Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
How to perform dentistry faster, easier, higher in quality and lower in cost.
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1156 Dr. Hana C. Hobbs DDS, MS, Periodontist, Diplomate of the American Board of Periodontology : Dentistry Uncensored with Howard Farran

1156 Dr. Hana C. Hobbs DDS, MS, Periodontist, Diplomate of the American Board of Periodontology : Dentistry Uncensored with Howard Farran

3/15/2019 5:38:21 PM   |   Comments: 0   |   Views: 107

Dr. Hobbs is a Diplomate of the American Board of Periodontology and has over 25 years of dental and periodontal experience. She earned her undergraduate degree from the University of Maryland in College Park and went on to receive her DDS from the University of Maryland Dental School, graduating Magna Cum Laude. Dr. Hobbs completed her General Practice Residency at York Hospital in York, Pennsylvania and was the Chief Resident the following year at Carolina’s Medical Center in Charlotte, NC. Dr. Hobbs worked as general dentist in Charlotte for a year before deciding to specialize in Periodontics. She attended the University of California at San Francisco where she earned her certificate in Periodontology Specialty while simultaneously earning a Master’s Degree in Oral Biology with emphasis on the link between Periodontal Disease and Diabetes and TGFB growth factor. She received the “Most Innovative” Clinical Research Award in her Senior Year at UCSF from the Western Society of Periodontology.

VIDEO - DUwHF #1156 - Hana Hobbs

AUDIO - DUwHF #1156 - Hana Hobbs

In 1997, Dr. Hobbs moved to Durham, NC where she established a private practice in Periodontology and Implantology. She operated a highly successful, private clinic in Durham and received her Diplomate of the American Board of Periodontology in 2000. She has been an Assistant Professor at UNC school of Dentistry Post- Graduate Periodontology Department since 1997 and she rose through the ranks of the North Carolina Society of Periodontist serving as President in 2014.  

In 2015, Dr. Hobbs started the Hobbs’ Spear Study Club. She enjoys the opportunity to interact with great restorative doctors and specialists and has been a member of numerous Study Clubs in the Triangle Area including the Wake County Dental Society and the Seattle Study Club.

In 2018 she sold her practice and joined NuImage surgical center.  She has presented to numerous organizations over the years, including Wake County Dental Society, Wake and Durham/Orange Hygiene Society, NC Chapter of AAWD, Durham Health Department, Duke Endocrinology Grand Rounds and numerous local Study clubs. Dr. Hobbs was born in Egypt and raised in Germany. At the age of 9, she came to the U.S. with her family.  

Dr. Hobbs is married to Jim Hobbs, a Greensboro native, and they are proud parents of their daughter, Madison. In her free time she enjoys spending quality time with her family, exercising and watching her daughter do gymnastics. Dr. Hobbs is a proud supporter of Hospice, The Food Bank of N.C., The Pulmonary Fibrosis Society, The American Cancer Society, Durham Rescue Mission, Doctors without Borders and the Salvation Army. She also volunteers for the Baptist Mission Dental Bus, Wake Smiles Dental Clinic and Miriam Dental Clinic.

Howard: It's just a huge honor for me today to be podcast interviewing Dr. Hana C. Hobbs DDS MS a diplomate in the American Board of Periodontology with over 25 years of dental and periodontal experience. She earned her undergraduate degree from the University of Maryland in College Park and went on to receive her DDS from the University of Maryland dental school graduating Magna Cum Laude. Dr. Hobbs completed her general practice residency at York Hospital in York Pennsylvania and was a chief resident the following year at Carolinas Medical Center in Charlotte North Carolina. Dr. Hobbs worked as a general dentist in Charlotte for a year before deciding to specialize in periodontics, she attended the University of California, San Francisco where she earned her certificate in Periodontology while simultaneously earning a master's degree in oral biology with emphasis on the link between periodontal disease and diabetes and TGFB. TGFB is transforming growth factor beta I had to look that one up. She received the most innovative clinical research award in her senior year at UCSF from the Western society of Periodontology, she then moved to Durham North Carolina where she established a private practice and Periodontology and implantology. She operated a highly successful private clinic in Durham and received her diplomat of the American Board of Periodontology in 2000. She has been an assistant professor at UNC School of Dentistry postgraduate Periodontology Department since 97 and she rose to the ranks of the North Carolina society appeared on us serving as president in 2014. In 2015 she started the Hobbs Spear Study Club. She enjoys the opportunity to interact with great restorative dentists and specialists and has been a member of numerous study clubs in the Triangle area including Wake County Dental Society in Seattle Study Club. In 2018 she sold her practice enjoy new image surgical center she has presented to numerous organizations over the years including Wake County dental, all around North Carolina Durham Health Department, Duke endocrinology, Grand Rounds and numerous local study clubs. She was born in Egypt raised in Germany, at the age of nine she came to the U.S. with her family. She's married to Jim Hobbs a Greensboro native and they are proud parent to their daughter Madison. In her free time she enjoys spending quality time with her family exercising and watching your daughter do gymnastics. She's a proud supporter of hospice the Food Bank in North Carolina the pulmonary fibrosis society, The American Cancer Society Durham rescue mission Doctors Without Borders and the Salvation Army. She also volunteers for the Baptist Mission Dental Bus, Wake Smile Dental Clinic and Miriam Dental Clinic. My gosh you've lived in Egypt, Germany, San Francisco and North Carolina. Which one was the best?

Hana: North Carolina

Howard: North Carolina?

Hana: Yeah

Howard: What I love about North Carolina is you got all four seasons but no extremes, just mild four seasons.

Hana: Well we had a lot of humidity. I love San Francisco I love grad school but it's just I'm not a big-city person so it's tough to live in San Francisco if you're not a big-city person.

Howard: So now do you remember Egypt or Germany or just a little baby?

Hana: Yes I loved Germany I was you know really I was young when we lived there it's a food I'll remember the food was fabulous like the food was unbelievable and no one gained weight you ate all the time and we always had a hazelnut ice cream after dinner so that was my memory of Germany it was awesome food was unbelievable and I played field hockey.

Howard: and this month is the IDF me that's the largest dental meeting in the world is every other year in Cologne, Germany. America is very fragmented cuz every state has their annual meetings and you got a bunch of big meetings like you just had Chicago and Yankee and all the dental meetings, but Europe pretty much just has one monster meeting every other year and over a hundred thousand dentists go there from every single country on Earth

Hana: Wow

Howard: and I love it because cologne actually the Roman Empire's furthest outreach East was Cologne Germany so it's got a mix so you can get all your German food you get all your Italian food and then you can get that hybrid Italian German stuff in the middle it's just it's just amazing and but you know I've always said on this show I've been a dentist for 31 years of all the nine specialties recognized by the ADA yours has probably changed the most. I mean I there hasn't been these monumental changes in endo and pedo and all these things like that I mean when I got out of school it was all four quads of replaying curettage and four quads of surgery and then about 10 years after school a lot of people decided the best way to treat pareo was just extract it and place implants and then after ten years of that they're seeing all this peri-implantitis and now I see it going back to old-school traditional stuff where people are you know I'm seeing treatment plans it's like my gosh is it 1987 all over again. So where are we at are you treating pareo with forceps and titanium are you going back to old-school traditional periodontal surgery?

Hana: Well I'll be honest with you I am trying more in the business of saving teeth because as you said you know 20 to 30 percent of implants will wind up failing they're either alien or failing but I do not do traditional periodontal surgery as much. I've been laser certified now for eight eight or nine years so I do the LANAP surgery and I've been doing it for many years and it's literally revolutionized my practice.

Howard: Well do you know our periodontist in my backyard Arizona Allen Honigman?

Hana: Yes

Howard: I have to give him so much credit because he was the first a doctor of LANAP and people were openly saying it was no good and he's crazy and all this stuff like that and then 10 years later every periodontist I know is like waiting in the deal. So I was telling Allen I said my gosh pioneers get the most arrows in their back, when he started it no one believed it and now it's going mainstream but I have to tell you it's a chunk of change it's a hundred and thirty-five thousand bucks is it worth it, is it a return on investment?

Hana: As a specialist, as a periodontist, I don't know as a general dentist but as a specialist for me it paid for itself in the first year that I had it. It was a little less than what it is now but within the first year of having it and I really cannot see a periodontist practicing without having that in their armamentarium because patients are savvy they they will look stuff up and this is a non-invasive way to treat periodontal disease and it really works I've seen incredibly ridiculous cases that I've been able to salvage teeth that I don't think a bone graft and to do an implant would have worked and I think I set you a couple of slides of that.

Howard: Yeah for the kids who don't know what LANAP is, explain what LANAP is.

Hana: So it's called laser assisted new attachment procedure. So there are several lasers in dentistry this specific laser is nd-yag so the wavelength is 1064, there's a erbium laser there's a co2 laser there is a diode laser so the diode laser wavelength is like 8:30 to 1060 for the ND AG is 1064 erbium is like 2,000 at 3000 the co2 is a little less. So the nd-yag the beauty about that is that it selectively removes the diseased tissue so you're not removing healthy tissue that is one of the biggest downfalls with periodontal surgery is that you're cutting gum away and you're counting on your naked eye to discern the healthy versus unhealthy gum and then what winds up happening as a result you'll have a lot of recession and the teeth are sensitive the teeth are longer the patients are and a lot of pain and/or discomfort and it just sounds horrible you're cutting the gum open you're cleaning the roots which you do with the LANAP but you're there's no sewing there's no stitches and so the on a scale of one to ten most people come back I saw somebody today that I did a laser on a week ago he said he took one Tylenol you know can is very subjective but he took one tylenol that's all. The biggest limitation with the laser is that you cannot chew on the side that was treated this you know for about a week to ten days but for the most part I've seen really great results and over the years as I've used a laser I've learned variations of things that I could use it for I've expanded my use of the laser and also I find tune, you know I've learned from my mistakes what I've done right and wrong.

Howard: Well when someone tells you they only took a TYlenol you got to make sure they're not Irish because it might have been an Irish guy and he had one tylenol and three quarts of Jameson whiskey so you got to qualify that. The lasers, it's amazing these kids come out of school and they're doing hygiene checks and it's very stressful for them because they see all this peri-implantitis around a late around an implant but you know it's like high blood pressure the patient doesn't feel it they can eat anything they want it's hard to communicate to someone that something's wrong when they don't have any pain what is your how do you successfully do that how do you tell grandpa who doesn't have any problems and you didn't have a problem till you started telling me at peri-implantitis, how do you sell that to someone with no pain?

Hana: So how can I just go back to just teeth in general, in perio we spend most periodontist spend a lot of time with the patient, we spend a lot of time educating the patient it is a silent disease. They're there because I saw somebody today why you here my dentist told me to come I'm not having any problems so you measure and they've got eight nine ten millimeter pockets they've got bleeding you could you have to sit down and explain to them that periodontal disease is like high blood pressure it's only bad when you have a stroke but in the meantime it could be high it's the same thing we use a lot of audio-visual aids to review probing depth bleeding these are all inflammatory markers that should not be there as far as implants the beauty is you can take an x-ray and show them when they started off with that what the implant look like and where we are today, you can just show them the bone loss and explain that to them well and they're like well it doesn't hurt it doesn't bother me and then you have to step in and say well if you don't treat it it's gonna take the adjacent teeth down with it you're gonna lose bone on the adjacent teeth now you have a three tooth side  problem not just the single implant but yes periodontal disease you know at when I first got out of school it was this is your problem you need to do it. Not many people were signing up for surgery or treatment it's because you know our skill set and dental school unfortunately is not to communicate clearly and I was talking about primary occlusal trauma secondary occlusal with trauma and you can just see the patient's eyes roll in their head you just have to keep it simple and you explain to them that there's so many links between periodontal disease and heart disease, pancreatic cancer, lung disease, lung cancer, Alzheimer's. All everyone knows now that most of the systemic disease they're finding a infective link like for example Alzheimer's, so if you tell the patient if you want to prevent that maybe you want to take care of periodontal disease and for me as a I got my master's degree with a Lincoln diabetes so what I tell the patient is periodontal disease is considered the six complications of diabetes. So imagine it and I says what I exactly say imagine you have ten toes that are infected and you're walking around you're just changing your shoe every day what kind of would that be on your system it would be an incredible amount your body's gonna be trying to fight off ten infected toes and while at the same time trying to manage your blood sugar and it's not gonna win the blood sugar they're gonna try to wall off the infection it's gonna go gangrene you know lose the toes. It's the same thing with your teeth you've got to remove the infection in order to systematically heal and lots of studies have shown if you could talk pair dolls disease you can improve the glycosylated end products you can reduce the blood sugar they've been many many many studies I mean I remember one graph specifically from grad school Pima Indians in Arizona where you're from they have a very high incident of type 2 diabetes and so periodontal disease runs very rampant in them and they were able to show when they control a periodontal disease they were able to improve the period of diabetic markers and vice versa when they improve the diabetes they're able to improve the periodontal disease. So it's a hand and glove sort of thing and that is exactly what I tell the patients I usually site that study.

Howard: Yeah and then and the biggest one the most expensive one is premature babies, I mean a preemie is a million dollars and you're starting to see these insurance companies when they see these on pregnant mothers and their medical doesn't cover dental they're starting to rethink why is the mouth not covered because if gingivitis or gum disease, well do you think gingivitis or gum disease causes premature low weight babies?

Hana: So I mean I do agree and Steve Offenbach arrest a soul had an incredibly beautiful model where he had hamsters and he introduced periodontal disease in them and they had premature pups the hamsters that had periodontal disease, so he had a very eloquent animal model for that. We obviously can't duplicate that in humans but in my experience I've seen that to be true. I've also seen that to be you know a lot of our patients are middle-aged patients that come to the periodontics and they have uncontrolled periodontal disease and then disappear for a few years because they have they had a heart attack or they had a stent placed and you come back and say well you know there's a huge link between periodontal disease and coronary vascular disease you know let's get this under control so you don't have another MI because the cytokines and the endotoxins from the periodontal pathogens create a clot just like you would you know a cholesterol clot in the arteries and that's been proven and shown.

Howard: When you're looking at periodontal disease and implantology, back in the day when implants come out they start going with h8 coatings and then and that's kind of no longer the deal. Do you think some implants are more resistant to peri-implantitis than others?

Hana: You know make it shot by like 50 in implant companies here but I don't think so. I had a patient today who had rampid periodontal disease, the one that had no idea why she was there but before she left she said can I have two implants on the lower right she's missing 30 and 31 I said ma'am no you have to control your periodontal disease. You wouldn't put a roof on a house that's on fire you need to put the fire out fix the damage and then you could put a new roof on. So I don't really think any implant come per se is resistant, you can get radon disease around implants as a matter of fact with the LANAP I try to get my patients not to be so insurance driven and do you know one side one year another side next year because one side will reinfect the other and also you can transmit it to your spouse's, to your kids.

Howard: I can't so I can't believe how many dentists on dental town don't even believe that I mean like I'll give you an example let's go to pediatric dentistry, whenever I see a two-year-old that needs to be taken to an O R and that needs eight pulpotomy and 8 chrome steel crowns, well everybody living in that herd in that house has got rampant decay the mom the dad the babysitter I mean you just can't have a two-year-old kid need eight pulpotomy and 8 chrome steel crowns, everybody sharing utensils and kissing that kid has got bombed-out teeth. Well it doesn't it have to be the same for periodontal disease?

Hana: It absolutely does, they actually forgot what study of it is they actually showed that you can share the same microorganisms with your dog if you're kissing your dog.

Howard: Yeah I'm gonna have to give my two dogs away this could be a problem Sammy and Rufus are gonna have to find a new dad but yeah but it's I mean you go to other Sciences they talk about herd diseases I mean our herd has their diseases and and when again when you see a two-year-old that has a bombed-out mouth and it's a great practice builder because you know that women are so maternal instinct as soon as they get pregnant I mean it's all about the baby and I sit there and have a long education talk with them and I said I can't have anybody kissing this baby with a bombed-out molar and peri-implantitis around a half erupted wisdom tooth and then your grandma's gonna come over and she's got an upper denture and a lower parcel and nine millimeter bleeding pockets and you think she's gonna babysit your child I need though I tell them I need the whole herd in here and then when you flip over to pareo how many times have you seen a patient that's come in every three months for ten years and they and the office has never seen her husband and say so she's kissing and her husband and you've never even seen them. I mean don't you think that in 2019 we have to treat the herd?

Hana: Yes that's an excellent point you make an excellent point and that's a great practice builder to say you know what I'm concerned about your spouse or your kid or your partner please bring them in we can do an examination and make sure that we're treating them as well that's you make an excellent point that's a great practice builder.

Howard: and it's almost like the mouth is a different part of the body that doesn't it's not can you know connected to the rest the body you know you have medical insurance and dental but dentists believe a lot of things they're us the medical doesn't like I wouldn't treat you for an STD every three months for ten years without saying hey I'd like to see your boyfriend can we get him in here. I mean it's just you know why would it be different below the waist above the waist and when you and when you tell grandma you know I think it's because your husband has gum disease and decay or I don't think it would you know be a problem and they immediately get him not no woman's gonna get their teeth clean every three months at a periodontist and then go home and kiss her husband hasn't been in in ten years unless she's educated on the event. I want to go through so what's you know they're young, they're out of school, you know they come into school they've only done like fifty fillings ten canals of endo maybe three dentures or partials. So I just want to go through some various subjects and just try to educate remember a quarter of our listeners are still in dental kindergarten they haven't even graduated yet and the rest are all under 30 talk about Mucogingival defects.

Hana: Okay great so the there's the old classification systems Miller one two three and then there's the new classification system from the American Academy of Perio and the European Academy Perio AT one, two and three. So Mucogingival defect the best thing the way I explain it to people and the patients and the doctors that I work with is the narrower and shallower the defect the greater the opportunity to get 100% of the route covered. So if you make two you have a cleft that on let's say in lower incisor that's five six seven millimeters deep that of you getting 100% of the route covered Goes Down but if the recession is like three or two or four even for the opportunity to get 100% of the route is covered and how I explained it to the patient is the gum recedes the bone recedes with it and over time what happens is either the tooth will drift facially or drift up so what we're doing a graph for and I do I have not done a free gingival graft in probably nine years I've done only connective tissue graft and I don't use the alador or a donor site I use the patient's tissue that if we use a connective tissue graph we can re-establish the thick band of keratinized gum and I have a sleeve like I'll use my sleeve on my gown and it forms a collar around your tooth and it protects it so a lot of dentists will come out there you want to put a composite on the approximation I would say hold off don't put the composite on until the recession is treated and then you'll see if you even need to go back and put a composite because a lot of times and I'll speak from my experience, I will go in during the surgery smooth up fraction lesion down so that it's flat he's a round diamond or a football diamond and then lay my graft across it and a lot of times you get connective tissue reattachment and you can cover that a fraction region obviously if it's an enamel you can't but if it's in dentin and you can.

Howard: You know it's funny when I was in dental school all those up fractions were told and taught to me that is from brushing back and forth in a sawing motion and then it wasn't even five years out of school the veterinary's were saying well that's funny we see him and sheep and hogs and horses and cattle and we're pretty sure they don't brush their teeth. So what does cause a abfraction?

Hana: So I'll tell you though I've been out of school for a while the more and more I see how occlusion plays an incredible portion in dentistry to me a lot of these uh practice that you see will be an occlusal trauma issue. I saw an abfraction lesion on the lingual of an upper molar there's no way you can brush that surface off that tells me that tooth is a traumatic occlusion and it's usually the centric stop or the center interference when the patient closes and so that needs to be equilibrated so that there's not that. If you do a graft on something that it's a traumatic occlusion it's going to recede again so one of the very first thing actually that I do is check occlusion even for a soft tissue graft check it in Centrex excursive especially protrusive for the lower incisor because you it's amazing how many people will ride on their lower incisors forward and then sometimes you'll get attrition with compensatory super-eruption.

Howard: Do you think it's fair to say that dentists treat three diseases caries, pareo and occlusal?

Hana: Yes I do, occlusion is so important I mean it is so vital to everything we do. Talk about peri implantitis, a significant amount of that is occlusal trauma and if that is not addressed or discussed with the patient before I almost always ask my restorative doctors to make a bite guard for the patient afterwards even if the patient refuses at least you've had this conversation with them and I also say you know keep the occlusion light use a custom abutments that are accustomed to the implant that's another very important point and I think a lot of the younger daughters so I'm gonna save you know a few dollars here let's say you're doing Straumann you need to use Straumann components because if the implant fails they're not going to cover the abutment in the crown if you didn't use component parts if you use some knockoff it's not going to be covered and so now you're going to be going back to your patient saying you got to pay lab and abutment see and most patients are gonna aren't gonna be happy with that. I mean one of my recommendations today I saw one my implants I followed up I said please use component parts that are specific to the implant and keep the occlusion light and make a hard mouth guard for the patient, at least somebody needs to have that discussion with the patient so that they are aware that there is trauma from occlusion on the implants and there's no appropriate septum ligaments so they cannot feel when they're biting very very hard on the implant and you can cause trauma from occlusion.

Howard: You know the late Carl Misch who was on episode 282 he actually got his start in removable prosthodontics and he was making dentures and people were having implants was just getting going and these people were all complaining that the implants were cheap because they were snapping at the bone at the gum line and he was looking at me said my god you're the bite is off so horribly that's so that's why and so it's amazing the cross-training he by learning how to build removable dentures that was the cross-training he needed to know how to properly plane an implant and I bet you most people when they look at peri-implantitis or just their mind says well I know it doesn't have a cavity it's titanium so it's all perio and they and that might be the blind spot that it might be all occlusal.

Hana: Yes you know I was like he said I was a general dentist first so I you know it to me that was really key and I I wish all specialists could be general dentists first because it really gives us a great appreciation it's kind of hard to jump out of dental school and go in a specialty training. I feel like we all need to have that one or two years where you're a general dentist, you're doing everything so you see when things come in like why something didn't work it's not necessarily the doctors fault or the patient fault it's just that circumstances and being have been a general dentist has made me like a really and you know I feel for the general dentists especially when you see something you know the patient it hasn't list like the lady I saw today she's more worried about the lack of 30 and 31 whereas her front teeth are splaying because she has no posterior occlusion to bite on and I said well the reason your front teeth is playing because you have no posterior teeth well can I just have the implants forget about my front teeth moving and I said no they also go hand in hand I mean I'm getting on my soap box but I do feel like a specialist we all need to spend one year as general dentist whether in residency or internship or whatever it just makes you a better specialist.

Howard: Well I'm out here in Arizona which is considered the Florida of the West so when you tell someone they have ten cavities and gum disease they say I just want the bleaching and so a little different out here. Same with MBA school I had a common times I told the Dean of the dental school you know I opened up my practice in 87 and then I went back to night school in 98 99 got my MBA and all the people who had worked at Intel or Motorola or Frys or whatever for five or ten years they were learning so much and tasting us but the kids who just graduated from business school went right to MBA school they didn't have any experience, you could tell by their questions they didn't even they didn't even get it and I always said don't why would you take a kid straight out of business school and because he just wants his initials behind his name I said let him go out and work in the real world and then after five ten years come back as a retreat. So I know they're gonna ask you, the IDF meeting is this month in Cologne and there's over 250 dental implant companies that have a booth there so she's 25 years old she's listen to you, you're a diplomat and pareo you've done this longer than she's alive she wants to know what system do you use?

Hana: I mean I can't speak specifically to one system but I would say pick an implant company that is gonna be around five years from now and you want a reputable company, yeah you're gonna pay a little bit more but the surface is better whether using Nobel, straumann, Astra. I was trained on Nobel and you mean at UCSF and it was we had to be Branmark certified I don't know if you remember those days...

Howard: Sure I do

Hana: You scrubbed in, it was like betadine on the face. The center got Branmark certified in order for you to place a Nobel implant as well. It's not like that anymore but I urge the people that are placing imprints whether there are general dentists or specialists use one of the top four or five because people move around with components. I saw somebody the other day and implant abutment screw broke but they're no this person had it done in another country well this is a brand that no one's heard of we try to look up it'll get up on a website what is this implant nobody can figure out so now that implant has to come out and that is not an easy procedure. So you know if I could give any advice to myself or the younger dentists is to have a long-term view do the right thing in the long term you're going to come out ahead because the patient will know that you did the right thing by them .

Howard: Okay the name and what is your short list of dental implant companies that are profitable will be here in ten years doing research what are the ones that you can go long-term with?

Hana: Nobel, Straumann, Astra, Biccon because the have the shorty, Biohorizons.

Howard: What did you say about Biocon?

Hana: They have the shorty fatty for like if you have someone who is...

Howard: Are you talking about me or the implant?

Hana: Me I'm talking about myself

Howard: I want to promote by I want to promote anything that's short and fat so I'm gonna go with the Bicon then.

Hana: So Bicon is you know the only thing with a bicon it's a single implant there's no custom abutments with it but it's just you know if you have a short sight but all the implant companies now make short fat implants all of them they all do but that was the big claim for Bicon is that you know if you have a five six millimeter you can just place an upper without doing a sinus lift boiler and it's a full sinus lift or a summers lift but all of them have that now but obviously in my mind you know and I probably I'm offending some company I don't know but the top three are Straumann, Noble, Astra and they're gonna be around you know the components are going to be around that nothing is worse when you have an abutment screw break and they no longer make that implant or that you know the moment there's...

Howard: Someone posts a picture every single day on dental town does anybody know what implant this is I mean yeah I mean there's even a website there's even a website.

Hana: Yeah

Howard: Just real quick you said treatment of Mucogingival defects there was the old classification Miller one two three and what did you say the new European classification was?

Hana: RT one two and three and I can email that to you if you want to...

Howard: No I want you to post it on dentaltown when you'd go under pareo and say hey I did a podcast

Hana: I did I have it on my I did a CE course periodontal plastic surgery and it's in there

Howard: Oh nice

Hana: Yes it's in there it shows that the old classification system compared to the new.

Howard: and when is that course go live?

Hana: I don't know I have to ask that or Goldstein they have my stuff and we'll see when they get it together.

Howard: Nice well thank you so much for doing that! Yeah he hasn't released it yet you might have to drive down to Bethlehem Pennsylvania and wake him up or something maybe he's on maybe he fell asleep but so the old system was Miller one, two, three and now the new system is...

Hana: RT one, two and three

Howard: and what's RT stand for:

Hana: I forgot sorry, I forgot

Howard: So I want you to talk about, I'm just gonna throw words out there or when you talk about, Ridge augmentation.

Hana: Yes so you can have ridge augmentation hard or soft tissue or you can have a combination so that classification is called the Seibert. Siebertone, two and three Seibert one you're missing buccal lingual Ridge width right Seibert two you're missing Corona apical ridge height. Seibert three is a combination of the two where that's also will be in my CE Course the Seibert classifications and the ridge defects, photos of what one two and three look like. So obviously Seibert three is the most difficult to handle because you have a buccal lingual and a coronal apical defect that you have to regenerate, so most of the time it's you regenerated with soft and hard tissue and what we use in our office is what you talked about with Dr. your the last periodontist you had, LPRF we use bone LPRF and then I'll do a connective tissue graft as well.

Howard: and when you're using bone what kind of bone do you like to use do you like to use?

Hana: Mineralized cortical bone

Howard: and why is that?

Hana: It just if you I have found that you get a turnover faster in three to four months of viable bone to place your implant versus if you have demineralized and I don't I'm not a big fan of the synthetics, I just don't think it has the tensile strength for Ridge augmentation when you go drill into it for an implant you lose like half your buckle plate that's been in my hands, now a lot of people like to use that in sinus lifts because it adds bulk to the site and you don't have to put as much but I usually just use mineralized cortical bone.

Howard: and when you say Siebert one,two and three, how do you spell Seibert?

Hana: Seibert, that will also be in that CE course

Howard: A lot of them are wondering, someone comes in and you know they're the vast middle class the lower middle class have to have a molar pulled would you bone graft that or not some people say they would bone graft it if you were gonna place an implant within a year some people say if they're not gonna get an implant in 12 months the bone grafting is useless what were do you weigh in on that?

Hana:  I would bone graft it this is what I say to the patient and people are welcome to you said do you want to have an alarm on your house before it's broken into or after it's broken into you want to have an alarm before, so putting in the bone will maintain the ridge height and width even if you decide to do an implant or not it maintains the ridge for the restorative doctor to place a proper size ponic. So in the first two years after you take a tooth out 60% of the buccal plate resorts 60% if you don't have something there to exclude the soft tissue and maintain that bone you're going to have the distance of the buccal plate which is very vital or the proper emergence and maintenance of an implant. So I always try to tell a patient if at any point you're going to consider doing the implant you need to do a bone graft it's just it is so hard to recoup what has been lost versus the preventable they're lost again the analogy of the burglar you know alarm you know it's better to have one before you broken into then after.

Howard: but what percent of dentists do you think in America they don't even offer to bone graft an extraction? I mean every time I go to McDonald's which is only two or three times a day and I order a cheeseburger the sixteen-year-old kid says do you want fries with that, I say yes they say you want a chocolate shake, I say yes and I always wonder why they quit asking I wouldn't go I would have kept going cookies ice cream what but they pull a tooth and a 16 year old kid would say would you like bone grafting with that afterwards and what percent of dentists in America you think don't even ask?

Hana: I think I think you're right that is the key if you're a young person starting out learn how to do bone grafting you got to take the tooth out you got to get every morsel of granulation tissue out you gotta get down to bleeding bone and pack bone if you want to use a membrane collet a pilot coat learn how to take teeth out A-traumatically about taking out the entire buccal plate and graft. I mean the patients will appreciate it and you know the bone grafting materials is not that expensive it you can go by jar you know I don't know for like two three hundred and you can split it up you don't have to use it all in one patient you just pour out some of the top and dish and hydrate it with sterile water and pack that there are bulk syringes you can buy you could use an amalgam carrier and just basically condense but the key to bone grafting is to get every piece of granulation tissue out of the socket otherwise remember this, soft tissue grows at a rate of a half a millimeter a day so epithelium grows at half a millimeter a day bone takes months right so if you leave soft tissue proliferate, proliferate at a half a millimeter a day you know in ten days you have five millimeters of soft tissue. So you got to get all the granulation tissue out get down the bleeding bone pack the bone not too tight close it over I use criss cross suture as a lot of times if I didn't use a membrane and you don't have to use a membrane all the time you just want to maintain that buccal plate and also comes down a surgical skill you do not want to wipe off the buccal plate and expect it to regenerate right.

Howard: Their's another, I know of this feud going on within group practices I know this existing feud several times. Some dentists and periodontist and oral surgeons will not do the bone grafting or place implant if you're smoking and the other people say well I mean 15 I mean who needs all the implants it's usually not your yoga instructor you know it's usually the guy you know going on your beer runs. So how do you I mean there really is a huge difference in different areas but what is your criteria I want to get I want to replace this tooth with an implant I smoked a pack a day what do you where do you draw the line?

Hana: So I actually have a different exclusion criteria if you're an uncontrolled diabetic and if you have a occlusal trot I mean you can't just do an isolated thing if someone smoked that to me is not necessarily an exclusion I have seen smokers that have had successful implants if their occlusion is stable if their oral hygiene is good if they are coming back from maintenance, they get a mouth guard that's not an automatic exclusion. I think in the olden days that used to be I just find that that's pretty limiting you can't just write off a whole group of people because they smoke. I mean people smoke but they still have coronary disease and they still get stents and they still smoke should the cardiologist say sorry you smoked I'm not putting in a stent right.

Howard: and what I do I always try to motivate them to switch from Marlboro to Marlboro light I think that might help.

Hana: My dad was a really heavy smoker and he was a periodontist and I'd be like look why are you doing this and he'd say I love it, you know he died when he was in his like early eighties but he loved it he loved to smoke and I would say and he smoked what's that really bad the camel that was his smoking thing so and he was a periodontist but I mean people are people you can't just automatically write them off you have to try to motivate and you may be that one person that says hey you know what I really can I get you to smoke less than that because if you smoke less than that it I'll have a greater success and I'm amazed that many people will. Now what do I want to tell you about smoking and smoking cessation when you stop smoking a year after you stop people's gums started to bleed more you know why right because all the immune factors are coming back into the site and you're actually on somebody who has had fibrotic tissue probing twos and threes and fours all of a sudden they're probing sixth seventh and eighth but that's a true reflection of their periodontal status not what they had before.

Howard: Yeah it's amazing I don't we've lost all the gains of the the kids in highschool 21 and under the smoking had been going down down down down down then vaping came out

Hana: Vaping is so bad.

Howard: and we lost all our gaines I'm so what would you tell a patient who says vaping is more healthy than smoking?

Hana: Oh I had that last week, the guy who I did laser surgery on and highly educated person he's in the medical field he said he started vaping because he went to Greece and he picked it up there and I said you know you've got formaldehyde in your mouth do you realize that he's like well it's not nicotine I said it's worse it's formaldehyde and a lot of those are based with sugar so they'll get a lot of cervical caries you'll see people a cervical decay that they I don't know how that's allowed but hey you know you try to encourage people again and with him he said well I have to do something I gave up smoking so I said well can you like chew gum can you chew on a pencil you know do something other than vaping because that's equally as bad if not worse we don't know that long-term effects you know they smoking his immune system deficiency lazy neutrophils host response is diminished so there's all these factors and I think it's the same with vaping.

Howard: So one thing that concerns me is like when you had bonding agents came out and you had you know the bottle of the A and B and it was just an amazing bonding system. I take bisko's bonding agent. I mean just great bonding agents but you know the dentists they didn't want a two-step and they wanted a one-step and they kept going to the next generation bonding agent and all that and I always sat there and thought you know you're a doctor if I was getting a bypass I wouldn't want some guys say well you know the great way to do a bypass takes two steps and I just want to do one steps like just do the right thing. I'm starting to see that or wonder about that with implants doing it in a immediate loading implants versus burying the implant and let it heal for a couple of months. I mean what do you what do you think about that everything immediate load or staged implants?

Hana: So I'm old but I'll tell you I've learned from my experiences it is rare rare that I do an immediate molar I've never done an immediate molar and I just don't think you need to push the envelope that hard. I will do immediate Implant, one I've been burned and I can tell you so many stories one time I did an immediate implement the media provisional it was beautiful but the patient decided I have a tooth I am NOT going on to step two which is an abutment and a crown so she left and never came back and had the implant restored, lesson 1 lesson 2 if you immediately load the implant you're putting everybody talks about getting the emergence profile for the soft tissue by immediate provisionalization right that way you can get the papilla to fill in. Well you can do that by the proper location of the implant, we can talk about that. You can tell you that has to do with using guided surgery not putting the implant too close to the adjacent teeth not putting it too deep putting it in the center of the ridge if you have to air, air on the palatal side but the emergence profile of the abutment and a crown has to do with the location of the implant and if it's placed correctly whether with a guide or without you're gonna you can almost you really want to start at the end and I all the restorative doctors that I work with, I tell them the implant is a restorative driven decision. It is not something I'm gonna throw an implant there and then send the patient back to them I need to start with them get you know work it up with them to begin with and then we work our way back so we know what we're gonna how it will end before we even start.

Howard: There are some there are some periodontist who believe that the cause of peri-implantitis is mainly that when it was surgically placed there was not a connective tissue all the way around the implant and that if you did the implant and you had attached gingiva all the way around it you would be seeing all this peri-implantitis. What do you think of that? I mean I'm sure you've heard that in a lecture before do you believe and are not believe it?

Hana: So that's also in the CT course that I'm gonna do it's talking about do you need attach gingiva around implants that's one of the topics that I cover in that CE course. I don't think that's necessarily the cause for all peri-implantitis but I do think you need a band of attached gingiva if you do not it is difficult for the patient to maintain it clean and then you'll get biofilm build up and then you'll get bone loss and threads exposed. So I saw somebody the other day that had an implant done in 2016 and they developed a hisense on the facial of the implant, so I did a connective tissue graft on the facial to cover up the threads and I tunneled it from the mucogingival Junction down because you can't lift the pillows or else they're gonna have even more threads exposed, so there is some truth to that but it's not the end-all be-all for why all implants fail or the implants that do fail. It has to do I think it's a combination I think of anything I could stress you know you got to look at everything you gotta look at the surrounding teeth, you gotta look the position of the implant, you got to look at occlusion, you have to look is that cement retain, screw retain, the profile of the abutment that's chosen and that's one thing I you know as long as I've been a dentist I recently learned in last three years about the restorative doctor choosing the correct abutment for the situation it makes a huge difference to the final crown and esthetics and then Cleanse ability for the patient.

Howard: Nice and I also want to tell the kids over and over and over when you when you were talking about the emergence profile remember a beautiful woman with who loves her teeth cares about that about 8000 times more than grandpa with a liver spot on his forehead. I mean you know when you're getting into implants the first hundred need to all be in short fat bald guys in the posterior first molar upper second bicuspid. I see so many kids and they're looking at this missing anterior tooth they think well that's easy access I can see it just lean it back in my lap and oh my god just just stay away from anyone gorgeous and stay away from front teeth for at least a hundred implants would you agree or disagree with that?

Hana: Absolutely that is the most difficult restoration the anterior single crown, especially you know the lower again you know that comes from just experience you know if you do a lower incisor crown those are the most difficult because it has to look right from the top this way and that way so an anterior implant you know like you said I wouldn't even try it without having placed at least a hundred implants and even that a lot of the patients yeah look at their smile on you look at the bio type of the tissue is a thin thick is their freedom pool what is the contact like of the adjacent teeth if you if your implants high your contacts gonna be too low so you're gonna have black triangles. I mean it's there are so many things that go into doing an aesthetic implant besides an immediate provisional, it really it takes a lot of planning and a lot of experience like you said maybe start off with you know number nineteen over thirty number twenty twenty nine those are all slam dunks right you know hopefully if you follow all a protocol.

Howard: Do you see a bigger cosmetic market among women than you do men is that is that a fair assessment or am I just being shown my old school?

Hana: I think your right but it also depends where you are like an LA I bet it's equal right you know there's yeah and here in North Carolina yeah more women are concerned with the aesthetics than they are.

Howard: One thing that I see where women just they just don't accept that is the gummy smile what would it what do you know do you think that's more an orthognathic surgery solution do you think that's a periodontal surgery solution what would you tell someone they need to see an orthodontist and an oral surgeon or a periodontist for a gummy smile?

Hana: That's an excellent question so that's a multi-faceted problem it could be as short as altered passive eruption or alter an active eruption if or they could have so if they have, so as a periodontist it's gonna be rare for me to just cut the gum away and not address the bone so if somebody let's say has a gummy smile and you're measuring the incisal and lengthen shorter you want to diagnose the correct problem is an altered passive altered active and you you might get a stent from this restorative doctor although in the years that I practiced I've never had I've always just kind of free handed it is usually after ortho you do a full thickness bob scallop and then you got to find the CDJ and see if it's covered with bone if it's covered with bone you gotta take away that bone two millimeters below the CDJ and then festoon like you would a denture and then close it close it up. Those by the way are the most gratifying surgeries because the patient's you set them up and you give them a mirror and they're usually crying because they can't articulate why they don't like their teeth until you do that and they're like oh my god I have teeth my teeth are whiter and brighter because it the gumminess will put cast shadow on their teeth.

Howard: Yeah it's a big self-esteem deal with women I admit that it's a big deal, but you're using some terms that might be over the heads of some of these on kids when they're still in school, go back and explain altered active and versus a passive eruption.

Hana: So when a tooth erupts through the you know it comes through the alveolus it usually comes through all the way with a CJ and then the soft tissue recedes back right, so that's your you're gonna have a natural option the CEJ is above the bone by two millimeter let's say on the upper and then the soft tissue will form a collar there. So with altered active eruption the tooth erupts but it does not erupt through the osseous crests at in the CJs at the osseous crest and the soft tissues on enamel but alter passive eruption it erupts through the bone the CJS above the bone but the soft tissues above it so you can do a gingivectomy there but most of us will go in and kind of fine-tune the bone festoon it a little, give like that root eminence you know how we did that indenture setup we did the festooning we give the eminence of the root between the teeth and that way you get the tissue to lay softer. Also I think I put that in my CE course that's coming up I read a lot of the aesthetic perio things yes.

Howard: So I'll read the I'll read a definition active eruption is defined as tooth movement in the occlusal direction as a tooth erupts from its osseous crypt altered active eruption occurs when teeth achieved the opposite relationship to the occlusal plane prematurely and the osseous cyst is on or very close to the cementoenamel junction. Do you like that or not really?

Hana: I do like it.

Howard: Okay, I want to ask you something I don't know if I'm drinking with the wrong dentist or you know maybe or maybe Arizona Cardinals fans are not as sharp as the New England Patriot fans in your backyard.

Hana: No no no Panthers

Howard: Oh your North Carolina Panthers, oh my gosh that Super Bowl I felt so sorry for you guys because when you guys played the Denver Broncos I would have bet my house that that young quarterback that can do a flip over the line and land on his feet lost to an old decrepit man who had neck problems and you know was fired from the Colts and how did that old grandpa cowboy Manning beat your quarterback in this in the Super Bowl that was just a...

Hana: Cheating

Howard: Deflating the balls

Hana: I think he cheated.

Howard:  but when I talk to my periodontist friends they tell me that they have five just like maybe only five or six dentists that refer almost a hundred percent of their crown lengthening and then the other twenty five dentists have never sent one do you see that? I mean is it the 80/20 rule why do you why do you twenty percent of all the dentists in the United States do 80% of the crown lengthenings and why are you there's dentists out there that are listen to you right now that it practiced ten years and have never done never done it one time they go they're all fine so do you agree with that huge diversion?

Hana: Yeah I do I definitely see that it is amazing because you do see some that recognize it again it's the short-term reward, yes it's easier to put a crown on it and do a post and violate the biologic with and by the way not every patient will have a biological width violation and not in every part of the mouth so for example you can see somebody where they'll have a biological which violation on number thirty but number thirteen also has a crown that goes subgingival it will not be so it's case by case and in the long run the patient's better off having had crown lengthening and so will the restored about their impression will be easier, seating the crown will be easier there were potential won't be any cement subgi but it is true I don't know why certain doctors are more comfortable with that where others will pull out a laser or cautery and just cauterize the tissue that's bleeding but I know if it was me I would want everything done you know step by step.

Howard: So this is dentistry uncensored it's my job to get you in trouble and so I'm going to say I ask you something on a controversial questions get you in trouble. These young kids get out of school they go work for a big DSO and a non dentist non clinical person says that every single pocket over six millimeters deep needs to have Areston because there's an insurance cold and sometimes they feel bad because they're placing like Areston and ten different sights on some lady and they don't even believe in it, so my question is Areston, do you think do you think you should be placing Areston in these deep pockets especially since are incentivized to believe it because there's an insurance code?

Hana: I mean if you're doing it in conjunction with scaling and root planing and you do it once and they come back for their maintenance in three months and there hasn't been a change it is time to refer that person out to a specialist. You know I understand you know I understand it's a business I understand the business model but in the long run if they try it they tried scale repair but it may work here and there and arrested you know the subject to the longevity of it is ninety days so if they do scaling replaying and Areston if you're just sticking Areston without doing scaling and root planing or anesthetizing the area I really don't think that's going to be beneficial but you may limit the amount of work that the periodontist needs to do or the amount of sites at the peridot see but if you do it time after time after time I'm not really sure that's in the patient's best interest and I hear that a lot it's like oh it's so hard to get the patients to go to the periodontist no one wants to go to the periodontist right, everyone would rather see the endodontist or oral surgeon or whatever because the perception is that perio surgery is so painful right but now we have modalities that make it not painful so it's you know especially if the periodontist you're using is up on the latest and greatest technology it's not a painful procedure it can be a non-event like that patient told me today it was one tylenol surgery where it's not gonna be as painful.

Howard: Can I ask you a couple more overtime questions?

Hana: Yes, sure sure

Howard: She's confused she's twenty five she's looking this it's got furcation involvement, when do you treat furcation involvement and when do you when do you treat it with extraction and titanium and when do you treat it furcation and is it fair to say a lower furcation on a molar as much easier than I upper furcation on a maxiler, so just talk about furcations to help her with her diagnosis and treatment planning.

Hana: So I would treat it as early as possible so in a class one furcation treated, we look for as as periodontists, we look for enamel pearls in the furcation which is a projection of the enamel into the furcation that would cause attachment loss, foreign body, bone loss. You always want to rule out endo always always because or a root fracture because a lot of times as the tooth is heavily restored you'll have a fracture in the floor of the chamber and that'll show up as bone loss in the furcation. You're not going to get the classic you know wide PDL but you'll get a horizontal bone loss interpretation. The upper furcations are really difficult to treat, so you know in when I was in grad school we would lay a flap let's say I'm number three you would put a membrane on the facial and wrap it around the mesial bone graft it first after you open it up cleaned it out with a Cabotron look for an enamel pearls, looked for any you know debris then you pack bone and then you put a membrane we would use guide or gore-tex now no one's you know doing that I would treat it now with my laser and I treat it sooner than later it's just the sooner you can treat it the better. I don't know that a for patient involvement condemns a tooth to an extraction I'm just not you know I'm not there may be other people are but I'm not there. I would do everything possible to save my molar if I had furcation involvement.

Howard: Yeah I agree you know there's so much social media out there saying all these things about electric toothbrushes versus manual brushing, you're a periodontist when someone's when someone really needs to be on top of their plaque removal and all stuff what are your thoughts on electric versus brush, mouthwash, chlorhexidine, iodine's some people on dental town you know so what are your what are your thoughts head do you think there's a big advantage of buying expensive electric versus a manual toothbrush?

 i do think it's an advantage i always recommend the sonicare toothbrush because the sonicare wave breaks up the plaque about three to four millimeters beyond the reach of the brush and they're not that expensive you can get in my Costco or Sam's Club you can get two for $99 I mean they have all generations they're ones that you can charge to your laptop there are some I have one from five years ago that dispenses toothpaste it had a cartridge that you place Crest toothpaste and you dispense a pea-sized but I do think the sonic care is better. I don't like a lot of the crazy denture faces that people are using like charcoal you know I think that's crazy people need to stick with toothpaste, not a whole lot if you have sensitive teeth use prevident just at night I live on a well I live in the country I use prevident myself at night and I don't believe in having somebody endlessly on pareo guard or chlorhexidine it does stain it stains your teeth so during this after surgery for example when I do even a soft tissue graft if you put them on it for a week and then when they come back I have them switch to just brushing it on with a very soft surgery brush that we give them because it does stay in your teeth and as you said most Americans are very you know they're not into having dark stained teeth they want white bright teeth.

Howard: You recommend Sonicare electric toothbrush, do you also recommend a water pick or not really?

Hana: Yes water picks are great for those that can floss absolutely, you just want to break up the plaque front you want to let not remember the corn cob theory of plaque when we learn in school so long ago, the longer the plaque gets the more virulent it becomes so you just want to break up the so it doesn't get more virulent.

Howard: okay and then I throw it out through a pinhole technique?

Hana: So I know of the pinhole technique I do not do it and I have not taken the course but I know several people that do for us many of us that have been around it's really a karoli reposition flap where you just hide the tissue down. If you have a nice zone of attached gingiva it works beautifully if you do not have a nice zone of attached gingiva fundamentally I don't know how that can last but I'm not knocking it, I don't have any knowledge of it I am not taking it and I know a lot of people do and you know for our patients to hear that you don't have to violate their palate but again the palate incision for our connective tissue graft is nothing like a free gingival graft, it's a linear incision it doesn't hurt it's you get primary closure so it usually heals up within one or two days.

Howard: You know when I got out of school those electric toothbrushes were free they were actually free but now they got all those security cameras at all those stores that now have to are they have to pay for them, but hey seriously I can't believe at the end of the long busy day that you decided to log on and talk to my homies for over an hour and build us an online CE course I just I'm so indebted to you I'm so honored thank you so much at the end of the long day.

Hana: Thank you so much.

Howard: My only advice to you is I can't believe you left Germany and San Francisco to go to North Carolina you might reconsider that decision. I still think San Francisco and Vancouver British Columbia that's the two greatest cities in the United States but your North Carolina is beautiful those four seasons. So thank you Hana so much for coming on the show.

Hana: Thank you so much I really appreciate it, I enjoyed it so much, thank you so much.

Howard: All right you have a great day. 

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