Dentistry Uncensored with Howard Farran

How to perform dentistry faster, easier, higher in quality and lower in cost. Subscribe to the podcast: https://podcasts.apple.com/us/podcast/dentistry-uncensored-with-howard-farran/id916907356

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Howard:

Today is a huge honor for everyone today to be podcast-interviewing Dr. David Rosania from Seacoast Periodontics and Dental Implants in Rye Beach, New Hampshire. Did I say that right, New Hampshire?

David:

That's pretty close. That's correct, yes.

Howard:

Pretty close?

David:

Yes.

Howard:

I want to read your bio, because I'm a big fan of yours. Dentists, the work, for me, it must be the right way, it must be the only way, and all doctors are authoritarian because, "I'm a doctor, you're not." You're just a man of the science. You are as familiar with the literature as any preacher is of the Bible. You're an amazing man.

I want to read your bio, "Dr. David Rosania is one of the most experienced surgeons in the Seacoast and the state. He was the first surgeon in his region to place a modern-era dental implant over 25 years ago and has placed several thousands since then. He has also performed well over 20,000 periodontal surgical procedures. He is excited to combine his experience with the state of the art training his daughter Amy has received at the University of Pennsylvania and the University of Connecticut, 2 of the most highly ranked dental programs in the nation.

Dr. David Rosania is committed to treating his patients with dignity and with providing a personalized experience as free of stress as possible. Dr. Rosania received his education at Tufts University, B.S. cum laude in biology and psychology, and the University of Connecticut and specialty certificate in periodontics and most recently earning a M.S. in 2008, again at Tufts University.

Dr. David Rosania is the past President of the Rockingham County Dental Society. He founded a 20-year-long dental study club and authored "The Perio Perspective," a newsletter for local dentists and hygienists. For the past 7 years, he has indulged his love for teaching at the Governors Academy, where he taught biology, physics, chemistry, anatomy, and physiology and environmental science, while continuing to practice periodontics and implant therapy. He continues to cherish his 3 grown children and wife, Pam. His hobbies include triathlon, electric guitars, studying science, psychology, philosophy, and trying to keep up with Amy running and skiing." It is a huge honor to have you on today.

David:

Thank you.

Howard:

I'm a big fan of your posts. You've been doing this a long time. Your talking points are so long, I don't know if I should even be talking to you or if you just want to lecture for an hour or however you want to do this. I would really like to get through all these talking points, because you have so many profound things to say based on literature and research and science, as opposed to so many of my homies, who just say, "Hey, dude, I've been doing this for 10 years and it works every time. Just trust me, I'm the authority." You like to see research. Where do you want to start? Do you want to go in order of your talking points?

David:

Totally up to you. Yes, I want to accept your gracious compliment about being profound, but it's not me being profound, it's actually trying to be humble and just accept what the scientific research guides us to do. We can go through anything you'd like to talk about.

Howard:

Do you have your talking points in front of you?

David:

Sure.

Howard:

You can go through that. I'm also going to try to put you on the spot here in front of thousands and thousands of townies, I hope someday you make us an online CE course.

David:

Maybe. We'll see how it goes, yes.

Howard:

They've exploded, because you don't have to close down your dental office to go to a course. Right now, Yankee's going on, and a lot of dentists are like, "It'll cost me $4,000 just to shut my office down and then I got to go there." We're up to 350 courses on Dentaltown and they've been viewed over half-a-million times. You can now watch them on your smartphone, your iPhone. They're in shorter increments, so a lot of times they'll just go to bed and take their iPhone with them and watch an hour-long course. They love it. They don't have to take notes, because if you need to go back and look at something, you just log back onto Dentaltown, go to that course, look at the handout. Take it away, buddy.

David:

First, again, I've been on Dentaltown for about a year. I joined when I opened a new practice with my daughter, mostly just out of curiosity, but it's a tremendous service. There are some excellent practitioners, surgeons, restorative dentists, endodontists, you name it, they show great cases and great technique. There are also some really highly scientifically-trained contributors to Dentaltown.

It seems like the community sometimes is a little bit of a free-for-all where everyone posts what they like, what their success was, so after being a member for a year, I thought it would be interesting to talk about what the science shows us. Just to start with a topic, why don't we talk about the correlation between periodontal disease and cardiovascular disease? That seems to be an issue a lot of general practices present to their patients, that gum disease makes it more likely that they'll have a stroke or heart attack.

There's been quite a body of evidence building about that relationship. It turns out that there is a relationship, but there's no evidence that it's causal. In other words, if you have gum disease, does that mean you're more likely to get heart disease? The answer so far is, we don't know. There's a relationship, but whether gum disease actually causes heart disease has not been shown.

To be skeptical, I would lean towards saying it may not exist. More likely, what exists is that if you're a person who's likely to get gum disease, you're also a person who is more likely to get heart disease. For genetic reasons, maybe your inflammatory response is different from a healthier person, but that they tend to occur in the same people, but not because either one causes the other. It would be like saying your heart disease is causing you to get gum disease. Most of us would think that that sounds ridiculous. It may be equally ridiculous to say that your gum disease is causing heart disease. We just don't really know.

Howard:

I once heard someone say something about smoking got him in trouble at a dental school. In fact, he actually lost his job over it. He was saying that if you're addicted to nicotine, it's so much safer to chew tobacco than to smoke. He was showing massive research, but in our politically correct climate, you just can't say that and you especially can't say it in dental school.

I also heard him say something about smoking where one of the reasons that smoking causes everything is because if you smoke a pack a day, you're probably more likely to drink every day, you're more likely not to exercise and eat fast food. Everything gets blamed on the cigarette, when the cigarette might be just tagging an individual, says, "This guy is not a healthy lifestyle person."

David:

Poor health habits, and they've tried to control for that. One of the things I'd like to stress is that when trying to figure out an answer to some of these questions, we're always looking for controlled trials. They're called "RCTs," Randomized Clinical Trials. In those trials, what they try to do is eliminate all the extraneous variables they can. In the smoking and periodontal disease and cardiovascular disease studies, they've tried to control out for people with poor diets, with poor other health habits.

Even when they control for that, they do still seem to see a correlation between cardiovascular disease and periodontal disease, even ruling out the other factors like poor diet, drinking, any other, lack of sleep, high stress, things you think about. You still see the relationship, but the question remains, is it a causal relationship or is it just that 2 things occur at the same time in the same person?

There is some evidence that there's effect on vascularity and fibroblasts with periodontal disease and with cardiovascular disease because they're both inflammatory processes, so it may not just be lifestyle related. It may be your immune inflammatory system that has an effect. Without putting everyone to sleep on this one, I would say that the relationship is there, but whether treating your gum disease will actually reduce your cardiovascular risk, there is no evidence for that.

There's been one recent study that came out a month or 2 ago in India where they studied people for 6 months. They found that treating their periodontal disease led to reduced blood pressure and somewhat better serum triglycerides, but they didn't measure for whether there was an effect on strokes or heart attacks. That's the closest we've been able to come to a causal relationship.

Howard:

I want to interrupt you one bit, because when you're on this topic of smoking, I do notice one controversy on Dentaltown is some dentists, if you're a smoker, they refuse to do an implant, a sinus lift. They just say, "I'm sorry, you're not qualified." There's other implantologists, they say they don't care, they'd do it anyway, and they don't have a problem. What do you think about that issue?

David:

The research shows that you have a higher risk of failure, higher risk of peri-implantitis, bone graft failure, "rejection," if you want to call it that, with smokers. The effect is not 0, but it's not huge. In my opinion, it's not a good reason to rule out those procedures. It might take your success rate from the 90-something percent to maybe 75 or 80 percent. Still favorable, it's better than 50/50, but I would inform my patient that as long as you smoke, the risk of this procedure failing or having complications is going to go up. I don't look at it as an absolute contraindication, no.

Howard:

I have noticed, one of my patients is a cosmetic surgeon and mostly does breast augmentation, he won't treat you unless you stop for 90 days before. He told me, off the record, that one of the reasons he does that so much is because over the last 20 years, so many women, they wanted the breast surgery so bad that they actually quit smoking and then they got the breast augmentation and now they're no longer smokers. He says that he did it because he did notice more complications, but he says he is hard on it because he knows that might be the reason they finally quit smoking.

David:

Yeah, we gently but persistently remind our periodontal patients of the same thing. We are always trying to get our patients to try Chantix, to join smoking quitters groups, whatever we can do, even if they can't quit, to cut back from a pack to a half-a-pack a day. Yes, I think that's a wonderful service he's providing his patients. If he can improve their esthetics and save their life at the same time, good for him, terrific. There's a high relapse rate with smoking. Those women may have quit for a while, but it's still tough for them to stay off the cigarettes.

Howard:

You know that Penn and Teller, how they were doing those documentary shows? They were saying that Alcoholics Anonymous has a 99 percent failure rate at 5 years.

David:

Wow, I did not know that.

Howard:

Humans are complicated. Your first talking point was mouth rinses. What do you want to say about chlorhexidine, "Listerine," fluoride, peroxide?

David:

Yeah, there's really only one mouth rinse that works significantly for most people most of the time, it's chlorhexidine. Unfortunately, it does have issues with the altered taste and with staining, but it's very effective. It has to be used twice a day. It has something called "substantivitity," which means it's not only anti-microbial, but it sticks around in your mouth for quite a while after you rinse with it. The other mouth rinses don't have that. They kill bacteria for a few minutes and then they're gone from your mouth. Chlorhexidine persists for a lot longer, so it's much more effective.

I think it's great for people with multiple implants, a lot of crown and bridge, where you don't have to worry about staining. Essentially, I've seen a lot of posts on Dentaltown where people with implants with issues, recurrent periodontal diseases, recurrent caries, something that never seems to get mentioned is a lot of those people would be candidates for chlorhexidine. Again, if they have staining issues, that's going to be a problem, but if you have a lot of teeth covered with crowns, implants, those people should all really be strongly motivated to stay on chlorhexidine. That's my next point.

Howard:

Now, can you buy that over the counter anywhere or is that still prescription only? How's that working these days?

David:

Prescription only. A lot of dentists' offices can either dispense it or prescribe it from their offices, but otherwise it's a drugstore prescription. Secondarily, Listerine is somewhat effective against gingivitis. It's better than nothing, but it's not a lot better than nothing looking at the studies. I think people who use Listerine, that's fine, I wouldn't expect it to solve a lot of their problems.

Then, the last thing is I'm surprised that a lot of patients who get sent to us with caries who don't know they should be on at least a fluoride mouth rinse once or twice a day, if not, something more significant like a paste in mouth forms. That's what I wanted to say about mouth rinses, don't forget chlorhexidine.

Howard:

Oh, I want to ask you, off topic, the fluoride, you and I have been in this for decades, doesn't it seem like the anti-fluoridation movement gets stronger over the decades? It seems like as we have more research and more science showing how obvious it works, most of the information on the internet is crazy.

When I search fluoride, just type in "water fluoridation" on Google, 90 percent of the sites are just complete batshit crazy, it's found in rat poison, it's a conspiracy. You really have to search a long time to find credible information on water fluoridation. You're in New Hampshire, I'm in Arizona. Am I just in the wild west or do New Hampshire people-

David:

No, it's a strong movement. We're in New Hampshire on the northern edge of Massachusetts and both states have a very active anti-fluoride community. Yeah, the bat guano is around here, too, just like it is around your area and on the web. Every time the anti-fluoridation community brings up another objection, again, they do scientific studies and whatever they bring up as an idea is generally discredited. Currently, it's thyroid disease, which has also been discredited, but they keep coming up with new ideas. The internet is a free-for-all and anyone gets to post, but it doesn't mean that it's valid. I'm a strong component of fluoridated water.

Howard:

Google has democratized misinformation. You now have more misinformation available at your fingertips than any time in history.

David:

You can find a lot of good stuff and a lot of terrible stuff. I'm sure you see it with your patients who come in with some concern or complaint about your treatment and it's just out of left field and it's hard to address it, because a lot of patients find it pretty credible.

Howard:

I can't even believe that you can stay in business as a periodontist when all you have to do is swish with coconut oil for 20 minutes every day. Have you not learned this?

David:

I tried, but yeah, they don't have coconuts in New Hampshire.

Howard:

I'm sitting here saying, "20 minutes? I can't even get you to brush for 2 minutes. You're really going to swish for 20 minutes with coconut oil?" Okay, SRP versus LANAP versus conventional osseous surgery.

David:

Okay, I'm going to be careful with this because I know it's bordering on something almost litigious, so I'm going to stick to the science. There's been a lot of comparative studies with LANAP and conventional scaling and root planing. The studies consistently show that LANAP and SRP are equivalent, in terms of clinical results. They're both very good treatments.

I think scaling and root planing is one of the single best services you can provide your patients with periodontal disease. LANAP is equally effective. There are people on Dentaltown who show amazing results and they're generally doing LANAP and maybe a little bit more than just simple LANAP and there are people who can show amazing results with conventional SRP.

The science has been pretty consistent that they're equivalent. I think that there is no science to show that either is better than the other. To propose to patients that LANAP is somehow superior to some other conventional treatment, I think has not been backed up in clinical research. It is effective.

Howard:

Isn't LANAP a lot better, though, because now you have another reason to get an additional $100,000 in debt and don't dentists just live to get in debt? They want big shiny toys. They got to have a CBCT, a CAD/CAM and a LANAP. You're saying that you don't need a LANAP, you just need some scaling and root planing? You're just not on the right train.

David:

We bought a cone-beam, so we ran out of the money for the LANAP, for the laser. Maybe next year, we'll start doing lasers. I don't know.

Howard:

The thing that I always thought was bizarre about LANAP, and I wish they would change their course, is I get so many questions on it and I go to LANAP and I say, "Why don't you put an online CE course to explain it?" They don't want to explain anything until after you've bought the machine.

David:

Yeah, there is some proprietary interest with that and with several other things we do. I understand it, they spend a lot of money developing their protocol and their technology and they deserve to earn their money back. It's the same as a patent. I understand where that motivation is coming from. It would be nice to have an open community for information, but I don't want to tell companies how to run their business, for sure.

Howard:

Okay, since we're on LANAP, what about some dentists who say, "The laser's a laser," so if you want to do the LANAP therapy with just any other laser, whether it's a $2,500 AMD laser, what do you think of those statements that they say?

David:

These other lasers haven't done as much research to back up that they have an effect. The diode laser, for example, which is much cheaper, may have the same effectiveness, but it has less clinical research behind it. I suspect that it is similar in terms of its results, but I have nothing to back that statement up.

Then, to get back to the financial thing you were talking about, my only question would be, if you're doing LANAP and you're achieving the same thing as SRP, whether you should be charging the same thing as SRP. That's something that everybody has to wrestle with in their own conscious. If you have a laser and you're charging 3 or 4 times your scaling and root planing fee, but achieving the same clinical results, I would question that. On the other hand, if your patient wants a laser or if somehow or another you feel that it's better without the clinical data, it's your practice, go for it.

Howard:

I would say 2 things about lasers. "LASER" either stands for "Light Amplification by Stimulated Emission of Radiation," or "Losing All Savings Equals Reality." I look at these lasers as, if the dentists buys a laser and she just loves going to work and it just lifts her attitude, she can't afford not to have it. Number 2, I've seen so many people do amazing marketing with laser foot surgery, laser dentistry. It's great marketing and if it's a toy that makes you ... Some people get a CAD/CAM and a switch goes off and now they're a super dentist. Humans are complex and you need motivation every day.

David:

Yeah, if you get a patient to do periodontal treatment because it's a laser and ordinarily they wouldn't have done the treatment, I think that's a plus, for sure. The last point on this is with regard to osseous surgery, if you're looking for pocket reduction and persistent pocket reduction over the years, osseous surgery still is clearly superior to SRP. In my opinion, that means it's also superior to LANAP, if you're looking for pocket reduction. There's never been a direct comparative study between osseous surgery and LANAP.

Still, as periodontists, when we are trying to eliminate pockets, we're still going to do conventional osseous surgery. Yes, it's hard to do, it's going to hurt more, you're going to have some sensitivity issues that you may not have with SRP and LANAP, but long term, we definitely see better pocket reduction and the research backs that up, for what it's worth.

Howard:

While we're on the controversies, I want you to address also something they didn't talk about 28 years ago when I was in school, is the contagiousness. If a married couple were coming in and you were treating one for chlamydia every 3 months for 10 years, their doctors would say, "Hey, we need to check out your husband," but we don't seem to do that. You go into a dental office and they've treated Amy every 3 months for 10 years, they've never laid eyes on her husband, and she's sleeping with him and kissing him. Do you think that's a factor?

David:

I actually tried that as a marketing technique back in the 80's, because there was a little initial research that showed that there was some correlation, the longer you were married to someone with periodontal disease, the higher your risk was for periodontal disease. We told our patients, "Free consultation for your spouses." It didn't really succeed that well as a marketing effort and the research hasn't really gone very far since then.

It seems like there's some small increased risk if you're married to someone with periodontal disease. As you said, people are complex. It comes down, a lot of times, to patients' individual immune responses, whether they are better with oral hygiene or worse than their spouse, other factors come into play. I would say, yes, I would tell your patients, "You've been married for a while to someone with gum disease. You might want to have us check you out also." That's probably just a good idea anyway.

Howard:

Great point. Okay, the next one was CT grafting versus free gingival grafting versus pinhole, PST.

David:

Yes, also controversial on Dentaltown and I've had some posts on that recently. There's been a lot of long-term research on, if you're trying to cover exposed roots, connective tissue grafts or subepithelial connective tissue grafts, different name, same procedure, that is clearly the best procedure to use to cover roots and have them stay covered for a long period of time.

It's technically difficult. You have to take palatal tissue, and I know patients are somewhat concerned about that, but that's the best option for covering roots, whether they're class 5 lesions, abrasion, abfraction, whatever you see that involves recession and exposure of root structure. If you can cover that and not have to do a restoration, which will then probably need to be repeated frequently, that seems to be the ideal approach.

If you want to just get keratinized gingiva, KG, then free gingival grafts are great, but they don't cover roots as well and they're more painful, because you're taking a patch of tissue right off the surface. You have to have secondary healing. We don't do free gingival grafts much, if at all, anymore. I'd say 90 to 100 percent of our cases are connective tissue grafts.

With regard to the Pinhole Surgical Technique, Dr. Chao's technique, he seems like a really reputable dentist. He's posted a lot on Dentaltown. I know he's done a lot to show case studies and it's a promising technique, but so far, there is no research, long-term, comparing it to the other procedures, free gingival graft, connective tissue graft. There is no comparison study out there. People who are trying it, if they're looking for scientific support, there isn't any, in terms of, "Why I would rather do this than a connective tissue graft." I'm not so-

Howard:

That sounds like your first online CE course on Dentaltown, an hour presentation how to treat abfractions.

David:

That would be fun, yeah.

Howard:

How would you do it?

David:

I don't know. If we did a continuing ed course, ideally, it would be ... Ziv Simon was a big contributor to your site, has several YouTubes on this already, so I don't know that I need to be there, but you can do it through his website on YouTube. I don't know if he's had a CE course on Dentaltown, but he would be another contributor. It would be nice to show a surgical procedure. It would be nice to show a lot of case studies with different sorts of lesions and the best way to approach them and then some before and after.

Howard:

The difference between Dentaltown and YouTube, and I think the reason that Dentaltown still adds additional 1,000 new dentists each month from around the world, we've only got 10 percent, there's 2 million dentists on Earth, is what the dentists keep telling me is they don't want to watch a YouTube video alone. They want to watch it in a community, where people can say ... When you show a case, everybody sees something differently. Everybody hears something differently. It's like when I lecture, you say, "Does anybody have any questions?" They say, "No," and then you go for a break and then 20 people rush you for a question. It's the follow-up. Dentaltown, in 1 word, is just a community. They want to talk about this with 210,000 other people, not alone.

David:

There's a lot more information exchange, absolutely.

Howard:

Yeah, YouTube, the comments at YouTube, there might be 3. On Dentaltown, there might be 3 world wars after it.

David:

Yes.

Howard:

Okay, next question, when to take CBCT and how it determines implant placement. What is the standard of care?

David:

This is fluid. It's changing week to week or month to month or year to year as we speak. This is not really based on research, but I think that within a few years, CBCT is going to be the standard of care for all implant cases. It's just like bitewings are the standard of care for recall patients, even though a large percentage of your patients will never have caries or rarely have interproximal caries, we're still expected to take bitewings on a periodic basis for all of our patients.

I think that's going to be the case for implant cases as well. It may be overkill and I'd drag my heels on this, because I've been doing implants for a long time, way before there was any CBCT option. Nevertheless, if you look at the various areas of your mouth, every area pretty much has a potential anatomic complication and all you need is 1 out of 100 to trigger a lawsuit, create a serious complication with your patient, have a failure, whatever.

You probably know that the American Academy of Radiology, in 2012, recommended CBCTs for all implant cases. That's on the books. As far as specific reasons to take a CBCT, the most pressing need is any area where you worry about any gingival or soft tissue or hard tissue recession. Oh, what's the name of your cat?

Howard:

[Mamimi 00:27:31].

David:

Beautiful cat.

Howard:

Mamimi wanted to join us. She heard about gum disease, so she jumped up on the desk.

David:

At least I know I have 1 person watching or 1 [inaudible 00:27:41] watching. Nice tail. With CBCTs, the esthetic zone is the critical area that you really always have to take a CBCT. You need to have 1.5 to 2 millimeters of facial bone. You cannot tell that without a CBCT prior to implant placement. I really can't see a way around getting a CBCT if you're placing an implant in the esthetic zone.

Then, there's all the other obvious anatomic concerns, like the floor of the sinus, the inferior alveolar nerve, lingual undercuts in the mandibular posterior, buccal undercuts in pretty much the entire maxillary posterior or the entire maxilla. By the time you get done, there is nowhere where you couldn't find a freak anatomical problem that you did not suspect on a panorex or a PA.

We bought a CBCT day 1. It cost us $90-something-thousand dollars. We didn't have the money, but we've used it a lot and we found things that we would not have known were there without it in most of the mouth. I think that CBCT is going to become the standard of care and it's going to become legally the standard of care, as soon as a few lawyers get their hands on some failures or some complications.

Howard:

What brand did you go with?

David:

We went with a Carestream 8100.

Howard:

That's what I went with.

David:

I heard that you had gone with that. I don't think there's any good way to know which unit to buy. There are a lot of great manufacturers. I think that the most important thing is to make sure you have good service and a company that's going to be in business in 5 or 10 years to keep supporting you, otherwise it's really hard to know which machine to buy. We've been happy with those.

Howard:

Carestream reminds me of LANAP, where LANAP, they don't teach you everything until you buy the machine. Carestream, they should have 20 hours of how to read a CBCT on Dentaltown. I've told them that a hundred times. I told them if someone didn't have a CBCT and they were watching these courses, they would realize, "Oh my God, I really want to do one." If I owned that company, I would find a radiologist and just cover the whole damn thing from A to Z and put the CE course up there.

David:

Yes, absolutely.

Howard:

When/how to graft after extraction and/or immediate implant placement?

David:

Yes, there's some controversy about socket preservation and whether you should graft the gap. If you extract the tooth and immediately place an implant, how large a gap can you leave without grafting versus when you absolutely need to graft to reduce the chance for dimensional loss? The studies are inconclusive. Some studies show something like 2 millimeters, maybe at most 3 millimeters can bridge naturally without a graft.

The dimensional change studies are strong enough to show that you should pretty much always graft the gap. If it's a half-millimeter and you can't even get a plugger in there, maybe not, but otherwise, grafting the gap on an immediate placement is probably the best way to reduce the chance of losing any facial bone or [inaudible 00:30:49] height. I would say bone graft the gap pretty much always, unless it's such a small gap that you can't even get an instrument in there.

As far as socket preservation, if you're not going to do an immediate placement, there's still dimensional changes. If you're worried about loss of height or buccal lingual width, you should always be doing socket preservation. If it's a mandibular molar where you don't really care about losing a millimeter or 2 of height and if it has a wide ridge, then socket preservation is probably not indicated. You can do it if you're type A, like us, but their restorative result is probably going to be fine either way.

As far as what to place, we think that the research is most substantial behind XenoGrafts. We place cow bone, because it does not resorb and it maintains the dimensions the best, in our opinion, a little bit controversial. There are a lot of people on Dentaltown who use DFDBA, other materials, and they work fine. They may lose a little more dimension, but the research is weak on that.

Howard:

Cow bone's cheaper, though, isn't it?

David:

Cow bone, I'm not sure, because we've just been buying that for the last couple years. I think ours for .5 grams is $120, I'm going to guess. We use Bio-Oss, but there are other manufacturers, too, so you can look around.

Howard:

Okay, immediate provisionalization of implants?

David:

Yes, if you place an implant, should you immediately temporize it, provisionalize it? Generally, we think that that's a good idea if you achieve primary stability. If you screw the implant in and it's stable, we would prefer immediate provisionalization in the esthetic zone. It allows you to train the tissue and maintain the papillas better than if you place the implant and leave it unrestored. You'll tend to see loss of the papilla really quickly, whereas just placing the implant and then a temp that supports the papilla will give you a better immediate esthetic result. Over a very long-term, the studies are not that clear.

I'm sure you know about the studies showing if you have a contact 5 millimeters or less from the bony crest, you tend to keep the papilla. That's the primary determinate. At least for the first several months or a year or 2, if you place an immediate temporary, you're probably going to have a better papilla form and the patients will be happy right off the bat, instead of waiting for their papilla to regrow over a year or 2. Immediate provisionalization, but you have to have stability and you have to have occlusal contact.

Howard:

I want to say something that's kind of controversial, but it's from my heart and I do it, I call these "esthetic health compromises." We all do them all the time. Sometimes when I have a beautiful woman and it's one of her front upper incisors, so many times, I just think I can nail it better with a bridge. I'm sitting here thinking, "Oh, an implant and a tissue and the papilla and I can nail it with a 3-unit bridge," but I'm filing down 2 virgin teeth, which some dentists would think I'm a heretic and should have my license taken away. Do you ever see a missing anterior incisor maxillary on a woman and think, "This is just going to look prettier with a bridge"?

David:

Yes, if they're all virgin teeth, not as frequently. If they've already had some restorations, that's something we consider routinely. In addition, if you have some kind of soft tissue defect where the tooth is missing, that's a pretty easy area to soft tissue graft for augmentation. You can make a beautiful pontic on your bridge.

Yeah, that's a perfectly reasonable approach. You and I come from the era when that was the only option before implants. There are a lot of 3, 4, 6-unit bridges that have been in function for 30 years that still look great. Now, we're seeing implant failures. Putting a single implant in the esthetic zone and hoping it'll look beautiful for 30 years, that's not a guarantee.

When we see the failures or when we see a number 7 with 2 threads exposed, that's a tough situation. It might've been better to do a bridge initially. Even now, when we see those cases, a lot of times we tell them, "We'll take your implant out, soft tissue graft it, but the next restoration's going to be a bridge," absolutely.

Howard:

If you look at board complaints with anterior implants, things like that, women are the lion's share. You put some implant on my front tooth, some short, fat bald guy, and a thread shows, he doesn't really care.

David:

Me too.

Howard:

When you do it on a beautiful woman and she smiles and it shows, she's not a happy camper. I just think women take beauty at a whole different level than men.

David:

They should, because that's one of the ways that men judge women, so I understand it. Yeah, it goes both ways.

Howard:

I want to move to a country where all the women only like short, fat, bald guys. Do you know where that country is?

David:

If you find one for skinny gray-haired guys, [inaudible 00:35:55].

Howard:

We'll move together and be roomies. Now, the next question was the most controversial article I ever wrote, that is, when to use fully guided implant placement. Oh my God, you got guys like Jay Reznick, my best buddy, oral surgeon MD in Los Angeles who uses it 100 percent of the time and then you've got people that have placed 10,000 implants who have never used it and thinks it's like having training wheels on your bicycle and grow up and be a real doctor and take the training wheels off. How are you going to step into this debate lightly?

David:

Again, to try to stick with the science, there is not a lot of data. There is some. They've done some studies on fully guided. It turns out that fully guided, it's not a guarantee that it will make the case easy for you. It's good if you want to do a flapless procedure, if you're trying to, say, hold papillae or for whatever reason you don't want to raise a flap, they definitely have a place to play in those cases.

Fully guided is great if you have difficult anatomic limitations, if you're really trying to, quote, "sneak an implant in" mesial to the sinus, or if your buccal plate is just barely thick enough, having something fully guided is an advantage. It's not a guarantee that you'll have an easy case. You still have to have your brain engaged while you're doing fully guided, because the guides don't always go exactly into place.

The best type of fully guided case involves soft tissue born guides, not tooth guides, in terms of accuracy. I'm not saying not to use tooth-guided guides, but they're not going to guarantee you that the implant will go exactly where you think it's going to have to go. You need to use your brain and the guide at the same time.

Do you need to use a guide in every case? Absolutely not. Should you have at least a surgical guide, a suck-down guide, for an esthetic case? Absolutely, yes. You need to see where the CEJ is going to go on your restoration. Since we're advocates of screw-retained restorations, you need to see where the cingulum is going to be so your access hole comes out exactly where you want. That's going to dictate the placement of the implant.

I would say fully guided mostly when you have multiple missing teeth and difficult anatomic guidelines, not where you have 1 missing tooth, I don't really see that that's essential, or if you have anatomic constraints, like a thin jaw, something where you really need to nail the exact placement. Even still fully guided, you have to be 3-dimensionally skilled while you're using your guide.

Howard:

Okay, now the reason you said you didn't like tooth borne guides as much as soft tissue is because a lot of the tooth borne guides, when you go to place them, the tissue's not letting it seat fully. Is that what you meant?

David:

It's difficult to seat them exactly, yes.

Howard:

You'd rather take an impression and make a surgical guide off the impression, not a CAD/CAM or a CBCT tooth guide?

David:

There is no science here at all. Anyone who wants to do it a different way, totally, I understand. For us, we would probably be using just a suck-down off a wax-up or with some denture teeth, somehow guiding us to where the cingulums and where the CEJs, those are what we're looking for. This is with people who have some natural dentition left.

Howard:

Okay, in answering that question, you open up an entirely different can of worms where you said "screw-retained." That's very controversial, because there's just a lot of dentists who have just seen so many screws back out over the years that they're going to cementing their implants.

Then, with the cementing the implants, the problem is the most popular implant cements don't show up on x-ray. They've got excess cement causing all kinds of problems. Talk about why you would screw-retain versus cementation and talk about the trade offs between the screw coming loose or having excess cement.

David:

Yes, we're biased. As periodontists, we tend to see the problems that come from cement. Again, looking at the research, the single biggest problem with peri-implantitis, peri-implant mucositis, is cement, subgingival. There are techniques to avoid that, there are forms that you can place into your crown before you cement to express excess cement, those help. Some cements are somewhat radiopaque, those help. If you have a very thin shell of cement, you're not going to see it on a PA and we see patients with problems because of that.

As a result, we generally prefer screw-retained. We have a lot of restorative dentists who don't, they prefer cement-retained. If a screw loosening is your biggest concern, I understand, screw-retained is an issue, but if your screws are coming loose, if you have cemented, your abutment screw is going to be coming loose and still have the same trouble. I'm not sure that screw loosening is that much of a different issue, whether it's your abutment screw or your crown screw that's coming loose. I don't know of any data on that as to which is worse.

Then, on Dentaltown, I learned about screw-mentation, which I'd never heard of before, which is a hybrid breed between screw-retained abutment and a cemented crown, where you actually cement the crown to the abutment and then screw that into the implant, which is a neat intermediate way to go. That's something I learned on your site. It's terrific.

Howard:

David, what would you say to my mother who says that I have a screw loose, but yet I don't have an implant in my mouth? What is she referring to?

David:

I never argue with anybody's mother.

Howard:

What do you think about, on cementing an implant, using a cement like zinc phosphate that would be so much more visible, radiopaque, if you had a excess? What do you think about that advice?

David:

Yeah, was it Carl Misch who just discussed that?

Howard:

Yeah, it's the only cement he likes. He doesn't like any other cement.

David:

Absolutely, we used to obsess about making the crowns cemented temporarily. We used a lot of TempBond. The problem is you cement the crowns on and they're pretty much permanent, no matter what you use. We rarely have final crowns come loose with temporary cement. We go to pull them off, we can't remove them anyway, so you might as well use zinc phosphate, make it permanent, and then you can see it. I agree, that's a good idea.

Howard:

Okay, Arestin. I know that Arestin's a buzz word, a controversy, because there's 460 DSO big box dental chains and a lot of these, they can send to place things like Arestin. Talk about Arestin and there's a couple other brand names.

David:

Yes, any other subgingival anti-microbials. Arestin is the biggest, yes.

Howard:

What are the top names? Arestin ...

David:

There's the chlorhexidine chip, that's called "Periochip." I'm not sure if you can buy that in the United States. Then, there's "Atridox." I'm not sure if that's even still on the market. Those are the 3 that I'm familiar with, but Arestin is definitely in the market.

Howard:

What do you think of it?

David:

Again, the research and the American Academy of Perio consensus report says that Arestin is best for sites that have had conventional therapy fail. If you've done root planing and/or surgery and you have a residual pocket, then Arestin may have some indication. It's probably going to give you a limited benefit for a limited time. You may see a millimeter or 2 improvement in the pocket depth for 1 to 3 years and then have to reapply it.

As far as Arestin as part of initial scaling and root planing, I think it would have to be very limited, according to the research. If you have one site, suppose you have a full mouth of 4 to 6 millimeter pockets and then you have an 8 on a maxillary incisor and you're trying to avoid surgery there, I think that's a great idea to place Arestin there. To place Arestin in 6 or 8 or 10 or 12 sites as part of full mouth scaling and root planing, there's no evidence to use it and it's maybe overdone in those cases.

Howard:

What do you say to people who said, "Instead of using Arestin, wouldn't it be cheaper just to write them a script of antibiotics and put them on, say, tetracycline?" What would you say about that?

David:

I'd say you're right. It probably wouldn't be tetracycline, but yes, to use systemic antibiotics, especially in the more severe, aggressive cases, you definitely get a boost in the effectiveness and it's way cheaper and it's got a lot more evidence behind it than Arestin in multiple sites. Yes, I think not necessarily for the average moderate case of periodontal disease with 4 to 6 millimeter pockets, but in the patients who are young with a lot of severe pockets, vertical defects, systemic antibiotics are definitely indicated, yes.

Howard:

Back in the day, they always wanted tetracycline, because it showed up in crevicular fluid so much more than other antibiotics. Is that still not the recommended advice?

David:

It does show up, but it's not as effective against all the microbes that seem to be pathogenic for periodontal disease. The 2 regimens that are supported, the first is a combination of amoxicillin and metronidazole. That is maybe the best supported and the most effective. The issue with metronidazole, as you know, if you have a beer, you're going to be in the emergency room from really severe nausea. Metronidazole is like super Antabuse.

I used that for a year or 2, but my patients, even when I warned them, would forget on a Friday night, they'd go have a pizza and a beer and at 10:00, I'd be hearing from the emergency room that they were having uncontrollable nausea and vomiting. I'm really careful with prescribing that now. I tend to use either Zithromax or clindamycin instead, to go along with our quadrant scaling and root planing. We put people on it for 2 weeks and we get all their scaling and root planing done in the first 2 or 3 or 4 days of those 2 weeks.

Howard:

If I heard you correctly, I can just paraphrase it, "Don't use metronidazole on Irish or Russians"? Did I get that right?

David:

That's right.

Howard:

Not to be mixed with Jameson Whiskey and vodka.

David:

No.

Howard:

That's funny when you said that, because I cringed when you said amoxicillan and metronidazole. Do you know what I always think of when I hear that?

David:

What?

Howard:

I took all 4 of my boys to Cozumel and we all went scuba diving. We all came back and the diarrhea wouldn't stop. Finally, you know what we had to do? I can't believe I'm saying this on podcast. The doctor made us go to the grocery store and get 6 containers of "Cool Whip" whipped cream for the container and then empty it out.

Then, we all had to do our business in that and then we had to package them up and then ship them to a lab in, I forgot where it was, Minnesota. I think Mayo Clinic used it. They came back and said, "Yeah, you guys got a parasite," and they put us all on amoxicillin and metronidazole for 10 days. My God. You go down there and you drink bottled water, but that's not the issue. The issue is the salads, the fruits, the like.

David:

Salads, yep, been there.

Howard:

[crosstalk 00:47:13].

David:

I didn't have to box up my feces like you, but otherwise similar story, yep.

Howard:

Next topic, selection of implant diameter and length, success rates with short implants, Straumann implants. You and I will agree that, back in the day, the goal was the longest implant known to man and now people are coming out with shorter, fatter implants and saying that it's not the crown to root length, it's the crown to root surface area. What is your thoughts?

David:

First of all, as several contributors to Dentaltown have indicated, most of the stress from implants is distributed right at the ridge. Having a longer implant doesn't seem to really have that much effect on stress distribution. Yeah, back in the 80's and 90's, I placed a lot of 16 millimeter implants. Maybe I wish I had some of those back now.

As they've done more and more research, the length minimum seems to be dropping. At this point, it seems for sure the 8 millimeter implants are just as successful as any longer implants and probably 6s also. The research is newer and it's mostly been done on Straumann implants.

Straumann 6 millimeter implants have a success rate just as high as any other length. The other manufacturers don't have as much data. If we assume that they're similar, we can assume that 6s are great for any system, but right now, it's just Straumann. Incidentally, we don't use that many Straumann implants, so I'm not really sure where to take that.

As far as diameter, wider diameter implants have a somewhat higher failure rate. The reason is probably because of encroachment on the buccal plate. Again, back in the day, I used to place a lot of short 6-millimeter-wide implants. Some of those lost some buccal bone and now I can see a little bit of the abutment, God forbid, even some threads, on 10, 15-year-old implants.

Currently, the best guide is to make your implant probably a minimum of 6 millimeters long, a minimum of 3 millimeters wide, and probably a maximum of 5 millimeters wide. I'd say 3 to 4 is the sweet spot, in terms of success rate. Even if they're short, you don't necessarily have to go with wide. The theory about increasing surface area is probably not supported that strongly by science.

Howard:

Wow, that was a lot of information.

David:

I had to breathe there at the end, sorry about that.

Howard:

That was a lot in there. I almost think you should go and paraphrase it. My first [inaudible 00:49:47], Straumann, that's out of Sweden?

David:

Yeah, is it Sweden? I know it's Europe.

Howard:

Sweden or Switzerland.

David:

Yeah, I'm not sure which.

Howard:

Okay, but they have the most research on this?

David:

It's Switzerland.

Howard:

It's Switzerland?

David:

Yeah. Straumann, they do a lot of clinical research. When it comes to treating peri-implantitis, success rates, short implants, long-term studies, Straumann is very strong. Of course, you have to pay for that when you buy their implants, but they do have a lot of research.

Howard:

They own other brands, too, don't they, or they're investing in other brands? They invested in Megagen right now, out of Korea, correct?

David:

I think so, yes. I can't keep track of all of the marriages and divorces in the implant manufacturing community. They're interesting.

Howard:

The information I heard is that one of the reasons they bought into Megagen is because the neat thing about Megagen is the founder of Megagen has one of the largest dental clinics ever and it's in downtown Korea. When they modify an implant design, they can go from modifying, to making, to placing 1,000 of them in a week, just massively assembly-lined research.

David:

That's a big plus if they don't have to go through a lot of bureaucratic paperwork and retooling and all that.

Howard:

Yeah, if you design the implant, you make it, and you have a dental clinic that can place 1,000 of them in a week, they've just shortened the concept to manufacturing overnight. Okay, implant placement in the perio patient. Now, I want to be selfish and ask this in my walnut brain for me first, to me, I'm getting confused because streptococcus mutans eats teeth and P. gingivalis cause gum disease.

We know these 2 bugs are coming from your mother when they do DNA testing, but when you have a newborn baby and you kiss it, there's no anaerobic place for this bug to live. If you give it an anaerobic, it doesn't have anywhere to live. As soon as a tooth pops through, then the mother can give you streptococcus mutans and P. gingivalis, because there's an anaerobic environment to live.

Then, doesn't it make sense that it would be more successful for preventing peri-implantitis that if someone's got a full mouth of gum disease to first pull all the teeth and put them in a denture and let all the P. gingivalis die and then place the implants? Wouldn't that be smarter? Is it most peri-implantitis when you place a single implant in a person that already has 4 and 5 and 6 millimeter pockets all over the rest of the mouth?

David:

Yeah, those are 2 great questions. My first answer would be you can refer us all your full edentulous patients and we'll take all their teeth out and put in all-on-4s everywhere. We'll send you the plane tickets. As far as eradicating the flora before you put in implants, there is some logic to that. The flora may not totally depend on teeth. The tonsillar crypts, the base and the rear of the tongue, there are other places in the mouth that these pathogens can hide out. Totally eliminating the teeth may not totally eliminate the reservoir of P. gingivalis. I'm not so sure about strepp mutans, because I'm more of a gum guy. I'm more aware of the pathogens for periodontal disease.

Even with people with no teeth, it's possible if they have their tonsils especially, that they may still be harboring pathogens. We see people with no teeth and 8, 10, 15 implants with peri-implantitis. That's coming from somewhere. I'm not sure that totally eradicating the teeth is the best idea. On the other hand, if you have 3 or 4 teeth left in someone's mouth, I agree, take them out and start from scratch with the implants.

As far as peri-implantitis in patients with periodontal disease, yeah, you're right, someone with 4 to 6 millimeter pockets should not be getting an implant. I know the incentive for the patient to want their tooth and for the dentist to want to restore it is there, but in terms of long-term risk, you should treat their periodontal disease first. There's plenty of research on that. That's another major risk factor for peri-implantitis, is placing an implant in a patient without treating their periodontal disease and without maintaining them.

Howard:

The reason you like chlorhexidine gluconate is because the chlorhexidine gluconate is a sticky oil, you called it "substantiveness"?

David:

Yes.

Howard:

Whereas, an alcohol-based Listerine is just going to rinse right off? You like the oily chlorhexidine gluconate. I want you to address another controversy, hygienists are always asking this. Some are taught that when there's peri-implantitis, you can't touch that with a metal scaler, because you're going to scratch it and that's going to be a big problem.

Then, their doctors might buy them some plastic instruments and the hygienists are saying, "Are you kidding me? This big bulky thing, it's just stupid." Then, other people are saying, "My dentist bought a very expensive diode laser. For peri-implantitis, I just take the diode laser." How should you clean? What do you on a 3-month recall when they've got number 3 peri-implantitis?

David:

Yeah, if they've got an implant and it's just a normal maintenance situation, we think plastic or metal curettes are both fine. If you've maintained an implant, if there's any calculus, it flakes off. You're talking about generally a smooth surface on the abutment. If you're needing to instrument the threads, you're already in trouble.

In a healthy situation, pretty much any instrument used judicially may put some micro scratches on the abutment. There's no evidence that that increases the risk of implant failure. I would say metal curettes are fine. You don't need to go crazy with them, you're just abrading the sulcus and flicking out any of that white super gingival calculus you see and that's it. I don't think that the instrument choice makes that much difference. You should not go too crazy with instrumenting.

If you're down on the body of the implant root planing, you're in trouble no matter what instrument you use. Now, you have peri-implantitis and you need to either get some bone grown back or you need to do pocket reduction or somehow treat that. The general preventive protocol, any instrument you want to use gently is fine. Using a diode laser is fine. It may be a little bit of overkill. Really, there's not that much accretion on a healthy implant or an abutment.

Howard:

Well said. Then, continue, implant placement in the perio patient. You're saying they got to go through the whole perio treatment and get that completely under control the best you can?

David:

Yes, if you want the best prognosis, otherwise, you're going to be raising the risk of peri-implantitis and some failing situation. They've done research now extending up to 10 years. They're finding 15 percent of those patients have serious peri-implantitis defects within 10 years. That's a lot. If I had a tooth with a 15 percent chance of serious periodontal disease in 10 years, I would be concerned, so yeah, we try to minimize risk.

Now that implants are a maturing industry and our patients have implants for 5, 10, 20 years, we're now seeing how naïve we we were thinking that implants were immune to some of the problems that teeth have. You need to consider the entire periodontal status of your implant patients.

Howard:

My oldest sister, who's a cloistered Carmelite monk, always reminds me that when you study all the major religions, they only have 1 thing in common. There's not a city, a person, a place, nothing in common except for 1 sentence, "Treat other people like you want to be treated."

I always had a red flag during the cosmetic revolution and all these dentists were becoming cosmetic dentists doing veneers, because their own daughter, like your Amy, they would put them in braces and bleaching. Then, if it wasn't their daughter, they'd shave down 10 teeth and do veneers.

I always noticed these dentists, you'd say, "That tooth, that's crazy. It'd be better to pull it and do an implant." Then, when doc's tooth is in the same situation, he goes and gets a root canal and crown lengthening and he walks from here to China to save his tooth. If it was his patient, he'd first just rip it out and place an implant.

That is so troublesome for these young dentists. Talk to these young dentists coming out of school. They're looking at an x-ray and it's a failing root canal. Their mind's saying, "I bet the person who tried to do the root canal was a good doctor and it didn't work. Do we really want to try it again? Should we pull the tooth and do an implant, is that better?"

That's an endo question. You're a perio question. What are we supposed to think when it's a lower molar and they're starting to get furcation involvement? When do you say, "Treat the furcation," versus, "Hell no, just pull the tooth and place an implant"? Then, it gets crazy on the upper molars, because now you got 3 roots and a trifurcation. Will you talk about diagnosing and treatment planning, when to treat with forceps and when to treat with a periodontist?

David:

That's a really hard question and I don't think we have time, but I'll try to make it quick.

Howard:

Okay, that's your second online CE course.

David:

This would be an hour.

Howard:

You should do that, because that's one of the most common questions.

David:

It is a very difficult question. To back up a little bit, when you said, for example, you need a root canal and a crown, why not just pull it out and put in an implant? Back maybe 10 years ago when we were a little more implant crazy, that was typically what I would tell patients, "If you need a crown lengthening procedure, a root canal, a post and core, and a crown, I think your prognosis would be better with an implant."

Turns out, that's not true. If you have a tooth that needs a root canal for the first time and a post and core and a crown lengthening and a crown, the success rate for that procedure is equal to or higher than the long-term success rate for an implant. Now, this depends on many factors, parafunction, whether the person has periodontal disease, whether they have a high rate of recurrent decay, things that are going to effect the overall algorithm. I think that we're seeing the pendulum is going to slowly swing back towards saving teeth, rather than putting implants in. That's for a tooth that's never had a root canal before.

If it's had a root canal that's failing, which was your second example, the success rate for retreating root canal teeth is significantly lower than the first root canal. Even though I'm not an endodontist, since I place implants, I have to know some of this stuff because we have to decide what to do with failing teeth. I would say if you have a second root canal, apicoectomy necessary, I would learn toward an implant, because the failure rate is just so high with retreating endontically-treated teeth.

In the first case, I might lean towards saving the tooth. In the second case where you're retreating, I would lean toward an implant, based on the success rates 10, 20 years down the road with the root canal, endodontic studies versus the implant studies.

As far as a furcated tooth, if it's a class 1 furca, those can be maintained with some reshaping of the furca, pocket reduction surgery. If it's a class 2 or a class 3, if there's a lot of bone still left around the tooth, I would probably tend to maintain that tooth. If it's developing symptoms, abscessing, any root caries, then it would be an implant.

Teeth with a lot of surrounding bone with just an isolated furcation defect, you might be able to maintain those teeth 5, 10, 15 years. If the patient's on good recall and you start seeing more loss and you're worried about having enough bone for the implant, then take it out. That was a long answer, I'm sorry. I'm pretty wordy today.

Howard:

That was like listening to an opera. I love that. You've gone on a couple of opera rants that I fell in love with.

David:

[inaudible 01:01:47].

Howard:

You did open up another can of worms, because you said "root surface decay." I have to tell you, I've been a dentist 28 years. I'm in Phoenix, which is a big retirement area. I'll tell you what, I think the 4,000 pound elephant in the room that no one ever talks about is what root surface decay does to 80, 90-year-old women.

Now, I shouldn't care because I'm a man and men never live long enough to get root surface decay, it's always women. There's a dozen nursing homes around here I go into and most gerontologists say that when a woman goes into a US nursing home, she'll get 1 root surface cavity every month she's in the nursing home. When your mom has been in there for a year, she's got 12. It seems like no matter how you treat it, it doesn't even last a year. What are your thoughts on root surface decay? Is that another chlorhexidine answer or are they the fluoride mouth rinse? What do you think?

David:

Yeah, you've made this point several times and it's an excellent point. When we're dealing with an aging population, especially if they're in some type of care facility which is not going to really be that attentive to their dental needs, that's a huge issue.

To see someone in their 80's who's, more or less, starving to death because of loss of function, they're eating blender food, they lose interest in eating, they start losing weight, and it's a predisposing factor to actually dying because of loss of function, your point is excellent.

Root decay is almost unmanageable once you get into an older population. Loss of saliva flow, maybe they've lost their immunoglobulin function, whatever it is, and no one's brushing their teeth for them, it can be a disaster. I've actually started talking to my patients about this, because of what you said on your podcast. You want to think about what life is going to be like for you in another 20 years. Do you want to be worrying about root decay, losing teeth or do you want to have something that's stable?

I think in those cases, I would lean toward an implant, as opposed to saving a tooth in a patient with caries risk, for sure. Another thing, if they have caries risk, they may have other problems with their immune function and they may lose their implant, too. It's a difficult decision in those patients, but titanium doesn't decay, for sure.

Just to beat a little bit of a dead horse, if we go back, in those patients, if they've got class 5 lesions, I'd rather cover those up with tissue. They might recede a millimeter or 2 over 10, 20 years, but the likelihood of root decay is going to be way less than if they've got a 6 millimeter dehiscence and you're chasing that down with your class 5 every 3 or 4 years. Again, to get a connective tissue graft in there might be worth thinking about, but that's going backwards a little bit.

Howard:

I'll never get root surface decay, because all 4 of my boys have promised that as soon as I can't recognize them or know their name, that they'd take me to the vet and just have me put down.

David:

I'm getting there. Can I ask you a question? What do you tell a patient who's missing number 7 and they want an implant and they've got gum disease and they don't care about their gum disease and they just want their tooth? They're sitting in your chair saying, "Give me my implant and my crown. I don't want to do root planing. I don't believe you, my gums don't hurt. Give me it," what's your answer? How do you deal with them?

Howard:

I deal with the fact that I see the 7.3 billion people living on the surface of this rock as talking monkeys. It's like the patient who refuses x-rays. I could be dogmatic and I could kick them out and excommunicate them from the church or I could sit there and think, "I need to give." I want to build relationships, not teeth. I'm not there to build fillings and crowns. I'm trying to build relationships.

I've been here for 28 years and I have people that got 6 month planings for 5 years before I finally talked them in to gum therapy, periodontal surgery, et cetera. I try to build relationships and I try not to be dogmatic and I try to earn their trust. It's a long-term situation. At the end of the day, what percent would you say of Americans are completely insane?

David:

It's way more than 50 percent.

Howard:

Yeah, they're talking monkeys and I love them. Also, I have no problem with them because if you ever went to a Farran family reunion, you would think the CDC would be there sterilizing everybody. The craziest monkeys I ever met was at a Farran family reunion. End of story, build relationships, not teeth.

David:

Yes.

Howard:

That's another controversy on Dentaltown. Some people are so dogmatic, they won't place an implant on a smoker. At the end of World War 2, half of American adults smoked and now it's down to 18 percent. 18 percent is almost 20, that's almost 1 out of 5. You can't have a dental profession that tells 1 in 5 Americans, "Sorry, you're not good enough." They need help. Like Carl Misch was saying, he'll do it, but his brother Craig won't.

I think most of the people I know, as they get older, look how much easier people are on their 4 child versus their first. My mom, me and my 2 older sisters, was like Joseph Stalin. Then, my little brother who was born 17 years after me, he could've done anything he wanted to on Earth. We all mellow out. Choice of bone graft materials?

David:

Yeah, I covered that a little bit. I think, generally, we lean toward Bio-Oss. If you want a graft around implant to use, FDBA, that's fine. There are a lot of other allograft, xenograft manufacturers.

Howard:

What I wanted you to add on that is there's some people who believe that you should be drawing blood and spinning blood. There's other people saying, "I've never done that. I don't see a need for it." When you're bone grafting, what do you think about drawing blood?

David:

Using PRP, we do not currently do that.

Howard:

Explain what PRP is. A lot of kids won't know what you mean.

David:

It's you draw blood, you spin the blood down, and you're taking out platelets and enriched plasma and injecting that into whatever site you're injecting it into. It's got some initial evidence that it works well. There sure are a lot of case reports that it works well, including on Dentaltown. It doesn't have any evidence that it works better than bone grafts. I think it's operator choice in this case. Whether you need to use it in addition to your grafting material, there's no evidence for that currently. We are currently not doing it.

Howard:

Okay, I want you to talk about the periodontist/general dentist relationship. The general dentists, they all know their world. I want you to talk. There's 125,000 general dentists, there's only 5,000 periodontists. I want you to talk about the other side of the paradigm. When someone has periodontal disease, do you like to see them twice a year at the general dentist office and then alternating twice a year at the periodontist's office? Do you prefer to have them every 3 months in your office? Do you think there's better success if they got all their recalls under the supervision of a periodontist? Talk about the referral relationship.

David:

Sure, 2 things. First of all, we're big advocates of general practices doing their own scaling and root planing. In the few cases where practices don't like that, we're happy to do it. We think that for most practices, the general approach to the average periodontal patient is to do 4 quadrant scaling and root planing with local anesthesia. Again, if you like LANAP, that's fine, but somehow to take that on initially in your office.

If you have someone with other problems like diabetes, immunosuppression, or someone who's very young with severe disease, they might want to be referred sooner, so that we could do the scaling and root planing and probably go to surgery. For us, it's difficult to get patients who've had scaling and root planing and the next step is surgery. We have a half-hour consultation to build rapport, convince them to do the surgery, spend the money, blah, blah, blah. It's nice if we can get to know our patients before we do the surgery. They'll be more compliant, it'll give us an idea of who we're dealing with.

Even still having said that, for the average periodontal patient, we think the general practice should do the scaling and root planing. They're your patient, you need to get to know them. Then, when you send them to us, if you need to, you can tell us what the background is, "This is a compliant patient, phobic patient," whatever the details are. That's part 1.

Part 2, if someone comes to us and they've had general periodontal surgery, 2, 3, 4 quadrants, they're at risk for life for more recurrent disease, so we would like to alternate their recalls with the general practice. We never want to do all the recalls here, for many reasons. We'd prefer, ideally, alternating every 3 to 4 months for the perio patient.

There's research that shows those patients have the best long-term prognosis, whether it's because they're compliant people and they're flossing and brushing and coming in every 3 months. I think that's the reason, as opposed to the periodontist does a, quote, "better maintenance procedure." It's just that coming in every 3 months seems to give you a better prognosis, alternating.

Howard:

I want to say something to the young kids out there who, every time they see "gum disease," they always think it's a behavioral deal and they're judgmental, the person's not brushing, flossing. I have a very close friend, she's a hygienist, about 5 years older than me. She's a hygienist, she's done everything right her entire life and she's been plagued by periodontal disease.

One time, she lost a tooth and she was just crying. She was telling me how she does everything right and I said, "This isn't judgmental. You've done everything right. Hell, you're a registered dental hygienist, but I didn't lose my hair because I didn't use the right conditioner or shampoo or wasn't bathing properly," even though all those are true. You can just have gum disease because of your immune system, right? You can do everything right and still have all the wrong outcomes.

David:

Absolutely, you can have a lot of genetic predispositions that will give you problems, no matter how hard you fight. You should still fight, but absolutely. By the way, that touches a little bit on an issue that periodontists and general dentists have, some people in our profession are critical of general dentists for not making the referrals sooner, but some patients do fall apart fast. Some patients do take 5 years to accept the referral. I think it's really important for specialists to not pass judgment on the referrer for whenever the patient came over.

A lot of times, in fact almost all the time, it's not on the referrer, it's something about the patient, whether their risk factors predisposed them, whether they weren't listening, whatever it is. I think it's a problem periodontists have built for ourselves to be critical of the referring doctor for not getting patients to us sooner. Your hygienist friend is a great example. If they came to our office, we might think, "Hey, where have they been for the last 10 years?" The reality is, they're just predisposed to periodontal disease no matter where they went.

Howard:

I think the whole judgmental thing, I don't care if you're talking about religion, politics, whatever, is all that, because once you start sounding judgmental to the patient, you're not going to motivate them. I look back at kids, you see they excelled in one high school sport and not another. It's almost never related to natural ability, it's usually motivated to the natural attraction of the coach. Some coach connected with them and convinced them to join the swim team, the wrestling team, the volleyball team. With the exception of basketball, where it really helps to have a 6-foot-4 mother and I had a little short, fat Irish mother. If you connect with your patient as a friend and a coach and there to help you and not the judgmental, talk down, make them feel bad, that's just got to go.

David:

Yeah, absolutely.

Howard:

We're not teachers.

David:

If your patient doesn't come back, it doesn't matter how good you are. That's right.

Howard:

Exactly. Now, the next topic I'm going to ask you about is something I have not been able to figure out in 28 years. It's about crown lengthening. It seems like, and I don't have data to back this up, but I personally feel that 10 percent of the dentists in America are doing 80 percent of the crown lengthening and that half the dentists in America have never done one 1 time. Do you agree with that or not?

David:

Yes, we see it in our referring patterns where some dentists, it seems like they're referring every crown to us for crown lengthening. Then, other practices, never, or we might see one after the fact, where the crown's been cemented and the gingiva's inflamed and it's clearly a biologic width violation.

Howard:

Okay, I want you to slow down, Spanky, on crown lengthening and talk to someone who doesn't even know the concept. I seriously think sometimes when I'm at the bar with some of my buddies, I don't even think they get it. What is crown lengthening? When is it indicated? Try to explain it slow enough so that we can maybe close the gap between half the dentists never done one and 10 percent do them all the time. The truth's probably in the middle somewhere.

David:

Probably, yeah. To simplify, first of all, if you're doing a crowning, you're taking an impression. You want to be able to see your impression. You don't want the tissue to be bleeding and you want to have enough clinical crown for retention. Those 3 things, I don't think take a really high IQ to get. You want to see, you don't want blood, and you want a long enough crown for retention. If you don't have those 3 things, think about crown lengthening. Whether it involves just using your in-office laser to trim a little tissue or whether it involves a flap with bony resection, that's a clinical judgment, number 1.

Number 2, generally you need soft tissue in between your crown margin and the bone. If you don't have enough room for that soft tissue, the body will make it. The body makes it by an inflammatory process that a lot of times hurts, sometimes causes the bone to get eaten away to the point where it just doesn't stop. Then, you wind up with gum disease and it threatens the tooth.

How much distance do you need between your crown margin and the bone? It's different for different people. Everyone says that there's a biologic width of approximately 2 millimeters. That's an average. Some people can get away with 1 millimeter between the margin and the bone, some people need 3 or even more.

In those cases where your margin is deep and you're worried about maybe causing this process, put a temporary in. If you have to leave it for a couple months, see what the tissue reaction is like. If you get away with it, you might be able to not do the crown lengthening. Again, as long as you have access, no bleeding, long enough clinical crown.

If you put the temporary in, it's sensitive, the gums turn red. You take a PA 3 months later and there's a little angular defect in the bone, you need crown lengthening. That's how I would look at it if you're a middle of the road dentist who's trying to save your patients a trip to the periodontist.

If you're really meticulous, type A, you want everything to be perfect all the time, anytime you get a subgingival margin, that person's going to be a candidate for crown lengthening. That's the 10 percent that you're talking about who are doing so much of the crown lengthening. That's how I would try to explain it.

Howard:

I want you to continue explaining it with regard to the ferrule. A lot of people think that, "If I cement this with this super glue cement with 27 megapascals, this will work." I still believe in the ferrule, that you have to have 3 millimeters of natural tooth structure all the way around. If you don't have 3 millimeters of tooth structure all the way around, I don't care if you did a root canal and stuck a post. I don't care if you used some super cement. If you don't have 3 millimeters all around, the crown ain't staying on. Do you agree or do you think that's not true?

David:

I think that's the best approach if you want to be safe. You can sometimes get away with not following that standard, yes. You'll see cases on Dentaltown where people prepare and they leave their margins on amalgam or on composite. They show the PA, 12 years later, everything's fine, but if you're looking for predictability, you need a ferrule to retain your crown. Yes, I agree.

Howard:

Just in case someone missed that, what is a ferrule?

David:

A ferrule is the area of tooth structure where you have your prep and your margin. Whether you use a chamfer or a bevel edge, it's the part of the tooth structure where your crown is going to achieve its adhesion. It's natural tooth structure, starting from the margin and coming up to wherever your restorative material is or the end of your margin prep. That's the closest I can come. I haven't made a ferrule for 30 years, so that's a challenge for me. I've reshaped teeth biologic with biologic shaping, but I don't actually re-prep them.

Howard:

Do you have any tips on how to manage or avoid the black triangle?

David:

Yes, I do, but no guarantees. If I could invent 1 thing as a periodontist, I would invent that procedure. There is no surgical procedure that predictably grows back papillae. Predictably, you can even leave that out. There's no procedure that grows back papillae. What do you do? You can orthodontically reposition the teeth so that if you have teeth that are divergent, you can bring the roots convergent and maybe somehow get the teeth closer together and squeeze the papilla so it will regrow. That's one option.

You can use restorative material. Again, you want your contact to be 5 millimeters or less from the alveolar crest. You give the patient a little local, you stab with your periodontal probe from the height of the papilla, or from the contact point rather, to the bone and measure. If it's more than 5 millimeters, you need to reshape the teeth somehow to get the contact closer than 5 millimeters. That will encourage the papilla to regrow. When you restore a tooth, if you don't have less than 5 millimeters, you're looking for trouble with regard to loss of the papilla.

There are restorative and orthodontic approaches to this. The last option would be to inject a filler, like Juvederm, which will get you a papilla for 6 months and you just have to keep redoing it. If someone's getting married and they want to look good in a month and you can't think of anything to do quickly, go get somebody in your area to inject the papilla. We don't do that here, but there are people who do.

Howard:

What I do is, if they're about to get married, I just pull that front tooth so hopefully they won't get married and they'll save millions of dollars. I try to help them all do that. If you are [inaudible 01:20:50] a crown and there is a black triangle, what I always do is, when you hand them the mirror, turn off the operatory light, and that really-

David:

Okay, that's a good point.

Howard:

Okay, flap versus punch technique for implant placement and flap design. It's your last question.

David:

Okay, sounds good. The punch technique is wonderful if you're trying to preserve papillae, if you're scared of flaps, which if you are, I'm not sure why you'd be doing implants. The punch technique is good for preserving papillae in the esthetic zone if you are really clear on exactly what the anatomy is like. It would be a cone-beam, maybe a guided case, and you can do the punch technique.

Otherwise, the flap technique is probably preferable, because you could determine bony irregularities, recontour them as needed. You can verify that there are no buccal undercuts in certain areas. Generally, the flap technique is what we recommend, trying to preserve papillaes with the flap, but not always possible. The punch technique is great if you have 1 tooth missing and you've got papillae on either side and you're trying to avoid elevating the flap there.

Howard:

Okay, now I'm going to ask the really last question. If you don't like the question, Ryan can edit it out, and we don't have to discuss it. I want to ask you a very personal question. Your daughter is a dentist and she works with you.

David:

Yes.

Howard:

When you go into dental schools, and I've been doing this for 20 years, you say, "Raise your hand if someone in your family, a mom, a dad, a uncle [Eddie 01:22:22] is a dentist," and a third of the hands go up. Any advice, father/daughter, father/son, to the young kids listening who are working with their old man or any advice to the old men who are bringing their daughter or child? I'm sure a guy like you really thought about everything that could go right or wrong and you're a healthy, functional guy and you've stayed married for a long time. Any advice on when your child's working with you from both sides of the coin?

David:

The biggest advice I would give if your child is working with you is that this practice is your child's practice. It's not your practice anymore. They're the future, I am not the future. I hope I'm here for 10, 15 more years, but no matter how long I'm here for, my daughter is the future of this practice. The decisions need to come from both of us, but they need to be in her favor.

That's the thing, to get the older person's ego out of it and to become this, I don't want to say the "servant," but subservient to the younger person. You can mentor them, you can see your patients, but in the end, it's their practice. That would be my biggest piece of advice if you're together with someone. It's kind of like your marriage.

Howard:

What would your wife say? Do you and Amy ever have something going on where Amy runs to mom or you go to your wife and say, "Talk to your daughter"? Does it affect the other relationships in the family? You have 2 other children who aren't in the practice and you have a wife that lives with you. Does it affect their relationships?

David:

You have to be really open about your relationships with all of them. They understand that I'm going to have a closer relationship with Amy in some ways, but I hopefully don't bias my feelings or my relationship just because I'm in a cubicle with her 8 hours a day.

Yes, we do talk about each other behind each other's back, like every other family, but it's only supposed to be for good things and not to get one up on some other person in the family. Yeah, I come home and gripe to my wife about Amy and she gripes to her husband about me. Then, I gripe to my wife with Amy, but it's all just griping. It's not meant to undercut.

Howard:

You know what's really cool about dentistry? I have spent the night in dentist homes in India and Brazil where there was 20 dentists in their family tree and 5 of them might be living in that exact house. Dentistry's a very nuclear family industry. Like I say, every country you go to, a third of the dentists have another dentist in their family. One of the greatest dentists that ever lived, [Kevin Coachman 01:24:55], I think he's 1 of 28 dentists in his immediate family.

David:

Wow.

Howard:

These issues are real. Someone some day should do a study and so some research on the family tree of dentistry, because it's really common.

David:

If you have a child who comes into business with you, like you and Ryan, what better thing can you have to think about what you've chosen for your life and that one of your kids want to do it? Whether it's tech or dentistry with you, it says something terrific about you and it says something cool about what you're doing.

Howard:

What it mostly says is Ryan made a really bad decision.

David:

Yeah? I don't think so.

Howard:

Hey, buddy, seriously, I'm your hugest fan. I love your posts. I love your love of research. I love your humbleness. I love everything about you. Amy's a very lucky girl. Dude, seriously, thank you so much for spending an hour-and-a-half with me today.

David:

Thanks for giving me your time. I appreciate it.

Howard:

All right, have a rocking good day, buddy.