I think.

Dr. Smith: It’s one of these things I’d rather not do. I’d rather not do that. I don’t like cleaning teeth either. It’s just nice to be able to delegate that somebody else probably is gonna do a better job anyway.

Shaun Keating: Tell me, what’s your most passionate thing about the dentistry? Doing like, obviously sinking implants. But do you like to do root canals? Do you like doing … You do what you want to do. What do you like to do and what don’t you like to do?

Dr. Smith: After doing this for so many years, we work with over 100 offices in our area, so I’ve gotten to where mostly what I do is implant dentistry and full-mouth reconstruction. I’ll do a root canal occasionally. They’re so easy to do. When I think about holding a K file, and my fingers, for three or four hours, just to do a molar. And now it’s just so darn easy. And it comes out so much better, and all that.

Like I said, once again, it’s almost like appreciate where we are today in dentistry. You’d almost have to walk through my shoes and your shoes back in the ’80s to be able to appreciate where we are now.

Shaun Keating: Oh, it’s so crazy.

Dr. Smith: And when I hear the negative stuff out there, it’s like, “Man, you have no idea.” It’s kind of like complaining that your toilet won’t flush, and then your grandfather, he had to go take a dump out in the woods. You know, it’s like, “Come on.” It’s just so nice now.

Shaun Keating: We got … Aw, shit. We got toilets that cost several thousand dollars that will do everything except take …

Dr. Smith: In college, I paid $250 for a calculator that would add, subtract, multiply, divide. Now, I’m looking at my iPhone 7, that’s got more horsepower than the Apollo 15. It’s just such a great time to be a dentist and to be alive in the United States of America. But there’s so much negative stuff out there, that … The glass really is half full, there’s no doubt.

Shaun Keating: It really … It seems like it, with all this. I’m not real political or real religious or anything, but it just seems like America, itself, there’s so many people that are just miserable. And it’s like, “Come on.” We’re just … We’re alive. It’s easy to be positive when you’re on top of the mountain. And we’ve all had our ups and downs. Everyone has issues, but there’s just so much ill will. And I don’t like it. You just read online and someone says something about something, and it’s just like the mob mentality. It’s just like, “Uh.”

I remember with the recession and all this stuff, and everyone saying how it’s so bad for business, and we just kept a positive attitude. We didn’t really grow much, but we grew some. It’s all in your positive … You just gotta have a good attitude and just really-

Dr. Smith: Where we are in Louisiana, oil’s down to $48 a barrel. We’ve lost 10 thousand jobs in our community. And I know that many of the dentists that I’ve talked to are down a good 15 to 20%. And there’s dentistry that dwell on that. And I remember in the early ’80s, when oil went down to eight dollars a barrel. Jimmy Carter was the president. Interest rates were 16 to 18%. The real estate market in our community just tanked out like nobody’s business. It was a terrible time to be a dentist.

Shaun Keating: Oh, I bet.

Dr. Smith: I was so glad to have $100 in my wallet for the first time ever. And I loved doing dentistry. So, 38 years later, looking back, it’s like, “Man, that was good. Things were fine.”

Shaun Keating: Absolutely.

Dr. Smith: That’s the focus that young dentists have to have nowadays. Because the earning potential is absolutely incredible.

Shaun Keating: It really is. It’s so … The work’s out there. There’s billions of dollars of work being done. You just gotta get off your butt and get out there and want it.

Dr. Smith: Part of it is they have to just be patient. Because it takes time. Everybody that is in my age group, they got more to do than they can handle. They’re ready to retire, they’re tired, they’re burn out, for the most part. It’ll happen, it just doesn’t come over night.

Shaun Keating: Yep. And like, I think of what you said, your first 10 years guys, I did it, too, when I started. I worked for a company for like 17 years, and you don’t have to worry about any of that stuff. But when I started my own in 2002, the first 10 years we didn’t make a dime really, and everything had to go in and … I had almost two million dollars in loans, SBA loans. You didn’t make a cent, but you just put your head down and just kept working. That’s when we met, at the beginning of all that. And I just met people, and keep your head down working. And that’s the way it is with every business, every company. If you work hard and just do your best it will come, but it takes time.

I always kid around, the first 10 years you build it, then 10 to 20 years you enjoy it, and from 20 to 30 years you try to keep it. You know? It’s just, you really gotta do it. And for everyone saying … Even me, with all these labs that are just chasing to the bottom on these $99 crowns and under, that’s from the 1980s at cost and stuff. But everyone always asks, “Glidewell and all these other companies.” I’m fine, it’s we’re just poised for greatness. And I’m just so excited that … It’s tough, where profit margins are down, we’re not growing as big like we used to have double digit growth. But you know what? We’ve got a bunch of great employees here. We’ve never missed a bill. And life is good, I’m so thankful. I’ve got $100 in my pocket, too, man. And it’s just-

Dr. Smith: To your point, on the way over, on the way to my prostate exam this afternoon, I was talking to Don Harris on the phone. He’s a dentist who practices in New Iberia, and he’s been a big fan of your lab for a long time.

Shaun Keating: Thank you for him, too.

Dr. Smith: He was telling me, he goes, “Man, they are really doing a fantastic job.” I said, “You know what? They really are.” And Don’s deal is, they got the contacts perfect every time. They get the margins right, the shades, all this stuff that’s going on with this translucent zirconium crowns. Y’all have really stayed ahead of the curve and y’all are producing a product that I think that is second to none, really.

Shaun Keating: Thank you so much. And you … And that’s Tabasco Don, man. That dude knows the Tabasco Company or something. Or he’s like a dude … He sent me a box of that stuff. But we’ve been … And thank you for him. You’ve sent other guys.

Dr. Smith: Sure.

Shaun Keating: So many doctors. And I thank you. What you’ve done for us, too, in just our implants and just got us better. It’s just a really beautiful thing, when you get quality people and working together to make each other better, that’s really kind of bitching. I love it, man. And I just … I’ve always respected you so much, man, because I know how much teaching you do to all the people.

Now, what about … Is there … I’m not sure how you do it, but my guys are always looking for CE and stuff like that. Do you do implant CE where people can fly in? Do you have weekend courses? What do you have there, Dr. …?”

Dr. Smith: We do two courses a year. We do one in November and we do another one in March. And basically, Dr. Gomang and I will treat five or six patients, live surgery, it’s all broadcast up in the meeting room upstairs. Some guys will hang around in the operatory, but you really get a better view upstairs. We try and pick a variety of cases, sinus lifts over dentures, immediate placement of the interior area, et cetera. And really try to show as much as we possibly can during the course of two days.

It’s both lecture and live surgery. And also, Cory Glenn, whose name has become more of a household name in dentistry in recent years. Cory comes down as well and goes through all the nuances involved in doing guided surgery. He teaches the guided surgery end of it. So he’s kind of teamed with us, teamed up with us over the last two courses that we’ve done.

Shaun Keating: Oh, dude, that is so cool.

Dr. Smith: It’s kind of a marathon. It’s a marathon.

Shaun Keating: That’s awesome. Cory Glenn’s a stud, too.

Dr. Smith: He is. We have guys that have been in this course five and six times, because every time they come it’s always something different. We just try and build upon what we’ve been doing. We have a website, I can’t remember the name of it right now.

Shaun Keating: If we could, we’d like to put it up on our site and let some of our doctors know. And then, you can just cut it off when you get too many. If you could, I would love to promote that out to my dentists, too, that aren’t aware of it. But we’d love to help you out there, November, and what was the other date?

Dr. Smith: The other date’s gonna be in March.

Shaun Keating: Okay. That’s perfect. So, November might … That’s not too far away. It’s something … We’d love to do that because that’d be a great course to attend. And I know I’ve got a few guys who would love to do it that don’t even know about you, that would really benefit. Even, too, if I have to pay my guys. It’s almost in my best interest for some of these guys, they do a lot of implants, but, dude, if you just did it right a little bit more I wouldn’t be so bad to go out and see Dr. Jerome Smith, man, it’d be freaking huge, dude.

Dr. Smith: We talk a lot about the restorative part, because it really is a restorative-driven procedure. When an implant is placed perfectly, with good attached tissue, good bone, the patient has good oral hygiene, got a nice custom abutment, and we have a beautiful crown placed over it, what a gift, versus what we used to do, and that was to hack down the adjacent teeth and make a [inaudible 00:44:11] bridge, which we were taught, if you do correctly it’ll last the patient for the rest of their life.

And I can tell you, unfortunately, that’s not true. Every day of the week, we’re talking to a patient who’s been referred about the fact they have three inner bridges failing and now they can lose one of the abutment teeth. And we’re gonna section the bridge at the, they say, the distal aspect of number 20, and we’re gonna place an implant at 19, 18, or something like that, because we’ve lost one of the abutments for the bridge.

Shaun Keating: Oh, absolutely. I had a posterior 28, 29, 30. Number 30 failed, did a root canal, my brother did, and then that failed, we had to put an implant. It’s just like a car, you gotta do a tune up, you gotta do oil changes. And once you get those bridges, they’re not forever. I got all my anteriors, but back in my day, we didn’t have the money to do anything. My mom would say, “Extract it for the $20.” Or whatever. But when you’re older …

But the implants, it’s just amazing that you can do what you do with it now. And just with the predictability of it when you’re doing it right, from my end and your end, we know we can be successful, more so than not. It’s just working together as a team, dude. Hats off to you, man.

Now tell me real quick, I know you do a lot of charity work out in Mexico and stuff. What’s the deal, you’ve been doing that for years. You go into these towns and you’re doing … What are you doing? Just mostly extractions and stuff? Tell me a little bit about all that stuff you’re doing there.

Dr. Smith: Well, 25 years ago, Dr. [Carlbro 00:45:44] and I went down to Mexico with a missionary who is a patient of mine. And all we did was extractions. We fast forward 25 years later, you go to, we have the medical clinic, a dental clinic, an eye clinic. We’ve treated over 60 thousand patients over the last 25 years.

The cool thing about it is, we have students from A.T. Still Dental School in Mesa, Arizona, LSU School of Dentistry. My partner now brings those students down. I bring the kids from Arizona, along with Fran and Tom [Maddin 00:46:16] and some other guys.

So it’s really blossomed into a big deal. One of the ways that we fund this thing is we take all the money, all the proceeded from these teaching courses, and that’s how we keep the machine going.

Shaun Keating: Oh, you’re kidding. Well let me know what I can do to help out. That’s the first I heard, but that’s a good thing you’re doing. And if I can help in any way, and maybe I can sponsor some things, or stuff like that.

Dr. Smith: That’d be great. That’d be great.

So anyway, that’s been going on 25 years. It’s kind of nice to go down there and just supervise it.

Shaun Keating: Yeah, absolutely.

Dr. Smith: But not actually do the dentistry. Because it’s hot as hell down there. But we’ve had a lot of good trips. And in spite of all the political situation over there, we’re in an area that really is safe, and we really have a good time. It’s not all work and no play. We have a lot of fun, and hang out in Acapulco, and see [inaudible 00:47:09] for a couple days.

Shaun Keating: Oh, you’re kidding.

Dr. Smith: And make the most of it. Yeah, we had some great memorable trips. I think we’ve brought … We’ve taken over 200 students down there over the last 20 years.

Shaun Keating: How cool is that.

Dr. Smith: Makes real good friends all over the country for people that have been down there to work with us. It’s been good.

Shaun Keating: Good for you, dude. Man, you’re the best in all aspects, man.

Dr. Smith: To those whom much is given, much is expected. It kind of feels like a duty. You know what I mean?

Shaun Keating: That’s so cool. So what other hobbies you have going? I know you like to fish. Anything else, there? You like motorcycles? Anything else? Tell me about that.

Dr. Smith: I like cars. I like cars. I have an XJ Jaguar and a Cayman Porsche, and believe it or not, my wife bought me a Ferrari 430 Spider for Christmas.

Shaun Keating: You’re kidding.

Dr. Smith: That’s used. It’s not new. But it’s like new. And, of course, I should have known, because within six months she said, “I want you to come take a look at this diamond I’ve been thinking about getting.” And I said … I knew. It was a setup. It was a setup.

Shaun Keating: She have to go [crosstalk 00:48:13] it?

Dr. Smith: She said, “I bought you this car.” I said, “With my money, you bought me the car.”

Shaun Keating: What color is your Spider?

Dr. Smith: It’s a dark blue with beige interior. It’s a really beautiful car.

Shaun Keating: No kidding. I’ve got a 458 Spider.

Dr. Smith: You do?

Shaun Keating: Yeah.

Dr. Smith: Oh, really.

Shaun Keating: It’s white. White with red interior, man. I always … My Ferraris are always white. That’s weird. I’m not a red-

Dr. Smith: That’s the coolest car ever made, I think.

Shaun Keating: I love it. It’s my favorite one.

Dr. Smith: Every time I take it out I had a smile on my face.

Shaun Keating: I always kid around, it makes my wiener tickle, man, when I get on that thing. Because you can feel it in your ass through that, you’re so low to the ground, the engine’s right in the back head, rarrr. I just love the way it screams, like a banshee. There’s nothing like it, man.

Dr. Smith: I like doing that. I love fishing. We duck hunt every year. Duck season is starting weekend after next [crosstalk 00:49:06].

Shaun Keating: That’s so cool.

Dr. Smith: We’re gonna see, we’ve had a lot of water from this last storm, so that might throw things off a little bit. But it’s all the guys getting together and hanging out and telling stories and drinking too much and bitching at each other, all this [crosstalk 00:49:21].

Shaun Keating: I don’t care, we’ll shoot a freaking tree, dude, I’m with you.

Dr. Smith: That’s right.

Shaun Keating: I don’t even need the ducks. I ain’t eating that crap, but I wanna shoot something, and I wanna drink some beer with you guys.

Dr. Smith: Right, right.

Shaun Keating: Well, Jerome, you’re the man, dude. I gotta get rolling here.

Dr. Smith: Thank you, Shaun. Enjoyed talking with you, man.

Shaun Keating: Oh, man, thank you for all the work. How are we doing as a lab, are we doing good for you?

Dr. Smith: Perfect. Perfect. Perfect. We were talking about you today. Two hours ago, I was talking to Don. I said, “Boy, they’ve really hitting on all cylinders.” And it’s a credit to your vision. And it’s like you said, back in 2002, things were looking tough but you stayed committed to it and Keating Dental Lab is known all over the place. We have a lot of friends using the lab, real happy, consistent, you have smart people working over there, and the results speak for themselves, they really do.

Shaun Keating: Thank you so much, man. Dude, I just gotta get more guys trained by you, because, you know what, it’s just hard to teach what you got, and you can teach it, and I think, for two times a year, I’d go to both the meetings if I was a dentist, if I was wanting to get into implant dentistry, predictable implant dentistry, I’d be going out, see Jerome Smith in Louisiana, man.

I know you guys do it up right, I know you guys like to have fun, and I know a lot of your friends that just, they’re all good boys, and smart guys, and they’re fun guys. That’s what it’s all about. And just a passion for dentistry, a passion for life. And that’s why I like you so much. God bless you and your family. I thank you so much.

Dr. Smith: Thank you.

Shaun Keating: If there’s anything that we can ever do, you let us know, dude.

Dr. Smith: Okay. Let’s stay in touch, Shaun.

Shaun Keating: All right, doctor.

Dr. Smith: Thank you so much.

Shaun Keating: Thank you so much.

Dr. Smith: All right, buddy.

Shaun Keating: Have a great day.

Dr. Smith: Okay, bye bye.

Shaun Keating: Bye bye.

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