There’ll always be another tooth to drill and fill!

“The reality is when you skimp , you really lose something down the line. It becomes reflected in the end result a year, two, three years later.” –Dr. John Comisi

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Full Transcription:

Dr. Hornbrook: Hello, I’m Dr. David Hornbrook, Clinical Director of Education and Technology at Keating Dental Lab in Irvine, California. Welcome once again to my weekly podcast on dental up. As always we bring in spectacular guests and this is no exception. John Comisi, I appreciate you being here.

Dr. John Comisi: Thank you so much for having me, David. It’s wonderful.

Dr. Hornbrook: We’ve known each other over the years. I don’t know a lot about you. I mean, some of the personal things that we just talked about, kids, and buying cars for teenagers, and the new generation. Even that ten minutes that we just had, you were very enlightening, and you’re very funny, and obviously, you’re very smart. I’ve enjoyed, over the years, in the meetings, where you ask the good questions. I keep thinking, “How come I didn’t ask that question? That was a good question.” You’re obviously very involved and very passionate.

Where I’d like to start is, as you know, I’m very passionate about what I do, whatever I do. What are you passionate about?

Dr. John Comisi: Well again, some of the passions that I have nowadays is trying to figure out what’s going on in the dental world, and how to communicate that to our colleagues in a way that is basically informative, entertaining, and helps them become better at what they do. There’s so much going on out there. The dental profession has changed over the last 30 some odd years.

Dr. Hornbrook: Just a little bit.

Dr. John Comisi: Tiny bit since I graduated.

Dr. Hornbrook: How long have you been in practice by the way?

Dr. John Comisi: I’ve been in practice since 1983. I graduated from Northwestern University. I live in a little community in Upstate New York, called Ithaca, New York.

Dr. Hornbrook: Right.

Dr. John Comisi: And stumbled into that opportunity. It was kind of weird. I was in Chicago my final year of dental school, and I didn’t know what I was going to do and where I was going to go. If I was going to stay in Chicago, if I was going to go back east, what was I going to do. I grew up in Brooklyn, New York.

Dr. Hornbrook: Okay. I was going to say, “This isn’t a Chicago accent.”

Dr. John Comisi: No, this is actually a blended chameleon accent.

Dr. Hornbrook: Okay.

Dr. John Comisi: No matter where I am, I seem to pick up the kind of the –

Dr. Hornbrook: Now that you’re in Southern California for four days, you’re going to say, “Groovy,” and “Dude.”

Dr. John Comisi: No, I do that anyway.

Dr. Hornbrook: Just checking. That and we do too.

Dr. John Comisi: It’s just amazing. I’ve had so many opportunities. When I was at school, I was looking around, an at that time period, the recession had hit, early 80’s. There were jobs unavailable anywhere. I was thinking at that time period, maybe go to New England, go to Massachusetts or something and start a practice there. At that point in time, I’d like to say that New England was closed. They weren’t letting anybody in. There was just no opportunities whatsoever.

I started calling around at various things and talking to various dental supply company representatives to find out where possible places would be. I somehow got into contact with a guy named Joe [Coss 00:02:36], from Syracuse, New York, who ran a company called Northern Star. Joe was about 60 at that time, and one of the most remarkable individuals I’ve ever had the opportunity to meet.

He came to the Chicago mid winter meeting and said, “Meet me. We’re going to go out for some drinks.” We went out for some drinks and Joe drank me under the table. He made a promise to me that he was going to find me a job somewhere in the Central New York area. I said, “Sure. Fine. No problem.” Chicago mid winter meeting came and went. I finished up my work at school, got my license, and saying, “What the heck am I going to do?”

It was at that time period, most of the guys in my class, there’s always the group called the super seniors. They had not quite enough credits to graduate, but they were close, and they needed to get just a few more cases done. I would work in the lab and do lab work for them and stuff like that. One day, I was paiged to the telephone assistance. I don’t have any patients since I graduated. I don’t have anybody. [inaudible 00:03:29] responsibilities here any longer.

The next thing I know I pick up the telephone and Joe is screaming on the other line, “I’ve got you a job!” I said, “What do you mean? Who is this?” He says, “It’s Joe! How soon can you come out to Ithaca, New York?” I said, “Where the heck is Ithaca, New York?” He says, “Get out here. I need you in the next couple of days.”

Okay. I hung up the phone, contacted the travel agent, because at that time, there was no internet access to anything like that. I got in touch with a travel agent, booked my flight to Ithaca, New York. I flew in and interviewed with a wonderful senior doc. He took me under his wing, and I had a job. I’m like, “Okay, that’s cool. How’d that happen?”

Dr. Hornbrook: Yeah. How random.

Dr. John Comisi: I flew back out to Chicago, packed up my gear, go a U-Haul trailer, hooked it on to my car, an drove from Chicago to Ithaca, New York. Over the labor day weekend, settled into an apartment that I had found when I was out there the first time, and slept on a mattress. I wasn’t married at that time.

Dr. Hornbrook: Right.

Dr. John Comisi: Went to work the day after labor day in 1983. Basically, scared as anything, but went to work. From that point on, I was a dentist. It’s a remarkable experience.

Dr. Hornbrook: It’s a good story.

Dr. John Comisi: There was always something new that needed to be done. My senior doc was a great guy. He’s still a good friend. We had a lot of interesting things. He was always on continuing education, very, very excited about education and learning. He got me involved in that and we started to do things. I joined the Academy of General Dentistry for the very first time in 1984 in Spring. My very first educational CE meeting. I’m like, “This is cool. All these guys are here, because they want to be, not because we have to.”

Dr. Hornbrook: Because we have to be, right.

Dr. John Comisi: Nowadays you have to be because of educational requirements and everything, so it’s kind of goofy, but it was really exciting. That got me a little bit of the buzz, a little bit of the itch to keep on learning. I joined the academy and started doing things, and incorporating the information that the key opinion leaders and the lecturers at that time were sharing with us all, which is really great.

I became a student of various individuals out there, like [Bashgar 00:05:47]. [Bashgar 00:05:47], I love listening to him on [inaudible 00:05:49], because he had so many incredible ideas that we still implement today. John … Oh, god. He’s going to kill me later. So many other guys that are out there at that time.

Dr. Hornbrook: John. There’s lots of Johns.

Dr. John Comisi: It will come later.

Dr. Hornbrook: [crosstalk 00:06:04], John.

Dr. John Comisi: It’s a senior moment. Don’t worry about it. We just had so many fabulous people on the circuit. Ron Jordan at that time period. Of course, Gordon. So many other wonderful individuals that were out there. It was just so exciting to keep on learning.

Years went by and I went to a lecture by our good friend Howard Glazer. Howard was showing all these different materials. I started looking at all these additional things, and I had no idea where would they come from. Thank god I went to the [Course 00:06:37]. I contacted one of the companies and I said, “Why doesn’t anybody know about this?” They said, “What do you mean?” I said, “Well, I’ve been in practice …” How many years at that point. “I’ve never heard of your company. I’ve never heard of your product. You’ve got something really special here. Why aren’t people talking about that? Why aren’t people using it?” They said, “Well, how can you help us?” I said, “Well maybe we can figure out a way to promote it. Maybe we can figure a way of showing people how to do it. Maybe I can help you in some capacity.”

That’s how I got involved in starting to do education for us, for various folks out there. I brought, I guess, a practical experience to it.

Dr. Hornbrook: You were a practicing dentist.

Dr. John Comisi: Yeah.

Dr. Hornbrook: Which is important. I share to people, and I think that brings us credibility behind the podium, because I do what you do. Yeah, I’m lecturing but I’ve still got to put that DO composite. I still go to go to a hygiene check. I’ve got to do this when the patient says, “Will insurance cover this?” Their head is going up and down like a bobble head doll. Mine is going side to side like a bobble head doll. You’ve got the credibility as you educate, because you are doing the stuff that day.

Dr. John Comisi: It was very exciting and still today, I kind of pinch myself when I realize I’ve got an opportunity to speak some place. I say, “They want to listen to me. What’s wrong with them?”

Dr. Hornbrook: They need a CE requirement.

Dr. John Comisi: It’s got to be. It’s really fun because the feedback that I get back from that plain, old, this is how you might want to look at how things can be done differently. As practices, as time has changed, dentistry has changed. When I was in school, when we were in school, you had golden lays on lays crown. You had amalgam. You had gold foil. You had beginning of some rudimentary good composites at that point in time, but our bonding systems were kind of only half –

Dr. Hornbrook: Oh yeah, Dycal and Copalite.

Dr. John Comisi: Yeah, good stuff. To the younger viewers, you may not ever want to know what those are. Dycal, maybe, but not the Copalite. Things have changed so much. As I got a little more introduced to various materials like glass ionomers and some of our newer materials, like our bioactive restoration materials –

Dr. Hornbrook: Yeah, and I want to talk about that, because that’s a field that people kind of know a little. “Oh, I think I read something.”

Dr. John Comisi: Right.

Dr. Hornbrook: You know, I interviewed Ron Jackson.

Dr. John Comisi: Yup.

Dr. Hornbrook: He was talking about that’s hopefully [inaudible 00:08:53] composites go by [inaudible 00:08:55], where we actually have a material that interacts with the tooth structure versus just hanging out, waiting to fail. Talk about that.

Dr. John Comisi: One of our biggest challenges today is the adhesive systems. Our breakdown, it’s not the composites. Composites are remarkable. If you think about what they can put up with, the stresses and the strains, when they are properly placed, whether it’s your layering technique, which takes 14,000 years to get a composite done, or you bulk-fill it with the various materials like Sonicare, and some of the other materials that are out there that you can really bulk-fill, that are really, truly able to withstand it.

Remember, you can’t bulk-fill regular composite. There’s just no way. The physical properties are just unable to do that without creating all kinds of havoc on the tooth. If you’re going to use a bulk-fill technique, you need bulk-fill material. Make sure you use the right one.

Dr. Hornbrook: And the chemistry’s totally different.

Dr. John Comisi: Extraordinary.

Dr. Hornbrook: I mean, chemistry’s totally different that’s why we can’t bulk-fill, but go ahead, John.

Dr. John Comisi: That’s really the most important thing is that we have evolved in the chemistry. The way that the filler particles, the way that the resin matrix, the entire capacity of the material is so, so different from regular composite to bulk-fill materials. That has to be completely understood by everybody at all times. You don’t bring a screwdriver when you need a wrench. You just don’t do that. Everything becomes a hammer if all you have is a hammer.

Dr. Hornbrook: Right.

Dr. John Comisi: That’s unfortunate. Reality is you and I know sometimes we in the dental profession aren’t the most brilliant individuals and we will skimp and under cheap. Let’s put it simply. Or look cheap.

Dr. Hornbrook: Dentistry, I mean, it’s a little bit of a culture of mediocrity.

Dr. John Comisi: Right.

Dr. Hornbrook: There’s how can I save time? How can I cheat a little bit?

Dr. John Comisi: The reality is when you do that, you really lose something down the line. It becomes reflected in the end result a year, two, three years later.

Dr. Hornbrook: Right.

Dr. John Comisi: I mean, think about the longevity studies that are starting to come out in the science nowadays, where you look at amalgam versus composite restorations and the longevity. When you have the average composite lasting 5, 7, as compared to an amalgam, which could be in the mouth for 20 or more years. It becomes a really significant challenge. That’s because of hybridization layer. The biggest challenge is hybridization layer and the way that the tooth responds to what we’re doing to it. I’m a total [inaudible 00:11:18] person, always been a total [inaudible 00:11:19] person.

Dr. Hornbrook: Thank you.

Dr. John Comisi: The problem is is that bacteria, when the decay process occurs, is secreting acids. What do we use in our total [inaudible 00:11:28] situation? Acid. When you’re bonding to a tooth structure, you’re setting off a defensive response from the odontoblast in the cell, in the nerve of the cell. It’s sending out defensive mechanisms as it would against the regular acid attack of the bacteria. We’re starting an action. As that hybridization layer begins to form and we’re looking at getting the resin tags into the tubular and peritubular collagen fiber of the dentin, we’re expecting that mesh to occur.

My friend Brian [Novy 00:12:03] likes to talk about having gum sticking to your hair. Well, in my situation, it’s really tough, because I don’t have much hair. In someone like yourself, well you’ve got a pretty good head of hair. It’s going to get stuck in there.

Dr. Hornbrook: That’s the best compliment I’ve had all day.

Dr. John Comisi: It’s all good. It works. The reality is is that even though you can put all of this resin into the tubules and into the peritubular collagen around it, if you have the dissolution of the collagen fiber, eventually, you don’t have anything sticking to the tube. That’s where gap formation occurs. That’s where failure begins to occur. It’s not the composite so much as that our adhesive situation right mow. We have some really remarkable adhesives on the market right now, but if you start looking at the science of it, they’re all talking about initial bond strengths.

Dr. Hornbrook: Right. They do it –

Dr. John Comisi: The initial bond strengths are extraordinarily high, which is incredible, and it’s wonderful, but over the course of time, if the average composite is failing in the time frame we’ve just indicated, the five to seven years, what’s breaking down? What interface is starting to fail. We have to start to look at the tooth as living, breathing tissue.

Most of our patients, patients come into us all the time. “My tooth never did that before. I was able to break rocks before.” Those other stuff. Yeah, but you’re at that time period, younger. Your teeth haven’t had the stresses and strains put on it as they do now. You think about the average posterior pressure of about 300 pounds per square inch, the pressure being exerted on the posterior teeth, with about 100 pounds of pressure being exerted in the anterior section. That’s a heck of a lot of pressure every time we bite and chew. The crystalline failure begins to occur.

Patients need to continue to be reminded that, “Hey, could you do exactly what you did five years ago as well as you did it five years ago? Think about the stresses and strains that you’re having in the mouth.” I also use the analogy think about the roof on your house. It sits there all day long. It doesn’t do anything, yet over the course of time, it fails. Why? Because of the stresses and [strains 00:14:11] of the heat and the sun and the snow and all the other factors that keep on hitting it all the time.

Dr. Hornbrook: The snow in Ithaca, New York.

Dr. John Comisi: Yes. Oh, lots of it, but that’s another story altogether. Even here, things fail over the course of time, but our patients don’t always gather that in. It’s always something else. That’s unfortunate.

Coming back to the gap formation, if we have failure because of enzymatic reaction to the procedures that we’re doing, then we need to stop the enzymatic reaction. There was an incredible review, retrospective review, in the journal of dental research just this past January and February, in which they look at the reality of what’s going on in the tooth structure, and how the teeth are responding to the stimuli that we’re putting on it.

They talk about the enzymes like MMPs and Cathepsins enzymes that are in there that respond and react at various time periods based on the PH of the oral cavity. You can have a really acidic nature of the mouth, which basically is causing most of the destructive process, and then you can have a neutralization process, which hopefully is helping to remineralize.

An interesting product that we pointed out in the courses is that the remin/demin process is a constant battle going on all the time, but you can’t have remineralization without some sort of demineralization.

Dr. Hornbrook: Right.

Dr. John Comisi: That happens. The challenge here is how to balance that. There’s a constant battle going on for that kind of a balance in the oral cavity. This is where bioactivity becomes exciting, and becomes very interesting. Now definition of bioactivity is anything that responds and reacts in the bio nature of the body in whatever capacity. Bioactivity can be either positive or not.

In Europe, bioactivity is sometimes not a good thing, because they get concerned, because they think about various ions and how they can respond to their body wrong. Here in the States, bioactivity is a more exciting thing, because we can do things with it. The release of ions.

When Shofu came out with its Beautifil II product several years back, which has the ability to release and recharge with fluoride and strontium release and the other ions that it has. That was an exciting thing in the 7 and the 13 year studies published in Journal of the American Dental Association regarding what it can do. It’s really remarkable in it’s overall longevity in reducing failure rate recurrence. That’s partly because of this activity, this interactivity in the restore material.

Then you have things that we’ve always had like Dycal. Dycal’s actually a bioactive material. It releases calcium. It’s in a physical property structure that basically breaks down extraordinarily fast because it can’t afford to have pressure placed on it, which is why amalgams, when we did amalgams all the time, we had to put a base on top of the Dycal in order to protect it, to give it that physical strength to be able to put up with the compression and the pressure being put on it.

Dycal is the granddaddy of all bioactive materials, along with glass ionomers. Glass ionomers release ions, releases fluoride. It interacts with the tooth surface. It forms a chemical bond to the tooth that doesn’t create a hybridization, but physical property’s challenging. A lot of the original glass ionomers washed out. The interesting part is even though they washed out, you look at the dental structure, it wasn’t [inaudible 00:17:41]. That’s the interesting part.

We needed to look at, and we still need to look at, materials that will interact with the tooth structure, have the physical properties necessary to put up with the acidic nature of the mouth, the various forces occurring in the oral cavity, and just basically give us longevity. Gap filling, gap formation, overcoming that aspect of gap formation is where we are currently in the dental profession. We have materials like [inaudible 00:18:11], which is Dycal –

Dr. Hornbrook: I call it Dycal on steroids.

Dr. John Comisi: Exactly. You stole the word right from me. That’s exactly what it is. It enables the calcium release because of the [inaudible 00:18:23] nature of the resin to be able to help the dental structure heal itself with the calcium infusion. That enables appetite formation over the course of time.

You have products like Ceramir. Again, another bioactive material that at first is like a glass ionomer, but changes its structure over the [inaudible 00:18:41], which is why it gets stronger as far as its retentive capability over time. No other cement prior to Ceramir could do that. That’s really remarkable. I keep saying, okay, what’s next from you guys? Doxa’s got to come up with something else. I know they’ve got something under the hood.

Dr. Hornbrook: They got something that’s aesthetic.

Dr. John Comisi: Aesthetic?

Dr. Hornbrook: There’s probably a lot of these bioactives. I mean, you look at Dycal, [inaudible 00:19:02], and Ceramir are just three. They’re white and they’re opaque. All of a sudden, we can’t use them in a lot of applications.

Dr. John Comisi: Ah, but there are materials that you can.

Dr. Hornbrook: Yeah.

Dr. John Comisi: We’ll talk about that in just a bit. A little company out of Watertown, Massachusetts called Pulpdent that people don’t really think about or know about, but they’re rather ubiquitous in the industry. Their hands is almost in everything. A lot of the stuff that we use is essentially has some rudimentary beginning in Pulpdent. The guys there are incredible.

They invited my wife and I, Karen, to them a couple of years back. We sat down and we started talking with them about some of the things that they had uncovered. They showed us what they were doing, and I said, “This is pretty cool.” They evidently read a couple of papers that I had written, which I’m very humbled by. They were really very, very kind to share some knowledge with us.

They showed us the very beginning material of a material that we currently have on the market called ACTIVA BioACTIVE. ACTIVA BioACTIVE is a remarkable bulk-fill material that is delivered in a dual barrel syringe. It doesn’t have sonic capability like Sonicare, which is an incredible product.

Dr. Hornbrook: Right.

Dr. John Comisi: If they became BioACTIVE, how cool would that be?

Dr. Hornbrook: I think that’s going to be the future.

Dr. John Comisi: It could be the present. That’s another story altogether. Basically, because of what it does and its embraced technology in the resin that they accidentally discovered years before, they were able to create a mixture of the various materials that has a property of a composite, wearability of a composite, with the ability to work with the tooth structure without creating a hybridization challenge and enable it because of calcium phosphate and fluoride release be able to create appetite.

What happens is when you’re using it, if you do your traditional bond, whatever type that you want to do, you’ll be able to initially get great initial bond strengths with it, but over the course of time, as our bonds break down because of the enzymatic response it goes on in the tooth structure, that forms the gap. Because the material isn’t able to release calcium phosphates and fluoride, it’s able to actually permeate through the bonding agent and adhere and create appetite to the tooth structure. That’s revolutionary. That is evolutionary in the way that we’re looking at things.

It’s rather remarkable to me that we’re on the verge of taking that concept and exponentially increasing that capability. Not only being able to recreate tooth structure, not only being able to regrow tooth, as Jack Griffin likes to talk about it in his lectures, but we can really be beneficial to the tooth, to the patient, to everything that we do, increasing and improving things.

Now there are some folks out there that say, “There goes my business.” I understand the business of dentistry, when I think about it, isn’t a business, even though it’s a business.

Dr. Hornbrook: Right.

Dr. John Comisi: There’s an ethical and moral responsibility as well, which I know is hard words for a lot of us to stomach today, because we have challenges in knowing what that is, because you have to balance that.

Dr. Hornbrook: We’re also competing with the DMSO, the corporate dentistry, that don’t have those too.

Dr. John Comisi: They have a unique property that we don’t have. It’s called bulk buying situations. Those of us that are in the individual practice level can’t buy in scale as they can. That’s how they can really compete. We can talk a little bit about that in a few minutes as well. The reality is we have the capability to actually changing how we do things. That’s one of the more exciting things. I love the ability of us moving the entire profession from drill filled bill circumstance to drill fill save and keep things going from a direct restorative aspect.

Dr. Hornbrook: .

Dr. John Comisi: There’s always going to be something happening.

Dr. Hornbrook: Let’s keep that one that we [did 00:23:19]. Let’s keep it around for a while. I’m your dental assistant, John, and we’re five years down the road. You say, “David, I wish your dress was shorter.” No, I’m just kidding.

Dr. John Comisi: Again.

Dr. Hornbrook: “Nice legs. Can you hand me the composite.” I had it to you five year from now. What would you envision that composite looking like?

Dr. John Comisi: I think it’s going to be a compilation probably. Delivery system’s going to continue to evolve and improve. I think the delivery system will probably be somewhere along the line of the Sonicare situation, simply because that physical property, that physics behind the adaptation and the ability of a material to really get into a tooth is extraordinary. There’s nothing quite like that on the market. In fact, looking at the science of what that does, it’s exceptional. No question in my mind.

The material can’t be inert. The material can’t just sit there as a piece of covering on the top of the table, or as I like to talk about our grandparents when they have the plastic covering on the couch. It just can’t be that, because all that water’s building up underneath as you’re sitting on it on a hot summer day. It’s eventually going to create a problem to some capacity.

We need something that’s going to be interactive. Something that’s going to work with nature and aid nature in neutralizing the acidic component of the mouth, bringing balance, enabling acidity to occur, but bringing it back to neutral in a reasonable amount of time, so that this way, that constant attack … Because if you think about it, you have a cup of coffee. Sip on it. Sip on it. Sip on it. A lot of people are sippers.

Dr. Hornbrook: Right.

Dr. John Comisi: Every time you drink, you reduce the acidity. If you don’t allow that acid nature to rebound and stay at neutral for an extended period of time, you’re going to continue to have that constant attack, eventual calcium removal from the tooth structure, hence the decay process.

Dr. Hornbrook: You just ruined my morning cup of coffee experience.

Dr. John Comisi: It has to be balanced. Again, a lot of us do that. I enjoy a good cup of coffee and I sit there at the table and reading my phone or my laptop or whatever, and I’m just enjoying that opportunity. The reality is is that we have patients who are chronic sippers. That can of Pepsi or Coke on their desk all day long, because they need that charge.

Dr. Hornbrook: And Red Bull, and Monster.

Dr. John Comisi: And all the other things. It’s just a constant thing that’s out there. Educating patients is probably the most important thing that I love to do, is helping them understand that their current pattern is causing some of their challenge.

Dr. Hornbrook: And further destruction.

Dr. John Comisi: Exactly. If they could find a way to alter that in some way, or incorporate something that will enable neutralization to occur more frequently, something as simple as Xylitol gum.

Dr. Hornbrook: Right.

Dr. John Comisi: How easy is that? After a cup of coffee, pop a couple of Xylitol pieces of gum in your mouth, chew it up, neutralization. Bacteria can’t use the sugar, because it’s a five carbon sugar rather than a six carbon sugar. Basically, it helps to neutralize, and it’s refreshing.

Dr. Hornbrook: Yeah.

Dr. John Comisi: It’s simple. I look for the simple ways of helping patients achieve a healthier circumstance.

Dr. Hornbrook: That should be our goal, all of our goals, right?

Dr. John Comisi: Exactly. I agree.

Dr. Hornbrook: It’s almost a minute a half hour. It’s amazing how time flies. I think I told you earlier that I call these treadmill podcasts.

Dr. John Comisi: Yeah.

Dr. Hornbrook: It’s okay. Times up. Time for a shower. As we wrap it up, I know technology. We talk a little bit about what we want to talk about today and we didn’t get to … We’re going to have to have you back. Let’s talk a little bit about technology because it’s changed so much. People have been in practice … I’ve been in practice 27 years now. We didn’t have technology. Our technology was an amalgamator.

Dr. John Comisi: Right.

Dr. Hornbrook: We didn’t have to mix it and shake it ourselves.

Dr. John Comisi: Right.

Dr. Hornbrook: What would you say right now … Let me ask you this question. What technology do you think should be in every dental practice? What technology should a dentist explore that maybe already has some technology?

Dr. John Comisi: Sure.

Dr. Hornbrook: What are the things out there?

Dr. John Comisi: The most important thing nowadays is computerization. You really need to bring your systems into the electronic age. It helps with tracking what’s going on in the office. It helps with the electronic filing with your insurance provider. Even if you’re not. I’m a non par, but we submit electronically all of our claims. Computerization is going to be critical.

Good digital radiography. Good sensors. We have Dexa system in our office. We love it. It’s changed our … We’ve been digital for probably 20 years. When we converted from our old system to Dexa’s, they said they had never seen that many files having to be converted from one system to another.

Dr. Hornbrook: Oh, really?

Dr. John Comisi: They were amazed that we had that much information on our desk. We have gigabytes of information.

Digital radiography. Digital pans, very important. If you have the wherewithal and the dollars and the ability, a digital city scan is a great option to consider in that aspect. I believe that great [internal 00:28:28] photography. You need a great camera. There’s a lot of really wonderful ones out there. Shofu’s special I2, incredible camera, easy to use.

Dr. Hornbrook: Things have to be easy for the –

Dr. John Comisi: That’s so easy and it’s so clear. It’s become one of our favorite cameras over all the years. You got to do that. Digital scanning for crown and bridge and other aspects.

Dr. Hornbrook: Are you using an internal scanner?

Dr. John Comisi: Yup, I am.

Dr. Hornbrook: What are you using now?

Dr. John Comisi: I’m using the [inaudible 00:28:54]. I love it.

Dr. Hornbrook: That’s a [inaudible 00:28:57]. I think it’s unbelievable.

Dr. John Comisi: Yeah, it’s a remarkable product. It just makes me a better dentist. Looking at your preparation, blowing it up, I use [inaudible 00:29:06] magnifiers on my face and I look like a borg as I’m walking in the room and everything. I was talking with Mike [inaudible 00:29:16] yesterday, and he says, “By being able to blow it up on the screen to 30 times, and to look at your preparation and seeing where you’re failing, makes you a better dentist.”

Dr. Hornbrook: Oh, for sure.

Dr. John Comisi: If you want to be a better dentist, that’s one of the ways.

Dr. Hornbrook: We see that in the lab. We’ve all, including us, where we look at the impression and we think, “Oh, that’s a good impression. That’s a great prep.” Then you get the stone back and say, “Who cut this piece of crap?”

Dr. John Comisi: Right. Exactly.

Dr. Hornbrook: What did the lab do in the meantime, because we never want to blame ourselves, right? We’re seeing that through Keating. Not only does it make us a better dentist, now define margins instead of using 10 power scope to terminal margins, now all of a sudden, you’re bringing this thing up, and you know, the whole screen, there’s 2 millimeters of margin.

Dr. John Comisi: Exactly. You can see all kinds of things.

Dr. Hornbrook: What amazes me is, because I did the survey last summer, only about 5% of practicing clinicians are using internal scanners as a means to take impressions, which is ridiculous.

Dr. John Comisi: Yeah.

Dr. Hornbrook: That is the future.

Dr. John Comisi: It is. No question. We are a digital community nowadays. We’re socially integrated with our phones and our smart applications on our tablets, et cetera. Digital is, unfortunately or fortunately, depending on how you want to look, the way that everything is going. Why not integrate with that kind of a situation? Why not bring a good scanner in?

When you’re doing that, I looked at every scanner that was available in the market before I finally settled on the TRIOS, because I needed to know what was going to work in my workflow. Did I want something that I was going to [inaudible 00:30:42] in office or did I want to [inaudible 00:30:43]? Once I realized for me, [inaudible 00:30:46] wasn’t an option.

Then I started looking at those that basically, I was going to be able to send good STL files off. How large those STL files were, whether or not I could see things in color or not, whether or not it fit into my workflow, if the speed … You need to actually have units brought into your office.

Dr. Hornbrook: Oh yeah.

Dr. John Comisi: This way, your assistants can, because your assistants are doing the preliminary scans.

Dr. Hornbrook: Right.

Dr. John Comisi: If they can’t operate this scanner effectively and if takes too much time, then that’s not going to be a good scanner for you. You have to really say and anybody can scan on a model.

Dr. Hornbrook: Right.

Dr. John Comisi: As you go to the shows and you’re doing things and they’re looking at things. You can scan a model in a heartbeat. Scanning in the oral cavity is another animal, so bring it into the office, having you sit down in the chair and have your assistant scan your mouth. It’s an educational experience for both of you.

Dr. Hornbrook: Yeah.

Dr. John Comisi: You’re getting the patient experience before the patient is experiencing it. Your assistant is getting to know how to get a handle on this new apparatus that you’re using. That’s the way I would strongly advise if you’re doing this. It’s an investment. There’s no question. It’s an investment into what you’re doing, but the investment pays off –

Dr. Hornbrook: Yeah, by [crosstalk 00:31:56].

Dr. John Comisi: Especially if you know how it’s going to fit into your workflow.

Dr. Hornbrook: Yeah.

Dr. John Comisi: If it fits into your workflow, if you’re going to do it in office and you have someone who’s adept at doing, and able to design, and get your crowns and inlays and onlays done in a time frame that isn’t going to take longer than it would if you send to a capable technician to do it. That’s what I love about it. The labs that I work with, their technicians are crackerjack. We’ve got such incredible people out there. Everybody in the lab [inaudible 00:32:23], we’ve got some great people who work CAD extraordinarily well. They know how to do it like that. I’d rather work with a CDT than have somebody in my office.

Dr. Hornbrook: I have a [inaudible 00:32:33] and if we did this, we’d have to wash our hands from the dust.

Dr. John Comisi: Exactly.

Dr. Hornbrook: Anyway, we got to wrap up. I’m so disappointed, because I enjoy talking with you and getting to know you as a person.

Dr. John Comisi: Well, I’m glad to be here. Thank you.

Dr. Hornbrook: What you shared with our viewers and our listeners is invaluable. Hopefully, they’ll take some of that knowledge, because you’ve got incredible science knowledge and you are very passionate. You can see the energy. Even if I didn’t know what you were talking about, I would think I want to hear this because you’re passionate about it, which is cool. We need to be passionate. I’m a true believer that the more you enjoy something, the better you are at it.

Dr. John Comisi: Thank you.

Dr. Hornbrook: Hopefully our viewers sense your passion, so thank you for sharing that.

Dr. John Comisi: It’s a pleasure.

Dr. Hornbrook: You lecture quite a bit. How would they –

Dr. John Comisi: I’ve got a website called thepracticaldentist.com. On there, you can learn a little bit more about me personally, a little bit about the types of courses I provide, and where I’m lecturing. The next place I’ll be is in Lake Charles, Louisiana on September the 11th.

Dr. Hornbrook: Wow.

Dr. John Comisi: It’ll be an interesting day because it’s the anniversary of the towers falling, but we’re also going to have a lot of great information to share with folks down in Lake Charles.

Dr. Hornbrook: Well good, well hopefully. So that was practicaldentist.com?

Dr. John Comisi: Thepracticaldentist.

Dr. Hornbrook: Thepracticaldentist.com. John Comisi.

Dr. John Comisi: All one word.

Dr. Hornbrook: We’re going to go ahead and wrap it up. I hope you enjoyed this session. I certainly did. Be sure to visit our website, www.dentalup, all one word, .xyz. We’re doing some very cool things with videos. We’ve got now 16 podcasts. This has been awesome. Also, there’s some information about some courses that we’re doing in the future at Keating Dental Lab.

I have a beautiful teaching operatory, a teaching center. We’re doing two CE Credit Live Courses, where very affordable. You spend two days with me. I have to prep a case. You can either look over my shoulder or we have cameras where you can look at all the monitors. We go ahead and provisionalize and then we have a great dinner and next day in the [inaudible 00:34:16] literally.

Dr. John Comisi: Now that sounds like an incredible opportunity, because if you want to learn from the best, you want to definitely learn from David. If you had the opportunity to be at a course like that to learn how to do things the way that David does, you can’t go wrong in my opinion.

Dr. Hornbrook: Well thanks for saying that. I appreciate it.

Dr. John Comisi: My pleasure.

Dr. Hornbrook: So we’re doing that October and November. Check out our website. Hopefully we’ll see you sometime soon. We’re in Irvine. We’re about 10 miles from Disneyland, 5 miles from Newport Beach. If you’re ever in the area, give us a call. We’d love to have you stop by.

Dr. John Comisi: Excellent.