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AUDIO - Michael Pikos - HSP #78
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VIDEO - Michael Pikos - HSP #78
Dr. Pikos shares in depth information about today's techniques, and tells how to learn the 'Why' of education.
Dr. Michael A. Pikos - Dr. Pikos is originally from Campbell, Ohio. He attended The Ohio State University where he graduated Summa Cum Laude and Phi Beta Kappa. He also graduated with honors from The Ohio State University College of Dentistry. Dr. Pikos completed an internship at Miami Valley Hospital and residency training in Oral & Maxillofacial Surgery at the University of Pittsburgh, Montefiore Hospital. He is a well published author who has lectured extensively on dental implants in North and South America, Europe, Asia, and the Middle East. He is also the founder and CEO of the Pikos Institute. Since 1990 he has been teaching advanced bone and soft tissue grafting courses with alumni that now number more than 3000 from all 50 states and 32 countries. Dr. Pikos maintains a private practice which is limited exclusively to implant surgery in Palm Harbor, Florida.
Dr. Michael Pikos
2711 Tampa Road
Palm Harbor, FL 34684
Howard: It is a supreme honor today to be here with Dr. Pikos at the ... We're both speaking at the 11th Annual Mega'Gen Implant Symposium in downtown New York City at the Grand Hyatt and I was lucky enough to bring a camera into the green room before we go on stage and speak over the next 2 days. You're a legend and a idol and a role model to me and so many. You're one of the only oral surgeons, the only oral surgeon I've ever heard of who doesn't even pull wisdom tooth. I mean, he's at a practice limited to implantology for 32 years. You have a board certification in diplomat and everything I've ever heard of and more.
You have a teaching institute that has people in there learning how to place implants and bone graft from countries of every continent from around the world. You're just a legend. First of all, it's just an honor that you would take the time to do a podcast with me. My opening question to you is, you've been doing this 32 years, I've been doing it 28 years, what's changed with dental implants from when you started placing your first one 32 years ago to today? How has that changed over the years?
Michael: Howard, again, first things first, I appreciate the ability to share some time with you. I've known about you for quite a few years and first time I get to actually meet you and to give you credit for which you have accomplished with Dentaltown. As an oral-maxillofacial surgeon, as you've mentioned, I've had the luxury of limiting my work exclusively to implant surgical-based reconstruction for the last 22 years of my practice. The first 10 years, I'd placed implants and did grafting, et cetera, but also did pretty much the full scope of my specialty of oral-maxillofacial surgery.
Being able to limit in one arena has afforded me the opportunity as a clinician, first and foremost, as I do practice 2 or 4 days a week, has afforded me the opportunity to do quite a bit of work day to day and thereby, I can accumulate a fairly significant caseload with regard to the different bone grafting, soft tissue grafting procedures I do, et cetera. I say that only because to more or less qualify the educational arm of what I'm about as well, which for the past 25 years having the Pikos Institute with some 3,000 alumni from all 50 states, 32 countries, has been a real honor for me, a real blessing to have the again luxury if you will, of having a clinical arm and an educational arm to what I'm all about. I've enjoyed it. I'm very passionate about what I do.
That said, your specific question with regard to changes over the past 30, 32 years, some significant changes for sure, so many. Just briefly, what comes to mind immediately would be basic implant design over time, different type of designs with regard to the thread design of the implant. It will offer primary stability for example. It will offer immediate load which is a concept that wasn't even around for so many years early on. That's a significant one.
What will continue to evolve will be further designs of implant surfaces, actually configurations as well as surface configurations. Nanotechnology will be playing I think a bigger role in the implant design element. The prosthetic components have been changing and evolving very nicely. It will offer a very wonderful aesthetic result for the aesthetic zone type cases. Certainly, impact of 3-dimensional radiography has been phenomenal. I embraced that about 10 years ago roughly. The cone beam CT element of what we do is huge. Taking a 2-dimensional radiograph comparing to a 3-dimensional, it's literally night and day. If that technology were taken away from me personally, I would retire for sure because the impact of it is just profound.
Being able to visualize everything we do beforehand, to virtually plan our cases to see most importantly just from the cone beam itself and the software built into these respective units that are sold, how we can assess the anatomy, existing anatomy, pathology, et cetera. Having a maxilla, a mandible in the palm of your hand before you even see your patient is just absolutely outstanding. The impact to be able to treat with a plan and with precision, et cetera. Those are just a few of the main things that come to mind with regard to changes. No question that we'll be seeing more changes.
From a biology perspective for me, a growth factor perspective, I will tell you that there are live changes within the biologics realm of implant dentistry, such that we're able to have some growth factors to work with and specifically some recombinant ones; BMP, bone morphogenetic protein that allows us to grow bone de novo. The trend of not having to take autogenous bone for our bone augmentation procedures is there loud and clear, such that we're able to utilize less and less autogenous bone, more growth factors, et cetera. We're able to be less invasive in general with all of our work, both hard tissue and soft tissue grafting procedures and implant placement for patients.
Howard: When we got out of school, the big thing was coating the implants with HA. I remember all the implants [crosstalk 00:06:52] ever coated.
Howard: Then that coating started to come off. Is coated implants ...
Michael: Specifically, HA had ...
Howard: You remember what I'm talking about where they were ...
Howard: ... showing up with like macrophages and knee caps and other parts of the body?
Michael: Sure. Unfortunately, not all the biology taken from say orthopedic circles can be applied with equal success to the mouth. That really is the problem because in orthopedics, we're looking at more of a close system, the joints, et cetera. Whereas in the mouth, we have a communication element that is there unfortunately, and the mouth having the bacterial content that we typically have, implants certainly are vulnerable as our teeth to the problems, specifically infection and bone loss, and therefore implant compromise and ultimate failure. Bottom line here is that the surface technologies have changed. Whereas HA coating had been quite a popular thing to do so to speak in the '80s and into the '90s, what was found, and by the way I placed quite a few HA-coated implants in my time.
Howard: So did I.
Michael: Not all of them of course were so problematic, but unfortunately those that were were problematic in a big way because of the weakening effect of contamination at the surface and therefore compromising bone loss, et cetera. Today, the nanotechnology is again what is available to us is a whole different level of technology that really affords the implant surface to be even better prepared to allow for bone to grow to it with that protein layer that interfaces regardless and in a nutshell, that's the big push anymore is to allow for the biology to be changed in such a way that again primary stability, immediate loading of our implants, that's really where things are at now. We're able to in one day literally extract the tooth, place an implant, put a provision on not just for a single tooth but certainly for a full arch of reconstruction.
Howard: Back in the day, when we were in school they taught us that there's 4 types. We have the mandibular anterior that is just pinewood. You could probably hammer a nail in there and it'd work. Posterior mandible, we got a lot softer maybe balsa wood. The maximally anterior is kind of Styrofoam, and the posterior maxilla, there is just nothing there. When you're talking about immediate loading, are you talking about immediate loading in all 4 different areas of the jaw or are you talking about just certain places?
Michael: Certainly Carl Misch was able to identify very nicely for all of us a very good set of analogy, if you will, in terms of as you mentioned, type 1 through 4, even a type 5 quality bone, identify it and being able to give us the analogy of type 1 ...
Howard: Go through types, those 5 types.
Michael: Type 1 basically being like an oak or maple, very dense, extremely dense bone, very minimal vascularity. Lends itself well to primary stability, yes, but care has to be taken with regard to preparation for the implant. A type 2 quality bone will be more of the spruce or pine kind of feel as one drills into that bone. It's a very common bone. Type 2 quality, we'll see in the anterior mandible along with type 1 there. We'll see type 2 sometimes posterior mandible and even pre-maxilla occasionally. Type 3 is more of the balsa wood that you referred to as a feel. That's posterior mandible maxilla typically. Then type 4 would be the Styrofoam, very soft trabecular bone. The gradations from type 1 to type 4 really go from a primary cortical bone with a dense marrow all the way to the type 4, even type 5 which is pretty much trabecular bone, a very mushy type, no structural integrity to speak of. That said ...
Howard: You said 5 types.
Michael: Yeah, the fifth type is really one that's just beyond the marrow point where even there's a degree of how soft is that marrow, so to speak. That's what been identified more recent is the type 5 as Carl has talked about. That said, when we talk about primary stability, the concept is really one now taken really from the Brånemark days where basilar bone was talked about if you may recall back, the buzz was back in the day in the '80s especially where trying to engage the cortical plates was a big deal.
Well, as we found out that wasn't so important for typical submerge implant cases which back in the day, '80s and '90s, early '90s especially, I would place the implants, bury them, and then uncover them. Almost like planting a seed and watching it grow into a little sapling, et cetera. Of course as we know, the last 15 or more years, we can place these implants and load them immediately. That is predicated on the implant being primarily stable. Meaning, basilar bone is huge. Once we're able to engage basilar bone, then in fact we can have insertion torques of 30, 35 Newton-centimeters and straight up to 90 and even 100, which is a tremendous primary stability element. That's really at the heart of what we're able to do today with our immediate load cases from single tooth to full arch.
Part 2 of that is splinting. When we get primary stability with our full arch cases, the key to success there too is to connect these implant bodies as well, making this as a rigid unit that then allows the body biologically to allow for integration to occur over time. In the meantime, the prosthesis is in the mouth and the patient is functioning. Soft food typically, soft diet, but very predictable, very successful.
Howard: This is kind of background of you hear a lot of the all on 4 where people replace 4 and trying to [inaudible 00:13:21]. You're saying that when you place 3 or 4 or 6, 8 implants and connect them together out of the gate.
Howard: The physics of that allows you to immediately load them.
Michael: Yes. Some great sciences is available that really validates that. The works of [Beumer 00:13:38] and [Bo Rangert 00:13:42] certainly have been really outstanding with regard to laying a science foundation for that concept of even really as few as 4 implants. I was really skeptical, to be honest, for a number of years how 4 implants could literally hold 12 teeth and work.
Howard: Upper and lower.
Michael: Upper and lower. Correct. The so-called "all on 4 none on 3" was pretty in fact still kind of a phrase that a number of folks used to say, "Well, I don't believe in that. I don't think it works."
Howard: Explain all on 4, none in 3. All on 4, none on 3 means you have 4 in there, connect it with a bar and it'll work.
Michael: Right. Lose 1 implant and ...
Howard: Lost 1 implant and it was okay.
Michael: Right, and potentially the case is gone, well that's not ... It's not quite that way. Yes in fact, 1 implant can fail or not integrate, but the reality is there's always a contingency plan. In fact, the in the maxilla, I rarely place 4 implants only. For our full arch immediate load cases, I typically will place 5, sometimes 6 depending on factors such as parafunction, the size of the patient, typically a male will have a harder bite, so to speak, biting with greater force than a female, et cetera. The bottom line is yes, as few as 4 implants can work, the science is there. What we've been able to see over the years now is that even the concept of tilting an implant to me was unorthodox. Seventeen thousand implants, axio-placed only all over my years, all of a sudden I'm going to tilt these, I got to be out of my mind.
Well, long and short of it is, like anything else, I have to do homework and went with a restorative colleague of mine to see Paulo Malo in Lisbon, Portugal. The trip began there and continued visiting different offices of colleagues of mine who've been working with all on 4, et cetera. Here it is how many years later where I feel now that, I'm very comfortable by the way with the concept, absolutely, because it's based on primary stability. Meaning basilar bone is huge, engaged with these implants, and of course the concept of, as we talked earlier about splinting. That is huge. Those two concepts alone allow with a [inaudible 00:16:01] occlusal concerns, occlusal concepts, allow for very predictable placements of these implants with teeth so patients can go home that same day.
That said, what in fact my lecture this afternoon here shortly will be on guided full arch reconstruction but from a fully guided perspective. Meaning, we can virtually plan the entire care and not just at the time of surgery convert say a denture to a hybrid prosthesis, still a denture, and teeth can pop off and there are going to be issues. The way I see it, the patient is paying me more or less for a really nice Mercedes and for 4 months they're walking around with a used 1987 Chevy. Not so good, I think. Not to say that that's a bad concept, no, absolutely. In fact, firstly everybody in the world is doing it that way, converting a denture.
Howard: Did you say used 1987 because that's the year I graduated in middle school. That's how used I am?
Michael: No disrespect to you of course. The way I see it now with guided, meaning not just guided for placements on the implants but in guided, allowing for prefabrication of, now think about this, not a denture. This is a hybrid prosthesis. This is a PMMA bar-supported monolithic hybrid prosthesis that looks drop-dead gorgeous at that time of placement. When these patients look at this and they go home with this, they're very excited as they should be. Being monolithic, teeth aren't popping off. They're not chipping off. It's a very neat concept. nSequence is the lab that I work with.
Michael: nSequence. The letter n, as in nSequence.
Howard: Are they in Tampa? You're in Tampa.
Michael: No. I'm in Tampa. They are in Reno, Nevada. Daniel Llop, L-L-O-P, is the brain behind this concept. We collaborated for the past 7, 8 years now, his lab and my team, such that we've been able to evolve the work now in such a predictable mode that literally an upper and lower case denti patient, terminal dentition patient, we can extract their teeth, place the implants and place these beautiful looking hybrid prosthesis all within a matter of a half a day, 4 to 5 hours maximum. They come in at 7, they're out at noon. They're not packing a lunch and staying all day. Again when they leave, they have a beautiful set of teeth for 4 to 5 months.
Howard: You know what, you have to do what you have to do. I'm going to throw you under a bus live on camera. You got a photo docu on one of these cases A to Z and get it on Dentaltown. We got 195,000 townies that would die to see that. I call stuff like what you just said as dental porn. These guys are watching on Dentaltown Online CE on their 60-inch big screen with surround sound. I want to see that.
Michael: Sure. I will.
Howard: Can you hook me up with the owner of that lab for a podcast?
Michael: Absolutely. I can do that.
Howard: I also want to go back, I try to listen for things that maybe there are some viewer out there who's not quite getting it. You keep dropping the term basilar bone. Explain that to the listeners.
Michael: Basilar bone, meaning basically that's the bone that we have in our maxilla and mandible. Once the alveolar ridge has resorbed to a degree, alveolar bone meaning the bony housing that we typically place our implants in. If we just took your teeth out, for example, the bone that's residual around in the sockets, et cetera, is alveolar bone. Under that at the base, literally at the base of the mandible, base of the maxilla, meaning in the area of the floor of the nose, the piriform rims, the floor of the sinus typically, this is basilar bone which is the hardest and most dense bone. This is a lamellar bone.
Howard: Do some people call that skeletal bone?
Michael: Sometimes it's referred to as that. Kind of a bit of a misnomer I think.
Howard: It's a misnomer.
Michael: I think so. Basilar is more descriptive and therefore the goal, and it's a paradigm shift, it was for me, to be able to place implants that are tilted. Meaning, the concept really is predicated from the get-go by Paulo Malo, Bo Rangert, et cetera, on the fact that to get primary stability, even in a short area of bone, small amount of bone, as long as one can penetrate remote areas of bone, i.e. basilar bone, therefore, implants have to be longer, 18, 20 millimeters or so, and even go trans-sinus for example from beginning say at the first, second bi-area typically sometimes first motor if we can, and transcend the sinus and engage basilar bone at the base of the nose.
That's perfect because those insertion torques then are again at a minimum 35, typically much higher, 50, 60, 70 Newton-centimeters which means ... By the way the baseline is 35. That's what's pretty much accepted in the literature now. Meaning each implant, if you're placing 4, has 35 Newton-centimeter of insertion torque, "it's safe to load those implants." The long and short of it is it created a paradigm shift for me because I never even thought about placing a tilted implant.
I'll tell you with loads, pathologic, et cetera, well there's a magic, if you will, of splinting these implants. That's really the bottom line to all of this. Splinting allows for immediate provisionalization and then ultimately integration of these implants. At the fourth and fifth month mark typically is when we now convert that same patient to a full arch of let's say zirconium which is absolutely gorgeous. Typically, we place a full arch zirconium prosthesis in the maxilla.
Howard: What brand name of zirconium are you using?
Michael: There's so many different types. There's no particular brand. The Zirkonzahn seems to be the most widely talked about because it was I believe the first one introduced here in the States from Italy. There are certainly ... The Prettau Bridge as its termed. There are variations on the theme, so to speak. The fact that it's such a hard material is a good and a bad thing. I say good in that it's fabulous. It doesn't typically fracture that we're aware of. At least so far the cases we've done now are 4, 5 years out.
However my concern, and this is a simple surgical brain looking at this now is I'm hesitant to place a full arch zirconium hybrid in a maxilla and mandible same patient because you've got 2 extremely strong materials against each other. Number 1, just the click, click, clacking of noise is not so great. Secondly, these are 2 materials that aren't going to give.
Michael: If something in the system has to be a weak link and that's going to be the implant bone interface. My concern is that long term we maybe looking at problems by having 2 arches zirconium. That's a simplistic way of looking at it. In essence what I'm saying is what we like to do is, in a 2-jaw case, zirconium upper is the bridge, it's final bridge, yes. Keep the lower provisional even for another couple of months once the upper is done. Allowing that patient to almost adjust and find their own centric, if you will, and their own comfortable bite so to speak. The do an acrylic wrap in the mandible so that we have a wear fatigue factor built into the system such that what's going to wear will be just the lower arch prosthesis and that can be changed out certainly over time.
As I tell all our patients with all of our implant work, the prosthetics is like a tire on a car. It's going to wear. It's not forever. The implants, yes, they should be indefinite. I don't say forever. Depending on the age of the patient. For all intents and purposes, our failure rate is so low now with so many different systems we work with that for all intents and purposes, it's safe to tell a patient what I just shared with you.
Howard: When older people asked me how long implants will last, I always say, "The best thing about old age is it doesn't last that long, so don't worry about it."
Michael: Just a quick aside, as a comic sidebar if you will, I tell a patient, "You know, of all the things that you possessed, the only thing you can take with you when you do die are the implants."
Howard: The aliens are going to be confused because they're going to come back a million years now and they're going to open up all these caskets, the only thing it's going to be is these little titanium wedges, these silicone packages. They're like ... The breast implants and teeth implant is the only thing they're going to find. I want to back up all the way to the beginning.
Howard: All the way to the beginning, here's an issue. A lot of the people that are losing all their teeth and need implants it's because they're smokers and/or have gum disease. I want you to first talk about this dentist out there driving to work right now and he's got these patients but he might be thinking, "This person is or is not a candidate because of their smoking history," and it's easy for non-smokers to say, "Oh, I'll just tell them to quit smoking for a month and get him and he'll be good," but a lot of them aren't going to comply with that.
Number 2, we keep reading articles that if you have a full mouth and gum disease and you pull all the teeth, well the gums heal up beautiful, but when you do place implants in the mouths of people who had lost their teeth in gum disease, they do have a little ... It can't be a true gum disease because the tooth is gone. I mean, when you don't have the tooth and the cementum and the plaque and the tartar, now it's titanium, it's a totally different disease process. Can you talk about those two things; smokers and gum disease?
Michael: Sure. As a matter of fact, that's a great question for lots of reasons. That's the least of which is these are the 2 most prevalent problems that we see today is a lot of smoker patient certainly in our country and throughout the world for that matter. If we had the diabetic element to that and that's a real nasty one too, a risk factor if you will, that compromise anything we do, whether it's grafting, bone tissue and/or implant placement. Now, that said ...
Howard: What percent of your patients are smokers or diabetic or both?
Michael: The diabetic population is increasing for sure for all of us as we see. Unfortunately the Type 2 diabetics are very common. Obesity is a huge issue. As you know in our country, 2/3 of all adults are overweight or obese basically. Obese being defined as a specific amount of pounds above normal weight, et cetera. Diabetes, we're seeing more of it. Percent-wise, I would say probably maybe hard to pinpoint an exact number, but it's on the increase. It's got to be at least a 10, 15% element, somewhere in there.
The smoker population is there as well. My rule of thumb is, up to a pack a day, I will graft, bone, tissue, et cetera. Beyond that pack a day, meaning if I can smell smoke on their person, then I know they're not being upfront with me. I can't find it in me to graft even if they're a controlled diabetic. A controlled diabetic, less than a pack a day, smoker, that's a pretty good risk factor. If they're smoking beyond that pack, and there is some science but it's a little tenuous to support what I've just told you, but that's been my rule of thumb for many, many years in my practice. Meaning, beyond that pack a day, I won't graft them.
Now, implants, more lenient. Up to even a couple of pack, I've certainly placed implants in these folks. That said, I qualify very clearly to all of my patients and tell them that, "Listen, our typical high 90 percentile success rate over so many year, 30 plus years now really is compromised by at least 10 to 15% over time. Meaning, you're not in that high number." Marginal bone loss, the literature is replete with articles to support the evidence regarding bone loss with our smoker population.
Howard: Explain that to the listener. That's because the ... Is it the nicotine constricting the ...
Michael: It's a combination of things.
Howard: ... the blood or is it the carbon monoxide?
Michael: Everything. Yeah, all of the above. It's a double, triple-edged sword. It's the smoke itself. The heat of the smoke in the mouth compromises tissue integrity. There's also the nicotine itself and the carbon monoxide that's formed that causes also a small vessel disease process and that's really what hurts the most is that the vascularity is compromised to all of the tissues of the mouth. As a result, you'll get tissue breakdown over time that you would not normally see in a non-smoker, generally speaking.
Howard: That's the same process with diabetes, right? The vascularity.
Michael: Correct. That's why the one-two punch of the diabetic who smoke is absolutely at the highest risk because they already have small vessel disease as a diabetic patient and now add the smoking element, and you're basically choking off blood supply which is at the heart of, of course, everything that we do. As you know, even though the mouth just happens to represent a phenomenal resource of vascularity for us to work with, it's a very forgiving environment. I say "forgiving", there's no real pathology to speak of i.e. the small vessel problem. Yes, the smoker, the diabetic combination is the most lethal one. If in fact implants are going to be placed in these individuals, they need to be explained that without question they can be looking at some issues.
Howard: In a case like that, I mean, would you just implant some extra spare tires there? I mean, if you're going to do a case on 4, would you just put in 6 just ...
Michael: Typically, not such a bad way to go. Yes. There's ways, some strategies to work with these types of folks and to plan for them. One being yes, in general more implants is one way to look at it. Another is just bioactive modifiers that I've used for more than 20 years now from PRP, these are blood-borne bioactive modifiers, PRP, PRGF. More recently in the last 2 years, PRF.
Howard: Can you explain all those terms of yours?
Michael: Sure. These are just acronyms for blood-borne bioactive modifiers. Meaning, we draw blood and spin down the blood in different types of centrifuges. The product that we get from that is one that is based on the technology and the concept of which particular one you're working with is predicated on either numbers of platelets as in PRP or the plasma itself with growth factors within it, i.e. plasma rich in growth factors, and then PRF.
PRF is platelet-rich fibrin. This is a growth factor, I'd say bioactive modifier rather, that is a second generation. In my opinion now as I've seen the literature and the science behind this which I've been using now exclusively for the past 2 years as a modifier, it's a second generation blood-borne bioactive modifier because it now is such a ... Rather I should say it creates a fibrin clot that has growth factors that actually are slowly released over time, 7 to 10, 11 days out. These cytokines gets released and what they do is they accelerate tissue wound healing.
For example in a smoker, how important is it to be able to get primary closure and have that water-tight as quickly as we can to prevent that smoke, because you know they're going to smoke that same day. We tell them don't smoke the day before or the day after, and pray that they don't smoke the day of. Typically they're going to light up pretty soon. The bottom line is, with these bioactive modifiers, they help regulate a growth factor called VEGF, V-E-G-F, vascular endothelial growth factor. This growth factor accelerates soft tissue wound healing big time such that within 15 minutes, you've got closure, you've got a seal because of using these growth factors. By the way, very inexpensive, $12, $15 per blood draw using test tubes, et cetera. Everything that's involved in the setup, very inexpensive and should be used, in my opinion, with virtually every case that we do from a grafting perspective ...
Howard: What percent of your cases are you drawing blood and centrifuging?
Michael: All my graft cases. All of them, bone and soft tissue, and a number of implant cases depending on exactly what I'm doing. Not necessarily a 1-tooth case or 2-tooth case. If I'm flapping tissue and exposing bone, typically I'm working with some bioactive modifiers.
Howard: Those dentists out there listening to you right now, tell them how we could go down and see you do this in Tampa.
Michael: The institute that I'm very proud to tell you that is now in its 25th year, the Pikos Institute in Tampa, Tampa Bay area. We've been having courses now over all this time as a continuum. My concept of how I look at this is we only become hybrid surgeons. By hybrid surgeon, I mean, we need to have the ability to work with bone and soft tissue equally well from a reconstruction perspective, and of course place implants appropriately. We have all of that together while the restorative element really falls in place quite nicely because all of these plans on so well, but most importantly, the skill set of that surgical-based individual being able to do bone and tissue equally well, I think is absolutely over the top because patients don't like to move from one office to another to another, as you know.
The trend today is under one roof doing virtually everything. That's the European concept that's been going on for many years. Without question, the trend now in this country is at it is. As you know better than I more than I would, is it 125,000 or so restorative dentists in our country? Not everybody is going to be jumping on the bandwagon to do surgery, of course, but those that are doing it, my advice would be commit to it. Don't dabble. As Carl Misch talked about years ago, if you're going to commit to this thing, you need to. In fact, quite honestly, virtually everything I do today Howard, believe it or not, wasn't even remotely around in my residency in 1983 when I finished.
Howard: Ohio State?
Michael: Residency was Pittsburgh, University of Pittsburgh.
Howard: In Pittsburgh.
Michael: College of Dental School at Ohio State. Then at Pitt, Montefiore Hospital for my residency. Came down to Florida in '83, set up on my own. Fast forward 32 years later, I will tell you that I have averaged 130 hours of CE every year my entire career. That's well over 4,500 hours of CE. It's not just sign in and take off to the beach. No. It's sign-in, front row, tape recorder. I'm pretty obsessive. I love to learn and it continues. Because of that, I've been able to continue to incorporate different concepts, different state-of-the-art technologies into my practice first, and then into my institute. As a result, the institute represents a continuum of bone and soft tissue grafting as well as guided full arch immediate reconstruction.
Howard: Pikos is how you say it.
Michael: Correct. Pikos. Right.
Howard: That's right?
Howard: Pikos Institute, go online P-I-K-O-Sinsitute.com. That area is a hot bed for state-of-the-art people. People know that area. Clearwater, Florida there's Bill Strupp.
Michael: Absolutely. Sure. There's Dawson Center.
Howard: I know [crosstalk 00:36:36] got Dawson.
Michael: It's just south of us. Sure.
Michael: Tatum, sure.
Howard: Is Tatum still down there?
Michael: No, actually Hilt is in France as I recall.
Howard: In France?
Michael: Yes. He'd been there for a number of years now.
Howard: He moved to France?
Michael: Near Normandy.
Howard: Was that for love? What, he found a French woman and moved there?
Michael: To be honest I'm not really sure.
Howard: Not really sure, huh? Most people they say you only leave your country for money or love. That's the only 2 reasons you got. He must have found a French woman. I want to back up again about the diagnosis here. We're talking about smoking, periodontal disease. You talked a lot about the smoking, but let's go back to the periodontal disease. Is it fair to say, I mean, you can't have periodontal disease around an implant like you do a tooth, I mean, that's just 2 different beasts, but we do see that if you had periodontal disease and you placed an implant, you're more likely to have peri-implantitis. What's the different between peri-implantitis and periodontal disease?
Michael: Really the 2 processes are very, very similar, believe it or not Howard. In fact, unfortunately, a number of our patients think once they get an implant or implants that they've got these third set of teeth and they're immune to anything out there, they don't have to brush, floss, et cetera. Of course, that's the worst way they can think. Without question, implants are vulnerable. They are. In fact, the seal around an implant is different than around a tooth. What God gave us with a healthy tooth, that PDL is a phenomenal element in that if a tooth is in trouble, if we hurt from a tooth, it's talking to us. The PDL is talking maybe hyperocclusion, whatever the case may be, it's something that is reversible typically, but most importantly we have a signal, a sign up front. Patient's hurting, we can address it and typically deal with it.
Unfortunately when an implant actually has pain associated with it, that's typically 99% of the time, it's history, it's a goner. There is no precursor sign necessarily. A lot of this disease process is insidious, so bacteria basically can invade an implant more quickly the interface between the implant and the bone than with a tooth and a bone. Believe it or not, the implant is more vulnerable. Peri-implantitis is basically the analogous element to periodontal disease more or less, periodontitis, if you will. The bacterial content had been shown in a dentate patient to be not that different really with an implant that's in trouble versus a tooth.
What I like to strive for and I think many of our colleagues are in agreement, and again as a surgeon, this is somewhat maybe radical to my own surgical colleagues but the importance of attached tissue for so many years now, I've been talking about it. In fact, my soft tissue grafting course that deals only with implants is now in its 16th year and it sprouted out of my bone grafting courses because I couldn't keep stuffing the soft tissue work into any of the bone courses. There wasn't any room. The 3-day soft tissue course we do is devoted exclusively to implant-based surgical reconstruction and the importance of what I stressed throughout that course of attached tissues everywhere, whether it's a single-tooth case or a full arch case, grafting with either autogenous tissue, typically from the palate or much more commonly using an allograft like AlloDerm, which I've used in a vestibular plasty concept for almost 19 years.
The long and short of it is, I think the literature can support nicely that attached tissue really does minimize trauma around that implant and therefore doesn't allow for that [inaudible 00:40:27] to increase any greater and allow for invasion of bacteria. Think about it, a smoker, a diabetic is at risk because that attachment which is really not an attachment as it is with a tooth, it's already compromised. Now, in a smoker, in a diabetic, et cetera, someone who doesn't have good hygiene, these bacteria just have a blast. They get in there and they do their thing and there's the unhealthy red erythematous mean-looking tissue that we all have to deal with, et cetera.
Howard: Now you wouldn't find any of those people in Tampa. Those are coming up from Clearwater.
Michael: Exactly right. They're totally right out of my area. We're immune. We basically allow them to swish with Ozol which is a fantastic ...
Howard: Great, great [inaudible 00:41:10].
Michael: Absolutely. Kills everything in site.
Howard: I love those. I'm going to pin you down and go back entirely. What should a diagnosing general dentist should be thinking if you got a patient with a mouthful of gum disease and you're going to pull those and go to implant? What should you be thinking from a diagnosing term? I mean, if you got a mouthful of gum disease ...
Michael: First things first, what caused the problem is important. I mean, it's important to sit down with your patient and ... Early on in my career, I would say I wasn't as nearly as sensitive to this as now. Over time, experience teaches you many things. Really looking at the patient as a true person, not just a mouth. We've said that from way back, sounds great. Not everybody follows it necessarily. The reality is getting to know the patient well enough and specifically what happened. Why are those teeth, why were they compromised?
In some cases, it's a genetic component. There's no question. You know that. We've seen folks in their 20s and 30s with rampant periodontal issues, hygiene is great, they've been to dentists, it's not that they've ignored, et cetera. It's unfortunately a genetic element. Why does someone die from lung cancer and they never smoke? Things happen. We're programmed differently. That said, that population aside, we've got the other issue of course just poor hygiene, the smoking patient, immunocompromised patients, patients that have, my goodness, a number of these vascular collagen diseases, Lupus and you name it, scleroderma, on and on. There are reasons that these teeth ...
How about Sjogren's? We unfortunately see a number of Sjogren's patients that because their salivary flow is compromised, they have decay so you start treating a couple 3 teeth, root canals, crowns. Before you know it, the other arch is in trouble. So many of these folks are so compromised that yes in fact, they may well and there are, a number of them, good candidates for extraction and hybrid prosthesis, because then they can maintain hygiene so much better. Basically, in a nutshell, to answer your question specifically, these folks, we need to know what happened first before we start edentulating.
By the way, even though I am surgically-based, I wrote an editorial, oh my, at least 7, 8 years ago in implant dentistry that specifically addressed, and I mean this with a sincere conviction as I can come across about this, and that is that this editorial was about our graduate programs throughout the country emphasizing implant work so much. We're talking with an oral surgeon, within perio, within pros, within endo, virtually all of them. Yes, pros as I mentioned. Meaning, the emphasis is so much now for implant dentistry that saving teeth has become a lost art.
I truly am a proponent of absolutely saving teeth as much as we can, depending on the circumstances certainly, but I'm not one to just jump in and take teeth out and slam dunk an implant home. I've done this too long now and I've seen cases that I thought honestly from the year 1 or 2 wouldn't last 6 months, a year or 2, even deciduous teeth maintaining their space over 20, 25 years. As I've seen patients come back over time, I've had to eat a lot of crow and digest it not so well, if you know what I'm saying. [inaudible 00:44:43] time, you'll learn.
The long and short of it is, without question, teeth can be saved even better today than ever before. I would prefer that the young dentist coming out of school can appreciate this even though they may not have been taught this necessarily in their programs and definitely in the specialty for the post-graduate programs, really all of our colleagues to keep a close eye on the importance of saving teeth. Teeth are body parts. Nobody wants to lose body parts really. You've been around long enough and you know that. Someone losing 1 tooth and that could be the last tooth in their mouth and they're freaking out over, "Oh my God, I'm losing that tooth" or 2 teeth left, whatever. It's a psychological emotional element, et cetera.
Certainly in those cases, that's a different story, but my point is, we can save teeth today. We really can. Root canal treatment, there's not a thing wrong with that. I think many of these teeth, even I thought, resourcing cases, et cetera, can be saved, yes. Now, that said too, not to sound hypocritical, it depends so much on the specifics of the case. In general, I would just say that that editorial that I wrote I think is real important to be able to put things in perspective. Yes, I'm surgically-based, yes, I'm passionate about what I do, but it's not one size fits all. Not everybody walking into my office gets teeth taken out even if they're sent for that reason.
Howard: They always say in politics if you want more of something, subsidize it, if you want less of something, tax it. I have to tell you, I don't really trust ... I love the specialists. I don't really trust an endodontist or periodontist who can't place an implant because if your only tool is a hammer and everything looks like a nail and you got a feed a family, you'll send a horrible failed root canal and they'll just re-treat it. Now, I'm using endodontist to, if they look at that and say, "I can make $1,500 either way. I can $1,500 re-treat it. I can just pull it out baby and put an implant." Same thing with periodontist. I really have a hard time trusting a periodontist when their only tool is flap surgery.
Howard: I'd rather have a periodontist who says, "You know what, this is going to be better. This would be better with a flap surgery," or "No, this would be better just to remove it." I want to go back to, we were talking about specialists and you're talking about all these specialties teaching implants. There's a new specialty, our ninth specialty now, oral and maxillofacial radiology. You were talking at the beginning of this podcast that when you got out it was 2-D, right now it's 3-D.
To a dentist out there listening, to the 3-D X-ray machine, a CBCT is, that's a 6-figure investment. That's a 100,000. What system do you use at your Pikos Institute in Tampa? What software do you use? If they came to your institute, do you actually teach them how to use a CBCT? The even harder thing is how do you learn to read a CBCT? Are you using software with your CBCT to help design and pick the length and width of implant? Can you talk about that?
Michael: Sure. First things first. With regard to the oral and maxillofacial radiology specialty group, these are really some very sharp individuals. I have great respect for what they do because quite honestly, any cone beam CT that we take, whether it's in our office ourselves or someone else is taking it, wherever, the long and short of it is we are responsible. As its true for panoramic radiograph to not so much interpret but be able to identify pathology on that entire field of view scan.
I'm not saying you have to identify and diagnose, but you at least have to know that there's something not right and therefore refer the patient accordingly because these dental findings, my goodness, in any given day, our endododists, they're not going to love us because periapical lesions for maxillary molars. Two different endo studies in '08 showed clearly that 1/3 of all of these lesions go undiagnosed with a periapical radiograph, and that's been the standard of care forever and the periodontist swear by that or have.
The long and short of it is there is pathology we know not just with teeth but certainly in the sinuses and if you're taking a full field of view, well then you've got the skull, the vertebral column, et cetera. Of course, not everybody's going to be comfortable reading that. Therefore, my advice loud and clear for 85 bucks or so, by all means send these scans to an oral and maxillofacial radiologist and these folks are well-trained and you don't want to send them to a medical based, an MD, because basically they'll give you a very generic vanilla, "No pathology noted, sinuses are clear," et cetera. Whereas an oral and maxillofacial radiologist will give you a detailed typically 2, 3-page report detailing maxilla and mandible dentition, et cetera.
Howard: Who are you using?
Michael: Typically, I'm using several different individuals. Cone beam, I beg your pardon, BeamReaders in Sacramento, California is one. Christos Angelopoulos is a maxillofacial radiologist here in New York. [Gil Riordan 00:50:05] who's in North Dakota is an excellent person as well. All these folks have their own websites.
Howard: I don't want anybody pulling over their car, wrecking, trying to write down these notes. I put notes at the end of my podcast. Could you email me those names ...
Michael: Absolutely. I sure can.
Howard: ... so then they'll be in the notes section of the podcast.
Michael: I'd be happy to. Have someone else interpret and therefore the monkey's off of your back immediately. If something is missing ...
Howard: That's $85.
Michael: On average, correct.
Howard: You do that through Dropbox? How do you do it?
Michael: You can. They typically have portals that you can input, you can literally upload immediately.
Howard: Explain the portal. You go to a website?
Michael: Yes, a website and it just walks you right through. It's very simple.
Howard: What's the www on that? That website?
Michael: BeamReaders is one.
Howard: B-E-A-M ...
Michael: B-E-A-M Readers, R-E-A-D-E-R-S.
Howard: What CBC did you go with? There's [inaudible 00:50:59] out there listening. Doc, name the one that you pick. Your a smart guy. Who do you go with?
Michael: There's probably 40 units out there now, different ...
Michael: 4-0, yes.
Howard: Are you serious?
Michael: It's a little confusing. From a cost standpoint, the good news is the cost has come down. For about $85,000 one can get a very nice unit that has more limited fields of view, but I would recommend especially if one is doing work in both arches and [inaudible 00:51:27] degree grafting, a full field of view machine is better. Typically they're about $125,000 range, 130.
Howard: Is there one that can do find a missing canal and a molar and do a full arch implant?
Michael: Full field of view? Not to my knowledge right now.
Howard: You got the [inaudible 00:51:48].
Michael: It's one of the other.
Howard: [crosstalk 00:51:48], you have to either find one machine to find a missing canal and a root canal or another machine ...
Michael: Right. The type I've worked with now for the past 4 1/2, 5 years is the Carestream unit, formerly Kodak. I have the 9300 unit which is the full field of view. Typically the endodontist in our area, in fact, thanks to me ...
Howard: That's the one I have too.
Michael: ... they have all gotten [inaudible 00:52:12] 8100 which is limited filed of view, but resolution is better so therefore they can identify canals better. The 9300 unit is the one that really for me gives me total access to everything I need to see. I had used for the first 5 years a different system, the i-CAT which is nothing wrong with that unit. It's just that the software, in my opinion, with the Carestream is better and their innovative element is on a different level too. I prefer their software as well.
Howard: Who's software?
Howard: I got that one too. You're using their hardware and their software?
Michael: Correct. Software, just for screening purposes. The importance to me, and by the way, all of my patients, all of them gets scanned. Even for a 1-tooth case. If a patient refuses a scan, it's real simple, I refuse treatment. I mean, I'm to that point and have been for years. I sound that dogmatic because quite honestly I can show you Howard a number of single tooth cases where there's pathology that's completely undiagnosed right in the area of the implant, the vision aid bone, a 10-year old could drill a hole and place a little screw in there and go home and Johnny is happy, but the reality is Johnny just put the implant into a periapical lesion that was completely undiagnosed with a PA, et cetera, and even a panoramic.
I'm very dogmatic on our folks getting scanned. The amount of radiation from one of these scans is minimal. I mean, flying cross-country from say New York to LA, you got more radiation at 34,000 feet than one of our cone beam scans. Be out in Florida, 2 hours in the sun, same thing. That argument gets squashed pretty quickly. I'm a big proponent of that. Scanning is important, absolutely, and being able to take that patient right from the get-go all the way through with virtual software use, by the way we used Simplant for a number of years.
Michael: Simplant, yes. Been around for quite some time. It's a very nice diagnostic software as well as a software that can be used for implant planning.
Howard: Where are they out of?
Michael: Simplant is basically out of Baltimore, Maryland, it used to be. Now, I believe everything had been moved to Boston since Dentsply has completely bought out the company from Belgium. They're now based in Boston. The proprietary software I work with for my full arch reconstruction is Maven Pro, M-A-V-E-N, Maven Pro. That proprietary to nSequence. They provide that software.
Howard: You know what I wish you would do, I wish you would ... I wish Carestream would put out some hour online courses on Dentaltown showing demo on the software. I think it'd be good marketing for them.
Michael: I agree.
Howard: Do you have contacts up there that ...
Michael: I do. I can certainly talk with them and see if they can ...
Howard: They came into my office about a year ago and I told them to do that. They provide that after you buy the system. Then you go to their website and enter your code and it's like, "Well ..."
Michael: They should have some upfront. I would agree.
Howard: That should be ... You should put that ahead free.
Michael: We did have a CT diagnosis ...
Howard: By the way, I'm going to be hitting you up everyday for the rest of your life. I know you have some of the most, not only some of the most amazing cases, but long term cases, 10-year follow-ups.
Michael: I do.
Howard: How could we get you to put some online courses on Dentaltown?
Michael: I will do that. I do pride myself in follow-up, and in fact, I've got 20,. 25-year follow-up cases with good histology from grafting for example sinuses, et cetera, that I pride myself in because it's not easy as a private clinician to follow these cases and to document them, but I've got a great staff, tremendous staff. I've been blessed with some terrific people. I have 4 full time employees just with my institute, separate from my practice but combining the 2 forces, we're really very fortunate to have some talented individuals to help me without question.
Howard: I know you're a legend before and I know you don't need me or don't have ever, but I swear I think if you put up ... I think the more and more courses you put up on Dentaltown, you're going to have [inaudible 00:56:25] in that industry of yours. The more you'll be able to raise the price because if you go to market and you sell something and you sell all the courses, you can raise the price yourself.
Michael: Thank you for your kind words. It's been fun. I've thoroughly enjoyed my time in this field. The R word isn't in the vocabulary. I love this work so much that I can see slowing things down, but walking away, I can't imagine what I would do 24/7. I've got my avocations of fishing and what have you, but this work is just so much fun and technology continues to change so nicely. In fact, the half-life quite honestly of what we do today, as I tell all of my course attendees, other than anatomy that the things that I call base knowledge, work, material, that's not going to change. Apart from that, everything else has a half-life of less than 3 years, which means folks taking any of my courses for that matter, within 3 years' time, 50% of it is obsolete. That's a scary thing to even grapple within your mind. It's tough for everybody to keep up. It's tough for me and it's all I do. Therefore, I am excited about what I'm able to do in terms of packaging, the different grafting procedures that I've done over the years.
Howard: Go through the Pikos and say how many different courses do you have? Can you go through the curriculum of the Pikos Institute?
Michael: Sure. I'd be happy to. Basically, again this hybrid surgeon concept evolves around starting with soft tissue. In order to do bone grafting well, it is imperative that one know how to do soft tissue grafting and soft tissue management exceptionally well.
Howard: Is your curriculum like intro, I mean, level 1, level 2, level 3?
Michael: It is in a sense, yes.
Howard: Where would a listener start with?
Michael: It's a lot like John Cuccio's program where, you know, because I had asked John, I'm his scientific advisor by the way on implants and I has asked John, "Where does one start?" The answer is pick a place, no matter where you start, you're going to not have everything you need to know for that course, but you got to start somewhere. That said, soft tissue grafting is what I recommend initially for clinicians coming to us with base knowledge. That's a 3-day course. All of our courses have live surgery, hands-on, which is typically pig jaws, and related items that we work with such as very comprehensive approach and lecture discussion of course. I see this 4 ways for education to be effective. The one being a good PowerPoint, high definition video scenario. They see it. They see the lecture PowerPoint. They see the video. Then they do hands-on and they see live surgery. That's all 4. At the end of that session, I'm not saying everyone could just jump and go home do everything we showed them. It's like an a la carte thing, you pick what you're comfortable with doing, et cetera. That's soft tissue.
Then, we have 2-day modules of bone grafting, 2 days of alveolar ridge augmentation, base level. Meaning, extraction site management, non-aesthetic zone. Then ridge augmentation to include ridge splitting, mesh reconstruction, and even autogenous block grafts. Believe it or not, after all these years, still there's a place for it and the concepts apply for so many other ways of augmenting ridges.
The next 2-day bone graft course is sinus grafting exclusively. That really is an exciting one for me because I've gotten now over 1,100 sinus grafts for 25 years, and the documentation, the way I do things in terms of just addressing complications. The whole 4-hour chunk of time is devoted to complications. Nowhere that I'm aware of is that ever shown as comprehensively. That's 2 days of sinus grafting. Again, live surgery, hands-on, et cetera.
Then 2 days of what we call complex bone grafting which is 3-dimensional grafting using titanium mesh and titanium-reinforced PTFE membranes for particularly grafting, including growth factors of course like BMP, et cetera. It just so happens in November, which we typically do once a year, we're going to probably start this twice a year next year because it's so popular is have all 3 courses back to back to back because we have a number of clinicians who come from overseas or from the opposite coast that want to come and spend not just 2 days but at least 4, if not 6. It's a la carte you can take the 2, the 2, the 2, or 4 or all 6 days.
Howard: Tell them how much that cost.
Michael: Boy, I'm going to say if you took all 3, I believe that is 9,800 for all 3 bone to bone, all 6 days of, we'll call it total bone immersion.
Howard: Ten grand? If they went back to their office and placed 6 implants, that's the value?
Michael: Oh gosh, yeah. The ROI is over the top.
Howard: As your first All-in-4.
Michael: The All-in-4 isn't taught there. The other course ...
Howard: I don't mean All-in-4 the brand, I just mean 4 implants.
Michael: Sure. Absolutely. The pearls that we share throughout all of the courses, and by the way, a number of courses, and this is no disrespect to anybody, but I construe them carpentry courses. Meaning, I can teach you if you were a secretary typing only, et cetera, whatever, how to place an implant and you know that. Even a sinus graft I could show a 12-year old. The reality is what's the why behind it? I've got to show you science, I've got to show you documentation of cases, I've got to show you protocols predicated on reasons that's been well thought out, evidenced-based, et cetera, and complications big time because you're only as good as a complication you can handle for whatever you're doing and you know that. With all due respect to many courses, they're carpentry. Even cadaver, you got to learn anatomy. Sure, that's a great for it but they become carpentry, for lack of a better term.
Howard: I hope to see some online course. I really think it'd be a win-win.
Michael: You will.
Howard: It would be amazing for Dentaltown and I think it'll be amazing for the institute. We're out of time. We're past an hour.
Michael: Thank you.
Howard: It has been a supreme amazing honor to be lecturing on the same stage as you at the Mega'Gen Symposium and to be sitting next to you.
Michael: I look forward to that. It's been a pleasure. Thank you so much for your time Howard. I appreciate this wonderful time together.
Howard: All right. Thank you very much. Hey, go to www.howardfarran.com and get a copy of my new book, Uncomplicate Business. I went through every monthly column I'd written from 1994 to 2015 and I looked at those columns and realized that in business, you only manage 3 things: people, time and money, so I stripped out all the dental and wrote a book that could take any business to the next level. I don't care if you're a dairy farmer, own a restaurant, you're a plumber, this book is for you. Pre-order my book now. Get your copy at howardfarran.com.