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VIDEO - DUwHF #781 - Sanda Moldovan
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AUDIO - DUwHF #781 - Sanda Moldovan
For almost a decade, Dr. Sanda Moldovan has lectured at the UCLA School of Dentistry, teaching other dentists how to perform optimum implant surgery. In 2006, she became interested in helping her patients heal better through natural techniques, such as diet, supplements, water, and bio-energetic devices. Dr. Sanda received her nutritional certification through The Certification Board of Nutrition Specialists 3 years ago.
As a certified nutritionist and periodontist, Dr. Sanda educates her patients that the mouth is a gateway to their health. Her new book, Heal UP! comes out in July. She practices in both Beverly Hills and Manhattan, NY, using minimally invasive oral surgery techniques and integrative nutrition.
Dr. Sanda is a frequent contributor to national television shows, such as The Doctors on CBS, NBC News, radio, podcasts, and she is quoted in numerous publications and blogs. She is a contributor to Huffington Post and Inside Dentistry.
Howard Farran: It is just a huge honor for me to be podcasting with Dr. Sanda Moldovan all the way from Beverly Hills, California. For almost a decade, she has lectured at the UCLA School of Dentistry, teaching other dentists how to perform optimum implant surgery. In 2006, she became interested in helping her patients heal better through natural techniques, such as diet, supplements, water, and bio-energetic devices.
Dr. Sanda received her nutritional certification through The Certification Board of Nutrition Specialists three years ago. As a certified nutritionist and periodontist, Dr. Sanda educates her patients that the mouth is a gateway to their health. Her new book "Heal UP!" comes out in July. She practices in both Beverly Hills and Manhattan, New York, using minimally invasive oral surgery techniques and integrative nutrition.
She is a frequent contributor to national television shows, such as The Doctors on CBS, NBC News, radio, podcasts, and she is quoted in numerous publications and blogs. She is a contributor to the Huffington Post and Inside Dentistry. Hopefully, someday Dental Town Magazine.
How are you doing?
Sanda Moldovan: I'm great, Dr. Howard. How are you?
Howard Farran: I am doing really good. I think it's so neat that you're combining nutrition and periodontal disease. Because when I get out of school 30 years ago all the older redneck dentists thought anything to do with holistic or nutrition or anything natural that you were just a whack, but then when you watch those dentists, they're all like that. When a dentist gets high blood pressure, he doesn't want to take a blue pill every day, he wants to lose weight and start exercising. When you look at dentists they're all natural paths. They all try to exercise and eat right to avoid the pharmaceutical pill and the surgery. So, congratulations to you for combining those two. How closely related is nutrition to periodontal disease?
Sanda Moldovan: Well, I don't think we could get separate one from the other. I do believe the mouth is the gateway to one's health. The mouth shows a lot of signs of inflammation in the body. For example, if you're lacking iron, you're going to red glossy tongue; if you're lacking vitamin C, you're going to get red bloody gums, we know that scurvy is associated. I think we stepped away from that. As we've gotten more and more scientifically-oriented, we lost a little bit track of just the signs that we get from nutritional deficiencies.
Periodontal disease is an inflammatory condition that's not just local. It's a systemic condition. When the immune system is triggered, like it is in periodontal disease, it's not just triggered in the mouth, we see inflammation all over the body. I work with quite a few integrative medical doctor here in Beverly Hills and whenever they have somebody with high inflammatory markers, I check them for periodontal disease and inflammatory signs in the mouth because if we're going to treat the person we have to look at the whole, the mouth and the body.
Howard Farran: You said you work with a lot of integrative doctors?
Sanda Moldovan: Yes. Integrated medicine or functional medicine, it's a newer branch of medicine. We have a lot of MDs or DOs that are doing just that with functional medicine who's been around for more than 30 years to actually connect the different organ systems. For example, now, just like with a periodontist, you go to periodontist, they just look at the gums, you go to a cardiologists, they just look at heart, then you go to GI specialists, they just look at the intestines. But really when the intestines are not functioning properly, we see problems with the heart problems, problems with the brains, it's all connected. Functional medicine takes in consideration all those organs and connects them together, so we had great results.
Howard Farran: I like the Soviet Union model better where dentists or stomatologists just a branch of the, all the MDs had the same undergrad the first two years of med school, then they went off to become dermatologists or internal medicine or stomatologists. I think that was a better system than what America did in 1880 where since the dentists needed a chair and the doctors needed a bed, they separated, and now 140 years later they're coming back together.
Sanda Moldovan: Yeah. It took us that long. But I've got to see, and I see this more in the medical community as well where they're trying to bridge the gap between dentists and medical doctors as we need it desperately. Twice a year I go to medical conferences to see what's new in the medical community. We have new diseases today like metabolic syndrome, for example, a pop-top it's right before like a pre-diabetes stage where all the organs are involved. Diseases like chronic fatigue and leaky gut syndrome, for example. Leaky gut syndrome where the intestinal lining is inflamed is very similar to periodontal disease, where the same thing, the lining of the pockets is leaking, so to speak.
Howard Farran: Of all the nine specialties recognized by the American Dental Association, I think your specialty, periodontist, changed more than all of them. I mean, 30 years ago, there's all these gum surgeries and the patients hated it, and then when implants came out everybody was so quick to, if in doubt pull any molar with periodontal disease and place an implant. Now I see pulling all the perio infected molars and replace them with titanium. I see that pendulum starting to swing back now.
I think a lot of people are thinking ... Well, number one, the patient decides that they want to pull their tooth and have an implant or try to keep their teeth. The other thing that I think the reason it's swinging back is periodontal surgery has gotten a lot less invasive than it was 30 years ago. I mean, 30 years ago it's always quadrant flaps, I mean, right down to the bone. Do you think periodontal disease treatment is getting less invasive than it was 30 years ago?
Sanda Moldovan: Absolutely, Howard. Everything is getting less invasive, not just for dentistry, but also medical procedures. Everybody wants minimally invasive. You're right about what you said about our profession as periodontist, it's changed so much. And it will continue to change because, with new advances in microbiology, we're starting to understand the role of the bacteria and how the biofilm gets formed, and how the different bacteria plays the role in the biofilm.
Now when we're looking at periodontal disease, we're like, let's do less surgery because whenever we cut something that's already infected all the bacteria has a chance to get into the bloodstream, and we know this bacteria travels. Periodontal pathogens have been found in heart valves, especially the highly aggressive periodontal pathogens, such as AAA. We've also found them in joints, in knees, in hips. They travel to the lungs. We know they don't stay in the mouth.
For my practice I completely changed the model that I've learned 12 years ago when I went to residency at UCLA. Essentially we were taught flap surgery, but I've moved away from opening a flap, especially when have an infection, and finding out what or who is causing the periodontal infection with a saliva test called oral DNA. Or somebody just simply swishes back and forth, spits it in a test tube, we send it to the lab, and we can find out within five days what microorganisms are causing that particular infection.
Then from there, we offer non-surgical procedures such as lasers and ozone to be able to clean up the infection, also give them nutritional support for inflammation, and together with this whole mouth disinfection we're able to get great results without the painful surgeries that we had in the past.
Yeah. We always used to get the 3% recurrence of disease. We never were able to treat everyone ,and I'm a true believer that, because of these highly aggressive pathogens that we didn't even know they were there before. Because we treated everyone the same, everybody else got their root planning, everybody got osteo surgery, but we never really tested on a regular basis what kind of bacteria this patient has. Now we're changing that model to be a little bit more specific and less invasive.
Howard Farran: Almost everyone listening to this podcast is commuting to work, they have an hour commute. They ask for two shows a day for their morning energy. But since I can't take notes, I always do a transcript of the whole podcast and put it on DentalTown. I also retweet their last tweet, you're @drsanda, S-A-N-D-A, it's sonda. It's on that sonda. You can find her there and she's got her website link on her Twitter Ask Dr. Sanda. By the way, you're the only person I've ever podcasted who is verified on Twitter. How cool is that? That is amazing.
Sanda Moldovan: Oh, yeah.
Howard Farran: I got 20,000 followers and you got 28. When I get to 28, do I get verified? How does that work?
Sanda Moldovan: No. I think, I'm sure you can get verified already. I sent an email to Hollene, and she let you know how to do that.
Howard Farran: I also know that you've been on CBS, NBC, and all these famous television shows because you have a face for television, and I have a face for a podcast.
Sanda Moldovan: You're funny.
Howard Farran: I only have a face for a sound. Also, you mentioned-
Sanda Moldovan: You have the personality for television for sure.
Howard Farran: We're talking about integrative medicine and being a physician of the mouth, what percent of dentists do you think have ever done any type of salivary testing?
Sanda Moldovan: Howard, actually I lecture nationwide on the topic of nutrition and this concept and I'm often sponsored by Nobel Biocare to do this, and I'm very thankful for that. I find that less that 1% of dentists actually do oral DNA tests, because I always ask my audience how many people actually do a salivary testing and very, very few. Mainly because oral DNA, it was advertised, it was started by a periodontist. I think they've been around for probably more than six years by now. It's such an easy test for dentists to be incorporate, even the dental hygienists can do this.
Because it's simply a saliva swish, they can spit it in a test tube. It can't get easier than that and then you get such good information from this. Not only that, but that could give good information, but it also when a patient actually sees this kind of infection in their mouth, it connects them to their own disease. Because all the time periodontal disease has no symptoms. It's hard for patients that say, "Oh, do I really have this problem?" But when they're actually seeing how much bacteria is in their mouth, then they have a tendency to get engaged in their treatment.
Howard Farran: Yeah. I think it's almost like the germ theory hasn't come to dentistry yet, because you still go into dental offices where a hygienist will see the mom every three months for a periodontal cleaning for 10 years, and she's never once seen her husband. Then her husband finally comes in and he's got a bombed-out molar and he's got, he's like, that they're kissing. I mean, isn't there ... They're giving this stuff. I've seen studies that says a single kiss can transmit 80 million microorganisms. I mean, how do you treat the mom and not the dad for periodontal disease?
Sanda Moldovan: Absolutely. I agree with you. That's something that we actually stress in the office, especially in the high level of aggressive pathogens. When you get the report back for a patient it actually says in there that this bacteria is transmissible.
Howard Farran: Seriously?
Sanda Moldovan: It actually says that, yes. Yes.
Howard Farran: Oh, my God. That is amazing. There's still dentists on DentalTown that deny it. As far as the microorganisms, [inaudible 00:12:02] Christian is a PhD oral biologist and she says that they're discovering a new species of bacteria every quarter in the mouth. So it may be even 100 more years, it could be 200 more years before we even know every name of every virus bacteria and fungi even living in the mouth.
Sanda Moldovan: Absolutely. That's exactly the point. It's not just bacteria. Well, we know it's also parasites. I work with this lab in Colorado called DNA Connexions. Oftentimes they do this floss test, you can floss and see what you have in the mouth. We don't know yet what to do with this information, but we're just kind of gathering data right now to see what exactly is living in the mouth. They're testing things and bacteria, everything that they have markers for. We find parasites, we find viruses, we find fungus, different species. We know the biofilm is not just bacteria, as you're saying. You're right. Right now it's just, I think just that beginning a microbiology studies in the mouth. Periodontal disease will change that way we look at it and the way we treat it for sure.
Howard Farran: What is this DNA Connexions? How are they different in oral DNA? What's the difference there?
Sanda Moldovan: DNA Connexions, they do things a little bit differently. They also biopsy things that are deep inside the jaw bone. For example, one of the practitioners who works with me, he's an endodontist, and oftentimes we biopsy things that are at the apex of root canal teeth. We're also trying to understand what's living in there. DNA Connexions, we use them mostly for a deeper kind of test to see what kind of microorganisms are living inside the jaw bone.
Also, some patients can contact them directly. They don't actually need to go to physicians and have one of their tests. DNA Connexions offers what's called a floss test, where you can actually floss all your teeth, put the floss in a little baggie and send them in the mail and they'll tell you what's living in your mouth. But we don't know what to do with that information really. We're not there yet.
Howard Farran: Okay. I just found them on Twitter. They are @DNAconnexions and their last tweet, what is Lyme disease and what are the symptoms to look for. Let's see if there's anything more dental.
Sanda Moldovan: Yes. Actually a lot of the physicians I work with are chronic disease physicians and they do treat Lyme disease. We do see a strong association between oral infections and Lyme disease. We see more and more patients, younger patients with Lyme disease. DNA Connexions offers one of the best tests for Lyme disease.
Howard Farran: While we're on that, I noticed ... When you're integrative natural, nutrition, what's your view on the silver filling, because it contains mercury, silver, zinc, copper, tin? Is that a no-no in your mind? What do you think?
Sanda Moldovan: Well, it's interesting you said that because today this morning I was reading the ADA Journal and they were actually talking about California Proposition 65, which goes into effect next year. We actually have to post in every dental office in California the harmful mercury in the amalgam. We actually have to make it official that if we take out amalgam we have to put up a sign saying, "Hey, it's a neurotoxin. It causes birth defects and other things." I think we have enough evidence now for all of us to realize, yes, the mercury in amalgam does cause a problem. It's a neurotoxin.
I know one of my dentist friends in Portland, she actually had to quit dentistry for a couple of years because her mercury levels were so high from removing amalgam fillings. She had blurry vision, headaches. She had to quit, chelate all the mercury out of her system, and finally she's getting back to work slowly.
I tested my own mercury level in the blood and I highly encourage all dentists to take, test their mercury level and see how high it really is, because we are getting affected, not only us but also the patients. But especially as health practitioner as dentists, we are exposed to high levels of mercury 2,000 times more when we actually take an amalgam out in the air than the EPA even allows. It is definitely a neurotoxin that we should all be careful of.
Howard Farran: Do you take any extra precautions when you remove them?
Sanda Moldovan: Absolutely. I don't remove amalgam. I do mostly extraction of teeth who have mercury fillings, but I never cut into a mercury filling. If I have to cut a tooth, I will cut around the mercury filling and not actually cut through the filling itself. Here in our office, we have a multi-specialty office. The dentists I work with, they take precautions, they use a smart certification for IAOMT and we have the vacuum to suck out all the vapors that come from the mercury and use a rubber dam to ensure that we kind of trap these mercury vapors and we don't inhale them.
Howard Farran: Even if we never place an amalgam again, we would be drilling them out for a century. Actually the worst thing about a silver filling, which was the nail in the coffin, was that when you look at environmental mercury in the air 50% of it comes from burning coal, but 6% of it comes from cremating humans who have silver fillings and there are amalgams. I mean, California, if they want to get a great lid on it, at least pass a law that somebody has to go in and extract the molars. You can't cremate a human that has a half dozen MOD amalgams in their mouth because it's all hot, it's heated, it's crazy.
I want to go back to patients hate surgery. They hate periodontal surgery and a lot of them emotionally don't want to lose a tooth. I want to go back to non-invasive. You talked about microbiological testing. I know LANAP came out years back, a lot of people are using lasers. Are you using lasers?
Sanda Moldovan: Yes. I use lasers now for 10 years. I'm more of a biolase user. The reason why I like the Biolase YSGG or the erbium YAG lasers is because they have the ability to affect hard tissue. LANAP just really just a soft tissue laser it's essentially a diode laser. But I prefer something, because when I treat pockets that are 9 millimeters deep, I actually want to recontour the bone on a closed flap situation. I want to get the osteoblast. I want to perforate neuro micro perforations of the bone to be able to get the osteoblasts to come out of the bone level. In my hands, the YSGG waterlase works great in reestablishing periodontal health in moderate to advanced periodontitis case.
Howard Farran: Are you saying it's the waterlase YSGG?
Sanda Moldovan: Yes, it's YGG.
Howard Farran: If you did 100 quadrants, what percent of time would you use a laser?
Sanda Moldovan: Ninety-nine percent of the time. I rarely will flap a case because I do see bone regenerating even an angular boney defect. I actually did one of the cases for The Doctors TV show on CBS. On my website you can ... That particular patient had advanced periodontal disease and 10 millimeter pockets that are fully been eradicated just by using the laser and not having to do major flap surgery.
Howard Farran: When I think of periodontal disease it's amazing how this oral systemic health that what's motivating the medical insurance companies the most is that the association between gum disease and premature birth. That's their most expensive line item ticket. It's about a million dollars cash to have a premie. Some of the CEOs are starting to look at that when you insure someone with medical coverage, if it doesn't include dental coverage for the pregnant mom, you're going to have to get it out of your checkbook. What do you think about the association of gingivitis, periodontal disease in premature babies?
Sanda Moldovan: Well, we know from periodontal research Dr. Offenbach, he published a paper showing that moms with periodontal disease have babies and they give birth earlier and their babies are low birth weight. We know that this bacteria travels to the embryonic fluid and has an effect for sure it creates inflammation and in turn then we have preterm or low birth weight babies.
Definitely, I think we should work more with OB/GYNs. I wonder how many OB/GYNs really look in the mouth when somebody comes to them pregnant, say, "Hey, how's your periodontal condition? Do you know that this can affect your baby?" and encourage them to actually have a visit with a periodontist to ensure their mouth is healthy.
Howard Farran: I still cracks me up because I've gotten a physical every year for 30 years and every time they go to the mouth, he says open up, and he looks down with this light like one second, and then he's done. I'm thinking, okay, I've been a dentist for 30 years. The hell you're just done. It means I opened up, say, ah, ah, and it's like, okay, and then he throws the Popsicle stick in the trash can and moves on to other body parts. I'm just like, I almost can't quit laughing.
When you're treating a standard patient for gum disease and you're using your laser and all that stuff, what percent of the time when you're done with your periodontal specialist hat, do you put on your nutrition hat and start talking nutrition, do you give supplements, how does that work?
Sanda Moldovan: In my office I created a program. When somebody has inflammation in the mouth we do what's called the full mouth disinfection and that includes automatically a nutritional support. We have such great evidence today that certain supplements are key to decrease an inflammation in the body. Of course, not just supplement. I'm a true believer that the diet and lifestyle influences how things heal.
Definitely, we have a chart. We talk to patient about what to eat. We help them with substitutions, not like, I'm not of the opinion that we should cut out everything that we really like, everything that we're addicted to all of a sudden, we just have to find good substitution for patients. For example, sugar, there's so many great substitutes for sugar today that could be even anti-inflammatory or promote the health of the mouth, such as xylitol or trehalose. We have also monk fruit drops that are good sugar substitutes. Things that are a little bit more natural, non-artificial to help them get off sugar.
Howard Farran: Have Russians invented the vodka yet made of xylitol, so you drink it and not be diabetic at all?
Sanda Moldovan: That’d be good, but-
Howard Farran: They were first in satellites, Sputnik, why don't you send their dental society and say, since you guys drink most of the vodka in the world, why don’t you make a xylitol vodkas? Do you think they could do it?
Sanda Moldovan: Those Russians, I tell you, they study microbiology unbelievably well, so I'm sure they have a method.
Howard Farran: They have probably one of the most disciplined education systems in the world.
Sanda Moldovan: They do. You know what they're saying, I was actually talking to one of their researchers. They're studying to do bacterial testing based on their quantum vibrations, so they're going back to quantum physics. So instead of doing of blood test, saliva test, they're just basically testing the quantum vibration to be able to tell what kind of bacteria is present in that infection instantly, without waiting the five days.
Howard Farran: We just had 6,000 kids graduating 56 dental schools on last week. Since I've got out of school, indemnity insurance paying a thousand for root canal, now it's 95% of dentists take PPOs, if you consider Delta, Delta is a PPO, at least 82% take two or more PPOs. A lot of dentists listening to people like you say, "Well, I'm not going to do it unless there's an insurance code." What would you say to the graduating class when they go get a job with some old fart in Parsons Kansas and he won't do anything unless there's a billable code for it and he just sits down and he drills, fills, and bills insurance codes all day? What would you say that the graduating class?
Sanda Moldovan: Insurance codes are revised every year. We actually do have insurance codes for microbiological sample for saliva test, there is actually codes for that and they're definitely billable. There are also codes for nutritional counseling in the dental office. So that is actually a billable code.
Howard Farran: Interesting. I really hope you write article with DentalTown Magazine on this periodontal nutrition. Because I've had that magazines since 1994 and I've never seen this. It's kind of like who got peanut butter on my chocolate. What's really exciting about DentalTown Magazine, which is crazy, is since it's online it's actually more people read it digitally than the 125,000 we mail it to.
I mean, this internet, it is so romantic when you get emails from little girl dentists in Somali, in Ethiopia, and Cambodia saying they look forward to them every month. This is truly new. What about, speaking of Soata, when you lecture in South Africa, they like ozone and it really never took off in the United States. What are your thought, why did the South Africans who are also brilliant, why are they into ozone and the Americans aren't?
Sanda Moldovan: That's interesting because we should be. Ozone has been around for more than 100 years. Nikola Tesla developed the first ozone machine for medicine in 1898. He was actually very popular during that time because we didn't have antibiotics. What really happened with us as the antibiotics came on the market the ozone later fell out of favor because somebody had that machine, you have to go to the office. It's much easier to write a prescription to give it somebody and have them treat the infection. It was fine then and it was taking care of a lot of infections, but now we're seeing that a lot of bacterial resistance is popping up with the recurrent infections. So we're trying to move towards something that cannot cause resistance. That's what I see with ozone.
Ozone, having three atoms of oxygen and have that one oxygen that comes off and it starts basically poking holes in all the membranes of bacteria and parasites, and it doesn't discriminate. It really has the ability to wipe out on contact any let's say pathogenic biofilm, not just one bacteria, like for example, as we do with antibiotics. Because really antibiotics don't get rid of parasite, don't get rid of viruses whereas ozone does. I started using it in my office, I would say probably about four years ago now and especially for periodontal disease where we're dealing with biofilms, we're dealing with pathogens. It's made a world of difference.
Howard Farran: It's the machine you're using. Who makes the machine?
Sanda Moldovan: There's different companies now who make the machine. There's actually good news if you … One of the dentists here in California, he has a machine called TherOzone. It just got an FDA approval for making ozonated water. I think we're slowly moving towards getting ozonators out there. Because for us, especially to use ozonator water to clean the dental lines, which we know are full of gunk in there, I think it was on 60 Minutes that they were uncovering how dirty that dental lines are, so ozonated water will actually flush those lines with no problems.
Howard Farran: It's called TherOzone?
Sanda Moldovan: TherOzone, yes.
Howard Farran: TherOzone. Man, you are a world of information. Okay. I just found it. Their website is T-H-E-R-O-Z-O-N-E TherOzone. You said a dentist made that?
Sanda Moldovan: Yeah. Actually I keep meaning to go visit him and he's on my list. He thought he's out in the Santa Monica area. It's so hard to get FDA approval for anything, so hats off to him for actually going those steps to be able to get this machine FDA approved. That was the biggest complaint before. "We don't have any ozonators FDA-approved." Although there's many things in dentistry that don't have FDA approval and we're using.
Howard Farran: Speaking of that, the graduating class is, they're young and they're learning communication skills. One of the things they complain about on DentalTown is that when they tell people to floss they say, "The New York Times said there's not a shred of evidence on flossing," and you just said there's a lot of things we use FDA-approved. What verbal skills would you give a 24-year-old kid who's telling some old man to floss he says, "Maybe you should read the New York Times because if you did you’d find out there's …" What would you say to patients who say that?
Sanda Moldovan: Well, that's a good question, Howard. It's like, if we actually listen to everything that FDA actually comes out with, we’d probably be dead by now because they put drugs on the market they say, oh, this drug is totally safe, and then a few years later the drug kills a bunch of people, then they take her off the market. I think we really have to look at the research and use common sense, what works what doesn't work. It takes really years or something to get FDA approved. During those years sometimes 10 years, one of my colleagues is trying to get a supplement for chronic fatigue FDA-approved. He's been in the process for 10 years and it's still not there. Does the product work? Yes, and it's all natural. He's been using and it's been shown trial after trial.
I suggest to those young graduates to go look at the research or ask an expert who has looked at the research. What does the research show? Is this product detrimental to one's health or is it not? Ozone, for example, is all-natural. We know that ozone has an immune effect. It stimulates the immune system and doesn't just kill organisms. So it stimulates one's immune system to clear up the inflammation and the infection.
There's lots of papers from all over the world, Europeans use it, Australians use it. It’s not one of these things that just popped up. If something has been in use for a long time and has good research, then I suggest to them to go to learn more about it and use it.
Howard Farran: I want you to address another very common complaint all these kids who graduate, they say, "I just graduated dental school and we never placed one implant." It'd be easy for you to go from a thousand implants to a thousand one, but she's got to go from zero to one. She's setting out there looking at ... What advice would you give her? The other problem that she says, "In America so much of the implant training is tied to the company they almost get paralyzed first because they think they have to find the perfect implant system first because all the training is tied into the implant and there's over 175 implants that are sold at the 88 convention. Give her some coaching, how Does she go from zero to one? Because, I mean, you're teaching it at UCLA, did the UCLA students, when they graduated they had placed an implant?
Sanda Moldovan: Yes. Not students themselves though, you actually have to be in AEGD program or have to be in a residency program. It's unfortunate when I hear these things that still there are some schools have not really implemented implants in their teaching facilities, because there really was a standard of care instead of bridges. Unfortunately, only about 20 to 30% of dentists are using implants right now. Some guidelines to recommend where to look for classes is one, pick a company that has at least five years of research to know that you're offering the patient good solution. The success rates for implants today in 10-year period is really should be over 95%.
But if a company doesn't have that yet and it's only been there for two to five years and they don't put money into the research, I wouldn't recommend going with that particular type of implant just to save some money. Because I think our reputation is the most important thing after all. Especially as a young dentist, you want to establish a good reputation from the beginning.
Then, there's so many courses out there and I know working with the implant education for 10 years you can find as part of university's continuing education or even the implant companies, the most reputable companies, they have great courses that they offer hands-on as well. I just gave a course actually in Portland, Oregon on pig jaws and that's a great way to learn before going on patient, to use something to simulate before you actually go into a patient's mouth.
Find a mentor, that's the other thing. I'm more than happy to mentor young graduates who want to learn the right way to do dental implant. I think general dentists have great surgical skills and they should really look into adding implant surgery to their practices and I'm happy to mentor.
Howard Farran: Well, I'm sure she's listening to this as she's driving to work and she's thinking, I want to know what Sanda uses, what does Sanda use? What are you teaching in UCLA?
Sanda Moldovan: We work with Nobel Biocare exclusively. Nobel Biocare has the most research that they've done over the years. I use mostly now Noble Active. Noble Active is like a corkscrew type implant and I use it in live media cases Teeth-in-a-Day when we use full-arch restoration in one of these surgeons actually before The Doctors when we replaced upper broken teeth with four implants, the All-on-4 implants treatment concept and a full arch bridge.
Because let's face it, a lot people are afraid and going into dentures, especially a lot of my women patients, they do not even want to see themselves without teeth and they say, "No. I just don't want to wake up in the middle of this. I just don’t want to see that I have a denture." This kind of replacement especially with an implant that's had great research and the All-on-4 treatment concept has had about 20-year research we know has high predictability if done correctly.
Howard Farran: That was with Palo ... Is it Paulo Malo? How do you pronounce that, Paulo Malo?
Sanda Moldovan: Paulo Malo, yes.
Howard Farran: Paulo Malo?
Sanda Moldovan: Yes. I was fortunate enough, I'm very thankful for his teachings. I went to his facility in Portugal and I spent a week over there just to learn from the best really. He developed this technique 20 years ago and nobody believed him that this will actually work, that four implants could support a whole bridge long term.
Finally, after 20 years, when we actually have the research to know it's predictable, a lot of people are getting on board with because it's a great treatment for patients. It's a treatment that saves people money because we don't have to do sinus lifts, we don't have to do the bone graft that typically drive up the cost.
Howard Farran: You like doing All-on-4s?
Sanda Moldovan: I do. I think it's so gratifying for me to see people's smile after the flap, now to go from [inaudible 00:36:56].
Howard Farran: I don't think we've ever published an All-on-4 case on DentalTown. Maybe there's another idea of an article to publish in DentalTown. Can you hear me?
Sanda Moldovan: Sure. Yeah. Absolutely. I can hear you. Okay. Sounds good.
Howard Farran: Yeah. Lisbon, Portugal. That was the first European, that was the first city outside of America that I ever saw, I was 16 years old. I went to a Catholic school and they had this on this, I don't know what do you call, a recruitment trip. They loaded up a 747. Every year they put 450 Catholic High School boys from Kansas, fly them to Lisbon, Portugal and Fatima, and all that stuff and every year they'd get about 10 conversions that would cancel their flight home and join the priesthood. So my mom tried so hard and she sent me on that trip. She was so hoping that I would switch from dentistry to priesthood, but it didn't work out.
You like the Noble Biocare, you like the Noble Active, you're doing All-on-4. How long would it take a 24-year old graduate from dental school to go all the way from I've never place one to Sunday I'm placing All-on-4? I mean, that's a long journey. Where do you think she should start at?
Sanda Moldovan: I think they definitely get some basics in dental school about dental implants. But if somebody has not placed one implant, I would say start small. Start with a single implant. My rule for this is always if you don't know how to treat the complications, don't do the procedure, because I think the most important thing is learning how to deal with complications. Of course, they arise rarely, however, if you don't know how to deal with them and you don't have somebody to help you deal with them, then it's a problem, we're not really serving the patients.
Of course, things happen to everyone. Like my mentor Sascha Jovanovic, he says if you haven't got enough complication, it means you haven't placed enough implants, because they will arise. Everybody heals at different rates, things happen, the bone quality can be poor to start out with. Things will fail. It's just learning how to deal with that. That's probably the most important thing in implant therapy.
I'd say start small and do a single implants, not in the aesthetic zones, start with a premolar molar side. We have a lot of bone. Once you get comfortable with that, take a bone graft course, and then do an implant and a bone graft, and then and just keep getting a little larger, do an implant bridge and then probably after you get comfortable with that, then go into All-on-4 treatment concept. In terms of restoration, a skilled surgeon and a lab technician who’s done many All-on-4s can definitely guide a young dentist into restoring these cases properly.
Howard Farran: I'm going to ask you the most controversial implant question on the DentalTown boards. I want you to know that no matter what you say, half of the dentists will disagree and the other half will agree. That is a lot of people say, like you said, you need to learn how to be able to deal with the complications, a lot of the, everyone who's placed 1,000 to 10,000 implants say you need to lay a flap and see the bone and you need to be a surgeon. But the Millennials are saying, "I don't want to lay a flap. I want to make a surgical guide and I just want to punch through the tissue." Then the old guys are saying, "That's like putting training wheels on your bicycle. You got your doctor, your surgeon, you got to put the scalpel to the bone."
My question to you exactly is when she starts her journey and is looking for sudden, not in the aesthetic zone, a premolar or molar, would you recommend a surgical guide or would you recommend getting a scalpel and going to bone?
Sanda Moldovan: When I did my residency actually we didn't start dental implants and so we learn to deal with flaps. My director of the program at UCLA, he said, you guys have to learn to manage flaps before you do implants because if you don't close the flap properly your implant can fail or you can have problems or recession and things like that. I think it's definitely key to learn how to do flaps and learning on an animal model, for example, if somebody who's already graduated is great, like pig jaw or a sheep head. There's lots of animal models out there that somebody can start learning flaps.
Then I believe the flapless procedure is a little more advanced procedure because you already have to kind of imagine what the bone looks like underneath. I know guided surgery is a thing of the future and I love guided surgery. I use the Nobel recommendation to be able to kind of simulate the surgery before we go in there so we can treat bone plan better and understand what could happen and things like that. But it's still not a foolproof. We still have to know in case that implant doesn’t engage properly to be able to raise a flap and correct the situation for sure.
Howard Farran: Another problem dentists are having out in the field is that patients come in with peri-implantitis and they have no pain, they're chewing, they're eating, and you have peri-implantitis. What do you think is the incidence of peri-implantitis on implants place in America 10 years ago, and how are you treating that?
Sanda Moldovan: This is actually a topic, peri-implantitis is a topic I talk about nationwide because it's such a problem. We know the statistics today, this was published in Perio just last year. One in five patients will develop peri-implantitis within five years. One in five patients. That's really scary, because we're offering a treatment that could potentially last a lifetime. But I think, as a student, you might remember going to the conference, then into the years after that and I hear not about how to do dental implants but nobody really took the time to spend time on how do we maintain these implants long-term.
That's something that I'm very passionate about kind of spreading the message. We do have some recent guidelines. We had a consensus in Europe and 10 of the best clinicians got together and say, okay, can we help prevent peri-implant diseases. They put some guidelines together, which have been published to help the practitioner maintain the implant long term. Because right now we're just telling patients, "Okay. Well, here's your implant. This is what I hear a lot, and just brush and floss normally." But that's not really correct.
For example, just using an oral irrigator around an implant we can increase the longevity of that implant because floss doesn't clean properly. Really oral irrigator versus string floss, we know oral irrigator clean much better. Even as simple as that, something as simple as that, it should be incorporated in the implant treatment plan.
Howard Farran: Do you know why I think patients don’t like using the WaterPik? Because it's something messy. I was so excited to see that WaterPik now has a rechargeable WaterPik that you can take into the shower. What I always have is, on mine is the shower floss because when you're WaterPikking or water flossing in the shower, no one cares where the water goes, when you're at your kitchen sink and there's splashes all over the room, I think they think it's messy and then moms will get one and then their kids come in and start using it, and the next thing they do is that they would they want to put it under the cabinet. I think the shower floss and that new WaterPik one that you can carry, that you can fill up and carry into the shower would be better.
You're talking about that you could prevent it better instead of brushing and flossing regularly getting a WaterPik. Do you have a brand, you're a periodontist, what brand do you like?
Sanda Moldovan: I use different brands. I like personally a portable one, and of course, WaterPik is the most well-known brand out there. They do have a portable, they have a shower pick one, and they have the one by the kitchen sink. I myself love a portable one. My portable WaterPik is even black so it matches everything else that it stays clean. Nowadays you could find really cool design portable oral irrigators.
Howard Farran: What is the name of that?
Sanda Moldovan: I actually use something called Poseidon. It's just a smaller WaterPik. Poseidon, yeah.
Howard Farran: Did you ever see the movie The Poseidon Adventure?
Sanda Moldovan: I haven't seen it. All right. The god of seas. It must be a good movie.
Howard Farran: That was a great movie. That was just a classic movie. There were so many stars in that movie, the Poseidon Adventure. They were on a Greek cruise and there was an earthquake and the boat got flipped. So that's how I remember that. Poseidon makes an oral irrigator. That's the name of the company?
Sanda Moldovan: That's the name of the company. Yeah.
Howard Farran: Did you like it?
Sanda Moldovan: We like it because it's inexpensive and people have a tendency to try it, it's a lower cost. I love it because it's smaller. It's more compact so you can take it in the shower, as you said, you don't have to make a mess.
Howard Farran: You're talking about prevention. You said you can’t just brush and floss, use an oral irrigator. You recommend a Poseidon. What other things to prevent and then go to treat, the 20% that have it. What other things were they saying to prevent it? Then let's say they already have it, so that 20%, how would you treat it as a periodontist?
Sanda Moldovan: The other big problem that I see out there is we don't recognize mucositis, let's say peri-implant mucositis, which is the initial inflammation of the gums that are being inflamed without penetrating into the bone. If we start recognizing that when it first starts we see them bleeding upon probing right away, then we can do something about it right away.
But I think what happens is and especially as specialist, I think these implants they actually have advanced peri-implantitis already. I think we should learn to recognize the signs. If somebody comes in for hygiene maintenance and their implants is bleeding that's the time to do something about it. If we keep telling the patient, just go on and brush and floss some more, it's not going to work.
At that time I think we should be more proactive into recommending them something different for oral hygiene. Also, doing some of ozone treatments or laser treatments to help tighten that tissue again. Also, recognizing that we have very thin tissue around an implant that also creates the problem with bone loss. Being proactive and grafting these sites and maintaining healthier and thicker periodontal or peri-implant tissues would be ideal.
Howard Farran: Then as far as treating it when you see it, do you flap that? I mean, do you try to regenerate bone around implants when they lost bone? Or is that very successful or is that more of hygiene, the implant needs to come out and be replaced.
Sanda Moldovan: Yeah. Unfortunately once the implant has lost bone, we don't already have a good predictable way to really rebuild this bone back. My favorite way to grow bone back around an implant is using lasers. There's peri-implant protocol again with the waterlase, with the YSGG, to help regenerate the bones and repair the bone around an implant.
With bone graphics and techniques when we have to raise a flap, I really reserve that for a larger bone graft, more than 50%, for example, But often the limitation is the fact that again the biofilm gets into the implant surface that we just can't clean it out before we do the bone graft. It's best oftentimes to just take the implant out if the bone loss is over 50% and just place a new one with the new bone regeneration.
Howard Farran: Are you buying that Poseidon toothbrush from ToiletTree products? Is that where you get it?
Sanda Moldovan: Yes.
Howard Farran: Yeah. Ryan found it for me. I just retweeted them. I've never even heard of it and but they're following me. They're @toilettreeprod. I play on toiletries. I think it's pretty cute. Toilet Tree. Toiletry was already taken. ToiletTree Products, I retweeted that deal and I saw the picture on the website. I can see ... when is Father's Day? Not this Sunday. What, next Sunday?
Sanda Moldovan: I think so. I don't even know.
Howard Farran: Yeah. Here it is. I'm going to tell Ryan, that's what you need to get your dad for Father's Day. Come on, Ryan.
Sanda Moldovan: The portable one is even better than that one. I think that's their sink model.
Howard Farran: Oh, that's a sink model?
Sanda Moldovan: Uh-huh (affirmative).
Howard Farran: They also got a sonic toothbrush. Oh, you mean? Okay. Right there, that one?
Sanda Moldovan: That's it. Yeah, that's the one.
Howard Farran: Nice. I've never even heard of them before. Very interesting. UCLA has an implant residency though, don't they? I mean, that general dentist can take?
Sanda Moldovan: Yeah. They have a one-year implant residency. Also there's Global Institute for Dental Education, GIDE. They also have a one-year masters program. I'm also involved with them in terms of the teaching properly. You know what I think about taking a one-year residency is that as somebody's starting with implants, they have a place where they can bring their cases and say, "Okay. This is my case. This is where I'm having difficulty with. What do you think I should do here?" It's a nice way to have a support group.
Howard Farran: You're on the faculty with GIDE, G-I-D-E?
Sanda Moldovan: Yes. Dr. Sascha Jovanovic founded that. He was my implant mentor and I am very grateful. I learned a lot of my surgical skills from him. He has asked me to come on board and help with the classes there.
Howard Farran: What does GIDE stand for?
Sanda Moldovan: GIDE is Global Institute or Dental Education.
Howard Farran: Global Institute or Dental Education. Where is that in Southern Cal?
Sanda Moldovan: That's not very close to Beverly Hills, probably, maybe four miles away. It's on the west L.A. area.
Howard Farran: Where's the UCLA?
Sanda Moldovan: UCLA is in Westwood, also about four miles away from Beverly Hills.
Howard Farran: You would recommend both of those or would you recommend one more than the other?
Sanda Moldovan: I do. I do recommend both of them. Of course, there's other great program in the country that have a one-year residency, also Loma Linda, for example. Their program is actually two years. It's a little bit more involved, so it really depends. The nice thing about a weekend program over one year is that somebody can still practice, they don't have to give up their practice in order to learn a new skill.
Howard Farran: What do you think of this new trend where you go outside the United States, to Mexico or the Caribbean, and place a bunch of implants where you're free from lawyers and all that stuff? Some people say it's a great experience because you're going to place 10, 20, 30 implants, but then other people say, "Well, the most important thing is to see those patients 30, 60, 90 days later and follow them a year later, and if you're not going to see that patient again you're not learning." What's your thoughts on that?
Sanda Moldovan: Yeah. I tend to agree with the latter thing that you said. That it's nice to be able to follow up the treatment of the patient to see how is it healing, is the patient having pain, how are you managing those conditions? I think literally placing an implant is easy. Anybody can put an implant into any bone, but did we give the enough prosthetic support where this implant to be restored properly? Did we take care of the tissue properly? Is patient in pain a lot? Most of the patients are in pain, maybe something with my surgical technique, I'm burning the bone. I think follow through is most important with any surgery.
Howard Farran: How much is the one-year residency, a GIDE or UCLA? How much investment is this going to be?
Sanda Moldovan: They run anywhere, I think from about $8.000 to $16,000, depending on the type of program and where you'll have it. Of course, I think you Loma Linda is even more than because it's a yearly program, but it's basically give up their practice to go there. That's even more expensive, I think 20,000 or 30,000.
Howard Farran: Yeah. Last thing, you've been so adorable giving me an hour of your busy life.
Sanda Moldovan: My pleasure.
Howard Farran: I'm almost out of time, but I also want to ask you, do you think this is true, just say if it's true or false, a lot of dentists, Tim, I believe that the critical mass for a doctor is you got to do it once a week. I don't see any evidence that someone who does an invisalign case three times a year is fast, high-quality, efficient, and profitable. These people will start learning sleep apnea and they'll do two cases a year. Dentists that make one denture a year, oh my God, they're horrible.
Do you think if you get into these implants, so it's an investment of 8,000, 10,000, 17, 000, well, you can recoup that implants or 1,000 a piece, I mean, 17 implants. Do you believe that you have to place one implant a week or do one dental procedure a week to really reach critical mass? The flip side of that question is, say, you needed a surgery, would you want to go to a doctor who does that surgery every three months or would you like to go find a doctor he does that surgery at least every week?
Sanda Moldovan: Yeah. You have a good point there. I do think if somebody starts doing dental implants maybe a way to motivate patients to come in is definitely able to offer them a lower cost, but I think recognizing what cases are good to do, like the simple cases especially in the beginning where you know it's not too stressful and everything goes smoothly and then they can tell other people, "Oh, you know, this was great." Also, I started with my family members when I was a resident. Oh, no. Luckily I had enough family members there so I practiced good 20 implants before on my patients. I think there's ways to build a practice with dental implants.
I was recently in Arizona actually. I had lunch with an Arizona dentist who changed his business model and now he's just really taking referrals and all he does is dental implants and he takes referrals from other general dentist although he himself is a general dentist.
Howard Farran: I think you're amazing. I mean, how did you get to be the contributor to the Huffington Post? I mean, those guys are crushing it on the internet. I mean, when the New York Times, the LA Times are still trying to build up their newspaper delivery thrown on your driveway, the Huffington Post is aimed at the internet and crushed it, and you got to be their contributor. Congratulations on all that.
Sanda Moldovan: Thank you very much. Really I think anyone can apply to be a provider for the Huffington Post, contributor. They're just looking for new ideas, fresh ideas, something new, a new way of looking at things. That's really it. I started my journey after dental school with my interest in nutrition and I just started going to medical conferences and just starting to connect things, and it was just a passion. I submitted an article and they accepted it, and I'm happy to bring new ideas for the world.
Howard Farran: Well, you know what, I was a still young kid, now don't worry about this, I said, well, you need to learn how to hustle you, need a strong work ethic, you need to be humble, listen to older dentists, colleagues, other people. When I started my practice 30 years ago, I went over and invited every single pharmacist over my house for dinner, and then I started dinner with the physicians. There's dentists listening in podcasts where there's medi-cal in Lancaster with AD MDs in there they've never even gone over there knocked on their door.
I think network, I mean, health care is 17% of the economy. That means 17 cents of every dollar is healthcare. This year it will be the first year it passes $3 trillion and there's a one million MDs in the United States. Especially in smaller towns, why would you not, I mean, you got to get out and press the flesh, run for mayor, invite them into your house, take them to dinner. I can't believe, and of all the referrals, the ones that send me the most are still the pharmacists.
So many people go to a pharmacist and ask what's the best Anbesol to put on a toothache, or which one, is Aleve better than Motrin, and Brad will say, "You know what, you need to my buddy Howard." So, yeah. You're out there pressing the flesh with the MDs, networking with the whole healthcare community and no wonder you're crushing it in Beverly Hills. I mean, that's amazing.
Sanda Moldovan: You're right. As you said, it's work, it's networking absolutely. Ultimately, we can treat the patient so much better when we have a good network of health practitioners. As a young practitioner, there's so many new grads coming out, they definitely have to think out of the box and be out there and spread the word about your skills and your beliefs.
Howard Farran: I want to end on a dark note. I don't want you to think I'm playing you, but here's a deal, DentalTown Magazine, its number one complaint for over five or 10 years is how come every time an article is written by a dentist, it's always a man; and if a girl writes an article, it's always a hygienist or consultant. Our team, it is so hard to get content from women dentists, role model leaders. The dental school class is half women. I mean, it's gone from a mostly male to 50/50 male/female.
So you, young girls out there listening, I mean, trust me, there's not one, we got 50 employees, there's not one single employee that hasn't been told a hundred times we need more content from women. Young women in dental school, they totally gravitate towards women role models. It's just a natural thing. It's kind of like when your grandkids are over your grandkids will spend time with grandpa until another little kid walks in. But as soon as another three- or four-year-old kid walks in your grandkid is gone, yeah, everyone gravitates to, if you're a young 24-year-old woman dentist, you are listening to some old, fat, bald guy, you want to see what women dentists are crushing.
Thanks for being a role model to so many women dentists out there. If you have other women dentist role models out there that could write content for DentalTown Magazine or podcast, I mean, I look back at the 800 podcasts I did, I just mail, mail, mail, if it's a dentist, and then if it's a woman, it's hygienist consultant, marketing, SEO. Thanks for being a woman role model and thank you so much for coming on my show.
Sanda Moldovan: My pleasure. I actually have definitely another female colleague of mine. She’s endodontist and she's really amazing. I'm sure she would love to be on your show. She uses lasers and ozone to treat root canal teeth and she's getting great results. She uses stem cells and homeopathy. I think you'll really like talking with her.
Howard Farran: I would love to and I hope both of you guys write articles, because we need more women role models. Tell her that the first question I'm going to ask her is, so many of the graduates walk at a school, half the class already has a self-limiting belief they say, "I hate endo." I say, "Dude, you got $350,000 of student loans, you're in rural America. Patients are knocking at your door in pain. I mean, imagine if you broke your arm and you went to the hospital, they said, 'Oh, we don't do arms. We only do legs. We need to refer you.'"
I mean, you're a doctor in your community. The person has a toothache. You don't have to sell them anything. You’ve got to get over I hate endo when you just walked out of dental school an hour ago. So tell her how can she get these half the class to revisit endo and maybe get over the hate thing and start learning how to enjoying it again?
Sanda Moldovan: Sounds good. I'll definitely pass that message to her. Thank you very much, Howard. It's been awesome talking with you. I'm looking forward to contributing to DentalTown and bringing you nutritional information.
Howard Farran: All right. On that note, I'm going to go eat some Doritos. Have a rockin' hot day.
Sanda Moldovan: Thank you. You too.