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AUDIO - Rella Christensen - HSP #76
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"Today is going to be my favorite podcast of all time. You were so motivational to me, so inspirational to me!" -Howard
What is TRAC Research? Are sugar substitutes good, or bad? Why are dentures coming back? Listen now as Rella Christensen, RDH, PhD covers all these topics and more.
In 1960, Dr. Christensen received a Bachelor of Science in Dental Hygiene from the University of Southern California, and practiced dental hygiene for over 25 years. She co-founded Clinical Research Associates (CRA Foundation) in 1976, and for 27 years directed this well-known dental products testing institute. Subsequently she served as Chairman of its Board of Directors. Currently she is the team leader of a non-profit institute dedicated to in-depth and long-term clinical studies of restorative materials, preventive dentistry, and dental caries, known as Technologies in Restoratives And Caries Research (TRAC Research). She has presented over 1040 dental continuing education programs, totaling over 5200 hours, at U.S. and international locations.
3707 N. Canyon Road, Suite 6
Provo, UT 84604
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Today is going to be my favorite podcast of all time, I'm talking to a woman who needs zero introduction, Rella Christensen. I can still remember getting out of school in '87 and making the pilgrimage to Provo. I thought Gordon was great but if there was ever behind any successful man a successful woman, you are the bomb. You were so motivational to me, so inspirational to me. You probably, the first hour I met you, gave me more inspiration and motivation than all my teachers at UMKC after four years. Your wealth of knowledge is amazing. Rella, why I wanted to get you on here, you have a PhD in microbiology, is that right?
Rella : Actually Howard, my PhD is in physiology, with an emphasis on microbiology. The reason for that is we are studying the oral cavity. In the oral cavity, the microbiology is essentially natural flora. The interesting thing is how come we have pathology when we're struggling with the normal flora of a person's oral cavity. It's a combination of both physiology and microbiology.
Howard : I would say that microbiology is all over the news. You and I talked about it 25 years ago how just generally speaking, if someone has a lot of perio they don't seem to have a lot of decay. If they have a whole mouth full of decay they don't have a lot of perio. Back 25 years ago they literally were telling us in dental school that a vaccine was around the corner for streptococcus mutans and p gingivalis and those two diseases would be eliminated like measles, mumps and all those other polio and all that stuff. Rella, explain why 25 years later there's not a vaccine for strep and perio.
Rella : Well, I'll tell you. What we're finding with the work that we're doing is both periodontal disease and [inaudible 00:02:50] are really not due to any one specific microorganism, but quite a complex of one. When you go for a vaccine you generally target against a specific organism.
Howard : It's really not coming down to on organism is it?
Rella : It's not.
Howard : I was reading a paper yesterday that one reporter was saying how streptococcus mutans was massively working hand in hand with candidus, albicans yeast. Did you see that?
Rella : We haven't done a lot with the yeast yet, but one thing that we have been doing this past ten years is developing the procedures to study the organisms right within the pathology. We go right into the dental lesion and harvest the organisms and roll them up and sequence the DNA. We've done the same thing with periodontal disease and basically have found organisms that we in no way expected to see in these kinds of lesions.
Howard : From all your research, what is the low hanging fruit that you think all the podcast listeners, dentists and hygienists and everybody working in dentistry. What is the low hanging fruit from all this research that could be applied today. I'm going to throw a couple of hard balls at you that we're facing everyday. Rella, when I go into, I'm in Ahwatukee, it's actually Phoenix, Arizona, but everybody in my neighborhood calls themselves Ahwatukee. There's about a dozen nursing homes and when I go in there and I've talked to all my dentist friends, when you go into a nursing home, when a woman is in there, after about a year, year and a half, she's completely loss her lifetime of dental work to root service decay. I have gone in there several times and I have followed around, I have worked a shift with the helper, and it turned out they're always a CNA, so they have about one year's training. They are usually assigned a wing of about 22 rooms for 8 hours and that woman has got to feed the, bathe them, brush their teeth, floss teeth, so there's almost no home care.
if there is brushing they take a toothpaste, put a little pea sized dill of toothpaste and scrub the front teeth for two seconds, have them spit in a Dixie cup and it's done. I want you to address, we're seeing people talk about various gums and mouthwash and that sort of thing, is there anything from your microbiological knowledge that we can do better for senior citizens with root service decay since that is the fastest growing segment of the population.
Rella : Well I can make a suggestion, Howard, but you're going to not like it and that is to cut the added sugar to close to zero and that's one of the problems with our senior citizens is they have a lot of soft food that is highly sweetened because they have other problems with chewing and they have problems with their digestion and other things and the lack of hygiene together with very high sugar diets and no fluoride therapy definitely are going to lead to serious caries.
Howard : Rella, when you say sugar, is there any difference between sugar and high fructose corn syrup with these bacteria or is that zero difference?
Rella : No, it's really zero difference. We are talking here about granulated sugar from king beets, we're talking about honey, we're talking about high fructose corn syrup, it's all metabolized in the same type of way and what we really need to get rid of is added sugar, not the natural sugar in fruits and vegetables, but that which is in candies and donuts and cake and icing and various sugar sweetened drinks. This is why it is called added sugar.
Howard : As opposed to a naturally occurring sugar in an apple or an orange or a banana.
Rella : Where there would be nutrients, where there would be fiber, etc...
Howard : By the way, everything you, it's 10 o'clock here, and everything you've mentioned I've already eaten today and it's only 10 o'clock.
Rella : Great.
Howard : I think you hit all four of my food groups.
Rella : Didn't you say you hired a nutritionist to help you learn to cook?
Howard : I did. After I turned 50 I finally said, okay I'm a workaholic, I've got to change my ways. I hired two personal trainers. They trade off every day at five and I did it for a year. I did one Iron Man, then the second year another Iron Man. I went from 238 to 200 and that's when I realized, that rock bottom, that you can't outrun your mouth. You can have a great workout and then go eat a cheeseburger and you've negated it. Your buddy Mike Detola, who me and him went to all your courses, he told me the same thing. He goes, if you go on a 6 hour bike ride then eat a medium supreme pizza you might as well of just stayed in bed.
We did hire a nutritionist. Now she comes to the house and she's teaching and three of my four boys still live at home. She's been teaching us how to cook and she calls all the processed foods chemical shit shows and when we talk to her about reading labels she said to me, Howard you don't get it. If there is a label on it you shouldn't be eating it. There's no label on fish and vegetables and chicken and pork. She goes, anything that has a label on it you shouldn't be eating. I would ask you about...
Rella : You know what's interesting, Howard, is dental caries is probably the only disease that I know of where we try to moderate or even eliminate the disease and actually allow people to continue with the causative factors. No sugar, no caries.
Howard : It's just that simple?
Rella : Pretty simple.
Howard : What about carbohydrates? What about breads?
Rella : They are also
Howard : Explain...
Rella : What did your nutritionist tell you about that? You know I always like to say, shop the periphery if the store and don't even bother to go into the whole in the doughnut. If you shop the periphery of your grocery store you're going to be in fresh fruit and fresh vegetables. You've got your dairy, you've got your meats and you don't start to get into those things that you're nutritionist calls your labels until you enter into the center of your grocery store.
Howard : Explain what you just said, it's fermentables, when I said what about bread, like whole wheat bread. Is that decay or it's not a simple sugar, but you said it's fermentable. Explain what you meant by that.
Rella : The micro-organisms can use the components to ferment it and produce acid as a byproduct. Acid is able to then attack the enamel and start the caries process.
Howard : Bread has no added sugar but you're saying carbohydrates are adding to this...
Rella : Oh, now you haven't been baking bread have you, Howard?
Howard : No, I do not bake bread.
Rella : It depends on what kind of bread you're baking. It has either a small amount or it can have quite a large amount of sugar in it, but we also have other components that are fermentable in it that the organism will react with.
Howard : You said stop with the sugars, what carbohydrates also concern you in the American diet?
Rella : You know, I'm going to make it easy. I'm just going to stick to the added sugar because most Americans have so much of it. What's been really interesting is just this year, 2015, both the United Nations as well as the U.S. Government have finally spoken out about the amount of sugar and they tried to say to limit about 5% - 10% of the diet. 5% in most of the world, 10% in countries like the U.S. and England and other Europeans where high added sugar is used and I think we're starting to see a bit of a ground swell. Of course there is a huge counter swell. You've got the sugar association, you've got the soft drink industries, you've got the processed food industries, these are huge revenue producing industries in the U.S. and they're not going to sit quietly by when there is a movement to start limiting sugar. It's very similar to when there was a movement to limit cigarettes.
Howard : I find it just almost sickening that if one of the three fastest growing diseases on earth is diabetes, dental decay and obesity and yet our government subsidizes corn farmers to make high fructose corn syrup and I have personally witnessed several times when a young teenager had a choice between a bottle of water and a 64 ounce thirst guster at Circle K or 7/11 and you hear the two kids talking about it and they say, "oh I'll get a bottle of water", and they go, "well the coke's cheaper", and the kid is like, "you're right, the coke's bigger" so he could buy this little bottled water, probably 16 ounces and that was 89 cents and the big old monster thirstbuster was 69 cents.
Rella : I'll tell you what's unfortunate about it, Howard, is that is what's happening in the rest of the world. This has been going on for many years but into the less developed countries in the world, over large soda-pop, soft drink manufacturers and basically the people don't have pure water or they have wells where the water doesn't taste very good even though it's a well that has been dug and it may not be microbial contaminated, it isn't good tasting water so they're basically drinking soft drinks that are highly [inaudible 00:14:13] and they'll drink 4 or 5 or multiples, even in a day.
Howard : Yeah, when I was working in a orphanage in Tanzania and then we went over to Ethiopia and they were telling, you heard, health care professionals saying "Drink Coke because you don't want to get ecoli, you don't want to drink dirty water and get sick." I had a local dentist in Tanzania tell me "Don't drink water, I only drink Coke because I don't want to get sick."
Rella : This is happening all over the world and you see civilization essentially [inaudible 00:14:52]. I see the same companies that sell sodapops around the world often use bottled water too. Frankly, you could drink water in the US right out of the tap and how many people do it?
Howard : I drink it out of the garden house but then again I was born in Kansas. I do, I still drink water out of the garden hose when I'm in the back yard.
Rella : As long as the dog hasn't [bit 00:15:29] it.
Howard : I'm going to switch gears. Xylitol. You hear someone's talking about Xylitol. Lots of dental offices have a bowl of Xylitol in their front desk and say learn how to chew gum with Xylitol. Do you think Xylitol is having a significant impact on dental decay? Do you think the more Xylitol products you use, the less decay we'll have or is that a less than you hope for?
Rella : Xylitol has been promoted [tons 00:16:01] of ways. First of all it was promoted as an anticaries agent. It's also been promoted as a sugar substitute and I think as a sugar substitute it's valid. It's expensive but it's valid and a sugar substitute is an anticaries agent and we've been very disappointed in it.
Howard : So you like it as a sugar substitute because it's not going to be metabolized like a sugar for structuredized mutans.
Rella : It's not going to be in the [inaudible 00:16:33].
Howard : Do you like sugar substitutes as general? A lot of nutritionists do not like [Sparatamine 00:16:44]. They don't like these sugar substitutes. Do you like them in general or is this your favorite one out of all of them or talk more about that please.
Rella : Ideally you already know this and most people do, it's best to stick to the fresh fruit, fresh vegetable, water, a little bit of protein. Basically more and more is coming out about a number of different artificial sweeteners and some of the problems that are being caused metabolically now that people are having enough in order to start showing up and showing what they call a metabolic syndrome which is actually a cluster of [fractures 00:17:31] that inflame the heart diseases as well as type 2 diabetes. They've shown [cuffings 00:17:40] in mice that are disturbing about some of the sugar substitutes. I think it's the quantity more than the material itself. I know people that will consume diet sodas all day rather than eat. Women try to control their weight this way. Young girls in junior high, high school, that get conscious of their weight because they want to be attractive to boys and so on ... generally get on to these type of things because they fill their stomachs for a period of time and if you look at the amount that we're talking about, that's the problem.
I don't think these things in small amounts will be a problem but we're talking 3, 4, 5, 12 ounce cans a day that gets worrisome.
Howard : I have a bottled water here and I have my morning cup of coffee. Do you think -
Rella : It's quite a large cup but is that a 3 or 4 [inaudible 00:18:51] cup.
Howard : You're right, I don't know but that's a good question. How many cups do you think that is?
Rella : I don't know, it looked pretty big to me.
Howard : Do you think that's unhealthy?
Rella : It's a low PH, it's close to 3 and 3, 4, depending on some of the additives you would add to it as far as the cream ... sugar in your coffee that you drink. The straight black and how strong is it. The coffee is definitely a low PH drink.
Howard : Okay, I want to switch gears to a whole another topic. There seems to be a debate in the scientific community. We know if there was anything positive that came out of AIDS which was one of the worst epidemics ever, it was the entire planet knows that you can transmit diseases below the belt. When it was just syphilis and gonorrhea and things that could be treated by a shot of penicillin, it didn't have the impact it did when HIV came out and the whole world understands it. Then we move above the belt to the mouth and we're told that babies are born with [Straptacogus 00:20:04] Mutan or P [Gingivalus 00:20:08] or H human [Paplovirus 00:20:10] that can [inaudible 00:20:11] cancer and then you see a society where you bring home a new born baby and everybody starts kissing it on the mouth. My first question to you is ... obviously they're picking up these pathogens from somewhere.
I've read studies that 95% of it comes from their mother, blowing on their food. What do you think about the contagiousness of streptococcus mutans and P Gingivalus and Human Paplovirus.
Rella : It is a fact that an infant is born into the world with a sterile oral cavity and then they pick up the organisms from various objects and people whom they associate and babies are placed on the floor. Sometimes with or without a blanket, they put all kinds of things in their oral cavity. Probably one of the most dangerous things relative to kissing the babies is herpes. In the first two years of an infant's life, it's very susceptible to the herpes virus and a natural immunity is generally built up over the years but people that carry this don't realize they're actually shedding the virus ... period of many days before lesion will break out on the lips and they're also shedding that virus for several days after the lesion is gone. They can spread it to a child. As far as the other organisms is concerned, you're right, it needs to come from somewhere. Objects, people ...
Things that they eat, you start to realize that your food is not [crosstalk 00:22:04] organisms in it that they just don't happen to be pathogenic.
Howard : Tell me what you think of this argument that I've used with many patients and other dentists. Some people agree and some disagree. I will see a dentist and they will see the mom every 3 months for the last decade. She's on a three month [inaudible 00:22:28] because she has [peridontal 00:22:29] disease and she's in there every 3 months and you look at the chart and she's been doing this for a decade. Then I say "What's the husband look like?" "I've never seen the husband" and I'll say "What if you saw her every three months chlamydiae for a decade, wouldn't you eventually say maybe you're sleeping with someone with chlamydiae and we need to bring your husband in here and treat you both." When I tell a patient, "I can't treat you for gum disease and never have seen your husband because if I'm going to treat you every 3 months for [peridontal 00:23:01]" and then you're going to go home and kiss your husband every morning and every night, I'm fighting a losing battle.
Is that argument valid or do you think that's not valid?
Rella : That's a valid argument. Many years ago a fellow by the name of [inaudible 00:23:18] who was the dean of UCLA actually used micro-free rodents called [notobiotic 00:23:28] rodents and was able to demonstrate the transmisability of dental caries and [periodantal 00:23:35] disease organisms are also a transmittable from human to human which would qualify them as an infectious, transmissible, bacterial disease. Both of them.
Howard : Whenever I tell that to ... especially the mom, whenever I tell that to the mom she's like "Are you kidding me, I could still be getting this for my husband?" It's like absolutely and -
Rella : I'll bet she doesn't find that unbelievable, does she? You find [crosstalk 00:24:12]
Howard : Remember, I`m in Phoenix and I was born and raised in Kansas so I`m not a fancy person from the big city on the coast but I find it utterly shocking how 9 out of 10 people understand below the belt STDs and have never even thought once that would apply to their mouth which leads me to my next question. I`m going to throw you a curve ball. Here`s your trick question of the day. Do you think dentists are doctors.
Rella : Absolutely.
Howard : Then why is it that people are dying of oral and [feringial 00:24:49] cancer in my backyard in [Ouatokee 00:24:52], in Phoenix, in [Tempee 00:24:55], who have gone to the dentist every 6 months since they were a child and then they get oral and [feringial 00:25:01] cancer and the dentist never offered and [HPV 00:25:06] vaccine, never told the parent that there is an oral cancer that`s related to HPV and then if I try to give a HPV vaccine, my own Arizona State Board of Dental Examiners, won`t let me do that. I`ve read studies for you, I think I`ve heard it first from you decades ago that Americans see their dentists twice as often as they see their family physician but I can`t offer a flu shot to grandma and grandpa when they come in but if I go to Walgreens or CVC, a pharmacy tech, and I`ve asked the pharmacy tech, how many years of college did you go to and they're like "one year."
I went to college for 9 years. I can't give a flu vaccine, an HPV, and I'm starting to say when people say "Dentists aren't real doctors", I'm starting to say you're right. Either is Dr. Pepper and I can't give him a flu shot and at this point I don't even know what I am. What're your comments on that rant?
Rella : That's too bad because in the beginning, dentistry was a specialty of medicine and that was many years ago and that persisted in Europe and that still persists in many parts of the world today and some people who are very proud hundreds or so years ago when dentistry split off and had their own dental school, their own dental profession, their own dental boards and so on ... And in my personal opinion, I think both medicine and physician and a dentist are both doctors. Physician and a dentist, they're both doctors. They go through very similar basic science courses and then you branch out into your specialty, much like a physician might become an [optemologist 00:27:04]. Is an [optemologist 00:27:07] a physician?
Howard : Yes.
Rella : Is a dentist a physician? I believe it's a specialty of the health care profession that we call a physician.
Howard : I've heard at the dental museum in Baltimore, I think that's where the first dental school was ... They were saying they think they split off because one needed a bed and one needed a chair and it was something that silly that made the split and I think -
Rella : That is silly because go back to the [optemolgist 00:27:44], go back to an ENT person. There are many specialties of medicine you and I could think of if we took a moment that you don't necessarily a bed or you don't need to go to the hospital.
Howard : Do you think over the next century dentistry and MD should merge back into one training program. Do you think it would be a better idea, 100 years from now, that dentists was specially like ENT or dermatology or gynecology with under the MD umbrella. With all the oral health systemic data coming out?
Rella : I would love to see it but I can't see it happen. The politics of it are incredible.
Howard : That's true. Politics in America is the older you get the more cynical you become. I used to think when I was little that America was about truth, liberty, justice, the American way. Now I think America is about money is the answer, what's the question. It just seems like that's all it is, it just comes down to money. If you follow the money you'll figure out America in 8 seconds.
So what advice would you give ... Tell me this, I have heard over the decades that companies sell a streptococcus mutans culturing kit ... when they come out with that, the only place they'll ever sell them is Germany and Liechtenstein and Austria and there's no [sells 00:29:20] of this technology anywhere else. When I've lectured and been and visited to Germany and things like that, you talked to dentists and when a baby is in the womb, it's a ritual that anybody that's [inaudible 00:29:34] is come into the dentist, everybody's going to get checked, everybody's going to get fixed up and there's dentists over there that tell me that they have dozens and dozens of teenage kids in their practice that still test negative to streptococcus mutans. Is that really what they're doing? Is that something they're believing, is this what they're actually culturing, believing and if that's true, why has that not taken off in America?
Rella : I can't answer why it hasn't taken off in America but I think it has been established that there is a correlation between numbers in the oral cavity of [strep 00:30:18] mutans and it's the correlation with caries, streptococcus mutans is the larvae and in plaque. Interestingly we don't find a lot of [strep 00:30:31] mutans in the actual caries lesion when we get even into [inaudible 00:30:38] and once we're into [dentum 00:30:44] we do find [inaudible 00:30:44] but we find a lot of strange organisms that we're not used to talking about in dental [inaudible 00:30:52]. Organisms that are not talked about in a curriculum in the dentist school where we talk about [strep 00:31:07] mutans, [strep-sebrinus 00:31:09], [inaudible 00:31:11] and we've been working here in our research with humans ... we always work with humans where we have established a sterile environment and we harvest the organism right out of the lesion step by step. Cultivate those organisms and then [inaudible 00:31:41] the DNA in order to give them a genus and species name.
And we've been especially interested in [inaudible 00:31:53]. Because this is the debatable lesion. Should we be excavating it and if we don't excavate it, what should we do with it? A gaping hole in the tooth, I don't think anybody needs to debate whether that needs to be excavated and restored. But when it comes to [fissure 00:32:18] caries, just the little black line in [fissure 00:32:22] type of things, it could be just watch it, what happens to it. Are they viable organisms and that's been where we've been this past 10 years and I can tell you that is not a lesion where we find [strep 00:32:40] mutans which is very interesting to us.
Howard : You're talking about the picture behind your head I'm looking at right now. I'm looking at a [bicuspid 00:32:49] with a very dark -
Rella : Actually Howard I'm going to move over here and now I'm talking about that picture behind my head where only the fissures are dark. That is a very debatable lesion should it be excavated or not and I've got the [inaudible 00:33:11] with you. I don't have a yes or no answer to that but I can tell you this much. There are organisms in there that are viable and are worked with all these ... actually harvest them and cultivate them to prove that they're viable. To cultivate them both aerobically and anaerobically. And we know that they're viable and they're viable very deep into the tooth. Four and four and a half millimeters and five millimeters into the tooth but we don't know what to do with it yet. We're still busy cultivating and identifying organisms and trying to figure out what the heck is going on. That it isn't [strep 00:33:55] mutan. That much I can tell you.
Howard : To our listeners on iTunes, when we put up one of these podcasts after two or three months. We get a 1000 views on Dental Town, maybe 300 on Youtube but they're exploding on iTunes about 2000 an episode. What you're looking at if you listen to this radio, it's just a [bicuspidal 00:34:18] with just normal pits and fissures that are just brown to brownish yellow. She moved away from the one next to her where it was a [bicuspidal 00:34:26] black and -
Rella : Let me move and show you more of it.
Howard : Tell the listeners what you would say different about this because the pits and fissures are more black.
Rella : It isn't just that they're more black, I think there's glass over it and we're not really seeing this [inaudible 00:34:54] very well here but if you were you would be seeing this show-through stain where if a dentist saw that he would know there's a serious proximal lesion going under there as I look at my computer screen, it's not showing really well there but that is nothing questionable about the caries in that premoment compared to this one over here which is just in the pits and fissures.
Howard : If today if that person with that tooth behind you went to a dentist, 95% of dentists would nothing. It's a premolar so they wouldn't seal it, they wouldn't do anything, they'd just watch it.
Rella : They've been very carefully instructed to do that and I've got to be honest with you, I'm not sure what they should do today. All I can tell you is that lesion will look almost exactly like that for virtually years so it appears to be ... It has been called a non progressing lesion but I can tell you that there are organisms in it, they are viable. They go down many millimeters into the tooth, the lesion is progressing, but it is progressing hopefully instead of spreading out facial label or [inaudible 00:36:29] it's going into the tooth and clinically the lesion will look nonactive like it's not doing anything.
Howard : For 25 years, I've taken a [inaudible 00:36:46] and I blast all of that out.
Rella : Perfect, I love it.
Howard : Then I put some [crosstalk 00:36:51] and if it touches [deten 00:36:54] then it's a [inaudible 00:36:54] composite and I would tell you that the lesion behind you, the way I'd do it and I'm looking at 3 and a half to the [loops 00:37:01], it hits the deten every single time. In my office it's really a preventative restoration, it's built as a [inaudible 00:37:09] composite and you said that picture ... Often times you'll find them 4-5 millimeters down, I've never cleaned one of those out in my life that it wasn't into the [deten 00:37:18].
Rella : I agree with you and if you were to use [inaudible 00:37:24] with it you would immediately be able to determine if that person had [sustained 00:37:30] fissures. If it was a smoker or a heavy coffee or a tea drinker, those pits and fissures become stained because the pits and fissures, 100% of the time, are stuffed full of plaque. We never clean the pits and fissures even with [inaudible 00:37:52], you have to be fairly aggressive to remove all of the plaque and even then there would still be organisms deep down.
Howard : The truth of the matter is I've had my same assistance for 20 years, Janet, she hates the mess of [inaudible 00:38:10]. Do you like any of these lasers for cleaning those out because the pretense is that cleaning that out with a diamond [bur 00:38:19] is the fastest, easiest way that obviously it's more aggressive and you're removing more [inaudible 00:38:26] structure. Do you like any of these hard tissue lasers for cleaning out the tooth like that?
Rella : We've worked with [herbium 00:38:35] and CO2 and I prefer the [inaudible 00:38:39]. Bear in mind the [herbium 00:38:41] and the CO2 laser will also remove the enamel much like a fissure. We work on these from a research stand point, we use the grassular H1 [Bur 00:38:56] which I'm going to call it an 8th [round-bur 00:39:00]. You know what a quarter [round-bur 00:39:01] looks like. This is an 8th [round-bur 00:39:06] so you know it's very tiny and we're trying to harvest just the material that will have the microbrial infection and not a lot of the other surrounding material so that's the way I love to see them excavate it. I would [inaudible 00:39:26] and then with an [H1-Bur 00:39:33]. [Grassular 00:39:34] is the only one that I know of that sells those and I'll be honest with you Howard, I don't know who in the world uses them, they're so tiny that you only get a few rotations before you used up the cutting ability of the blades on the [bur 00:39:50].
Nevertheless they are available from [Grassular 00:39:53] and it's what we use exclusively in our work in order to attack the lesion at the very part and we'll use many of those [burs 00:40:06] in a lesion like that because we only allow a single cut and then we cultivate the [bur 00:40:15] and move to the next level. We're actually cultivating what you sucked down the sewer, the dust, and that's what we're culturing and retrieving the microbes from. [crosstalk 00:40:35]
The way a lesion is normally excavated, it leaves the prep contaminated 100% of the time and the reason for that is you use 1 or 2 rotary instruments for the entire excavation and you actually innoculate the ... what would be the sterile part to the tooth by running your [bur 00:41:07] across those [virgin 00:41:08] parts of the tooth.
Howard : What would be the remedy for that after you prepped the tooth. Would you recommend [inaudible 00:41:20] or something to clean it out?
Rella : We tried a number of things and the best we found has been ... it's been in the market for years, it's called [inaudible 00:41:32] sensitizer. It's a simple formulation of 5% [Gluteraldehide 00:41:39] and 35% [Hema 00:41:41]. You remember [Hemo 00:41:43] from your adhesives ... [hydroixethylmethacrive 00:41:47] is a wetting agent and it will help pull that disinfectant down into the [detonal 00:41:57] tubules. It was used that way originally in a product called [inaudible 00:42:02] that was marketed 20 years from now from the [Byer 00:42:11] company in Germany and it was a four bottle adhesive that clinicians liked ... The bottles had great big black numbers on them and you knew which bottle to use in which order.
Do you remember that? It was a market when you were a young dentist and that's written off into the sunset where most of our dental products go, I don't know what happens to them, they just all of a sudden gently ride over the mountain top and they're gone but basically that bottle 3 in that 4 bottle system remained don the market exactly the same as it was in the 4 bottle adhesive system. Only they regained [inaudible 00:42:57] desensitizer which was used around the world and still is today for desensitizing [inaudible 00:43:04] other restorations but the point of it is it's a powerful disinfectant and fixative and it was added originally to help to fix the dent in order to increase [bond 00:43:17] strengths.
Howard : You recommend cleaning off all your [inaudible 00:43:21]
Rella : I would.
Howard : What brand would you recommend?
Rella : There are a number of them out now since [Gluma 00:43:32] patent expired. There are several. [Danvil 00:43:36] has one, [Choice 00:43:41] has one, there are about 4 or 5 different products that have that very same formulation.
Howard : Interesting and Rella, what you are saying is that an interproximal cavity has different bacteria than a pit and fissure and there's different bacteria in a root surface so I assume a root surface decay is the same as [meth 00:44:06] decay.
Rella : I didn't actually say that but I'm going to tell you that is most likely true. You are going to find different organisms in different types of lesions. Particularly the ones that are large and open. There you are constantly taking in organisms from the surrounding plaque and saliva and various organisms that come into the oral cavity from foods and drinks and environmental ... people kissing and so on.
Howard : Would you say that [meth 00:44:44] decay and root surface decay are usually the same bacteria too?
Rella : Say that again?
Howard : Meth mouth decay and root surface decay, are those the same bacteria?
Rella : I'm not going to say that because I don't know that. We haven't worked with [meth 00:45:02] decay. The theory concerning methamphetamine decay is ... as saliva flow goes down and also people using meth generally are large consumers of soda pop because they have a dry mouth and sugar tastes good and there are several co-factors in the meth decay situation.
Howard : It's amazing how 28 years after I've been a dentist, dentures are coming back for two reasons. Meth and a continual flow of immigrants from south of the border. I know a lot of my friends, especially the ones in Bakersfield, where the first 10 years they practiced, they did not do a denture a month and now 25 years later, they're doing a denture a day.
Rella : Both of those is preventable. It's too bad. In fact all of them caries in my opinion is preventable. It's a man-made disease. It isn't something that has to be. It has to do with diet and oral hygiene and saliva flow. Those three factors are key in dental care. At least from what we've found these last 10 years.
Howard : Is it fair to say that dentists should not own cats because the bug was originally picked up from a cat in the fertile crescent about 15000 years ago. I read a paper on that where somebody said that streptococcus mutans first came to humans from a domestic animal and it was a cat. Is that a reason we should -
Rella : That's really interesting. What I'm wondering is how many dentists kiss their cats.
Howard : What do you mean when you talk about your TRAC research. What is TRAC research?
Rella : TRAC stands for Technologies in Restorative and Caries Research and in this past 10 years that's what we've focused on. I was the director of CRA or clinical research associates for 27 years and then we left for a period of 2 years to serve a religious mission and when we came back I had an opportunity to do the kind of work in microbiology that I was trained for in my PHD program and set up this lab devoted human research. That's what's unique about it. We had traveled all over the US carrying an aerobic and a aenrobic lab right with us. There were 2 to 3 of us that go at a time and work with [inaudible 00:47:58] and culture and harvest these organisms and then grow them back here and we work with a lab in the east to confirm all of our DNA sequencing. They receive an [alkoid 00:48:16] of everything that we're working with and we try to see if we can match in our results and we work with them, a restorative materials, we see it's a continuum, it starts with caries and it ends with restorative.
Things don't get controlled along the way and so we've also done these large clinical studies. We're especially interested in these particular time and monolithic restorations. We worked with over 200 white materials. Actually Gordon gave us a challenge 40 years ago to find something that performed like [inaudible 00:49:04] but was white and we [prompted 00:49:08] all over the world working with materials you've never heard of. And most of them you have heard of and finally ended up with [inaudible 00:49:18] and lithium [disulfide 00:49:20] which has been the two most successful materials anywhere of all time.
Howard : Lithium and say it again.
Rella : [Zirchonium 00:49:32], [Zirchonium-Oxide 00:49:33] and lithium [di-sulfide 00:49:34]. You would know the brand names ... brand names we have data on would be [inaudible 00:49:41] and [Zmax 00:49:44].
Howard : Do you like any of those more than the other?
Rella : They have their indications and [confer 00:49:48] indications and that's what's fun today is in 2015, you're starting to see the [Zhirchoium 00:50:01] challenge the beautiful asthetics of the lithium [disulifide 00:50:04] and [crosstalk 00:50:03]
Howard : Is [ZMax 00:50:06].
Rella : Of course you can go press and mill and make them beautiful and make them reasonably durable. The [Zirchonia 00:50:18] has been more durable [crosstalk 00:50:19] and nowadays we're just starting a study with five different brand names of new [Zirchonius 00:50:29] that are truly new because they're translucent and when you move through a translucent [Zirchonia 00:50:37] it's a different bird. You drop about 450 mpa of [lectural 00:50:47] strength and you pick up more of the cubic [Zirchonia 00:50:53] in that molecular form so it's like starting all over again. It's [Zirchonia 00:51:00] but we don't know anything about it so we've got a whole bunch of new brand names. Not only do we have [inaudible 00:51:07] but you have names you may not have heard of before like Cubex or you've probably heard of Katana from the folks at [inaudible 00:51:18]. Have you heard of Xenostar from [inaudible 00:51:21] coming into America. Fusion One coming on with a [screet 00:51:30] and so we'll be placing a bunch of these and calling them in once a year to see how they're doing. It's going to be a lot of fun.
Howard : I want you to rant on this for a few minutes. One of the things really frustrates me about my colleagues is that when I got out of school, most of the restorative materials in the back teeth were [amulgum 00:51:56] and [amulgum 00:51:58] is half mercury, half silver, zinc, copper, and tin. I was taught that tin ions were very anti-bacterial, bacterial static. I seem to always see the research showing that silver feelings last 14 years, 15 years, 20 years and then the movement was to go tooth colored so we replaced them all with these inert plastic fillings that have no anti-bacterial properties and I keep seeing study after study showing 6 and a half years later these things have [recurrent 00:52:31] decay. As a clinician and I know my sample size is too sample, 28 years, 8000 people, but it seems to me that when I place a [inaudible 00:52:41] [amulgum 00:52:41], 9 times out of 10, 5-10 years later it's still there.
But when I place posterior tooth colored restorations, 6 and a half to 10 years later, it's not like recurrent decay, it's like mush underneath it and then I look at old senior citizens who had these gold foils or in my mouth everything's gold. Something about the high surface energy of the gold, I see gold foils where there is no margin. There's gaps, it looks like Stevie Wonder placed it and it's 50 years old and it's still fine. First of all I want to ask you, with all your knowledge, there's a gazillion dentists that believe that their composites, if done right, last longer than [amulgums 00:53:29]. What would you say to that guy out there because there's literally 50000 dentists in America who believe that if you use a rubber dam and you do it right and the ones that fails because they're all done poorly but if you do it right like they do out there in the middle of Parsons, Kansas, they'll last longer than [amulgums 00:53:45]. What would you say to that statement?
Rella : I've got to be honest with you, when you talk about doing a composite right, I think the dentist need to understand they are [fighting 00:54:09] the material and they've been trying to do it right for 40 years. We started CRA with [inaudible 00:54:19] and ... that was actually a Johnson and Johnson product.
Howard : Really?
Rella : Yeah and basically you have resin [inaudible 00:54:38] shrinkage that is more of a problem than in my opinion, has ever been acknowledged so you have this pull-away from the margin and essentially they try various different [inaudible 00:54:56] but the truth of the matter is we don't really have anything in dentistry that seals. We talk about seal and we [inaudible 00:55:09] but they don't really seal. Any kind of a seal "that you have" is broken someplace around the margin because of the polymerization shrinkage. What we found here is that you have to have a shrinkage less than 1% in order to avoid that pullaway somewhere.
And wherever that pullaway is ... is the canyon at the margin. You call it a white line, you bring your white line and we'll pull under the scanning electron microscope and I will show you the Grand Canyon [inaudible 00:55:50] and I think the dentists have been fighting this material from the very beginning that never had the opportunity to work with something where they could really get a seal. I don't want to imply that silver [amulgum 00:56:08] was sealed. What you had going with silver [amulgum 00:56:14] was an actual expansion.
Once it was [inaudible 00:56:18] it actually expanded. In the preparation particularly, it got a little bit wet so that it actually grows in the preparation. What you have with the full casting is a possibility because of its malleability. You have a possibility to drag the gold right over the [inaudible 00:56:40]. That would be for the careful operators that were willing to take the time to run a disc over all the margins and accomplish that pulling of the gold and all of them aren't going to be like that. You've seen some very fine gold work and you've seen very horrible gold work so it's been an interesting thing to live through that era in dentistry where almost everything was done in gold and silver to the white and now we're in to almost everything. We still have bread and butter dentistry which is the last two [resin 00:57:30] of the world and you're still fighting that polymerization shrinkage, you're still fighting back that you can't ever get a perfect seal and the seal [inaudible 00:57:41] over time.
Within a year or two years, you just don't have a seal. Without a seal, we've got leakage but what's interesting with the leakage is I have in my little mouth cat's gold that is [seated 00:58:02] with zinc phosphate and if I look at those restorations by a standard electron microscope, there's no zinc phosphate left and there are these big black caverns all the way around the margins and yet I don't have any tooth decay and I also don't have any sensitivity so leaking margins are not really the cause of tooth decay. The cause of tooth decay is sugar in the diet, low saliva flow, and poor oral hygiene. If you want to arrest and remineralize, you control those three factors.
Howard : Sugar, saliva flow, and oral hygiene.
Rella : That's why I place it in 2015.
Howard : From a disease that you most likely caught from kissing your mother.
Rella : I don't know.
Howard : As a man I want to believe that.
Rella : You can believe it if you want to but the truth of it is you can have strep mutans in your oral cavity that may not be terribly active if you're not ingesting a lot of sugar.
Howard : With what you know, does the anti-bacterial property of the matter, matter, that the fact that a composite is basically a [inaudible 00:59:36] and an [amulgum 00:59:35] has high service energy and tin ions flying out of it and a -
Rella : It has zinc in it too and zinc is anti-microbial and silver is microbial. A lot of things going on there but you also know that you take out the [amulgum 00:59:54] many times and the liner or base has turned to mush and there's caries under it too.
Howard : You're a research freak.
Rella : I'm on of those.
Howard : What would you say to this dentist who believes in his ... the one thing I love most about humans is they can rationalize anything. They want to believe something but there's 50000 dentists in America that believe their composites last longer than their [amulgum 01:00:22]. I want you to tell that person right now how long does the average [amulgum 01:00:29] versus the average direct placement composite on posterior teeth.
Rella : That's not a straight forward question. Do you know why? Many times today, young dentists haven't had much of an education in the placement of [amulgum 01:00:47]. Therefore they find it very difficult whereas an older dentist who learned to place [amulgum 01:00:56] and became proficient at it then [inaudible 01:00:59] with composite resin particularly with proximal [contacts 01:01:04] and so it depends on where your expertise is. The truth of the matter is composite resin is not anti-microbial. There are some factors in silver [amulgum 01:01:17] with the metals that could be helping in that process. Those same factors are not present with ... gold, but how about the cements that we use them to place them with. The cements could be anti-microbial if the manufacturers wanted to design them that way.
Howard : I'm going to end with a trick question and I'm going to try to play on your emotional maternal instincts. Let's say you have a 6 year old grand daughter and you love her to death. She's 6 year old, she's got four 6 year molars and her pits and fissures are just light yellow to brown whatever. What would you do to those.
Rella : I would [blast 01:02:09] them with a [inaudible 01:02:09] polisher like a [propojet 01:02:13]. I will disinfect them before [inaudible 01:02:22] and I would seal them and I would monitor those twice a year and not be afraid to [airbraid 01:02:34] that, seal it out, and replace the seal fairly regularly.
Howard : Now let's say she comes back to your office, now she's 12, and she has a measial inter-proximal lesion that the radiograph says it's through the enamel. What material would you place there? Would you go with MO [amulgum 01:02:56] and MO direct composite or an MO indirect [catcam 01:03:01] or an MO impression gold MO on-lay?
Rella : That's a tough question.
Howard : Thank you. I consider that a victory for me. How would you answer it?
Rella : Depending on how caries prone that child was ... caries prone meaning how much sugar are they eating, how do they take care of their oral cavity, how does the family live, whether their traditions and habits and their diet and so on. If you're caries prone I would probably use a [inaudible 01:03:38] there. If not so caries prone, I'd have to think about it. If I had Gordon as the dentist, I might even think of [inaudible 01:03:57]. But not just any dentist and any lab because a lot of them don't know how to handle it anymore. The question I can't answer is would I use a composite resin. There's what I think you're getting at. Would we use a class 2 resin? I can at least tell you from our work here [inaudible 01:04:24] but as far as it being [anti-cariogenic 01:04:36], Howard, isn't, and yeah, you're going to really think about that child and what you're going to place.
The problem with [inaudible 01:04:45] is it's not fun. It's sticky, it doesn't [set 01:04:54] so you can finish it like you'd like to right away. It's not pretty, it washes out, but it does have fluoride and several of the products we've been monitoring for a number of years and they have a substantial fluoride release so those [inaudible 01:05:16], we have monitored a substantial fluoride release. We've also taken teeth yeast to be second diet [dairy 01:05:32] mass spectroscopy on them. Call it [SIMS 01:05:35] for short and found that the fluoride does go into the tooth from the restorative materials, particularly, those parts of the tooth with the [inaudible 01:05:47] tubules that are wide open which would be more on the [inaudible 01:05:52] and the proximal and you just defined a proximal lesion. But we're still going to get more fluoride into that tube than if we had used a class two resin. There are class two resin materials that claim to have fluoride release but I will tell you that release is within the first few weeks and then it's gone.
Howard : On a planet that's got seven billion people with dental decay being one of the fastest growing disease in the world if not the fastest growing disease. Why are we using inert direct [resins 01:06:33]. Do you think we should all be using [inaudible 01:06:36] for micro-biological help there?
Rella : I wonder if there are other materials that we don't have yet that are also resistant and anti-microbial. The question with these kinds of things is are they toxic? Can they be leeching chemicals into the oral cavity and into the body 24/7 through [mirrors 01:07:07]. That's what's slows down the release onto the market of materials that maybe would be anti-microbial but they could also be toxic to the body and I'm not going to tell you that [inaudible 01:07:27] are as you say, inert. They also release various chemicals into the body and you watched those dissolve over time. You see the anatomy that you put in smooth out and round of and you know you're using material from the surface. Where does it go? It's swallowed, I don't think we can assume that it's excreted. We don't actually know that so that makes it difficult to come forward with chemicals because you always wonder about toxicity.
Look at [inaudible 01:08:11] the last four years or so. For its toxicity. 50 percent [marketing 01:08:20] right?
Howard : Does that concern you?
Rella : Does that concern me? I don't know if it concerns me. I've seen people that have a lot of hyper-sensitivities to a lot of things and they claim to have symptoms from the silver [amylgum 01:08:39] and I'm not smart enough to know if it really is from [inaudible 01:08:44] other factors. I've looked at them and seen these difficult to pin down symptoms and I've been grateful that everything that I have in mouth is gold. I don't have to worry.
Howard : We've both lived through the Hal Huggins era. Do you think on the whole, was Hal Huggins' work holistic or on to something or quackery?
Rella : I don't know. We lived in Colorado at the time Hal Huggins and his institute were at their height. I know he was sincere about what he was doing and after meeting and working with some of these people that have hyper sensitivities. [Howard 01:09:35] knew a lot of things, things that don't other me personally but they really do bother them and you see the inflammation, you see the various physical symptoms that they have and I can't tell you absolutely that every human on this earth is not hyper-sensitive to the components of silver [inaudible 01:09:58]. I think there's some people that are hyper sensitive to it. I think there are some people that are hyper sensitive to other metals that we don't think of that way such as titanium and some other metals. We have to look at some of the things that are happening with implant. People would like to nail that on to microbes but I think we have to consider possible hyper-sensitivities to the metals too.
Howard : I only have hyper sensitivities to women wanting my autograph because it's usually on an alimony check but other than that -
Rella : I'll tell you how I have solved it. I've told my husband that I can only accept real diamonds and pure gold.
Howard : Rella, let me just generally say this. Moving forward, would you like to see more glass [inaudible 01:10:48] placed and more [amulgums 01:10:51] placed and less resin or is that not a fair statement?
Rella : That's not a fair statement because I have to be honest with you, I don't know. I wish I knew the answer to that.
Howard : We are out of time and I just want to say, seriously, from the bottom of my heart, you mean so much to mean for 28 years. I love you to death, I called you mom dental mom, I think you -
Rella : That's a scary thought, Howard.
Howard : You and your husband turned me and Mike [Detola 01:11:22] into that dentistry was just a massive science. We went to 12 of your two day courses and we'd go back to the hotel room and talked till 3:00 in the morning. There was nothing that jazzed me up more about the sovereign profession dentistry than you taking our two little young minds and saying ... I can still remember you saying to me as you said "Howard, when you retire, you still won't have understood dentistry. It's so complex that in your entire life time, you're never going to have it all figured out so you made me realize at 25 that if I dedicated my life to this, when I retire at 65 or 75, I'll probably have more questions at 75 than I did at 25 and that's a true statement. You are the role model for more people than I can ever count.
If someone ever tells me "Who turned you on to dentistry" it's always going to be you or your husband and for that, thank you Rella.
Rella : Thanks Howard, that's really nice. You know why you don't have the answers? Because none of us do.
Howard : Probably a 1000 years before we can answer all the questions we've talked about today.
Rella : Maybe so, I hope not, but maybe so.
Howard : All right, thank you so much for your time and if you're ever looking for a clinic to take your lab to, I'm down here in Phoenix, I'd love to have you. If you come to my office we'll film it and it'd be a riot. I'd love that.
Rella : That sounds super cool, I'd love it.
Howard : Let's do it. Come down to Phoenix, we'll get a film crew and we'll photo-document and try to educate the world's two million dentists of what you're trying to do.
Rella : Sounds great.
Howard : Can we make it a date?
Rella : Yeah we can.
Howard : It takes me 11 hours to leave my house and drive to your house so get in your micro-biology van and come on down.
Rella : That's great.
Howard : All right, have a rocking hot day.
Rella : Thank you, you too Howard.
Howard : Bye bye.
Rella : Bye bye.
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