Waching daily Apr 26 2017

Hi guys I just wanted to

and say something that I hadn't planned

I'm going to let you into a secret, I love

you and in the same way you are so loved

by so many people that would never say

it to you, like they'll never walk up to you

and say I love you because that's

uncomfortable and socially mostly

unacceptable and they don't mean

romantically they just mean you're great

there's something about you that they

like and that's cool but nobody says it

so you just need to know that when

somebody smile at you maybe they like

your style maybe they like your smile

maybe maybe they just think that was

something about you the makes them feel

good you don't need to know what it is

just know that you are loved

For more infomation >> "love is like air" - Duration: 1:04.

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Chandur Wadhwani (FOR.org) - Healing abutment to final restoration - Duration: 38:32.

bSo I'm gonna explore with your some of

the science that I've been working on

over the last seven or eight years as it

relates to me a restorative

prosthodontist working with implants.

So here's the question I would like to pose

to you.

Where do we common commonly see bone

changes or bone loss around implants or what site?

And if you could help me here

to get an understanding of what you

believe. If you could text to the number

and tell me where you consider is the

optimum... or not the optimum. Where is the site we most commonly

find bone changes when we make radiograph.

Do we find it commonly at the apex of the implant?

For example something similar to a

periapical lesion on a tooth.

Do we find it at the crestal bone area that's commonly being lost.

Do we find it at midway down the implant? Or do we find

that bone around adjacent teeth is being lost

Where do you think is the most frequent

site we lose bone? Because this is

something that I've been thinking about

over the last few years I've been

developing my concept, as to why is we

have problems with certain types of

restoration. So nearly everybody in this

room believes that bone is being lost

predominantly around the marginal site

of the implant or the crestal bone;

which is what I believe.

Now we do know that bone changes do

occur at the apex, but we also know that

this is very rare and very infrequent.

It really only occurs when an

implant is placed in a site that had a

previous endodontic lesion or scar

tissue or is adjacent to a tooth that

has also got an endodontic issues.

So our premise that bone loss develops at the

margins of of the implant is something

that we're all seeing. So I'm going to

explore with you why I believe this

occurs. Why is it

we're losing bone specifically at the

crestal sites, rather than in other areas.

So we're finding bone loss at margins, we

see evidence such as this in clinical

photographs in and in radiography when

we're looking at where implants are

failing us. Where the bone is actually

resorbing. So why should that be?

I've found is very perplexing because

when I think about what I do is a

restorative dentist I know there's

certain things that will affect the

long-term stability within the bone of

the implant and I want to minimize those.

What I've also realized is that the

first line of defense for the bone is

the soft tissues. You have to somehow

damaged irritate or negatively influence

the soft tissues, then the bone loss

appears to be secondarily to the

information and the effect with the soft

tissues changing their position.

This is made me think very very

differently. So I started looking at how

soft tissues attached around implants.

I started looking at this fragile

connection that hemidesmosonal

between the implant surface or the

abutment surface and the actual

soft-tissue at this connection.

What is it? How does it develop and how

can we affect it. Now we know from

data that's being taken from a study

done in Brazil, which we would never be

able to do here. In this particular study,

published last year, they placed 16 implants

in eight live human being.

Then after four months they harvested

the implant even though they were

completely healthy. Then they looked at

the bone and the soft tissues around

them. They found that there is a mark

of biological width, if you like,

an attachment site that has a definite

dimension around implants. In the same

way we have a biological width around

teeth. Now we understand what happens

with the biological width around teeth

that we can invade it.

We also know that if this biological

width is affected around implants, the

soft tissues don't like it. They do what

they're supposed to do, they collapse.

What's the core of the body, they're

doing exactly what they're supposed to do,

what nature design them to do.

In order to collapse towards the core of

the body they have to resorp bone in

order to make space for them.

So I started to believe that our

understanding about implants is slightly

skewed. We always talk about the bone,

because that's the only thing we can see

on a radiograph. But maybe we should be

talking about the way the soft tissue

complex, actually protect the bone.

Because it is the first line of

mechanical protection. So how can we

damage this. Let's look at this

particular case that came out from the

University of Washington where a

prosthodontist is trying to cement a

restoration and he's trying to safeguard

cement from getting down around the

tissues. So he packs retraction cord, but

what he doesn't realize is the

retraction cord is going

to cause him a problem. Because not only

does he leave some of the cord behind,

what goes beyond the cord is really

important. Because the cement has been

given a space to flow. The reason it was

given a space to flow, was because that

fragile connective tissue and epithelial

attachment was blunt dissected away.

We know some data from Van de Velden

that the average force we use when we

push cord around any soft tissue site is

1 newton per millimeter. That's the

average for the pressure. We also know

that you will tear tissue, not between

the titanium and the soft tissue, or the

zirconia and soft tissues, but

into epithelial cells will be displaced.

You'll tear it within the tissues.

That occurs when you use approximately

one eightsh of the force that we commonly used to

pack cord around the soft tissue site.

So this is one of the ways we can

mechanically abuse the soft tissue and

get a response in the bone if it's left

long enough. My topic over the last

eight years has been cement. People

that asked me if it is that the chemistry of

the cement. Is it the pressure of the

cement destroying the hemidesmosomal attachment

what is it about cements that caused the

problem. The problem is

it can be physical. We can disrupt it

by the loading of the crown, seating the

crown down. As that cement squeezes out

it can disrupt the hemidesmosomal

attachment. It could be an allergic

response to the materials that we've

been using. Iit could be because bacteria

are allowed to grow around that site

causing inflammation of the tissue.

The tissue resorts towards the core.

The bone underneath it goes. It could be

foreign-body reaction. Or it could be

that we've irritated or change the

chemistry of the titanium by results due

to corrosion. So the soft tissues, to me,

have become the most important aspect.

And if you think about, we now know if

you exchange an implant abutment

multiple times, you take it on and off

take it on and off, taking on and off.

What happens? Bone resorption, why would that be?

Because we irritated and inflamed the

soft tissues. They get so inflamed again

they move towards the core of the body.

I believe the most of the results

that we're getting after surgery, after

an implant has been allowed to integrate,

is because we are damaging and insulting

the soft tissue. So let's talk a little

bit about my favorite topic: cement

extrusion. Why is it problematic?

It's problematic because we don't understand it.

We don't understand the cementation

process is actually a system. When you

have your abutment and you see your

crown on it with a fluid, like cement.

This is actually a system, it's like a

piston being driven into a chamber.

The studies that we've been doing in

conjunction with industry and the

university of Washington and Texas, have

taught us where you place the cement.

Simply where you put the cement will

have a critical effect on how it flows

and how it displaces air and how it will

affect the soft tissues. So placing it

higher up is much more beneficial. Sorry

placing it near the coronal aspect

by the margin is much more beneficial

than placing it near the occlusal. The

studies have shown that time and time

again using million-dollar computers

being run simultaneously four months.

We also know from this same processes

we can actually find out

what speed the cement is ejected at

depending on the form of the abutment,

where we place it. Is it going to tear a

hemidesmosomal attachment. All the

things that I do every day, I've now

realized that I'm more of the biologists

then I am a prosthodontist, because if

the biology of the soft tissues is it

maintained in health

I cause destruction. Mechanical

trauma tissues is not as infrequently

as you think. We've all seen it, when you

look at things like this, you know the

cement gets down there because you see

it being pushed past the hemidesmosomal

attachment. You see being pushed

within the tissues. Whenever you take any

kind of abutment off the tissues you

noticed bleeding. Because you've torn the

cells. They're sticking partly to the

abutment and they tear. Blood comes out

in spots. Now when blood comes out, the

blood red blood cell has a dimension of

628 microns. It's not very big, but

unfortunately some of the cement

manufacturers are actually producing

cement that are thinner than a red blood

cell is. So we can push these cements

directly into the tissues, if we don't

control our processes. Material

within the tissue occurs in dentistry.

This is foreign body giant cell reaction

that develops around implant sites. We

rarely see it in periodontal disease, but

we see it around implants, because the

tissues are getting so angry and

inflamed, they don't like it. What do you

think the bone responses is like

underneath any one of these? What can the

bone do. Nothing but resorb. So Naomi Ramer,

pathologist from New York, has

been taking the tissues and she's been

looking them at them under scanning

electron microscope and doing

histological studies on them. We find

routinely cement in the tissues. We've

gone one step further at the University

of Texas. We took soft-tissue from 34

failed implants. We looked at it under a

scanning electron microscope.

We found that in 19 cases, 19 out of 34,

not only could we find cement within the

tissues, because we were using some

elemental diffraction. We can actually

tell you what the cement was. Things like

this, that you see up there. These are

globules of cement that have got within

the tissues. Now dentistry is familiar

with things going into tissues, because

we frequency amalgam tattoos. We've all

seen those. The amalgams getting into the

tissues. There's a site, which is

written up here, that shows you that is

also alginate gets into the tissues.

Cavet gets into the tissues. Cotton ball

gets into the tissues. And even titanium

particles get into the tissues.

This tells us the tissues are fragile.

They are particularly fragile around

implant sites and we have to respect

them. If we don't, the bone

doesn't understand what's going on and

it simply resorbs as a secondary effect.

So how does titanium get into the tissues?

Let me show you one example of how

titanium gets in. This comes from one of

my really good friends Roger Lawton, who

practices about 40 miles from me. He

described this case, where there is a

titanium tatoo. Because the implant

components were in sufficiently strong

to maintain the force placed on them,

this broke and after a few months, the

titanium from the implant was wearing

and it was washing into the tissues.

But that's not the only place that titanium

can come from physical manipulation.

Believe it or not, we can chemically

manipulate it.

I always thought the titanium was

supposed to be a very robust material.

But then I realized doing my cement

studies, it's actually very susceptible

to certain elements that we routinely

using dentistry. I find this out by

looking at cement. Durelon, which 17%

of the US dental schools, claim to use for their final

restorative material on implants.

Now most of us use titanium implants. When I was

going to do a study I wanted to do a

radiographic, an x-ray study on this

material to see how dense it was. But I

did something that very few people do.

I read the instructions. And it says in

the instructions don't use it for

titanium. So when we contacted the

manufacturer and we said what's the

problem with titanium and using your

materials. They say it corrodes,

it activates a corrosive process

So we decided that

we're actually going to do a study, which

we just we just published in the Journal

of Prosthetic Dentistry. We take these

cement. What we do this is a study

that was sponsored by Nobel Biocare, we

take two types of machined titanium

aluminum vanadium alloys; it's either

turned or it's machined/milled and what

we do is we stick these components

together. We leave them in a moist

environment for one week. Then we pull

them apart and we examine them

underneath scanning electron microscopy.

The picture on your right shows black

holes in it. That's corrosion

that's very similar to the corrosion you

see in the amalgams that go black. It's a

self-perpetuating electrochemical

reaction that goes on indefinitely

unless you cut it out. Now the

interesting thing about this is you can

actually use the corrosion to your

advantage. We've just published the

material on that. What we do is we

actually actively corrode certain parts

of titanium by using this corrosive

aspects. The chemical that we use is

fluoride, something that ubiquitous in

restorative dentistry to save teeth.

This is why Durelon causes corrosion

on titanium, because Durelon is a

polyacrylic acid with zinc oxide. But

what they did was SP added stannous

floride. By the adding of

stannous fluoride in an acid environment a

chemical reaction occurs. You get HF -

hydrofluoric acid. Now the hydrofluoric

acid when it reacts with titanium

releases hydrogen. I''m going to show

you that. I''m going to show you the

effect of hydrofluoric acid

on titanium. One of the effects is you

can roughen titanium. So I no longer

have to go to my lab with a piece of

titanium abutment and ask them to etch it.

I can do that in my office. And I

can do that within 10 seconds by simply

adding some hydrofluoric acid. So watch

this. This is me with an abutment and

I'm going to etch within 10 seconds

I'm going to use force Lich now I

usually protect the tissue touching

components but watch how quickly this

react

this is titanium that material is

supposed to be robust that doesn't

corrode you see it bubbling like a

volcano that's hydrogen being liberated

this is how quickly is fire button then

I watched them off in deionized water

and I have a beautifully roughened

titanium surface that gives me

micromechanical retention for my cement

so this is what we've just published in

the journal prosthetic dentistry to show

people what we do because everything i

do i published because i'm out there I

want people to tell me i want the

reviewers to say you're not correct

there's a problem that we etch titanium

like this with hydrofluoric acid very

clean very quick very efficient we've

just finished a study at the University

of Washington that shows etchings

titanium like this gives you the same

micromechanical return retention of your

cement as does air abrasion sandblasting

but there's a problem because we use

Hyper thought we use fluoride to save

fish so we are beginning to get a little

bit of a dilemma because when I have a

mixed dentition like this morning the

two slides I couldn't show you because I

ran overtime Milkha was what's the

problem with trying to keep teasing

implants in the same mouth in somebody

who's taking medications that are going

to induce the dry mouth Ingram where I'm

going to use camera where I'm going to

use carries assessment and management by

risk assessment and I'm going to throw

fluorides that if I use the wrong

fluoride i will damage the implants and

this is particularly true it's

especially true when the titanium that

is used by the implant companies is not

commercially pure so when you start

adding things to titanium it become more

and more corrosive related to

hydrofluoric acid so if you put aluminum

and Van Diemen your implant system it's

more corrosive and commercially tight

commercially pure titanium if you put

the co nghia into your implant system

you get a wonderfully strong implant

that is far more corrosive the normal

implants that are commercially pure and

i'm going to show you what happened

so titanium is a noble metal is an order

of noble metals that exists is it

existing chemistry so the most noble of

all the metal this platinum then we have

gold then we have feel that but they

look at commercially pure titanium and

you'll see towards the right of it are

the alleys so in particular cases where

you have a patient that is going to be

Kerry's prone and you want to do your

damnedest to save those teeth you have

to be particularly aware of how you're

going to save them and you're going to

have to start thinking about the product

you're going to use here are two

implants the one on your left is

commercially pure titanium the one on

the right is an alloy look at the

difference which do you think made

potentially give you a lot more problems

in the mouth when hydrofluoric acid is

involved now hydrochloric acid doesn't

just come from that you forcefully match

i gave you or I showed you the

hydrofluoric acid comes from bacteria

bacteria can induce corrosion we've done

an experiment of the university of texas

where we've induced corrosion on

titanium by changing the microbial flora

it also comes from agents like peroxide

patients coming to me to have their tea

speech before they have their implants

restored I have to be very careful with

the Carbonite peroxide because that is

another corrosive agent and so if some

of the acidic phosphorylated of acidic

saw spirit of fluorides that we used on

children so you have to be very aware

that there are some patients you're

going to increase the septum

susceptibility to corrosion and if you

do

titanium will come out of the system so

there is a problem and this is a study

we gained at the University of Texas we

took failed implants for failed in class

and compare them to a brand new implant

and we looked at them understanding

electron microscope this is a brand new

implant have a look at the surface

detail on it

compare it to the failed implants where

we're seeing pitting corrosion and

pitting corrosion may not have a really

extreme effect on the implant site but

it could tip the fresh home

if a patient has a threshold or is near

thresholds are getting soft tissue

disease the reactive oxidative species

that results in corrosive agent can tip

it over the edge so corrosion is

something that you have to think about

especially with alloyed components

titanium is not titanium is not tithing

and please be aware of that and another

problem with soft tissues allergies

now we know some cement induce allergies

but did you know that some of the

materials you might use have been

documented to cause allergies as well

for example apartment that are made of

titanium nitride this was documented in

the journal of prosthetic dentistry

titanium nitride is a very nice

aesthetic material it warms our crowns

but the soft tissues and some patients

don't like it

my next question would you tell me

whether or not you can recycle healing

abutment so if you have a patient and

you finished with the healing abutment

you restore the implied how about

cleaning it sterilizing it and reusing

it do you do that

what do you think would you like to see

if you could answer these questions by

texting me and see what what you do in

your clinic

what are your surgeon

so we're beginning to get a spread some

people don't know and it's roughly even

between yes or no

so here's the dialer for you what do you

do with your hitting buttons do you

reuse them because in the literature the

literature suggests that you can reuse

them literature says when you get the

healing abutment clean it so in your

autoclave when it comes back you can

reuse it because it's tear off let me

show you some of my latest research I

understand now that the soft tissues are

paramount to the health of the bone if

the soft tissues aren't healthy the bone

cannot be healthy so where do the soft

tissues initially start to heal they

start to heal against our healing

abutment like this and when we finished

with them

can we use them because what is

important to me for my patients is that

the first time the cells grow they touch

something that allows them to spread out

here and proliferate we know that

titanium oxide is the best material

irrespective of whether you think peak

is dead or the Korea the studies have

shown that titanium oxide is the most

superior materials because it's got a

very high surface energy so epithelial

cells really like it we also know that

unlike the Kolia so the kona has to be a

little bit rough as Marcus splats

reported this morning

titanium should be machine so should be

machine it should have a high surface

energy and it should be titanium so

people like this

published report 2012 things you can

sterilize these healing abutment think

about reusing them save some money for

yourselves in your patients so I got

contacted by my oral surgeon when I work

with very closely Superguy brilliant guy

he calls me about 10 months ago he says

would you do me a favor you're restoring

an implant today when you finished with

the healing about meant could you

sterilize it send it back to me and I

said short because I've been doing that

for years

I mean driving home and I'm thinking

what's the validity of sterilization of

a healing abutment so I look at this

article and I go with it it's there are

it's great but then I look at it closely

does anybody think that healing abutment

is clean compared to a new one so we

just found a study that we submitted for

publication

we took a hundred used and clean ceiling

apartments from eight different offices

in the US and canada and what we did

with them is we asked the offices how to

clean them and they say well we wipe

them and some of them wipe them with

alcohol

some of them like them with disinfectant

cloth then they put them in an

ultrasonic bath and then they sterilize

them in an autoclave and so we have

healing abutment from these different

companies and what we're going to do is

we're going to do something special with

them

we're going to look at them and

photograph them in all directions to see

if there's anything that we can see that

we know that the naked eye is not really

very useful at finding things

so what we're going to do after we

photograph them is within a place them

in a forensic stain the type of stain

the police would use when they're

looking for proteins and polypeptides in

this particular case its course locks in

be we're going to put them in a bag and

we cannot ultrasonically pay them into

solution thereafter for 20 minutes then

we're going to take them out the bag

we're going to wash them underwater and

then we're going to let them air dry and

then we're going to see what we can see

I'll show you what we can see

so fluxing be is also unknown stain the

bacteria for proteins and polypeptides

that's what we found

what this lock-in be does it gets

absorbed by proteins and polypeptides

which then expand and it shows up

orange-red do any of you think those are

clean and the epithelium would really

like to stick to them as the patient

heels

what do you think because i don't think

they are so my oral surgeon is never

going to get any healing abutment back

from me because I want my patients

a feeling and connective tissue

soft-tissue attachment to be optimum

from day one

now people say to me what's the clinical

relevance for this we will never find

out in the u.s. because i don't believe

there's any study that would allow us to

do this on patient if we know that we're

putting dirty healing abutment back

inside them

yes they are sterile they have no

microbes on them but they are not clean

epithelium will not attach it will not

spread it will not optimize its health

we found out of 9999 out of that 100

hearing but abutment had contamination

of them somewhere 99 we found it in

cracks and groove some healing abutment

have actual grooves in them if you use

those you're going to get material

inside there that is going to be a

contaminant we found it in the engaging

part of the screw why would we not find

in there because that's where food passu

we found that there was protein all the

way down there and we nearly always

found it on the screws rate nearly

always because the blood gets down there

in other products and what we did find

out about the one handing about moment

that was clean that it is probably never

been used in the oral environment now if

you want to do this in your own office

piloxing be is disclosing solution if

you don't believe what I'm saying to you

when you go back to your office get some

disclosing solution this one I don't

know if all brands are the same put your

healing abutment in this disclosing

solution for 20 minutes

agitate them take them out give them a

quick rinse let them dry and see what's

happening to them because you will be

changing the surface that is the most

important from day one for that

influence so that left me for the

dilemma because my oldest urgent dodge

is never going to get those healing

buttons back again the development that

I now personally have is what do i do

when i make an impression I've taken the

hearing about mine out my patient I lead

on the side i make my impression am I

going to put that dirty

the apartment back in the patient's well

now i have a dilemma or do I have to go

and buy a new healing abutment and

charged my patient another fifty dollars

or whatever

what should I be doing as a clinician

and I thought long and hard about this

should I throw the healing about my way

or can i reuse it

my opinion is that i can reuse it if I

clean it reasonably well because the

tissues are now mature I'm not

anticipating healing from day one

because they've already here they have

college and inside of them and I know

that they can now maintain their own

position and I also know that when i

unscrew the healing about man I've torn

some of it and there's a load of plants

around the sulcus anyway so this is what

I've decided that I would do I would

clean my apartment while I'm making the

impression so I would have the apartment

to my assistant while i'm placing the

impression coping in the first thing

that she will do is to clean that

apartment very very solidly with an

alcohol wife now I know some people say

that they're still live epithelial cells

attached to that that might be true in

sports because if you remember when you

take a healing about it off it believes

in isolated sites it doesn't bleed

uniformly so it means that there's not

your not caring at uniform you're

tearing it from spot attachments only

and it's true there will be live a

fulfilling yourselves on that

environment but when you go to try to

get back in because of the way of screw

works you will never get it back into

the same orientation and when you took

it out so the bleeding spot is now most

likely going to be opposite from plank

or some contamination so I think those

epithelial cells die anyway so what I'm

going to do is wipe it

I'm going to make my impression and then

i'm going to do citric acid which is the

cleaner that most people agree today is

useful for peri-implantitis riparian

flatteries to clean a titanium surface

because it removes most of the biofilm

so i'm going to use food-grade citric

acids this is a food you can buy this in

a food store believe it or not and i'm

going to make a forty percent solution

up by using two brands of the material

three mils of water and then i'm going

to put in an ultrasonic far for about 10

minutes and then I'm going to wash it

with deionized water and that makes me

feel comfortable

the only sad thing about the protocol I

just told you about

it's what I feel it hasn't been

scientifically tested but i think that

people will scientifically test in the

future but I have to do something I can

tell my oral surgeon know you're not

going to do this if I don't do something

differently myself so that's the soft

tissue i believe that the soft tissues

are the problem not the bone the bone is

important in the planning stage the bone

is important in the execution of the

surgical stage the bone is important for

stabilization both initial and long-term

once the implant field but after about

four months if everything is going well

I believe the soft tissues are the

vulnerable site that causes destruction

so I'm going to ask you some questions

about some x-rays because I realized

that we have the group of dentists are

very very poor at reading radiographs

something we do all the time so let me

ask you this question

have any of you seen this on the front

of these themes journals that we get

it's a flyer that you tear off in order

to get into your journals i see this

routinely on many of my journals and I

started looking at it very closely and i

and i truly don't mind if you if you

like this company and you want to place

your prosthetics in with a hammer

fine i don't mind them advertising

because if you advertise on the front

cover of one of my journals we get

better pictures we get more paper at the

qualities that i have no problem but

what I had a problem with was the

content on the top right hand corner it

says bone gained over time and so I

thought I'd look at this

so what do you think look at the

difference between 2006 and 2010 the

bone changes and here's another 1 2003

nine years later that

it's really quite impressive at first

gloves right and here's another one

this was from nobel biocare this was a

very interesting study i met the

officers that publish this study and the

story goes like this i met the primary

officer in a bar in New York and I said

to him I went up to him and I said

you've never met me before

my name starts with money i'd like to

buy you a drink and he looks at me and

if they actually I'd like to buy you two

drinks because i don't like your study

that got his attention so he says buy me

drinks so I open my computer and I shown

this picture i say you're trying to make

a point here that this implants cord is

allows bone to grow at these particular

sites and he says

yep and I say then I have a problem

because by the same radiograph you also

cause I split in the bone here and he

looks at me and I say that's not a spit

in the bone that's the mid powerful suit

shot of the maxilla it was always there

why don't I see in the first x rays I

see a little bit on the second xtreme by

the third x rays very prominent the

reason i don't see it is because you

change the angle of the x-ray so I get

no comparative measures from these three

radiographs they show me nothing I see

him

just imagine you had put this implant

two millimeters over towards the midline

in the first year you would have been

telling everybody this implant is

horrible because you've lost two

millimeters the bone by the second year

you'll be telling everybody take this

implant off the market because look at

the bone loss around it and he stopped

and he thought when he bought me a drink

so let's go back to this one what do you

think now because I contacted the author

that published this very nice guy and I

called him up and I see renia you

publish this and he says yes and I say

did you change the restoration to your

left and he says no I say radio you are

an amazing dentist you are the only day

since I've ever met in my life who can

actually grow attachment on adjacent

tooth by placing an implant is fabulous

and when you know you're the only person

I've ever met in my life who can make a

stainless steel pin disappear and radio

if I truly believe your implants can do

this I'm gonna buy shares of them and

I'm going to tell my family to buy

shares now because this is the only

implant system I've ever met in the

world that grows gold look at the size

of those two goals components on the

Crown's we have to become much more

astute at reading x-rays the trick is

never look at the influence ignore the

implant look at everything else around

it and if you truly did believe that

these pictures the 2012 groove on how

did you get grown too attached all the

way out titanium and then on to

partially how do you do that I can't do

that we have to start looking carefully

so now if you look at the thing that

comes on the journal you see they

propped the picture they crop the

picture so you don't get any indication

what's happening around it if you see a

prompt radiograph ask them to show you

the whole radiograph so it hasn't

finished hasn't changed position the

reason is changing position is because

when we standardize radiograph we do it

very poorly least two radiographs of

this implant site effectively could be

considered to be standardized as I use

the same materials same ring jolla hold

the same x-ray i'm going to use the same

x-ray unit they're not standardized and

if you don't believe me have a look at

this this is what I published on where I

made a healing abutment propped up by a

hundred microns against one of the

implant anilos that they had and I took

radiographs that measure different

angles so here we go this is orthogonal

the radiographs the 90 degrees on to the

long axis of the inside you see the gap

the gap exists you know that that

component doesn't fit i'm going to make

it fit now by changing the x-ray angle

oh it's this and I'm going to grow some

bone by changing the radiographic angle

as well now if any of you

leave the I grew plastic bone I've got

some implants I'd love to sell you so we

have to be much more careful with the

way that we read radiograph and that's

not only from other people

that's your a graph that's you when you

make a radiograph sequentially from one

time to the next time

learn to standardize them otherwise you

get no information about a

three-dimensional object that's being

projected in the two-dimensional plate

play so i think with that I'm early so i

will say thank you very much

For more infomation >> Chandur Wadhwani (FOR.org) - Healing abutment to final restoration - Duration: 38:32.

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Website content writer testimonial from John Verhoeven of Antiques Wanted - Duration: 0:48.

I was coming over today and I was

thinking about my business and I was

thinking that I no longer have any

stress or pressure about wondering when

the next call is going to come through

It is a given.

I'm so busy. I've just come back from

two weeks in Thailand and I

came back to three weeks' solid appointments

My website has seen an

increase of more than 1,000 percent and

it was almost like a switch was thrown

It was instantaneous

I have gone from

hovering one or two from the bottom of

the page to permanently number one

For more infomation >> Website content writer testimonial from John Verhoeven of Antiques Wanted - Duration: 0:48.

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Technology: Is the Internet Ruining Your Brain? - Duration: 21:25.

For more infomation >> Technology: Is the Internet Ruining Your Brain? - Duration: 21:25.

-------------------------------------------

Is the Customer Always Right? 5 Top Rules For House Cleaners (2017) - Duration: 7:00.

Hey there.

I'm Angela Brown, and this is Ask a House Cleaner.

This is a show where you get to ask a housecleaning question,

and I get to help you find an answer.

This question comes from a woman who was watching her house cleaner on a home security camera

and the girl sat down and was visiting on the phone for an hour and a half, while she

was being paid by the hour.

And the homeowner wanted to know: "What are the rules and regulations behind that?

If someone is charging me by the hour, don't I have the right as the person paying the

money to demand that they work during that time?"

Well, that is an honest and a very fair question.

And the answer is yes you do.

If you're the one that's paying the money, then yes, it is in your power and it is your

right to declare your own rules.

Now, every homeowner is going to have a different set of rules, and every housecleaner is going

to have a different set of rules.

So, when you hire a house cleaner to come to your house, or a maid, or a housekeeper,

or whatever the term is that you use.

You need to be very specific about the rules that you create.

One of the rules that I would recommend upfront, and they're probably five or six rules that

are really important that you clarify upfront.

These are things that are important to you.

One of them is no talking on the telephone while you're on the clock.

"I understand that you run a business.

And so, if you're running a business and you're working in my home, you either need to turn

off the phone while you're at my house, or you need to have the little setting that sends

the quick message that says "sorry I can't talk right now."

So, you can respond really quickly and then after you get off the job and you're back

in your car, you can return the phone calls to your regular customers."

But if you're my customer and you're at my house and I'm paying you right now for a service,

I expect a full 100% of your attention.

I think that's fair what do you say?"

I think that's fair.

The next rule that I would suggest is no eating on the job.

There are numerous reports that I have heard where a house cleaner will come and they may

work for an hour and then they stop and take a half hour lunch break.

Okay, they're at your house cleaning.

Right?

They're at your house cleaning and while they're cleaning your house,

they should be working.

That's just common sense.

So, I would make a rule that when a housecleaner comes to your house that they not talk on

the telephone while they're there, and that they not eat while they're on the job.

The next thing I would recommend and strongly suggest is that you have a rule of no smoking.

There are lots of house cleaners who smoke.

And what you don't need in the middle of a two-hour cleaning that you're paying for or

a four-hour cleaning that you're paying for, is two or three 15 minutes smoking breaks.

Where a housecleaner leaves the job, and goes outside and takes a smoking break.

What is that?

"Smoke before you arrive or smoke when you leave.

But don't smoke when you're at my house cleaning."

Right?

I think that's a fair rule that you as a homeowner have the right to make.

And so I would have at least those three.

The other one that I might recommend (and this sounds very peculiar and you're going

to ask why I even bring it up) but this happens so many times, is no leaving while you're

on the job.

No leaving while you're on the job.

Do you know how many house cleaners check into a customer's house?

They type in the alarm code, and they start cleaning.

"Oh, I think I forgot something I'll run to the store and go pick it up."

And they leave.

Don't lock up the house because they don't want to trigger the alarm

that they're not there.

They just leave and they're gone for an hour or two hours.

"While I'm at the store I'll just do my regular grocery shopping and then I'll come back."

Then they come back to the house and lo and behold, "Well, my time is up."

So, they tidy up a few things and then run a few vacuum lines over the front of the carpet

and then they leave.

So it looks like they've been there.

Your alarm security code says that they've been there but they've been gone half the

time there was supposed to be there.

So, my other rule is I would recommend, that you recommend them not leaving while they're

on the job.

That's just sort of common sense.

Another rule I might suggest is that if your housecleaner has a friend that's in from out

of town unless that friend is actually bonded and insured with the company that your housecleaner

works for, they should not be able to bring their friends over.

No friends, no family members that are not specifically bonded and insured from the company

that you work for.

The reason for that is this.

Even with the best of intentions, a person that you bring along with you to help clean

a house that's not insured and not bonded, they can use the wrong chemicals on an appliance

that you have.

Or on the top of your desk, or the top of your fancy china cabinet or whatever and they

could ruin it.

And because they're not insured by that cleaning company it's going to be on you to pay that.

Or also if that person steals something from your house and that house cleaner is not,

they are not bonded through that housecleaner, that's not going to be covered.

Right?

Now, this person might trust their friend.

But you don't know their friend.

For example, my Mom came to town one time.

And I love my Mom.

She's the greatest housecleaner in the world… (well maybe besides me. ha ha)

Anyway, she came to town and she says "Oh, you've got houses to clean today.

Why don't I come help you?" and I said "Mom, I would love to have you

come help me clean the house.

And there's nobody that's probably more qualified to clean houses than you.

But unfortunately, you're not insured or bonded with my company so you're going to have

to stay home and watch TV or read a book while I go clean some houses because I can't take

you with me."

And she's like "I'm really good.

I am trustworthy."

"I trust you, Mom.

I know you're qualified to do it.

I know you've been trained properly.

My clients don't know that.

They don't know you and they don't they don't know that."

And so, I had to leave my Mom at home.

(She loved the day off, I mean don't get me wrong.)

But you can't bring people with you that are not licensed and bonded through your company.

So if you're a homeowner and you're looking to hire a house cleaner

I would make those rules.

I would say no telephone while you're on the job.

No eating while you're on the job.

No smoking breaks while you're on the job.

And no bringing people with you that are not licensed and bonded with your company.

Or insured and bonded with your company.

So, those would be my rules.

And that's it for today.

If you found it helpful please pass it along to somebody who may benefit from it.

And until I see you again, leave the world a cleaner place than when you found it.