Dentistry Uncensored with Howard Farran
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The Balanced Oral Environment with Dr. John Comisi : Howard Speaks Podcast #93

The Balanced Oral Environment with Dr. John Comisi : Howard Speaks Podcast #93

7/8/2015 1:00:00 AM   |   Comments: 2   |   Views: 549

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AUDIO - John Comisi - HSP #93

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VIDEO - John Comisi - HSP #93

When "something is out of whack", as Dr. Comisi says it, "we need to look a little further than just telling them to brush and floss more!"

Dr. Comisi has been in private practice in Ithaca, NY since 1983, and is President and CEO of Dental Care with a Difference®, PC, where “Knowledge Brings Health”®, and is Chief Dental Officer for Vigilant Biosciences, Inc. He is a graduate of Northwestern University Dental School and received his Bachelor of Science in Biology at Fordham University. He is a respected Key Opinion Leader, who lectures nationally and internationally and contributes regularly to the dental literature.

Howard: It is a great honor today to be interviewing a fellow MAGD. You and I, John [Comisi 00:00:13] and that's Italian, right?

John: That's correct.

Howard: Were any of your parents from Italy or you are third, fourth?

John: Actually as my dad came over, my mom's family was already here. I'm one and a half generations.

Howard: Your mom was born in Italy?

John: My dad was born in Italy, my mom was born in Pennsylvania.

Howard: Your mom's Italian too?

John: Correct, yes.

Howard: Were her parents born in Italy?

John: Yes they were.

Howard: Wow, so you're very Italian.

John: That's correct.

Howard: Do you speak any of it?

John: Very little, not as much as I would probably like to. I took it in school and we talk it in the house, but mom and dad wanted us to grow up American and not Italian. They didn't have us learn the language from them as much as we probably should have.

Howard: Yeah. Back in the day they thought assimilation was so important that a lot of them would go out of their way not to teach their kids. I have a ton of Hispanic friends because I'm on the Mexican border. So many of them, their parents refused to teach them, and now their kids are really bummed out that they're not bilingual. I want to open up with, we both have our MAGD. Why did you set out for that goal? First of all, there's a lot of kids right now listening to these podcasts that are juniors, seniors in middle school. Start from the very beginning, what is an MAGD and why did you set out to do that?

John: The Master of the Academy of General Dentistry is the highest award that you can receive in the Academy. Basically it is the culmination of a great deal of study and a great deal of work that is done by those of us in the Academy. The Academy of General Ministry is the one of the premier organizations dedicated to continuing education and the betterment of the general dentist, representing it not only from an educational point of view but also from an advocacy point of view.

Years ago when I first graduated from dental school and was starting to work as an associate, I found out about the Academy and the various educational opportunities. I started out probably half a year or so out of dental school and started working toward accumulating enough credit hours to receive my fellowship award, which I received maybe about 12 years ago. That of course entails 500 hours of continuing education plus passing of the Fellowship examination. Then the addition of the mastership award, as you know, is another 600 hours of CE with 400 of that being hands-on, et cetera. It's a nice assimilation of things. It's really been a great ladder to climb. I feel really really accomplished because of it. It's an award that makes me feel good about what I have been able to do. It just makes me feel like I have continued to become more proficient and more aware of what we in the dental profession can offer our patients. It's a really exciting opportunity to get.

Howard: It was the singular best move I made coming out of dental school. It was just the singular best move. A lot of it was because I got to meet all the local people that are just like you. I'll never forget these, I don't like golf just because it takes too long. Door to door, it's like 6 hours. I don't even want to eat Thanksgiving dinner for 6 hours. There's nothing I want to do for 6 hours. I remember one time these 4 other dentists asked me to go golfing with them. I asked a dental question before we teed off on the first hole.

This guy turned to me and said, "Look, we're on a golf course. We don't talk about our wives and we don't talk about dentistry. This is sacred ground. This is where we go to escape our wives and our profession." I just thought, I don't even want to be with you. Who doesn't want to, I only went because you're a dentist. I didn't go because I'm trying to, there was no other reason I went. I wanted to find my colleagues. The people that you met at the Pankey Institute, even the people that you talked with, I look back at the weeks I spent at the Pankey. Yeah, you got a third of the learning during the day [inaudible 00:04:43] during classes. You got two thirds hanging out in the dorms at night talking about everything from A to Z until 3 o'clock in the morning.

John: That's exactly correct.

Howard: Sometimes the next day at the Pankey during the lecture you slept the first 2 hours because you're up talking with 10 dentists until 3 o'clock in the morning.

John: I find that's the same thing. Most of the important work and most of the important communication happens at the lunch hour and after the meeting when you're just hanging out just talking with everybody. That's when you really gain the most knowledge. That's what collegial situations were supposed to be. Sometimes we've lost that collegial atmosphere, and it's a real same. We were talking about that at a recent meeting that I was at how we used to get together to share and to help each other out. Today it's worry about whether or not they're stealing your patients. There's more of a worry about business rather than collegial atmosphere. That's a real same.

Howard: That was one of the biggest singular draws that I had in dentistry, because I live next door to my idol and dentist Kenny Anderson. I would go to work with my dad, and it was a Sonic drive-in making hamburgers and cheeseburgers. Then I go to work with Kenny and that was making root canals and crowns, far more exciting. The coolest thing is he would always take me to lunch and he would always buy, and it was always to the West side bowling alley where about 8 other dentists met. I thought it was just so romantic and cool that all the dentists on West Street would meet for lunch at the bowling alley. Then I came out here to Phoenix, Arizona and every dentist you met had never gone to lunch with the same dentist in the same medical dental center.

At first I thought, is this the difference between small town country Kansas, and now I'm living in the big city? I also can tell you this, now that I've been doing this for 28 years, the dentist in my Ahwatukee little zip code that always want to do lunch or go to dinner or have happy hour afterwards, those were the most successful dentists. The ones who viewed you as a competitor and didn't want to know your name or whatever, they have dingling practices and they're miserable. When you see them, they don't even look happy. The best thing about the AGD and getting your MAGD is to find the people who eat, live, breathe, die, and shit dentistry and they just love it. You're involved, I see your poster all over the place. I can tell this is a big part of your life isn't it?

John: It is. Education and trying to share the insanity that I've learned over the course of the years with other people who are crazy enough to want to listen to what I have to say is really a lot of fun. As I tell the people that I have the opportunity to speak with, I learn as much from my audiences as I hope they learn from me. It's always a dozen pearls that I get from every audience that I ever have the opportunity to speak to. That's really the exciting part, just getting out and being there. Today our younger docs are not getting the tutorage that you and I had when we were starting out in this business. At that point in time, the senior doc would take care of us, bring us under their wing and essentially help us understand how to do better in dentistry. That's not happening today. We are really falling short of what we really need to do. That's where the Academy comes into play, that's where Dentaltown comes into play, where we can all meet and talk and basically vent when necessary.

Howard: Yeah, I see this podcast as going to lunch on the west side of dentistry at Rose Bowl bowling alley, just a different format. Anyway, when we were talking, start with the warning signs of imbalance in the oral cavity.

John: That's an interesting thing. I think that we're seeing a lot of issues today with our patient population in which patients are presenting and they've got rampant decay or they've got some kind of oral lesion or they've got some kind of periodontal disease. Something is out of whack in the way that I look at things. I believe that we need to look a little further than just telling them to brush and floss more. There's a heck of a lot more going on to that. People have dry mouth circumstances occurring, people who are not physically taking care of their mouths the way that they need to, drinking more and hydrating appropriately. Medications, our physicians are throwing folks on meds left, right and backwards, and it's having all kinds of interesting physiological effects on the oral cavity. We need to look at things very closely.

Medical history and everything that we do with our patients, that's critical, that's job one. If we're not reviewing the med history really closely to see what meds may be creating a situation in the oral cavity, we're missing a big boat there. That's really important part. A lot of meds are causing dry mouth. A dry mouth situation is going to create cavities and other issues within the mouth that could be simply adjusted if we just took a look at the med history.

Howard: The meds are completely out of control. I read things that, there's 7 billion people on earth, 330 million of them live in the United States, and we take 50% of prescription pills.

John: Isn't that crazy?

Howard: When you're old school, some people you say you have high cholesterol, and they say okay, I'm going to change my behavior. I'm going to exercise more. Other people say I'm going to just to take a pill. Then you go in there and you have high blood pressure. Some people say if I have high blood pressure I should probably move more, sweat more, eat less salt, eat more fruits and vegetables. The other people say I'm going to just take a pill. I don't want to say not take your pills, but I do want to say this insight, having all these patients for 20 years. It seems like the men in their 60s who are already on a half dozen prescription pills, they're all dead by 65 or 70. Every time I walk in the room and it's an 85-year-old man who just got off the tennis court or the golf course, he's not on any prescriptions. Have you noticed that trend?

John: Yeah. Obesity is a really major challenge in the country right now. Basically we've got an extreme situation going on. We've got those people who are obese and we've got those people who are extraordinarily physically fit. Interestingly enough, a report that came out of the London Olympics a couple years ago showed that a lot of these folks that were really physically fit and working on getting medals and everything failed because they had disease in the oral cavity. Cavities, periodontal disease, abscess, et cetera and so forth. We've got to be on the lookout for not only the people that are overweight, but we've got to look at these people who are really incredible athletes and working on their physical physique, but they may not be taking care of their oral cavity as well. That was a really interesting study in the British Journal of Sports Medicine that came out about two years ago, really fascinating.

That started me thinking, also I'm sure that you've had over the course of time, a lot of your patients would come in, they say my teeth have always been soft. Teeth aren't soft. Teeth become soft because of the acidic effect that goes on in the oral cavity. We need to look at the possibility of an acidic mouth going on. One of the key questions that my good friend Brian [Novie 00:12:13] told me years ago, he said, "John, if you want to know if your patient has an acidic mouth, just ask them if they like the taste of water. If they don't like the taste of water, they have an acidic mouth." That's an incredible clue that he gave to me. I use that all the time when we're looking and we're talking and we're analyzing what our patient's problems are. If they do have a situation in which they don't like the taste of water, we need to find a way for them to change this acidic mouth.

We drink a lot of Coca-Cola in this country and other carbonated beverages because the sweet of these carbonated beverages makes the acidity dissipate, at least temporarily. It overwhelms that acidic feeling. We need to find ways of changing that and challenging that. One of the ways that we recommend on a regular basis is the use of xylitol products. Gums, mints, sugars, putting a 4 gram pack of xylitol into a 16 ounce bottle of water twice a day, that gives you 8 grams of xylitol throughout the course of the day. That's going to help to relieve acidic mouth. It's going to affect [tre-bu-tans 00:13:21] in the mouth and the other bacteria so this way they can't attach onto the dental structure. That's going to help. Baking soda, using baking soda to brush or to rinse with a couple of times a day, that's going to help with neutralization id the mouth. These are all really easy inexpensive ways that we can help our patients. The first question is, you got to find out, do they have an acidic mouth?

Howard: How would you find out if they have an acidic mouth? Just simply ask the water?

John: That simple question, do they like the taste of water. If they don't like it, I'll give you dollars for donuts that they don't like water because it tastes bad because of the acidic mouth. Have them changing that oral environment is going to help it. You're also going to help arrest the activity of the decay and other issues that are going on. That's one of the ways to stop the my teeth have always been soft conversation.

Howard: How MMPs are involved in the destructive process? Explain that.

John: That's another interesting one. Matrix metalloproteinases are some of the endogenous proteases that are found in the tooth structure, especially in the dentin. They also found in saliva. Basically our overall approach to bonding our dental restored materials in place, over the last few years some of the literatures coming out with changing maybe the way that we need to look at things. When we're creating a hybrid layer, and I know folks like John [Canker 00:14:52] is probably going to attack me the next time I see him, but the reality here is that we've got a real challenge with MMPs. The hybrid layer, the odontoblast and the dentin of the tooth structure are, as you and I know, are living breathing cells. They are affected by everything that goes on.

When we create a hybrid layer, we're actually enabling the odontoblast to set up an inflammatory response, a response to that hybrid layer attack. In that, they are essentially secreting these MMPs and other proteases that are starting to destroy the hybrid layer. When you and I placed amalgams years ago and you went to go take them out, sometimes you found that that amalgam never came out. You had to use a bulldozer to get out of there, some dynamite. Nowadays when the composite fails, that thing goes flying out of the mouth. That's the MMPs, that's the endogenous enzymes that are destroying our hybrid layer. We need to look at this very differently.

In the February issue of the Journal of Dental Research, there was an article called the role of dental MMPs and Caries progression and bond stability by Mazzoni, Tay and Pashley. It was a really interesting one because it was a 10 year retrospective that talks about this process of bond failure over the course of time. It's another issue that I really think that we need to look at. We are failing because even in our best 2 step bonding processes the overall effect is occurring, and this breakdown of the acidity from the mouth and from the overall proteins of these enzymes in tooth structure are just destroying everything. It's a really interesting article. I talk a lot about this on the road, I write a lot about this as well. It's just making me think that maybe we need to re-approach things. We need to work with things that are more bioactive that can help create apatite in the tooth structure rather than a hybrid layer.

There are certain materials and products out there that help us with that, things like TheraCal LC that'll help to form an apatite formation over the course of time. Activa bioactive restorative base and liner material will do that. Ceramir is one of the cements that I use for almost all of my crown and bridge nowadays, will help create apatite formation. Biodentine, which is another product that you use for dentin replacement, that's a great way to replace dentin and to stop the MMPs and to create apatite. What we need to do is not create a hybrid layer, we need to create an apatite layer so that this way hydroxyapatite and the overall tooth structure can become more together and synonymous with one another again. I think that over the next couple of years, as you and I start to work with newer materials like that, we're going to see apatite becoming a more important aspect than bond strengths. 

Howard: Any way we can get an online course about all of this out of you?

John: Sure, I think we can probably arrange for that. I know that the other Howard has been trying to twist my arm into it for a while and I'm sure that we'll get that done.

Howard: That would be amazing. For our listeners, you're a big poster on Dentaltown. Could you start a thread that started this MMPs?

John: I'd be happy to. I've tried that in the past Howard, and what happens is there are some zealots out there, and you get attacked. My hope is that they will be kind this time that I try this out. I know that I've made statements on this, and Don of course has been one of the guys that, he and I have conversations, he's a good friend. He doesn't believe in MMPs. He doesn't believe in these endogenous proteases that are there. I think as the years have gone by and more of the literature starts to show that it is present and it is an activity going on. My hope is that we can find great workarounds. We've got so many great composite materials out there, we've got all these great tooth colored things. If we're failing because of our bond, then we're failing our patients. Certainly I'd be very happy to do something in there.

Howard: For our viewers, first of all I still apologize. I've been apologizing for 5 years that when I started Dentaltown in 98, I'm still a registered libertarian. I don't understand people who are proud of being a Republican or Democrat. One robbed the bank, one drugged the getaway car. How could you love either of those parties? The deal is I just thought that everybody's a doctor. You got 8 to 12 years of college. I'm not going to be the truth police, not going to be a moderator. What I did not understand was cyber bullying. That's why we brought on Howard Goldstein years ago and put a report abuse button on. You and I both know that we all know what we know, but we don't know what we don't know. Seriously 1000 years from now we're going to look like a bunch of cavemen right now. The smartest dentist in the world is going to look like the Flintstones and Barney Rubble in 3015. We all know that none of us know. None of us know. We're all in this together. What would be the name of the ...

John: Howard, townies of the greatest people in the entire world. Every time that I've gone on and been able to read and share some posts with them, it's been an absolutely fabulous thing. The majority of the townies out there are absolutely incredible. There are periodically a few folks that are just unfortunate, but thank God they're not as bad as they used to be.

Howard: Yeah. Like you say, if anybody ever posts something that makes you feel bad, you hit that report abuse button. A lot of dentists say things like I have freedom of speech. Moron, that's the Constitution, that's between you and your government. Dentaltown is private property, I own it 100% and it's like having a party at my house and we're having a party at my house. You be nice to the guests and we can discuss all these things in a fun way. If you want to have too many drinks and start calling names, then we're going to ask you to leave. I want to back up even further, all the way back to the amalgam composite. You were talking about all these composites and bonding layers and hybrid layers. I'm amazed at how many dentists will look at you square in the eyes and say, "Composites last longer than amalgams because it bonds the walls together, you moron." I'm like, "Do you believe in gravity or research?" I'm going to ask you this question, what lasts longer, amalgam or composite?

John: The reality and the science continues to show us amalgam lasts almost 4 times longer than the average composite. The average composite according to studies is living about 5.7 years. Amalgam is lasting between 15 and 20.

Howard: Why do these dentists, I get in this argument all the time. It would be like a dentist, and it will be his own son, and he'll be like 6 years old with a booger hanging out of his nose. He needs an occlusal on number 3 and they put in composite. I'm like, dude, what are you thinking? This won't even get him out of high school, it won't even get him out of college. Then these dentists are proud when they say they are amalgam free. It's like, at what point have you left science and you're no longer a doctor? If you're telling me that in your practice of 2000 patients you never had one indication for an amalgam in 2014? At this point you're not even a doctor. Would you agree with that?

John: I agree 100%. The reality is that amalgam unfortunately got a really bad rap. We took it away from ourselves a lot faster than we really should of all because of 60 Minutes and Morley Safer and all the other stuff and the Mercury release of gases, which basically we found out over the course of time was a lot of hooey. There really wasn't, the overall measuring capabilities they used was wrong. Amalgam is a good material and it has its place. I like the opportunity to use as many types of materials and have as much in my [inaudible 00:23:12] as I can.

A lot of materials nowadays and some interesting stuff that's coming out there like Pulpdent's Activa bioactive restorative material, that's got some really interesting properties that can be used in a lot of places in the mouth. It doesn't require a bonding agent, even though if you use a bonding agent initially it's okay. What happens with Activa, one of the interesting parts is that after a period of time as the bonding agent becomes dissolved by the attack of the MMPs, it's actually able to penetrate through the bonding agent and start to create an apatite layer and actually form a union with the tooth structure.

I think that Pulpdent with this product and some of the other things that they've got in their pipeline is going to change how we look at restorative procedures as we go forward. It's really exciting to work with and play with this kind of stuff and to be on the cutting edge with what Pulpdent and a lot of other companies are starting to come out with. It's really very very key. I've been very blessed to see associated with the folks over there and being able to help work with things. It's the same thing like with Shofu's Beautifil products. Those things with the SPRG fillers that release fluoride and other ions into the mouth that neutralize the oral cavity, these are things that are really very exciting because it helps to reduce plaque formation, it helps to improve the overall ability of that area to stay Caries-free. It's got 13 year studies that shows that restorative material actually lasts well for 13 years because of the ion release from these surface partially reactive glass in it. There's a lot of really cool stuff.

Howard: Is that considered a glass ionomer?

John: No, actually I like to call it a reservoir restorative material. It has a partially reactive glass ion fiber that's embedded in this resin matrix. That's the Beautifil product. The Pulpdent Activa product is a kind of resin modified glass ionomer, but it's not really because it has other components to it. These are two of my major restorative materials that I use in the office today. They are very very incredibly useful and it's certainly something that I talk about all the time and I write about all the time, these kinds of materials that are very very effective that are resilient, that are highly polishable, that are lasting without failure. These are the kinds of things that I really think that we need to be looking closer at.

I know that a lot of folks like a lot of the other composite materials out there, and they're all great because they have excellent physical properties. Again, they don't bring anything to the game. There's nothing bioactive, there's nothing that releases ions that are going to help to neutralize the oral cavity to help with the acidic effect that's going on, that's going to help to help with re-mineralization of the enamel surface and form a bond like glass ionomers can and do in their product capability. There's so many different things that we've overlooked. In my opinion, the US is a little bit more composite-centric rather than bioactive-centric. Hopefully over the course of time more and more people will look at it in that capacity.

Howard: You're saying composite-centric instead of bioactive-centric. I've been calling it something else. Your other bald brother with an MAGD calls it that, dentists are like engineers. They're always talking about building bridges and houses and crowns. It's like, dude, everything fails from biology invasion by bacteria and now we're finding out that fungi, because candida albicans is interacting with the structure [inaudible 00:26:56] It's going to fail from bacteria and fungi. You need to be a biologist. At the end of the day, we're civil engineers building buildings, but everything's failing. These barns we're building are failing from termites. At the end of the day all of our failures come from biology.

We went from an amalgam where it was half mercury, that's not very bacterial friendly, the other half silver, zinc, copper and tin, all that's in. Then we went to this inert composite with nothing bioactive. Then you go to the other parts of the world like Japan and they're like, shouldn't there be active ingredients in all this stuff? They're huge into glass ionomers. Why are the Japanese who give us Lexus and Infiniti and cars that last 3 times longer than Chevys and Fords, why are they all using bioactive glass ionomers and we're using inert plastic?

John: It's a lot of places, Australia, New Zealand also are in that category. That's where a lot of the materials come from, from both Japan and Australia. You've got Japan with GC and you've got Australia with SDI. These companies have been producing great glass ionomers and resin modified glass ionomers for years. EQUIA from GC is an incredible product. It's a bulk fill restorative material that basically has the ability to wear because of the coating that you put on top of it. That coating protects that glass ionomer underneath it and it enables it to basically work harden over the course of time.

Why does Japan do it? Because they look at things a lot differently. We've been basically told that bonding is the way that it is and that's the only way that it is. The reality is there's so many different games out there. You're right, most of us in our undergraduate degree probably have a bachelors in biology in some capacity. We've forgotten that we're supposed to be scientists and look for the truth, look at the oral condition, as you've just indicated there. Why do we not look at that? Because we'd rather take things into a cookbook rather than using our mind and trying to analyze a circumstance

It's not everybody, but I do run into that a lot. It's unfortunate because I drive my assistants crazy. They don't know what material I'm going to ask for when we do a procedure. They know that every procedure that I do depending on what we're doing is going to call for certain materials at certain times. Sometimes I need X and other times I need Y. They know that on a moment's notice I'm probably going to call an audible, change the overall formation on the huddle, and we're going to go out and score that touchdown in a different way than we were originally thinking.

Howard: You opened up this can of worms buddy, so now you're going to have to close that can of worms. Okay, first thing's first, it's a beautiful woman and its anterior teeth. She doesn't care about fluoride releasing, she wants beauty. What material would you use canine to canine on a beautiful woman?

John: If I'm doing something like that, if I'm going to be doing something like that I'm probably going to be doing some kind of veneers unless they're just small restorative materials. If it's a big cosmetic case ...

Howard: No, not a big cosmetic case, we're talking direct.

John: Okay, then I'm probably going to use something, initially I'm probably going to use stuff like the Beautifil products. I like the Flow Plus, the Beautifil Flow Plus products because I can get in there.

Howard: Who makes those?

John: That's Shofu.

Howard: Okay, Shofu, out of Japan. Is that a microfill?

John: It is a nano hybrid material, really beautiful. It polishes up really nicely. If I'm doing a direct veneer, I'm probably going to use something like Uveneer to basically create my overall shape and outline. It's by the company called Uveneer, U-V-E-N-N-E-R. Really easy quick kit to work with. I do a lot of direct composites, veneers with that.

Howard: Where's Uveneer out of?

John: They're out of Australia.

Howard: Australia? When I think of Australia I was thinking of Jeffrey Knight.

John: Jeff Knight is a good friend. Jeff is a wonderful, he's basically one of my mentors. He has incredible, he's the guy that got me excited about glass eye ionomer many many years ago.

Howard: He [crosstalk 00:31:29]

John: Yes.

Howard: Out of Adelaide?

John: Yeah, exactly. These folks down under really are brilliant. They have a a lot of great things. [Graeme Milicich 00:31:44] I guess is the other guy that I talk a lot about.

Howard: Out of new Zealand.

John: Yeah, he talks a lot about G.I. as well. Again, these are people that I've read and talked about and really admire because they open up a new avenue. When you get to cosmetics, you need something that's going to be highly polishable. If you can use a material like a Beautifil product, a Beautifil II or Beautifil Flow plus materials, you're going to have a really great aesthetic. You're going to have a great strength. You have to bond them in properly. You've got to realize that if you're going to use a seventh generation and you're on enamel and you don't etch, you're going to fail. Our strongest bond is to enamel. Try to bevel as much as you can and create a nice aesthetic in that capacity too.

Howard: What if it's a direct composite on a molar, and it's on a teenage kid that drinks Pepsi and has a high decay rate?

John: Activa. Activa bioactive restorative, I would go in there.

Howard: Activa by bioactive, where are they at?

John: That's the Pulpdent product. It's called Activa bioactive. Anywhere posterior I'm placing Activa because of its bioactive capability, its ability to create an apatite layer once the bond is dissipated. Really very very exciting material. It's been on the market now for a couple of years. I've been working with it in trials in my office for about 3 years now. We're seeing an incredible polishability, incredible wear resistance. That's by Pulpdent, it's A-C-T-I-V-A bioactive, it comes in both the restorative material and a base liner material.

Howard: Where's Pulpdent out of?

John: Out of Watertown, Massachusetts.

Howard: Watertown, Is that a suburb of Boston?

John: Just outside of Boston.

Howard: It's just outside of Boston, okay. Interesting.

John: They've been around for a long time. People don't realize what they do. You guys ought to check into Pulpdent, they really got some remarkable stuff.

Howard: Is the founding father still running it?

John: No, Mr. Hal Burke is no longer with us, but his 3 sons are in charge there. They with Larry Clark run the business, and they run it incredibly well. The Burke brothers are great folks.

Howard: Was the founding father a dentist?

John: Yes, he was an endodontist at Tufts University.

Howard: Really? Any of his 3 kids dentists?

John: No, none of the 3 went into the profession but they went, they continued the manufacturing business and they are innovators in everything that they do. They are incredible scientists, they are incredible folks. They're just wonderful. If any of the folks ever get out to Watertown, just call them and let them know you want a tour of their plant and you want to speak with them about things. They're very hospitable and they're very warm and open and loving people.

Howard: Who's their dentist's product championer?

John: I guess I'm one of them. I guess I'm one of them, yeah. I've been working with them for a number of years now on different of things. They're terrific. You can talk to folks like Rob Lowe about it, Bob and I have worked with Pulpdent for a long time now. There's a whole bunch of other folks that are out there. Definitely I think Bob can give you a good lowdown on things as well.

Howard: Another thing you answered, the can of worms I'm going to finish, you just said seventh generation bonding agents. My god, how many generations are there, and it is all noise? What are we on now? Is it 7, 8? 49?

John: It's at least 7, some companies are claiming possibly 8 but the reality here is as we're becoming trying to make it simpler and simpler, the chemistry has to become more and more exquisite. Whether or not it's really bonding, the initial bond strengths are always great no matter what bonding agent you use. It's the long-term 3 months, 6 months, 2 years, et cetera and so forth where you start to see the problems. We can use all kinds of things to try to reduce MMPs like chlorhexidine gluconate to try to do things. The reality is in the long-term studies, chlorhexidine gluconate has only been studied at most up to 3 years. After 3 years it fails to stop the MMP activity. There's still that activity, there's still that enzymatic resultant going on in the tooth structure. The odontoblasts are still responding, they're still reacting to the hybrid layer. It's just a weird phenomenon.

Do these things work? If they don't have an MMP inhibitor in them, there's only a few out there that have any kind of MMP inhibitors in their chemistry. Unfortunately there is not more at this point in time. Shofu's BeautiBond is one of the few that I'm aware of that has an MMP inhibitor in it. Its carboxylic acid inhibits the MMP formation at least initially. That's a good thing. I don't know what long-term it does. I have to continue working on that and finding the research that they're doing on that, but that's it. The problem is no matter what generation, you still have those enzymes that are going to start to attack, and they're certainly going to release and they're going to break down that bond over the course of time. Bond strength is bond strength initially. You can tell me you've got 100 megapascals of bond strength initially, but what is it going to be like in a year? That's where the rubber really hits the road. What is it like in a year?

Howard: Another thing you and I have seen in our lifetime, when we got out of [cosmin 00:37:33] Crown was a PFM. You and I have literally lived through almost the disappearance of the PFM. Talk about that. Are you still doing PFM's? Have they disappeared in your practice?

John: They have. I've been going with a lot of zirconia and e.max nowadays. Since I switched the scanner for my work, I'm using a 3shape TRIOS in the office now in working with my labs. I'm loving being able to do digital scans. Zirconia and e.max, now the aesthetic zirconias that are starting to come out, they're looking really exciting.

Howard: You're optically scanning instead of taking an impression?

John: Yeah.

Howard: Okay, so how long you been doing that?

John: Almost 2 years now.

Howard: 2 years, and what scanner did you go with?

John: The TRIOS 3shape.

Howard: Who makes that?

John: That's by 3shape. They're a European country. Basically if you think about it, every lab has 3shape in the lab. It made sense to me, why not have 3shape on my side of it? Their imaging will go together better, and that's how they process everything on a 3shape lab generated product in the lab area. They've got the software, they've got the hardware. Why not give them something directly from [inaudible 00:38:51] I was at IBS a couple of months ago in Germany, and the new stuff that's coming out from 3shape that will start hitting the market within the next couple of months are just going to be remarkable.

Howard: What country are they from?

John: God, I can't remember. I think it's Scandinavia. I can't remember. I apologize. My brain has frozen up.

Howard: What impression material did you used to use?

John: I'd love working with Kettenbach's Panicil, and I love DMG's Honigum. Those are two of my favorite impression materials when I was using impression materials.

Howard: Are those polyethers or polyvinyls?

John: Polyvinyl siloxane. I love them.

Howard: I was always a polyether guy, I was always an [Emperor gum 00:39:33] man.

John: Emperor gum just basically smelled so bad and the patients hated the taste of it. It was always hard to reintroduce that, even though it got easier with the automixing.

Howard: Since I don't bathe or shower or use deodorant, I can just blame it on that and they would say, "What is that smell?" I would say, "It's not me, it's the Emperor gum." How much did you pay for the 3shape? What kind of investment were you looking at?

John: It was between 30 and 40 if I recall correctly. It was probably around 35K at the time.

Howard: Is there any variable cost with each impression, or you just buy it and now your scans are ...

John: There's an annual licensing fee. Basically that also incorporates the upgrades and software, et cetera that goes on. Cost comparisonly, for me at the time, that was 2 years ago, that was the best machine on the market in my opinion for someone who wasn't going to mill in office. Guys of course are being on [CEREC 00:40:31] It's an incredible mechanism, an incredible machine. What I didn't like about CEREC unfortunately is the closed architecture. Mostly everybody else was gone to open architecture. I think that CEREC is moving long into another aspect. I'm not as familiar with it today as I was when I was doing my research.

Howard: It also depends on how many ops you have. There's a lot of dentists that only have 3 or 4 ops, they don't have room for another fifth op. To see the patient, numb them up, prep it and press, let them out, you flip that chair in an hour, and then you buy a CAD/CAM and now that chair's going to be occupied for 2 to 3 hours. A lot of times it just doesn't make any sense. If you're chair long and you delegate to your assistant, you can go to another room, this assistant can stay in there and do everything, it's fantastic. Sometimes operational logistics is just not going to work.

John: You have to really look at your business model and how you operate. You're exactly right, because if you don't have that additional room and if you don't have an assistant that can really be be trained well to do the crowns for you, it really doesn't make sense to do it in-house. There are some guys, and a lot of my friends like Sam Halbow out there in California, Sam does all the CERECs office. He's got an incredibly well trained staff that does his work for him. Jack Griffith does that as well. These guys are great buddies and they've talked to me about this. The reality in my office and in my work is that it made sense to send everything to lab rather than playing in the office with it.

Howard: Yeah, it's totally different for me because I'm spoiled rotten. I'm in Phoenix and my good buddy Samir at the Scottsdale Center is literally right up the street. He comes down to my office or I send my staff up to him. You're right. On the zirconia, what brand name are you using? Are you doing BruxZir with Glidewell?

John: BruxZir is one of the main brands that are out there. It's a beautiful, yeah. A lot of the labs have licensed the BruxZir.

Howard: What brand are you using for zirconia? 

John: The BruxZir.

Howard: You're using the BruxZir? What are you cementing that with?

John: I'm using the Ceramir by Doxa. That's C-E-R-M-I-R by Doxa, D-O-X-A. They are from Scandinavia. It's an incredible bioactive, it's a nano activated cement that basically forms apatite onto the tooth structure, will bond to the zirconia without doing anything to the zirconia. You don't have to do any special prep, you don't have to silinate, you don't have to use any primer on it or anything. You can just take it from the mouth, wash it off, put the Ceramir in there, and put it on the moist tooth. It likes moisture, it sets up. It's a nanostructurally biointegrating ceramic, and it's really very exciting. That's a really nice thing. The problem is you've got to titrate it, you've got to mix it in an amalgamator. You can't just mix it by hand. That's the downside for those folks out there that don't have [titrators 00:43:37] Since I use a lot of glass ionomer. we have titrators in every treatment room. It wasn't a big deal.

Howard: What would you say though to a dentist that didn't have a titrator? Do you ever use amalgam?

John: No. I haven't used amalgam in a while. I have the titrators, because you need to titrate the glass ionomer into capsule form that they have. Basically I think that the investment in a good titrator, the 400 bucks or so for a titrator to use a cement like Ceramir or to be able to use a resin modified glass ionomer or a glass ionomer for restorative capabilities, it's a good investment short and long term, in my opinion.

Howard: Come on man, I don't want to be the only jerk on this podcast, I want you to throw this guy driving his car under a bus. What do you say to a dentist that doesn't have a titrator? Let me say this, you got a 75 year old man with Alzheimer's who doesn't even know what country he lives in. He's got root surface decay on the buccal of 2 and he's got poor hygiene and you can't keep it dry and it's a disaster. Really dude, you're going to bond in an inert composite?

John: You can't, it's impossible. There's no way in hell.

Howard: What would you say to a dentist who didn't have a titrator?

John: Basically then you're going to have to use something like Activa in there because basically that can be used in a slightly damp environment. You don't want it soaking wet. It's going to adhere to the tooth surface. You can do that. Basically in my opinion if I can get a good G.I. into that, I'm a happy guy too. Again, that's why I said Howard, I've got more crap that I can pull from because I have a very open mind as to what I want to use. There's no way that I'm going to get stopped because of a circumstance. If this isn't going to work, and there have been times where one material just doesn't work, I say all right, let's go to the next one, and they drag that out for me. You can't be just a one shot Charlie, otherwise you're just stuck.

Howard: That same dentist who says he's a doctor, now he's got a 73-year-old man with Alzheimer's with almost 0 home care in a nursing home. It's the same dentist who's whining about high overhead and how the insurance companies are cutting his fee. I'm telling him, dude, a barrel of bonding agent is about a million and a half dollars where a barrel of oil is 50 to 100 dollars. I can fix that with amalgam in literally 3 minutes.

John: In order to do that, he needs a titrator in order to do that. He still needs a piece of equipment. That's the problem here is we've gotten away from an important piece of equipment, you're exactly right.

Howard: The only secret to lower prices is lower cost. They always complain about overhead. Then when you ever put a decision in front of them and say, "Okay, you use 3 different kinds of gloves. Can we pick one glove?" "No." "Okay, you won't ever use an amalgam when indicated. Can we just use amalgam sometimes?" "No." You lay down 20 decisions, he says no to every single decision, then he says, "But what about my overhead?" Dude, if you're going to change something big, you've got to change something small. If you can't change anything small, you're never going to change anything big.

John: I agree, there are some folks out there that unfortunately are always going to be, as my father used to say [inaudible 00:47:05] thickheaded and won't understand simplicity when they have that opportunity. My hope is that as time goes by and they continue to bang their head against the wall, that they start to listen to these simple ideas that folks like you and I are trying to provide to them.

Howard: You also have the same type of street smart I see in the MAGD's where if your only tool is a hammer, everything looks like a nail. The best thing about the AGD is they made us take classes in things we didn't want to take classes in. You're telling me you don't want to do ortho. Are you telling me there's never an indication to just unravel some teeth before you do veneers?

John: Isn't that the coolest thing when you can do that too? Suddenly you start to see things lining up. Then you get the veneers on there. That patient has the happiest smile on their face when they're done. You did something that no one else suggested.

Howard: What you're hearing, I'm 52, how old are you dude?

John: I'm 58.

Howard: Okay, what you're hearing from two old guys that have been doing this 30 years is the fact that the most tools you can have in your toolbox, the most products, if you're just going to say I'm never going to do an ortho case, you don't even know what you don't know. Carl Mish told me something most interesting. He said that the reason he made it to the top in implants is because he mastered removable first. He cut his teeth in making full mouth dentures. Then when all these dentists were complaining that these implants weren't strong enough, they're all snapping to the gum line, he says, "Yeah, because your denture occlusion is so bad, the bite is off so pathetic."

A lot of people say, "I don't want to go to Pankey because I don't have that kind of practice." Dude, you go to Pankey because you're still going to have that case that you're going to need all those deals. There's a time where you're going to need to mount something in order [to ticulate 00:48:54] it. There's a time where you're going to need to do, in learning all that stuff, if you just come out thickheaded and say I'm never going to pull teeth and I'm not going to go to Pankey and I'm not going to do ortho. You set up all these parameters, you just really limit your thinking. You know what I mean?

John: You are exactly correct.

Howard: I'm always on the watch out for extremism. I just still think that there's one indication for amalgam every year. Having that roadblock just starts a whole series of roadblocks and chain reactions. I only got you for 10 more minutes. I want to ask you this, first of all I got to go back to your oral cancer. You're involved with Vigilant Biosciences. I want to do a little rant on oral cancer. I always thought in America, which is an 88% Christian, that oral cancer really never got that care because it's very judgmental. It was always like, you were bad, you smoked and drank. I remember hearing this as a kid, everyone who died of alcohol, cirrhosis of the liver. Why did you get cirrhosis liver? He was a drinker. It's like, a lot of drinkers don't die of cirrhosis of the liver. Later in my lifetime they found out there was hepatitis A, B, C, D, and there was a viral component. I always thought that, think about that, the largest dental insurance companies in America don't pay for an oral cancer exam. Is that true?

John: It's an unfortunate fact, yeah.

Howard: Downstairs, medical insurance pays for a pap smear and all this stuff like that. I always thought, you know what, someone dies every hour from oral cancer. The reason no one pays attention to it and insurance companies don't pay and all that is because it was judgmental. You shouldn't have smoked. You were a drinking, smoking, drunk Irishman, you got what you deserved. Now we're finding that oral and pharyngeal cancer, that there's a viral component to it, HPV. Yet dentists who call themselves a doctor don't talk about it. They don't even have the legal right from their own dental board to give an HPV vaccine. Talk about your role in Vigilant Biosciences and how that's changed in the last 30 years.

John: It's amazing, I just finished writing an editorial for Dental Product Shopper that will appear next month in the June issue regarding oral cancer, in fact. We just finished in April oral cancer awareness month. It's funny to me, the whole topic of the article of the editorial is that, why are we only talking about this in April? This is a year-long problem. This is a thing that needs to be looked at all year long. Oral cancer is there, we need to be evaluating, we need to be screening, we need to be checking. The gold standard still today is the [bimanual 00:51:42] patient of the head and neck area, oral soft tissue, making sure that you get in there in some fashion to look what's going on there. A lot of us don't take the time to really look well. The American Academy of Prosthetic Dentists have created a YouTube video on how to do a good oral cancer examination. I encourage everybody who's got new staff members or just a refresher to go to that video and watch it. It's about 17 minutes long, but it's the best thing in the entire world.

Howard: Do you know how to upload a YouTube video on Dentaltown on a message board?

John: Sure.

Howard: Can you start a thread for listeners?

John: You betcha.

Howard: What are you going to call that thread?

John: I'll call that the best video on how to do an oral cancer exam. I'll do it in that way. It really is a remarkable video. It shows you step by step. It's really a great educational aspect. Oral cancer screening is a really important thing. Several years ago, I'm a cancer survivor. I had testicular cancer 24 years ago. I figured that I'm here for a reason. I'm here to help to bring a message or a couple of messages to folks around the world. When I was approached a couple years ago by Matthew Kim, the CEO of Vigilant Biosciences to come on board as a consultant and be their chief dental officer, to help give them perspective from the dentistry aspect, I was very honored.

The company is working with creating a salivary diagnostic test that's different than anything else that's currently available. You don't have to wait to see a lesion. You can do this proactively for everybody, if everything goes through with 510K and the FDA the way we want it to. My hope is that this will be available sometime next year. It's a very simple task. I did some videos at IDS at it with a couple other groups, industry news organizations that came by.

Basically it's a real simple test. Within 10 minutes from the beginning, it's not going to disrupt the workflow in the practice. You're going to be able to take a salivary sample basically using a saline rinse. 5 seconds rinsing, 5 seconds gargling, spitting it into a cup, placing the test mechanism into it which is basically a couple of protein strips in a special cassette, leaving it for 10 minutes. At the end of 10 minutes if there is no markers activated, that means your patient doesn't have the CD44 and the total protein concentrations associated with oral squamous cell carcinoma. If you have both marketers indicated, your risk of oral squamous cell carcinoma is 25 times that of the average person. There's something going on in there.

As you just indicated regarding HPV, the face of oral cancer is changing. It's no longer the tobacco and alcohol user any longer. It could be your teenage son or daughter, it could be your friend next door. It could be almost anybody who doesn't present with the typical risk factors that you and I had traditionally been looking for. It could happen to anybody at any time, especially because HPV hides back in the tonsillar area and down the pharynx region. We've got to look at these glandular areas. You can't view them, you can't look at them as well.

Having a salivary diagnostic that basically evaluate the entire oral pharyngeal cavity with one simple test starts to open up our eyes as to possibly the earliest indications, diagnosis and treatment modalities available than we've ever been able to do before. That's with Vigilant on the forefront of it. It's taking more and more of my private practice time and my otherwise time working with them. It's been really exciting to start to see them ramp up as we're getting closer and closer to product launch. Hopefully next year at this time you and I could be talking about the new product and how we can use it in our offices every single day on every single patient.

Howard: This will test equally for, whether it's HPV, oropharyngeal or oral cancer? Are these different cancers to you?

John: They are all tumors. The CD44 protein, which is the basis of Dr. Elizabeth Franzmann's work, she's the oncologist surgeon and faculty member at the University of Miami that basically identified the CD44 protein as being indicated in every step of tumor genesis in the oral squamous cell carcinoma, no matter where it was located in the oral pharynx and in the oral cavity. That was the interesting part. Then as she continued her studies and coupled it with this total protein component, when those two markers came together, she found that 25 times risk of having oral squamous cell carcinoma than the average person continued to pop up in her studies. These are all peer reviewed studies that have gone on over the years. As we continue with our validation studies, we're hoping that the FDA sees that this is a way to help you and I be more of the CSI dentists than we've ever been. We need to see this crime scene and investigate it properly, so that this way we can help folks stay healthier and use our brain.

Howard: Most of the technologies that you and I have lived through for oral cancer screening were just technologies from downstairs where they put toluidine blue and were looking for a change. That's basically cervical vaginal techniques. Where's the status of the toluidine blue? There were different lights that you would shine.

John: Lights are very helpful, and I still use a light every day because I don't have any other tools. I think that as I worked with OncAlert, which is the product name from Vigilant Biosciences, I'm going to be still using my light simply because if my test shows me that there is proteins going on, that makes me want to look even closer. I'm going to be using that until something better comes along for identification.

Howard: What light are you using?

John: I've been using VELscope since its introduction years ago. I love that light. OralID is another great light. If you don't want to invest in a VELscope, you want to get a good light for visible fluorescence. OralID a really good one too, it's less expensive. It takes a little bit more understand how to work it because you've got to put on a pair of glasses as well. It's a really nice light as well. These are great mechanisms that are available. The problem with some of them are specificity and sensitivity.

The biggest problem is false positives with most of these other adjunctive tests that we're using today. If you don't cut down on the false positives, you really continue to have people questioning. Oral surgeons have been very resistant to adopting a lot of invisible fluorescence because of the false positive circumstances. What OncAlert will be doing in our test studies, we've shown that it's 88% sensitive and 95% specific, which means that it's only 5% false positive probability when you use OncAlert. Our ability to rule out healthy is extraordinarily good with the testing mechanism that Vigilant is putting together. 

Howard: John, how do I say I'm a doctor and a physician of the mouth and I can't give an HPV vaccine? Should dentists be talking to parents about getting their kids an HPV vaccine? What are your thoughts on that?

John: We can't even give influenza vaccines. The pharmacist can do that.

Howard: Not the pharmacist, the pharmacy tech. The pharm tech can give a flu set and we can't.

John: I agree with you 100%. For some reason, the dental boards out there don't think that you and I as doctors are able to inject in the pink skin, into the flesh skin, even though we give injections into the pink oral cavity skin all the time. Essentially the training is so small to be able to provide these types of vaccines. I'm on your side. I think that it's kind of silly that we're not being able to do that.

Howard: It's sad, because the average American sees a dentist twice for every time they see a physician. The number of people that are killed each year from the flu when we could have been giving grandma and grandpa a flu shot is crazy. The HPV vaccine, when you talk about parents, some people don't like it because they believe in abstinence. They don't want to talk about birth control, condoms, HPV. They just say abstinence. There's nothing wrong with that if it works. If they're not abstinent, then it would be nice if they had an HPV vaccine and understood that you need to have a condom on for regular sex and oral sex. It's a conversation where a lot of dentists do not want to have that conversation for religious purposes. What would you tell a guy, where do you draw the line between going to mass every Sunday, because you're Italian, that means it's about 150% chance you're a Catholic. Where do you draw the line between I'm a dentist and I fight disease versus I go to mass on Sunday and receive communion? How do you navigate that?

John: It goes along with the vaccinations on the children that the parents were refusing have them vaccinated for simple things like measles and mumps and stuff like that that created an entire outbreak of disease that shouldn't have. When do we start to look at things from a preventive basis, from a healthcare basis, from a public health basis versus, again, not to get our religious folks upset, but religion is there as a guideline as well. It's a basis by which we try to live our lives, but if it starts to interfere with common sense, then I get a little bit concerned. Yeah, vaccinations of whatever type, I think that they're smart. I think that since we can use an injection on a regular basis, you and I should be able to vaccinate when the time comes and in the appropriate manner. I think it's smart being able to offer that to patients and the children of the patients that come in. Why not? I think it makes sense. You have to move forward.

Howard: John, we are completely out of time, I'm 2 minutes over time, I got to wrap this up. I just want to say that there are 9 specialties recognized by the ADA, and everybody's talking about endo, perio, and all the 7 clinical, no one wants to talk about the little public health side. At the end of the day we are a public health dentist, and we're in a community and we treat the whole community. That means fluoridating the water, that means talking about prevention, that means oral cancer. A fireman doesn't say I only do houses over 3000 square foot, I don't do apartments and condos and I don't go to trailer parks. That's not your job when you're a fireman. When you are a fireman, you put out the fire wherever it is. When you are a dentist, you're a public health dentist from A to Z. Hey, John, you're the busiest man I know, thank you so much for spending an hour with me today. Thank you for all that you've done for dentistry. Congratulations on your MAGD. Congratulations on everything. Man, it was an awesome hour for me. I hope you had fun too.

John: It was a great pleasure and a great laugh. I enjoyed every second of it. I look forward to doing it again sometime.

Howard: I hope so. You got to promise me you're going to come back next year. If this gets a 5, 10 year lease, you've got to come back on and tell me all about it.

John: You betcha, I will do that. Thank you Howard.

Howard: All right buddy, have a great day.

John: Take care.

Howard: Bye-bye.

John: Bye-bye.

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