Dr. Geisinger received her B.S. from Duke University, her D.D.S. from Columbia University School of Dental Medicine, and her Certificate in Periodontology and Master of Science degree from the University of Texas Health Science Center at San Antonio. She will be a speaker at Dentaltown's Townie Meeting 2019 and is an Associate Professor, Director of Advanced Education in Periodontology, and Director of Faculty Development and Support in the Department of Periodontology at the University of Alabama School of Dentistry. Dr. Geisinger is a Diplomate in the American Board of Periodontology. She is the Immediate Past President of the American Academy of Periodontology Foundation (AAPF), a Trustee of the American Academy of Periodontology (AAP), the Chair of the AAP’s Women in Periodontics Task Force. She is a member of the American Dental Association’s Council on Scientific Affiairs and Chair of the ADA’s Seal Subcommittee. Dr. Geisinger lectures nationally and internationally on topics including periodontology and systemic disease, implant dentistry, and periodontal surgical techniques.
Geisinger’s research focuses on the relationship between systemic conditions and periodontal diseases. Her recent work has focused on gingivitis and periodontitis and their effect on pregnant patients as well as elucidating the mechanism of interaction between diabetes mellitus and periodontal disease. Her body of research established a rationale for oral health intervention in pregnant women and developed reliable methods to instruct oral hygiene and measure improvements in oral health, both clinically and from cytokine levels in the gingival crevicular fluid.
AUDIO-DUwHF #1107 Mia Geisinger, DDS, MS
VIDEO-DUwHF #1107 Mia Geisinger, DDS, MS
Howard: It is just a huge honor for me today to be podcaster Mia Geisinger DDS, MS. She received her BS from Duke University her DDS from Columbia University and her certificate in Periodontology and a Master of Science degree from the University of Texas Health Science Center of San Antonio. She is an associate professor director of advanced education and Periodontology and director of faculty development and support of the department of paleontology at the university Alabama. She is a diplomat of the American Board of Periodontology, she is the immediate past president of the American Academy of Periodontology foundation, a trustee of the American Academy of Periodontology, the chair of AAP's Women of periodontics Task Force. She's a member of the American Dental Association's Council on science and affairs and she was the chair of the ADA sills subcommittee. Gosh you have so many credentials she lectures nationally and internationally on topics including the Periodontology and systemic, disease implant dentistry and periodontal surgical techniques. Her research focuses on the relationship between systemic conditions and periodontal diseases, her recent work is focused on gingivitis and periodontitis and their effect on pregnant patients as well as hallucinating the mechanisms and interactions between diabetes in pario. Her body of research established a rationale for oral health intervention and pregnant women and develop reliable methods to destroy oral hygiene and measure improvements in oral health both clinically and from cytokine levels in the gingival corrector, you might be the smartest most ambitious person I've ever had on my show.
Mia: That's very kind Howard I don't think that's true but thats very kind.
Howard: Well I mean I'm serious so obviously you have a lack of sleep disorder man there's so many reasons why I wanted you to come on the show by the way thank you so much for agreeing to speak at the next Townie Meeting in Scottsdale Arizona.
Mia: I'm excited about that absolutely.
Howard: Well you know they say in American money is the answer what's the question I'll never forget was a past executive director of the American Dental Association because he was Beretta and now he works some big dental insurance company, do you know who I'm talking about?
Mia: Yes I do.
Howard: Where does he work now?
Mia: I don't know to tell you the truth.
Howard: What he said he said that when health insurance looks at dentistry the first thing that they can't get past is that when a pregnant girl with gingivitis has a preemie they're gonna have to write a check for a million dollars and they've got research that is the number one thing their focus on you know whether periodontal disease causes other things the first thing they are laser focused on is pregnancy gingivitis lead to a low term wait baby. Do you think there's a connection between periodontal disease and having a premature low birth weight baby?
Mia: So one of the things that our research focused on was gingivitis rather than periodontitis there have been a series of studies done looking at periodontitis, motor there was a study done out of Minnesota and they looked at periodontitis which is much rarer in pregnant women and they did not find an association. So we were actually one of the sites for the motor study which was a multicenter clinical trial funded by NIH and one of the things we noticed was we had to go into the delivery room 24 hours after delivery which makes you really popular by the way, you know pregnant moms really want you to do a full comprehensive probing periodontal chart you know it's within 24 hours after they've given birth but we noticed we couldn't tell the difference between the moms who had received the non-surgical periodontal therapy during pregnancy and those that hadn't because their plaque levels were all really high at our site and so one of the things that we found was that you know they were still experiencing a significant amount of plaque accumulation and gingival inflammation even though they had had that non-surgical periodontal therapy and so we actually started recruiting underneath that motor study so patients who had a gingival index of two on at least half of their teeth they're pretty pretty inflamed gingiva and but without Bommel to see if we could take a simple intervention like intensive oral hygiene instructions you know kind of a fancy-pants electric toothbrush and personalized oral hygiene instructions and get them to change their habits during pregnancy that first study was a pilot study and compared to historic controls we saw a 50% decrease in the rates of prematurity in patients recruited at the same site with the same faculty with the same nurses and OBGYN with the same demographic characteristics same inclusion exclusion criteria. We saw a drop from about 9 percent to about four point seven four percent. So about a 50% drop in prematurity rates and that led us to do future studies where we looked at both prematurity rates in individuals receiving intensive oral hygiene regimen and those who didn't and also we looked at their kids and what the caries rates were in those kids whose moms had gotten the more intensive oral hygiene during pregnancy because we know that maternal oral health is also an indicator of early childhood caries and pregnancy is a really unique time to change someone's behavior smoking quit rights are twice as high during pregnancy than any other time in anyone's life and people who quit during pregnancy are more likely to stay quit. So our theory was if we could change people's habits for six months nine months we potentially could have a lifelong effect on both them and their children and we had very promising results. I'm really excited we you published a few abstract and our our seminal paper is actually going to be published very shortly so it's really it's an exciting outcome because the intervention is really widely available it's cheap and you know you don't have to be a genius to teach somebody how to how to brush their teeth, you know it's you can tailor it to people and and you can put that out to the masses pretty pretty comprehensive.
Howard: That is just huge if you can cut the premature baby rate in half I mean why isnt that on minutes? What bigger story is that?
Mia: So you know one of the problems with that study was that they were historic controls and so when our randomized control trial comes out we should have better data regarding the clear effect of the intervention but you know it is it's a huge economic motivator like you said the average cost of a premature baby from birth to the first year range is about a million dollars the average expenditure for premature births is 50% of all perinatal care and the average cost of just the birth for the mom is tenfold higher so $3,500 average costs for a non premature birth full-term birth and $35,000 related to mom an immediate baby care even if there's no deficits going forward.
Howard: That is just huge I mean everything talked about there's a connection between the mothers pareo an early childhood decay.
Mia: So oral hygiene in moms is an indicator of both the level and quality of their bacteria intraorally and we know most of the infections for kids is a vertical transmission but also kids get their habits from watching their parents and so the primary caregiver and their oral hygiene habits and their value of oral hygiene and their feeling about the importance of oral hygiene and overall health transfers to the frequency of oral hygiene delivery in the children.
Howard: So what is the vertical transmission versus I assume horizontal transmission?
Mia: So generally parent to child transmission is vertical or primary caregiver to child's so you know other transmission would be peer-to-peer spouse to spouse you could you could have those types of transmissions but generally the first the first oral bacteria the kids are associated with is is from mom you know mom don't got that hole right saliva or let's clean the passey in the mouth that kind of thing and that transmits their oral bacteria to their kid and I'm up on myself I'm probably guilty of a lot that.
Howard: Now you said passey in the mouth now I want to know where you were born and raised? I've never heard that term, where were you born and raised?
Mia: I'm from I grew up in Connecticut.
Howard: Passey in the mouth I've never heard that term.
Mia: Like mom takes the passey it's dirty and she cleans it in her mouth and then...
Howard: In Kansas it was a pacifier and in Arizona it's a binky.
Mia: Okay yeah i've heard both of those terms.
Howard: but you know what's amazing is the entire planet knows that STDs, they understand the transmission but they don't I don't think 99% of the eight billion Earthlings understand the oral contagious. Just like like every time the child in Arizona we've had a couple accidents one last December and one about three years for that work a two-year-old was taken in to the OR to be put under for a bunch of chrome steel crowns and they died during the anesthetic and of course the knee-jerk reaction is always the dentist was a bad guy in the anesthesiologist were the bad guy but they've never the media never covers well first of all why did your two-year-old child need to be taken to an operating room and have six or eight root canals and chrome steel crowns these pulpotomy and it seems to me in my 31 years of being a dentist that when a two-year-old needs a lot of you to grow so crown my god mom and dad have opened acadia bombed-out to teeth, the whole herd in that house is highly infectious they have open decay untreated perio it's a home disease it's a herd disease.
Mia: Yeah so I mean one of the things we find is absolutely that early childhood caries in particular clusters in certain groups of individuals in particular lower socioeconomic individuals whose parents may not have access to dental care you know I live in Alabama and it's one of two states where there's no coverage for dental care at all even emergency coverage under Medicaid but our chip program are what we call all kids here but the Medicaid expansion for kids for dental care is excellent and so you know getting Medicaid utilization for those kids to make sure that they're getting treatment but also educating parents you know that infant visit that first visit to the dentist which is recommended to occur within a year of birth is really critical from a parent education standpoint both about sugar substrate and about the importance of oral hygiene.
Howard: I laugh every time anybody says at Alabama I always think about the bear
Mia: Oh yeah
Howard: The greatest food ever and he used to make everyone in the socialite circle so upset because he said you know if you got A's go to an Ivy League school you got B;s find a good school but if you got C's D'S and F's you send them down to the bear and he openly admitted Willie one of these boys who didn't care about school and just wanted to come and learn how to run through a wall one of the greatest football players ever but there's I still see what do you think on this vertical tear down a child which is horizontal peer-to-peer spousal spouse. You go in every dental office in America I mean every one of them and they might see grandma every three months for a pareo maintenance the last ten years and they've never seen grandpa. I mean does that make sense I mean because if it was below the belt I couldn't treat you every 30 date 90 days for an STD without after 10 years thinking hey can we see your husband you know but they do that in the mouth all day long. What would you tell all the dinners here listening to you today do all these 3-month recalls that have never seen their horizontals transmission and peer-to-peer spouse to spouse partner?
Mia: So you know that bad it's absolutely a problem and women have better dental utilization than men as you know 56 percent of our patients are women but from from my perspective it is a huge deal and you know we should be now obviously there are different levels of susceptibility but we should be aware that those bacteria get transferred back and forth and in particular the more bacteria there are in someone's mouth the more influent inflammation there is also the more opportunity there is or ulcerated epithelium to allow that bacteria to coming into the bloodstream and cause some of these systemic effects right. So if you have moderate gingivitis the surface area that is ulcerated and it could allow for bacterial transfer into the systemic system is about the size of a golf ball if you have moderate periodontitis it's about the size of a softball and if you have severe periodontitis it could be as large as a football you know if I had an ulcer the size or an abscess the size of a softball somewhere else on my body I would be running not walking to my doctor. So the fact that can't see those ulcerations is a challenge for dentists because chronologies doesn't hurt patients think that bleeding gums are normal or you know I just don't floss and then my gums don't bleed anymore but healthy tissue should not bleed when you strike it and that amount of surface area is really concerning and can affect a lot of other things that are going on that non healing tissue.
Howard: Dentists have to be more physicians of the mouth and they I mean they're just I mean I always wonder how can you see this lady every three months for ten years and never see her husband. I mean I just got to stop the train right there and say did you take a biology class and I mean you always complain everybody else complain in undergrad why do we have to take all this math and calculus and trig and none of this is gonna matter when they're working with their hands pouring cement in a hole that's like yeah dude because you're not a cement worker you're not a welder you're supposed to be a doctor and this is a microbiological infection and it's just stunning to me that they don't see that and what's even more stunning is last year did you see last year's flu epidemic. I mean usually eight thousand to thirty eight thousand Americans die each year from the flu and they're sitting last year was tops eighty thousand. I mean that was that was double the high and you see all these dentists in there checking for gingivitis but hygienists themselves you know checking for gingivitis on grandma's they do eighty eight thousand grandma's didn't come back for their six-month cleaning why didn't you offer her a flu shot it's only only the dentists in Tennessee. Shoutouts to Tennessee for the dentist you sit there and got the right to give a flu shot because I would rather my grandma hyper than my moms or the dentist and get a flu shot then be checked for gingivitis because that was the most immediate concern and then also the HPV vaccination.
Mia: Yeah that's huge absolutely
Howard: I mean how how can it dentist how could it dentist see a child every six months for 12 years and then they answer and they never even mentioned the HPV vaccine what are your thoughts on that?
Mia: So it's it's really timely because this is a hot topic both of the ADA and the AGd and I know the AGD foundation this is their year for HPV I also know that the the ADA House of Delegates will vote on a proposal to support HPV education and HPV vaccine identification of at-risk patients and referral potentially depending on the state regulations it could also be something that at some point was delivered in a dental office but I mean I think even before we get there talking to patients about the risk of oropharyngeal cancer right now for men in the third and fourth decade of life their rates of oral and pharyngeal cancer associated with HPV are higher than that associated with smoking and that's huge.So it definitely is a hot topic I think that dentists absolutely need to be aware of the risk conferred by HPV on oral and pharyngeal cancers intraorally and you know we need to be talking to our patients about it. I can't look a twelve-year-old girl in the eye that I hadn't talked about it when she comes back at 35 and says why didn't you tell me.
Howard: It's just shocking I mean it's this is yeah this is our cancer this is the oral pharyngeal cancer and we have this massive high technology to prevent it and it's just like and you talk to your dentist and they their only question is switch from impure gum to a digital scan, it's like hey you can make a perfect with a vinyl poly vinyl ether or digital scan I mean that's but compared actually to the flu shot and HPV. You know the most famous dentists in the world is the guy who shot Cecil the lion. I think you know just I think dentist should just go out there and start not only giving the HPV shot and the flu shot but market it all over and tell the governor there's they tell everyone because then I mean then the dental boards you have to sit there and say I mean think of the perfect case, some young dental school graduate bright-eyed bushy-tailed saying we have to do this. I mean what would the state Dental Board decided to take your license away?
Mia: I mean I think particularly if this ADA House of Delegates resolution passes I don't think you know I think that that becomes the standard of care. I think it becomes a standard of care to have that conversation with our patients and then you have your conversation about you know what are the regulations for delivering vaccines in your practice but I absolutely agree with you I think this is a huge issue and when you think about the things that we do that save someone's life I mean I deal in millimeters right I'm a periodontist you know give me a break but when you think about the things that we do that save someone's eyes oral cancer screening and discussing risk factors including smoking but now also that we know better HPV and what you can do to prevent those risks.
Howard: Wow yeah I hope they really get out in front of that because you know it's just that the last flu season is so big and what's bizarre is this is 2018 if you go back 100 years to 1918 the United States you know a lot of people think the times or you know they would say oh the political times are so tough and so I was like come on dude I mean this is a country that lived through the Civil War I'm pretty sure the United States was more divisive during some war the first president that was alive when I was alive was assassinated. I don't think these are Nixon was impeached oh my titty the Spanish Influenza killed 5% of Americans and now what do we get, we get people saying well oh well she's just got a DDS and a MS behind her name. Im against vaccines I went to dr. Google into the search and I'm an athlete back soreness like are you out of your mind the greatest thing we did in the last century was vaccinations the Spanish influenza killed five percent of the planet and what is the lesson learned a century later oh now I'm anti vaccine....
Mia: and neither you are I ever had polio which is awesome
Howard: The boy in my class in high school this is real high school that actually had polio because his mother didn't get the vaccine actually took his own life. well I mean it's so sad to go through school when you're you know disabled and no one else is because they got a vaccine in your mom didn't and he couldn't take it and he took his own life. and it's really interesting times with this social media because now people a lot of people I say about a quarter of the people believe in things that you talk about charcoal toothpaste Turmeric brands, ozonated water, oil pulling. Oil pulling to me is a funny sight, okay so you didn't have two minutes to brush your teeth twice a day
Mia: You have 4 to do the oil pulling.
Howard: Now you also get 20 minutes twice a day to do Oil pulling it's like could we just brush and floss the first two minutes of your oil pulling?
Mis: If I could get you to do 40 minutes of any kind of oral hygiene I think I'd be ahead of the game come on now.
Howard: Yeah I still am positive about social media because I think what it's doing is just giving transparency to what's always been like you'll hear Alzheimer's say you know when you say well you know if you're in prison in the United States you got three variables you're in the poverty level you didn't finish high school you have substance abuse and they say oh yeah during the Great Depression there was no crime because there were no records but I grew up in Kansas I'm pretty sure the stories of God city it wasn't all that civilized and all that pretty wild time. I think all social media doing is now giving a platform for what high percentage of people who are always thinking and now they've just got a platform which i think is the first part of the diagnosis if you want to get an X rating you want to get propings and now we I think we really have this transparent x-ray of what eight billion people are truly thinking which now gives us a foundation to start talking about what do address. How do you address people that come in and don't want vaccines or after your hygienist explains everything once charcoal toothpaste or oil pulling all these things how do you address my 15-minute Google search is better than your dozen years of college?
Mia: Well you know it is difficult because I do think we're in a very commoditized environment for information and people definitely have the sense of skepticism about things that their doctor told them and some of that is healthy. You know people do need to be an advocate for themselves but all information is obviously not created equal. So if you have resources that you can point patients to that demonstrate you know what some of the the research shows and what some of the information is out there, sometimes you know that can help you and then sometimes you have to think about what you can do to risk mitigates right. So oil pulling realistically probably is not harmful it's probably just not helpful. So you know talking about well pulling if someone has 40 minutes extra in their day that they want to spend on top of brushing and cleaning interdental I guess that's okay but the brushing and flossing or brushing an interdental cleaning has to come first.
Howard: and I want to keep going through what about charcoal toothpaste?
Mia: So you know charcoal to plates is interesting because a lot of the brands out there have a very high level of abrasiveness and that's concerning there's also currently five brands of charcoal toothpaste on the market that contain fluoride but the availability of the fluoride in that toothpaste is unknown or limited and so realistically if you're brushing with a non fluoridated toothpaste you are not helping yourself from the standpoint of the major dental disease that we see the most prevalent dental disease that we see dental caries and Stannis fluoride in particular also have anti gingivitis effects. So you know you're also limited in your ability to treat that as well. There have been no studies that demonstrate comparative efficacy of charcoal toothpaste versus any other type of marketed toothpaste that has fluoride or anti gingivitis characteristics and even the whitening seems to be spurious because the whitening comes from its abrasiveness not necessarily intrinsic whitening properties like you would see from a peroxide containing product.
Howard: and I'm going to keep going, what about sumaric rinse?
Mia: So a lot of these ingredients are used elsewhere in the world for their purported medicinal purposes and it's not that there is no evidence but there's low levels of evidence. So there is some evidence for a tumeric with regard to blood sugar control and there's been some studies on that but as far as if anti-inflammatory effects in the mouth there have been no studies that have proven it and again there's no tumeric containing dentist that has fluoride in it and you know if I'm going to pick one ingredient I want it to be poor because I'm most worried about caries in our patients.
Howard: You know and it's funny how it's hard to say things I mean fluoride the I mean the problem of fluoride goes all the way back to McCarthy when he went to the floor of the Senate he showed the human brain with a red dot showing that when you drink coordinated water this area the brain becomes susceptible to communist ideology and it's all because the Russians who had a sputnic before we did who landed a vessel on the moon and the first unmanned vessel that's why we sent a human. They had the first women in space dog in space and they had put fluoride in the water in Moscow and the Americans thought there were they're not the Soviets couldn't do anything good so it was only a communist plot to make them drink fluoridated water and I cannot believe I worked out the fluoride campaign in Phoenix in 89 and then they put it in for 20 years then we just had to redo it again and I'm telling you one-fourth of Americans are crazy. I mean really they are there's no other way to say it other than one out of four Americans is crazy and then when you would give them studies from the Centers of Disease Control they would say oh they're just a shill for the American mining indicate companies and when they're mining a woman they have this by-product fluoride and it's so toxic there is no place on earth to store it so they pay off the government officials to slowly pour it in the water you're like dude are you out of your mind.
Mia: The number one public health interventions that our our country has undertaken it's been wildly successful and one of the problems that we're seeing now is just like we have potholes in a lot of our roads and our infrastructure is needing to be revitalized you know a lot of the infrastructure around fluoride and around the municipal water systems is needing help too and so I think you know one of the things that we're gonna see with some of those those infrastructure issues are not just related to traffic accidents or bridge collapse but also related to health and the municipal water supply and you know similarly when we look at the e-cigarette use in teenagers and the nine hundred percent increase in vaping and e-cigarette use in teenagers you know I'm concerned about periodontal disease in a ten year outcome because the nicotine delivery still has that they micro and macro vascular effects. You know it's a risk mitigation from the carcinogen standpoint if you were smoking and now you're using vaping to quit but it's not harmless by any stretch of the imagination and it concerns me from a periodontal movie standpoint.
Howard: So there's always the debate is this correlation or cause effects I mean every morning that I turn on my coffee pots the Sun comes up now I know that i'm the center of the universe and I know it was me who caused the sun to come up. Some people say it was just a correlation. Do you think well what is the correlation with periodontal disease let start with rheumatoid arthritis.
Mia: So rheumatoid arthritis is very interesting because rheumatoid arthritis has probably the best story associated with it so rheumatoid arthritis is a infectious inflammatory disease that is focused in joints and is caused by is it mediated by a host response absorption of bone and soft tissues in the articular processes and one of the things that they found that are at very high level patients with rheumatoid arthritis and particularly associated with something called the disease activity score 28 which is a score of how severe your rheumatoid arthritis is, it's something called citrullinated proteins and in particular in the antibodies to those the trillion ated proteins anti CTP and interestingly the only organism in the world that they have found that can citral innate proteins which is the replacement of an arginine peptide with a petroleum peptide is P gingivalis Porphyromonas gingivalis and we know that that's one of the very bad actors in periodontal disease. So biologically the story is very very interesting and there's been some studies from Mark Bartol who is a periodontist in australia who has looked at a lymphatic tissue around teeth that have periodontal disease and it has found very similar reservoirs of lymphatic plasma cells and b-cells that are producing some of these anti-ccp molecules. So that's really interesting although Ted Nichols who thin Omaha have done some correlation study both at the VA and then in their own patient population looking at rates of periodontal disease in patients with RA and then also in what they call pro bands patients who are first generation the first-degree relatives excuse me who have who are rheumatoid factor positive but are not yet symptomatic and it's very interesting I don't think we have the longitudinal studies yet to say one is causing the other but there are some data to suggest that it may be one of the hits that induces a an autoimmune reaction in patients with rheumatoid arthritis susceptible patients.
Howard: Wow you are amazingly brilliant on this I'll be the bigger go next to diabetes mellitus.
Mia: So diabetes we for sure have good evidence that patients with poor glycemic control and patients with hemoglobin a1c or glucose levels that are elevated in their blood have worse gum disease that's been established for quite some time. Bob Janko did some studies on the Pima Indians and looked at the rates of periodontitis and and basically decided that diabetes is the sixth complication of periodontitis is the sixth complication of diabetes. You know it's a little bit more murky to say that diabetes influences glycemic control there are some data out there to suggest that it does but a lot of the interventional trials did not show that. The most recent trial which was funded by NIH with a child called DBTT and it was actually stopped before it was finished due to futility so they didn't see a difference between the groups that got non-surgical therapy and the groups that did it one of the things that that you have to look at is you know was non-surgical therapy adequate treatments and is it bring how we treat our patients or Julie jus non-surgical therapy evaluate if the patients have had disease resolution and if not do we put them on to another phase of therapy. When you look at some of the studies that we're done in other parts of the world that were smaller and less definitive they used antibiotics and some other things which seem to improve the hemoglobin a1c rates. The other thing that complicates all of this diabetes research is that a lot of patients with diabetes are also overweight or obese and one of the things that we know is that as patients become more and more obese there is a lack or there's an uncoupling or maybe a swamping of the effect of periodontal inflammation all on there by thenat controls. So you know that can affect some of these studies too because you have so many different things causing inflammation in these patients diabetes affects periodontal disease in patients with diabetes need to have additional para dental care in fact Kaiser Permanente health insurance in California will pay for non-surgical periodontal care because their average expenditure for diabetic patients in the year after they have non-surgical periodontal therapy goes down by somewhere between 25 and 35 hundred bucks.
Howard: Now they say successful people are the ones willing to have uncomfortable conversations that's why I call my podcast Dentistry Uncensored. Things that Americans don't want to talk about is the other end of the mouth and now we're seeing at the rectum area a huge amounts of research about how you know there's 10 trillion bacteria fungus microorganisms viruses, do you think gut microbiome flora someday will be linked to diseases 30 feet up the canal into the mouth do you think both ends of that 30 foot tube are connected?
MIa: I do I have to say I think that microbiome in general there are so many niches from microbiome in the body I think that oral microbiome is not all uniform either right super gingival microbiome and like buccal swab microbiome is very different than sub gingival microbiome and the access that those bacteria have to different parts of the body are different so I think that we are going to find that that there are differences and you know right now they've actually been able to look at some of the microbiome shifts and associated with different diseases is your oral microbiome shift and associate it with different diseases including prostate cancer and obesity. So that's really really interesting.
Howard: Yeah whenever you talk about that people just giggle of you notice when you're in Asia, Asians are far more tuned into their bowel movements when you when you tell an American mother you don't build that she puts her hand on your forehead or might take your temperature Asian women are very quick to ask how their bowel movements are what they look like maybe give an enema etcetera but it's very huge in Australia and these are the people who blew apart the American theory of an ulcer we're going in there surgically removing them yeah and now it's the it's the Australians again who were looking at people at chemotherapy and they're just you know they're just rundown and they're weak and we're starting to get fecal matter transplant from the mother to this child and like bring it back to life but just repopulating has gut microbiome and and there's also some antidotes as some guys talk about when we sit around and watch football games or bars that is it kind of true that when you see someone with a whole bunch of cavities they're less likely to have gum disease and when you see someone with a full mouth of gum disease or less likely to cavities I mean isn't that something and going on in the jungle?
Mia: So they are finding that there seems to be distinct oral microbiomes that are associated with caries or periodontal disease and even in edentulous patients seem to have one of those two not both even without the teeth so that's very interesting too you know those sample sizes are really really small and a lot of them are Bayesian analyses which are sort of mathematical expansions of the data but it's really interesting.
Howard: Yeah I mean I've always been aware of that and and Phoenix is a real cross-section I mean it's a real multicultural cause of American Indian we're 100 miles from Mexico big immigration it just seems obvious to me but you know I dont have the date. I want to say another uncomfortable conversation she graduates from dental school she goes back and works with her mom, her mom's her mom she's 25 years older than her she's big into implants and her daughter's looking at these implants and after five years like 20 percent of them have peri-implantitis and after a decade you know maybe 40 percent have it and mom or dad saying well you know they don't hurt you know it's not painful and then the daughter is thinking of all this oil systemic connection first of all and then you have other periodontist who are saying that maybe titanium isn't is all inert as there is and you see these big companies the biggest implant companies in the world they all seem to be buying up a ceramic component zirconium and there's a lot of people out there who say I think whatever is going on in pier implantology might be related to the metal so address peri implantitis. Do you think it's do you think 20% of implants places in America are implantitis of five years and 40% of a decade?
Mia: Yeah so the mean is actually 23, now how much of that is associated with poor maintenance how much of it is associated with other risk factors like smoking, retain cement, restorative or prosthetic overload or design and how much of it is strictly related to a virulent microflora? That's hard to stock that but bone loss and attachment loss around implants is happening it's a huge part of my practice and most individuals practice and there are certainly patients who are more susceptible to it than other patients you know I think that this is one of the challenges that we as dentists will face in the next generation the next century is really looking at this sophisticated dentistry that was placed and what do we do when if and when it outlives its utility and I think another thing that you know I'm concerned about my mother passed away this year she had dementia and she had a full complement of dentition. How did we brush her teeth you know when you send someone and they're there in a nursing home in a care facility and they they have dental implants they have sophisticated crown and bridge work which you know baby boomers are retaining their teeth much better than their parents and grandparents did. You know how were we caring for those in non retrievable situation I think silver diamond fluoride is going to be a tool for us from a carries standpoint but I also think we have to think about how are we disinfecting some of the bacterial plaque in these patients so that we don't see some of the systemic effects that are potentially out there for the reaction.
Howard: So I have personally gone to Phoenix, Mesa, Gilbert, all these areas where I've gone into the nursing home I followed around an LPN and it was so eye opening. I mean this poor little girl and I don't know why they're always a little girl because when a six flip to the 215-pound grandpa falls out in the shower and she has to call 911 and the fire department has to come out and she knows the name of every fireman on the firehouse near her in this okay we'll be over we'll get them off but but anyway the blessing was a Dixie cup of toothbrush one little pea-sized you know six scratches across the front of the incisors spit in the cup and that was the oral hygiene and she has like 20 people on this wing she has to feed bath brush. So there's basically no variety so I would look at that and I've done this several times I think the only thing that LPN can do but it's got to be in a dixie cup it's gotta be you know swish this or there's gotta be some electric automatic thing where they just bite into it but yeah it's it's a huge problem but luckily I'm a man because the thing I noticed the nursing offices there seriously like 95% women
Mia: Yeah 80 to 20 I think, pretty amazing
Howard: Is it 80 to 20?
Howard: Yeah I mean I've seen entire wings where their was one man on the entire deal so men are lucky we all die before the nursing home. Another thing I was wondering about you know what some of your research and measuring cytokines and that particular fluid do you think there's a place for these like oral DNA these tests where you're actually trying to find what bugs are in there is this?
Mia: I have to say you know my area of Dentistry is probably the most guilty about this because our diagnostic tool is a teeny tiny ruler and we make these grand assumptions about what's going on based upon a millimeter here or there right. So you know I think if we're looking for the next paradigm shift and how are we best diagnosing and treating our patients it's going to have to be a biologic basis for the diseases that we're treating. So you know I think realistically looking for biologic markers and currently frankly the best one we have is minored amount of blood in saliva if there is blood in your saliva your gums are not healthy and that's the best marker we have thus far but I think we can get to a point likely during the residence and I'm teaching that all their practice lifestyle maybe not mine but I think there's where our diagnostic tools are such that we have a much more specific idea of the activity of the disease profits the types of bugs we're looking at and targeted therapies to best address the the specific component of the infectious in 2008 for Adobe that we're seeing in there.
Howard: So here the you're the director of the Periodontology residency that was at University of Alabama?
Mia: At UAB yeah
Howard: Well I have to tell you that my 31 years as a dentist of all 9 specialties recognized by the American Dental Association's yours Periodontology changed the most. I mean I can't think of I bet I bet you're shaking for so so the young boy because most everyone listen to this right now it's under 30 but you know 31 years ago pareo was all four quadrants root canal four quadrants to surgery and then it started working into you know what on if it doesn't work on three rooted teeth let's just cure all this gum disease with forceps extractions and place implants and after about ten years of that now it looks like the pendulum swinging back saying you know you can't cure periodontal disease with an extraction and an implant. So where are we at now? Do you see the pendulum swinging back to the 80s when we're going back more towards soft tissue surgeries and trying to receive natural teeth?
Mia: So I actually think we're probably hopefully headed toward the happy medium I think dental implants have their place. I think that sometimes dental implants are the key to salvaging remaining dentition. Teeth that are lost and patients have a lack of posterior support if we don't give them something for posterior support they're gonna they're gonna have too much function and too much of occlusal forces on their remaining teeth so I think you know particularly in a period on elite compromised dentition or a dentition that's been compromised due to caries dental implants are a tool but they cannot be the only tool and because a history of periodontitis is such a huge risk factor for peri-implantitis we really cannot do informed consent with our patients unless we know their periodontal history in their periodontal condition and so I think that treating active to these utilizing the tools that we have to be able to work with patients to both reduce their pockets but also improve oral hygiene is going to be critical to the success of both retaining their dentition and their implants over time and so I think both of them have a place in dentistry today. I certainly don't see foresee that we're going to eliminate pair analogies or we're gonna go to a strictly titanium based you know specialty but I think that from our perspective our patients are served by retaining teeth and you know implants are a tool but they're not our only tool to help us retain those teeth and manage patient occlusion, mastication, aesthetics, phonetics.
Howard: Well this is dentistry and says your excitement I always go for the toughest roughest questions this one's going to give you an ulcer. You know this is when they're trying to decide between two bonding agents they might spend an hour on dentaltown but when they're about to spend a hundred thousand dollars or a hundred and thirty thousand dollars like on it on a laser to treat periodontal disease you know they go on there and you can see their time so they'll go on there for three or four hours that's a lot of money.
Mia: A big investment
Howard: So do you recommend that they buy a hundred and thirty-five thousand dollar laser to treat periodontal disease do you have one in your office and your residency is that a return on investment or not necessary?
Mia: So we do have lasers that we use in our residency I will tell you that there are a couple of very very good articles that just came out in the journal and Periodontology basically looking at the cost utility and the bottom line on several of those articles was that there is a benefit to laser therapy at least as its presented in the literature but the benefit is small and you know you have to do your assessment of how you're gonna pass the increased costs along to your patients and the benefit that's been shown there's really over non-surgical periodontal therapy alone. When you compare the the attachment level gains and the longevity of those attached Olympic games to traditional periodontal surgery we don't necessarily come out on top with some of the laser protocols. So the question is you know is it useful it may be useful so for some patients who are not surgical candidates it may be useful as an adjunct for non-surgical therapy but you do have to do a cost-benefit analysis because a lot of these technologies are very very expensive and you know there's also the expense of the licensure and the training that's associated with that.
Howard: I'm going to say LANAP, is that the laser they were talking about?
Mia: I'm sorry?
Howard: LANAP was that the laser they were talking about?
Mia: Yes they they looked at the millennium laser and some of the other lasers out there as well they also looked at diode laser with photodynamic therapy for peri-implantitis and that's actually been the most promising treatment modality thus far but yeah the millenium laser is you know the one that there's probably the most saturation in the market and the most data on.
Howard: So I just emailed you a link on under periodontist and dentaltown is LANAP still a thing would you mind posting those two papers?
Mia: Yeah I can do it
Howard: Yeah I wish you would because you know I really fell for these kids I mean in their heart they want to be the best they can be they started with $350,000 as a student loan so they're already already broke and then and then if they buy a CBCT that's six figures one app that's six figures they buy a CAD cam chairside mill. I mean you can make three just you can make three purchases and double your student loan debt so I can't believe I've been talking you for over an hour but what would you say to some kid who thinks they might want to go into perio? There's nine specialties they could be a general dentist and what do you think the future looks like if you were coming out of school of twenty five, do you think especially in periodontics is still a good idea for the next four decades?
MIa: Well I'm not one of these people who thinks that being a periodontist is the best choice for everyone but I know for sure with the best choice for me and I think that the future in perio is very bright. I think that when you opt to do a specialty you're making a decision about how you limit your practice and the type of practice that you're going to to perform and I think you know from that perspective it definitely it's something that not everybody wants to do you know some people that I like doing a little bit of everything and as a periodontist you know you don't necessarily get that chance but from my perspective some of the reasons why I think that and of course you know I think periodontist is the best specialty but you get a lot of the continuing care and the relationship with the patient that you have in General Dentistry that's so appealing when you're going to dental school you know you know where Mrs. Jones the kid went to went to college and you know where Mr. Smith's new grandbaby is a girl because you see them back you know on a fairly frequent basis but you also have the opportunity to really delve into a very small part of the body become an expert at it it's very scientifically an evidence-based. So you know for me that's exciting because things are always changing we're always getting new information and then just like you said I think that one of the things that's very appealing is the opportunity to be a physician and also to have that relationship with the patient's physician going forward from the standpoint of managing and a patient's overall wellness and health and I think that that's really really critical.
Howard: Another huge buzzword in the parade all circles is the pinhole graph technique. You know you usually you take that you gotta fly all the way out to California you got to drop a couple grand what are your thoughts is that the return on investment is that something you'd recommend flying across the country to learn thoughts on the pinhole technique?
Mia: I'm totally gonna say that I had not been to the course and I've heard actually very good things about the course but I personally have not taken it so I just want to put that disclosure out there. I think that there are data to suggest that a vestibular approach for soft tissue grafting can improve patient-centered outcomes in particular post-operative discomfort and aesthetics but I don't know necessarily if there are data to suggest that the type of grafting that's done with the pinhole technique is better or worse or if it takes more or less time than other techniques. I certainly think that all types of dental education are advantageous but I think as dentists we need to be smart consumers and we need to understand the biology because you know if you know the biology there's not a lot of wool that can be pulled over your eyes, so if you understand the innervation the blood supply if you understand the principles of surgery and you feel that a new technique is helpful in your practice that's reasonable.
Howard: Yeah I'll say it a million times I mean you know matters we burn and if you learn $50,000 a year and you only burn $40,000 here and you're debt-free you're rich but dentists, lawyers, physicians only seek no matter how much they earn they always burn more and you know they're always asking me the same question. Should I fly all the way across the country to make course... dude why don't you walk across the street and not on your periodontist door it's free, there's no airplanes, you don't need an airplanes, you don't need to stay in a resort I mean I think the best city in the world is to have a drinking buddy a cheeseburger eating ball game watching buddy periodontist, oral surgeon, pediatric dentist, endodontist. I mean and then what's also great about that is then you have a specific problem you can actually fly over there on lunch at the end of the day and show them the x-rays show them the data and then you know you can't do it send them there or if you're curious you know what's the Pentagon is doing you watching just finds the one that wants to be your brain if they tell you they don't want you coming around here they don't want you watching them maybe it's maybe it's your body odor maybe you spell maybe they're introvert but just find a buddy up the street that is the cheapest fastest easiest way to learn the best dentistry. Was there any questions you wish I asked?
Mia: No no I was the breadth of subjects we covered was was was pretty impressive. So I'm impressed by how much ground we covered during this talk.
Howard: Well I still got one more for ya, I know were an hour and ten and you promised me an hour of your life, and when I ask this question a lot of dentists are going to be like I can't believe he doesn't know he's crazy dude go to Wikipedia, Wikipedia doesn't even know what causes an infraction. You still have dentists saying it's a toothbrush sawing back and forth and then you have veterinarians saying that's interesting because we see those lesions in Antelope and they dont brush their teeth and then other people are saying its occlusal traumatic but I seriously believe that 2018 does anyone really know what an infraction?
Mia: So I wish you were there at our AAP American Academy of Periodontology EFP European Federation of Periodontology world workshop that we have a year ago in November because there was almost this knock-down drag-out fight over this. So what we know for sure is that abfraction is just the out fracturing of those enamel rods and that happen you know we see that whether it's due to undermining of tissues dentin below the enamel rods that causes them to out fracture and that could be due to erosion or abrasion or whether it's due to occlusal forces that's a little bit less clear. I think there's probably an occlusal component but in humans we do not see those types of abfraction lesions on the lingual or palatal surfaces of the teeth. So if it truly was flexure just over time flexure alone I think you would see contralateral lesions on the palatal or the the lingual surfaces of the teeth. So I think again it may be one hit the occlusal forces are one hit and then the loss of dental tissue through abrasion or erosion is another hit which then causes the enamel rods to fracture out.
Howard: So are the classroom sawing the tooth brush back and forth?
Mia: I think both, I think you probably need loss of tooth structure apical to the enamel and you also need the occlusal forces that then cause flexure of those enamel rods.
Howard: and are you for water picks or flossing?
Mia: Oh my goodness
Howard: Your so good I'm not gonna take off your mic you just walk out of the room and so you drop your I might... no
Mia: Interdental cleaning and my preferences if you can get an interdental brush in there that's number one because that's been shown to remove the most plaque and then floss next and then water pick third
Howard: Okay yeah I think water pick might make it a little bit of comeback this my patient what they hated the most about it was just make some mess in the bathroom.
Mia: Yeah now they have air flossers too.
Howard: Well now they have where you gonna charge them and take them into the shower.
Mia: Yes i've seen those.
Howard: and then last but not least and then I'll let you go you've been so amazing to stay on with me with all this garage of questions is, some dentist just work in DSS where if somebody has a pocket of over say five millimeters they'd have to put like an ariston or a perio chip and each one of those and sometimes they wonder is that because there's an insurance code as the billing or that because they have a clinical director like you who's a periodontist with an MS degree. What do you think of that what do you think of a blanket statement that said if they have a six millimeter pocket you've got to put it in a perio chip or areston or something like that?
Mia: So the minocycline microspheres the areston in the studies that were done on them initially were nine-month studies and the areston was applied at zero three and six months and they saw an average whole mouth reduction in probing depth of 0.5 millimeters. I think you know what you have to look at realistically is again that cost-benefit analysis if you're one five millimeter pocket and you think you can get half a millimeter a millimeter of gain in addition as an adjunct to the scaling and root planing game that you anticipate that might be worth it. If you have eight your cost and the cost of the patient probably warns that that patient have some kind of gingival surgery to reduce those pockets because the cost benefit analysis and the longevity of the the treatment is better.
Howard: Okay can I add my last last last last question, I was born and raised in Kansas, I now live in Arizona which they call the Florida of the west coast. Do you know how many dentists need your reaction after their hygienist does root plane Caritas and just writes a script for NDK?
Mia: No but this is so timely it's so interesting that you bring this up Howard because our department is participating in a study and they're going through the ADA and the AAP to actually ask them it's exactly that question. So I don't know now but if you come back to me in about six months I will likely know the answer to that but it's very interesting because what we're looking at is there are clearly patients who benefit from the systemic antibiotics as an adjunct to non-surgical periodontal therapy but it's not everybody. So how do we limit on antibiotic exposure and target just those susceptible patients so that we can make sure that we're doing the best thing for our patients but also not breeding superbugs.
Howard: but you know the being born and raised in Kansas that that that trying to guilt the dog into not breeding superbugs when every dentist in Kansas and Oklahoma and Texas knows that 90% of all the antibiotics used in the United States are in cattle and chicken and feed and if the Centers of Disease Control seriously wanted to make a debt they would start with chickens,cows and pigs I'm not grandma on her three months recall or you know and so that's... we live in interesting times don't we. hey I just want to say that I asked you to come on the show you didnt ask me, I'm your biggest fan I'm so excited you're gonna speak at Townie Meeting, no really you're just a wealth of information and on dentaltown the periodontal forums are one of the most active I mean the pediatric the periodontal forums they're so active because I say if there ever was a specialty that's been changing more it's not your local orthodontists dealing with Invisalign or your local pediatric dentist dealing with silver diamond fluoride, it's you guys man you're at the front of like every war in dentistry whether it's superbugs to technology to everything and you're a busy busy person thank you so much for coming on the show today it was an honor to interview you.
Mia: Thank you very much Howard I really had a lot of fun and it was an honor to be on.
Howard: All right thank you so much.