Dentistry Uncensored with Howard Farran

How to perform dentistry faster, easier, higher in quality and lower in cost. Subscribe to the podcast: https://podcasts.apple.com/us/podcast/dentistry-uncensored-with-howard-farran/id916907356

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Howard: it's just a huge honor for me today to be podcast interviewing Dr. Todd Hanna MD DDS F ACS he's a double board certified dual degree MD DDS oral a maxillofacial surgeon and had neck reconstructive surgeon he is a double fellowship trained in head neck oncology surgery and micro vascular reconstructive surgery of the face head neck and jaws he maintains a private practice in midtown Manhattan and a faculty appointment at the NYE head neck Institute at Lenox Hill Hospital Northwell health system formerly North Slope lij within the department of head and neck surgery dr. Hannah was born in New York City where he attended primary and secondary school he graduated from New York University with a Bachelor of Arts in 2002 taking a pre-med curriculum and studying in Florence Italy after he performed clinical research at Bellevue Hospital NYU with the Department of Pathology he then graduated the top of his class from both NYU College of Dentistry and the University of Alabama at Birmingham School of Medicine he was inducted into the Omega Kappa Epsilon Honor Society and one to Alpha Omega Honor Society Awards while nyee served as vice president tutored classmates and had the highest national board exam score in his class and in the 99th percentile nationwide dr. Hannah was accepted into the prestigious 6-year oral of maxillofacial surgery residency at the University of Alabama Birmingham regarded as one of the best of the nation here he learned full-scope faced jaw surgery with emphasis on orthognathic cosmetic and reconstructive surgery during the time he completed a one-year general surgery internship he won the clinical performance award as an intern and served as chief resident in his final year he then completed the fellowship for maxillofacial head neck oncology and micro vascular reconstructive surgery at the University of Maryland Shock Trauma Hospital in Baltimore here he was trained in reconstruction of the face head neck jaws with free tissue transplant surgery for tumor and trauma related defects as well as treating cancer of these regions dr. Hanna then received a rare opportunity for a second fellowship in head and neck surgical oncology with the Department of odor odor ontology ENT at the NYE head and neck Institute northwell health Lennox Hill Hospital Manhattan here he was trained in full scope head neck surgery included a minimally invasive thyroid parathyroid melanoma robotic surgery tonsil cancer and facial reconstruction dr. Han is likely the only surgeon in the nation to have this combination of training during his training dr. Hanna was directly mentored by passing current presidents of the American head-neck Society American Academy of cosmetic surgery American skull based society American Board of oral maxillofacial surgery and the American Association of oral and maxillofacial surgery dr. Hanna is a diplomat of the American Board of oral maxillofacial surgery a fellow of the American College of Surgeons and a candidate fellow of the American head/neck Society he has authored publications in peer-reviewed journals on facial reconstruction tongue reconstruction oral cancer head neck cancer micro vascular surgery fibula free flap jaw surgery reconstruction facelift and cosmetic surgery dog bites and lip augmentation he has participated in medical outreach programs to third world nations as well as underserved American communities dr. Hannah values communication and compassion and possesses an aesthetic sense he lives in Manhattan where he enjoys spending time with his family and follows Formula One racing I posted one of his cases on Instagram and my buddy dr. and honest tez rides who was on the show he was on podcast 10/10 he said Howard that's my buddy dr. Hannah on Instagram who has 21,000 followers at a doctor . Hannah and that that case is just unbelievable it's a huge honor for you to make time to come on my show today and talk to my homies oh my gosh she just elevated the status of the show at least three notches and I could talk to you forever I just want to start on your his website his website is dr. Todd Hannah MD DDS so Todd Hannah Haan an A then he's MD and a DDS Oh Todd him calm and he's got a just a unbelievable list of procedures that he does and I just want to start at the far left because our listeners a quarter of them are still in dental school and the other three quarters are all under 30 so I want to start with just with oral surgery what's hot and what's not in worth and ethic surgery is that still a very invasive is are they doing less of that from when I got out of school at 87 to now or the same amount

Dr. Todd Hanna: good question so I think first of all thank you so much for having me on the show you know you're the legend and you know what you do with the show on the podcast and the website is pretty impressive so thanks for having me secondly with regard to the oral surgery in orthodontics you know I think what we have seen in it was in the 80s I think it was quite popular I think people realizing the aesthetic benefits that you would get from it prior to that I think people were doing a lot of nose and chin augmentation when patients really want to benefit more from bad or thematics so there was a guy in Pennsylvania blanking on his name but he was both an oral surgeon at the plastic surgeon and he really did a lot of the earlier work in showing the aesthetic benefits of working at the surgery as the guy William Bell who practice TX now is son Brian Bell neck oral surgeon but um so there were a lot of people that pioneered in the 80s bacala like the hamate orthognathic surgery and then over time I think you know quite candidly I think what we saw was the insurance companies were struggling people are struggling to get the reimbursement from the insurance companies for it so really wasn't sustainable for surgeons to offer these surgeries for a while so I think in the 90s and maybe the early 2000s you saw orthodontists going back to doing this huge compensation to get patients into you know the pseudo class one occlusion without surgery but I think what we've seen now is kind of a swing back to orthographic surgery for a couple reasons one is the use of virtual surgical planning where we could use 3d computer images to actually do this surgically the surgery before even going into the operating room you know you do it on the computer it's a tremendous amount of predictability to the procedure and is decreased the operating time and it's made the procedures technically easier of any ways so I think that with with the advancement of that we're actually seeing an increase in talked about the surgery at least I have in my practice over the last couple years and also I think it's to some degree becoming a little bit more on track I think the aesthetic benefits are denied I think patients have become more informed about it so you know those two things I think are resulting in an increase in automatic surgery at the bomb scene question one 

Howard: when I got out of school in 87 the ents were all telling everyone that if you're storing come into my office and we'll take a carbon dioxide laser and and I clean out the back of your throats in that fade away where is sleep apnea surgery today 

Dr. Todd Hanna: a lot of friends and colleagues who Enki and they do sleep surgery traditionally historically speaking now everything is different now because there's a lot more crossover as to procedures that people do from different specialties but historically the Otolaryngology specialists who treated sleep would do things like set the plasti by U Triple P which is a reduction of the uvula of the palate and the posterior palate thank you what's that called you sure will be you Triple P yeah you yellow triangle powder plus the ru uuu low a little wrinkled plastic which is very you know can be very uncomfortable post-operative experience for patients and that's something that's not quite as it's falling out of favor a bit a person that I trained with in Alabama named a Peter we get a lot of studies on maximum and dibbler advancement for sleep apnea which is basically or thematic surgery but with these large advancements and most people believe that that is the most successful way to treat sleep apnea what's it called the most successful way to MMA and are you are you doing those yeah I mean what do you think do you think it's um you think it's yeah it's the way to go I think in most cases it is I think to shy away from doing just soft tissue you Triple P work I think you could and giving patients a insufficiency palpable tissue and they could have reflux hyper nasal speech things like that I think the MMA is the best way to go in most cases and most patients that have sleep apnea are either have a large amount of tissue around the throat and jaws or they have a red dramatic skeletal development where they actually needed backs no to the jaws but I think the true way to treat patients the best way to destroy patients is really a combination of where their deficits like meaning it could skeletal then you need to invest at jaws if they have an elongated palate then in that case of powder reduction is warranted so you know I think that you have to kind of tell it to patients and what where the problem lies that being said I think in most cases the jaw dan smoot the MMA is the most predictable and gives the best resolve

Howard:  nice is that this is not just so much free quality information it's gonna be hard to keep up so on so mandibular advancement surgery for sleep apnea man maxilla mandibular advancement surgery mm a can be an effective treatment for obstructive sleep apnea and MMA the bones of the upper and lower jaw reposition to relieve airway obstruction common sentiment has been the MMA is reserved for patients with craniofacial dismorphism and which is mandibular retro nasiha you agree with that sentiment yes okay so next one yeah seems like you know when I asked you the first question about our orthognathic surgery immediately it goes to the reality of insurance I mean they invented x-rays in the 1840s but the dentist didn't even look at it until dental insurance came along in 1948 and said we cover x-rays a hundred percent and then like a domino effect the whole country in Europe all got x-ray machines and when you said they orthognathic surgery when the insurance reduce their reimbursement rates it started to go away and so when you go around the world when you go to three of the greatest cities in the world like Tokyo Paris London the national dental insurance plan only pays $100 u.s. for a molar root canal so you go to those countries night podcasted live dentists from those areas they say well we can do a molar root cow have to pull the tooth and do an implant and so when you go around the world every but all the dentists are getting into implants and Invisalign because the insurance company isn't setting the fee and they find that they're using their their insurance pool a population they're trying to upgrade one implant a week or one Invisalign case a week so I know all my homies listening right now want to know what your thoughts are on dental implants what would you say to a kid who's in dental school or just got out and wants to learn how to start placing dental implants 

Dr. Todd Hanna: I would say that should be you know there shouldn't be a second thought I think he if he wasn't thinking about places that are on implants he should be concern because if you're not advancing with the specialty and you know are you gonna get out you're gonna be well-being on the curve so I think that you know if you look at it now every community is different but if you look at New York where I am I think a fair amount of general Dentist is placing implants as they should be I have no problem with that you know as a whole surge and I you know you hear a lot of our surgeons say

Howard:  oh she be specialists throw that but I don't agree with that I think it's it's well within the scope for general Baptist and I think that you know it's it's part of the advancement of the practice so yeah so um I know what they're thinking they're thinking they always go to brand they're like well what implant should I use place or where should I go get trained do you have any simple sort list of you thought this out where they should learn more about placing implants 

Dr. Todd Hanna: you know most schools that imagines it's some by this time you you know when I was a student it was already starting to be part of the curriculum where if you wanted to have the opportunity to do it you could I would imagine now most students actually have the opportunity to place implants before they graduate but I think that this is in the experience that they should have in their residency whether they do a GPR for general dentistry or whether they do a you know a specialist residency they should be able to get that experience there I know there are a handful of courses as well that many of the implant companies will hold and many of the schools will hold as well where they could get additional training but I would say something that you should do in the residency

Howard:  um I you with the university Alabama and bio horizons is right there in Birmingham is that an implant company that you like that you're more familiar with maybe because you were closer well it's a great it's a great implant other great implants and

Dr. Todd Hanna: ones that are popping in New York where where you know the community here strong in a very popular novella are still very popular you know you should about Harrah's and 

Howard: my favorite not that anybody's asking is strummin because he came on the show he was on the CEO of Marco God Ola in he's in he's on on the in Europe so the only time we could meet is I was lecturing in Canada and I said forget it man I'm just to stop my lecture and I'm gonna do the podcast live it was the only one I did live an audience and it was amazing because the questions were were just amazing and there was no there was no question that even got under his skin he did he'd love to hear what they were thinking and just a great guy and also their number one I'm just like the biggest dental practices I see around the United Sates are number one for the same reason stroma is it's called M activity which is in your backyard mergers and acquisitions Stroman has bought neo 10 in Brazil they bought em is and Israel they've been on this series of mergers and acquisitions and right now probably last thing I read from Wall Street is you know they're they're the number one implant Pele's and then when I go to these small towns they'll be like five dentists in the town and some old guy will retire and he'll sell the practice and bring in some highly energetic young kid that'll just crush you and the smart ones just say all bye you give me all your patients and now my town's gone from five minutes to four and then five years later goes down to three and when I see some dentist that's my age I'll be 57 this month and he's got a office doing two to four million it's because he did the mergers and acquisitions and it's just it's so obvious for so many companies so I um I want to get into some a very common question with these young kids um one of the controversies that they believe is whether or not if they're gonna learn how to place implants they need to draw blood do they need to draw blood and start doing all that stuff when you would even draw blood well what the pba you know the they spin out and you know

Dr. Todd Hanna: oh no I think the literature on the benefit of like PRP in PRF for healing in that context is still relatively soft meaning we know that there  is benefit potential in in blood product and stem cells and all that but I don't necessarily know that we have an idea how to apply it in a way that it really translates to a better outcome so you know I think that it's very trendy it's very popular now to do to use PRF and all spin-down blood product and to use that kind of you know as a membrane if you will I don't know that it's necessarily something that's  proven to really benefit patients right so I don't think so I think people are placing implants without that for a long time and they were doing quite well they're very successful so I don't think deterred from placing a box at all well yeah I don't think it's that hard to do to learn how to do either to spin blood to you know all you need is is to learn how to draw blood and get a centrifuge it's not a difficult process either so

Howard:  I think we should put a over-the-shoulder surgical implant placing grafts in Alabama where your went to school and you'll be placing bio horizon implants why we're playing Sweet Home Alabama although at full volume so so but so um you know Carl Mich was on the show and it was the I think on I I think among he was on episode 282 and just on YouTube it had 13,000 views because he said that he didn't think he didn't agree with the iPlayer platelet-rich plasma PRP and platelet-rich fibrin PRF and oh my gosh to the  that was that controversial I mean he I don't know what out what else he could have said that got under the skin of so many people but it sounds like you're agreeing with Karl

Dr. Todd Hanna: I think the literature supporting it is soft so I think that it's not proven in a meaningful way to have a significant if any benefit I don't think it hurts but I don't think that it's proved that benefit so people are doing it and they find that in their hands it works better and they have good results I think that's fine but if you don't do it or if you don't know how to do it or you don't want to do it I don't think that's price below the standard of care I think the jury is still out on how effective it truly is and some literature needs to be done so that we know but I'm not I don't haven't bought into it a hundred percent I don't necessarily think that it offers much in my opinion well you 

Howard: you just walked into perfect segue to my next question you said the jury sellout I noticed the jury is changing their minds on impacted wisdom teeth there are oral surgeons and Germany that are very outspoken that Americans in and specifically remove way too many wisdom teeth without scientific evidence where is the jury between your ears on the removal of impacted wisdom teeth 

Dr. Todd Hanna: okay so I actually have this discussion with every patient when they come and see me for worse includes council most of the literature to true how to treat impacted wisdom teeth came from either America or it came from the UK for men book report to Europe and in other parts of the world seem to da the literature philosophy of one of those two nations and I think that's about to insurance or socialized health care or things like that but I think law in large part is due to the European model of socialized health care especially in England with NHS trusts in the private practice model in America that may have been somewhat of the influence of the literature of findings Americans historically took out wisdom teeth on just about everyone whether they need to come out or not and I think that in parts of Europe and in nearby countries to to that I think they were more what's the word reserved and he would observe these wisdom teeth for longer periods of time I think the correct way to treat wisdom teeth is really somewhere in the middle meaning we have a pretty good idea based on panoramic x-ray or comb beam cat scan will have a pretty good idea which wisdom teeth are gonna grow in from and a problematic way and which should grow in a normal way and if they they appear to be growing in a problematic way I think it's better to treat them all the patients are young preferably in their late teens and certainly before the age of 25 because after the age of 25 the complications from wasting tape removal start to increase based on all the studies they all keep going back to that age of 25 but if you know if they look like you're gonna grow normal and there's no reason to remove it definitely benefit to treating people younger but I don't think there's benefited did you're taking everyone's wisdom teeth out 

Howard: um America has always been a licensee America that's on unnecessary say it but I'm Beauty I mean I I don't know if they're going to the dentist for just mental health they want to be prettier or oral health I mean it seems like when I tell someone at Phoenix you have ten cavities and gum disease they say can you bleach my teeth today and so so is like zygoma implants is that a thing or is that just a Hollywood thing or do normal people get that 

Dr. Todd Hanna: so when you say zygoma implants do you mean like cosmetic she can plan to do me as I go and plants their identity for a dental prosthesis well let's do both let's start with cosmetics and then implants okay so in 90s and even up to the early 2000s facial endpoints were becoming very popular right cuz matte cosmetic implants like cheekbone zygoma implants if you up as the filler materials have gotten better the meaning the types of filler that we use to augment the face injectable filler then the implants shell out a favor because instead of going in to the office and going to sleep and getting these two cheek implants you could have an injector inject into your cheeks and get very good results without having to have a formal surgery I think there's some degree some of the implants are kind of coming back into fade into favor because much like with orthographic surgery where you will actually customize these facial implants now then we can say shall we take a cat scan and make whereas we used to use silicone we use something called peak Coleen ethyl ether ketone I believe PE ek and we can actually make a custom implant to the cheek and exactly the way that we want it place it exactly where we want and get a very very predictable controllable result that way so implants that kind of custom implants are coming back in a way where implants are coming back but they're coming back in a customizable way and that's part of the reason that being said it's though the  filler material is still very good and very effective so you see a lot of that as well and in general like you said America's very cosmetically oriented so all those procedures seem to be seem to be becoming more and more popular every year 

Howard: that is amazing i'm says i'm here with me on until yeah it says poly poly ether ketone piqué piqué is a synthetic material that was used initially in spine and hip surgery computer designed patient specific peek implants for cranioplasty czar a viable alternative when autologous bone grafts are unavailable and available or suitable but you're saying that your what your CAD CAM designing these with software and they look customizable yeah I'm gonna send you another link to one that I did I wish you I wish you would I mean you would kill on dental town you should just start posting a few these cases I mean oh my god I've been on that thing for hours a day since night and st. Patrick's Day 99 and I mean they would kill to see some of this stuff

Dr. Todd Hanna: I'll certainly share whatever  is useful on battle pong but yeah the peaking plants are really nice and they're the motor you know the thing that's different about them is they're customizable meaning you can shape them you can mirror them you can mirror the left side to the right side so they're symmetrical you know you could do all these really cool computer things so yeah here's the link to another one for the mandibular angle but you could do the same thing as that you could do the same with the cheekbones as well and

Howard:  I just want to say for the record everything you see on me is all natural no one believes it how they all think it's all made but so so all on for you were gonna say psych coma for cheek implants but what about is like coma is that a implants is that a big deal with all on four 

Dr. Todd Hanna: I mean you can do different ways to do it I mean I think applications for it are few but they're certainly applications for it you know I think it's  I've done a series of zygoma implant cases for patients who haven't been able to have traditional implants because of severe maxilla atrophy and failed procedures you know they come to me they have 10 fellow procedures at different places they know bone you know really you really just port dense poorly dense bone so those patients are good candidates for either for zygoma implant so you could do two zygoma implants and then try to get a couple anteriorly two different eerily two to three normal implants in theory but I've also used it for patients who have had Mac selected me meaning they've had a tumor and their upper jaw was removed and no bone there's no there's nothing to even graft or to even you know sinus left or anything like that and we can get them into some kind of functional prosthesis with say gamma implants most of those patients end up getting like a fibula transplant or some kind of bone transplant but some of them aren't healthy enough to undergo that kind of surgery so so those patients you could do is like oh man implants and I could get him something mean below as well 

Howard: wow that must be just to have a Mac selected me I mean being a dentist and just hearing that I mean that just must be rock bottom on you have one of those and still be glad you're alive

Dr. Todd Hanna: yeah you'd be surprised you know it's funny I was walking I was walking down the street on sad Sunday and I walked by a couple and I dude I'm just trying to you know just walk right by them and I didn't realize that a second but one of them was a woman she was perfectly normal one of them was a young woman who had a Mac so who did a Mac selecting me on but two two and a half years ago and she also de fibula and I hadn't seen her in a while because she was international which comes back and forth to New York and I saw her walking through diamond Manhattan with her husband and I had only a second luck she'll perfectly normal you know from the outside I'm sure there's tightness I'm sure the things that she feels a different but to perfectly normal I had a max faced prosthodontist through her dental prosthesis they code that went into the fibula and you'd be pretty amazed at what we can do these days with regards to reconstructing them against them back to have a meaningful life

Howard:  I always think with all on for a little bit my thing I don't like about on for is that when you go to all these major meetings they always have some rock stars showing a bunch of all on for cases and then ninety percent of us go home and mostly do all on none cases you know we're doing dentures and it's and then if we do implants it's usually to replace a six year molar and but but but all in four is controversial there's some people that think they don't like it do you are you a fan of it or not a fan of it I 

Dr. Todd Hanna: I think there's a lot of a lot of moving parts to it there's a lot of coordination some there are some people that do the holding themselves they do the  surgery and the process all themselves and they love it I think that when you try to coordinate all those moving parts between the surgeon the restoring their stormed out there and all those things I think it's it can sometimes seem to be a little bit uh a little bit of the juice may not be worth the squeeze just the way you're really getting whereas if you place the implants and temporize them and let things settle and go back down the road and you know and make them the permanent prosthesis saying you know I don't see a major problem with any pathway so I'm not a huge fan of all on floor I don't think that it's something that doesn't work with some people's hands but I think it's a lot of moving parts to it yeah you died

Howard: I was born and raised in Wichita Kansas and you definitely picked up the juice might not be worth the squeeze while you're in Alabama that is not a New York statement that is totally home brewed in Candice Bergen sauce I'm sinus lift one of the biggest controversies I've seen in the last 30 years regarding a sinus lift is it seems like in 87 the only successful sinus lift was the longest employee that the  most successful implant was the longest implant you could put in a head and then they seemed over time they seemed to get shorter and fatter just like me so does shorter fatter implants has that really reduce the need for a lot of sinus lifts

Dr. Todd Hanna: popular I'd say like 2008 I was hearing a lot about the bike the bike ons and Shorty's those seem to be popular I think they kind of fell out of favor in my own experience if I can get you know an eight or ten millimeter implant in I would certainly prefer that over six millimeter implants I think you know it's most of the literature says it's really the width and not the length of the implant but I think that what makes most sense to me is really the surface area of the implant so I think it's a combination of lengthen and so I on the side if I'm at eight millimeters I'm comfortable but I wouldn't I don't feel comfortable putting in implants that are less than eight millimeters on mass on posterior maxillary bone particularly which is not so dense so I'm not a huge fan of the shorties and the by cons I don't use them

Howard:  so you'd like to have eight millimeters for maxillary first molar implant yeah I do and what what brand of implant would that be for you

Dr. Todd Hanna: I typically most often used Raman I know as well whatever dr. Watts good strands probably the one I use most and I used the bone level tapered s always the SL ace Drummond yeah rock solid rock solid SLA yeah rock solid it's Auto Expo I'd be like one one word okay let's see what uh-oh wok solid 

Howard: okay ro x oli D and how long am why do you like that one and how long you been using that one 

Dr. Todd Hanna: I mean for years now I've been using those I like I like the Cape I mean the system that they have I've had great results with them the science behind them is very clear meaning it's not like this kind of speculative solid seems like there's legitimate science behind it and  I find that most restoring dentists are very comfortable with the restorative portion and the restorative components so it makes their job easier as well which their jobs easier that improves the success of the whole thing so

Howard:  um the next one is very controversial but this is dentistry and sensory I don't want to talk about anything everyone agrees on I want to go right to the controversies I'm here in New York where Joan Rivers went in for a simple procedure had IV sedation and is no longer with us and I cringe when I see these young dentist are getting into IV sedation because 32 years of doing this I've seen what happens to the dentist if something goes south and it's they don't smile again until I and one guy no didn't smile again until he died and another one became an alcoholic what would you tell a kid he thinks I'm gonna go learn IV sedation 

Dr. Todd Hanna: yeah so-so you know a year cherrylle surgery which has four months of anesthesia where were intubated patients and giving them paralytics and all that and you know putting people to sleep did you know there's the six year residency for surgery did a couple fellowships including one with an ENT group where we're in the airway and even now there are times where you know I have to like really kind of step back and really Washington's carefully with sedation it's not I don't take it lightly even after all the training so unless you have a lot of experience in that kind of thing I do think it's something that I'd imagine could be overwhelming I think that if they really want to learn how to do IV sedation themselves then they should they should make sure they get enough training to the point where they're really comfortable and also use sedatives that are limited they use things like first set or things like that but I wouldn't start using propofol and ketamine and things like that the other thing I'd say is another option if they want to keep it in their office is they can hire either dental anesthesiologist or even just a general anesthesiologist to come in and put people to sleep they if they want to do it that way and everything a lot of stress off yeah 

Howard: um that's what I don't understand I mean why even even where I practice in a Phoenix but everybody in my area calls it all what Sookie because it used to be a different city of xanax and we just have one oral surgeon and Edmunds great guy he's been on the show and but he even has an anesthesiologist he says why I'm trying to do the surgery I don't want to do another thing and that that's where I call crazy because in the hospitals and you work with several hospitals you're not allowed to do the surgery and the anesthesia so why is it only in dentistry from New York to London where a surgeon does the anesthesia and the surgery and it's not done in any of the hospitals in the town that you're doing this in 

Dr. Todd Hanna: when I was a student I spent two weeks and in England in Southampton shadowing the surgeon Barrie Evans who's an oral surgeon and did a lot of had next up too and took me into his private practice one day and he was dealing no matter he was doing wisdom teeth out of a military care center putting patient patients under general anesthesia he wasn't doing it but that it's easy I'll just was so I could see the point with that I think part of it it's largely related to the culture especially within oral surgery we learn IV sedation you buy a good amount of anesthesia so it is part of the culture and part of the training for that specialty but you know I agree that I think these courses and IV sedation you go for a three day course or one-week course I think you know I would imagine that being very daunting and I don't think I would feel comfortable putting people to sleep you know for not if in 99% of the cases it would be fine but you get that one case like you said things go south and they don't smile again you know I think that the mistakes can be very high with that

Howard:  so oh my god the patient is named Joan Rivers that should have been your first clue you're gonna be on CNN Headline News and you know my the other Suzy ologist that I talked to here they're so mad at Michael Jackson because they say it's so hard to use proof propofol because when they say that a lot of people in Phoenix say no that's what killed Michael Jackson and you get that pushed back in manehattan people more and 

Dr. Todd Hanna: more people ask what agents they use there's a lot of pros like last resort medication but people do ask he definitely is definitely popularized the drug in a negative way oh my god so what about what 

Howard: so what happened she's young she just got out of dental kindergarten school uh a couple months ago she sees a patient on their health history form there's by bisphosphonates what should she be thinking about bisphosphonates 

Dr. Todd Hanna: I mean depends on which ones the IV versus the the PIO versus the pro ones have different implications as to the risk of you it's called around you know used to be called branch the be stuffer bisphosphonates now they called a Roger stands for auntie resort if so these are the in-between they called it a mirage for medication related but they all refer to related osteonecrosis of the jaws so if she sees a bisphosphonate or any other kind of auntie resort if that's correlated with osteonecrosis of the jaws then she needs to do a couple things want to meet she needs to understand which agent was given the timeline of when it was given if it if it if it is still given our first op and then she also needs to discuss with usually these are prescribed by a by a ecologist because they're usually treating them for either breast cancer and metastasize to bone or something or a prostate cancer where she thought sighs the bone or sometimes just a endocrinologist who's treating so like severe osteoporosis and they need to talk to the prescribing doctor and to see what the need is for the medication in most cases with with uh with P o with P o auntie resort dose all and the innovation needs or surgery or they need an attraction or in the plan I'll recommend some kind of drug holiday so trying to have from one to four months a drug holiday I've never used that term now that has to be a Manhattan term that is made it this far west that's not that I actually picked up Alabama but I think it's ubiquitous so so you'll haven't going to drug holiday yeah for Pio enters of it possible 

Howard: oh that is amazing so you call the bisphosphonates related osteo chrono so the jaw is bronze BR onj for bisphosphonate related osteoporosis of the jaw and a stands for tears or bleed the rest of the acronym is the same anti resort of 

Dr. Todd Hanna: yeah because what they found was even even certain medications that they were given that weren't classified as bisphosphonates what they were giving for the same reasons to to maintain bone density and skeleton we're having the same kind of effects in the jaws one medicine that's well known that his Donna was called X Kiba 

Howard: with Sally Fields she's always the one out on the commercial isn't she is she know that I thought so excuse me I'll check that uh yeah probably a millennial and never even remembered that movie what was that him she was driving across the country with Burt Reynolds they just robbed a beer truck or something it was uh but so in cliff  cleft lip and palate that'll be my last whirl surgery but I mean anything a peak you mind on cleft lip and palate sure always be forest comes mother in my mind

Dr. Todd Hanna: I think that could be sitcom where she was been done so if clipping palaces yeah so so the typical the common way that those are treaters they're usually treated by a cleft surgeon or cranial facial cleft surgeon for the early stages meaning the lip early palate I knew those are people that have done some kind of fellowship training in cleft and craniofacial so it's either commonly it's a plastic surgeon or an ENT surgeon and even now oral maxillofacial surgeons that are that have done fellowship training after residency cleft lip and palate and craniofacial disorders and those are the people that treat the initial cleft issues with the ancients typically the lip is done at somewhere around three to four weeks I believe is eight weeks maybe things actually weeks and the palace done somewhere around nine months and and so on the oral the oral surgeon typical oral surgery I mean and anon fellowship trained oral surgeon for class can come into play later on in the child's life usually around anywhere from nine to twelve years old when the alveolus needs to be drafted for closure and and that is done in conjunction with orthodontist as well those teeth are moved and they'll typically do something like an anterior iliac crest bone graft to the alveolus to get them continuity of the arch helps to support the nasal floor in a Khmer Croom to either move teeth into that position or either make room for an implant to be placed down the road then oftentimes a lot of these club patients developed like a pseudo class three deformity where the the scarring on the upper jaw the maxilla from all the surgeries even the palate or surgery doesn't let it advances as it should so they have this it looks like a class-3 but it's not because their lower jaw so far out it's because their upper jaw so far back so then later on in their later teens they'll get an orthographic surgery to move the upper jaw out and that's his gang with oral surgeon comes back in to play those patients

Howard:  well interesting um the cleft palate I'm certain that because of clappa the first american plastic surgeon was john peter maduro who in 1827 performed the first cleft palate operation with instruments he designed himself so so cosmetic surgery in America originated because of the cleft palate and so how is cosmetic surgery during day when let's start with face and necklift do you are you doing many of those do you like those 

Dr. Todd Hanna: well one of my favorite procedures so again trained because they trained with Peter way it was used the first oral surgeon to be the president of the American Academy of cosmetic surgery kind of opened up the doors for a lot of oral surgeons to get into who is that Peter wait waa ite from Alabama yeah he was the first doctor to do what he was the first oral surgeon to be president of the American Academy of cosmetic surgery which was largely plastics and other people of other specialties 

Howard: Wow I did not know that and so I'm because I'm because now you know like say back in 87 I a school oral surgeon role DDS now you see a lot of them with MD and their dual trained and they're doing stuff in the hospital that used to be only Emmys and you're seeing Peter weight was the first American oral surgeon to become the president of the American Academy of cosmetic surgery you know what year that was I do further guess I can't even remember that far back but um so so what do you so is that if someone was in dental school right now and they said you know I want it when I graduated I want to see if I can get accepted oral surgery school would you recommend an MD program over a DDS program or 

Dr. Todd Hanna: you know you have to look at what their motivation was for doing it you know I think that if they want to get out and they want to go on a private practice and viola then I don't and they don't really have a desire to get the medical degree and I don't necessarily it's something that is going to help them you know you climb or dead is it's two to three years added on to your training where you go so it's not something that's needed but if you want to do this bandits hospital procedures and you have an interest in learning medical curriculum and it's it's a great city it's a great deal you know you do two to three years to get a medical degree as well and I don't think people who do it I think they did a study amos which is the american academy or oral maxillofacial surgery did a study and they found that most people that were dual degree even private practice guys who did largely Dental alveolar most little degree people did not regret doing the medical degree as well so you know if you have any desire to do it and I think it's worth it but if you're very clear about what you want and you just want to do ten - all the older and get through as quickly as possible but you don't need it it doesn't it doesn't add much to your ability to perform oral surgery but I think it does add to your ability to function in the hospital you'll have a better understanding of a wider array of conditions so you know you usually get exposed to a lot of the different surgical specialties while you're in med school so it does give you it does give you some benefit that way 

Howard: so what I'm so back to face and neck surgery what are you what are you doing and all that stuff so

Dr. Todd Hanna: so face and neck surgery so typically you know it's been said a key to a good facelift is a good necklace so most cases the neck has to be addressed and facelifts so I'll do a lot of you know cemento plasti some mini facelift some face and neck lifts that are more comprehensive but the landscape and that is all changing as well you have some skin-tightening procedures so better coming out so younger patients that have some next slide neck Lac City or sometimes candidates for non-surgical treatment which we used to have to remove skin pinch it up behind the ear now you can use these devices that actually take the skin not surgically so things are changing but still the gold standard for people with neck and facial soft tissue laxity is a face of back lift and it's one of my favorite procedures to perform actually I actually enjoy that very much and wait wait you enjoyed that very much the soft tissue always enjoyed the soft tissue I mean there's an artistry to it there's a subtlety to it the the soft tissue and the geometry of the flaps I've always felt very interesting and rewarding and the results that we do well the results are outstanding that you make patients very happy

Howard:  um whenever you talk about the difference between a girl or a boy you're called names but is this is this a girl thing I mean if you did a hundred of these cases how many M would be girls how many would be boys

Dr. Todd Hanna: it's less of a girl thing then it was you know in the past I think if you do 190 of them will be girls ten of them would be boys here in New York my patient population still out 

Howard: so it's still 90 percent a girl thing yeah Wow poor girls that that's why it's so and and then they get him a brow lift I mean is that so is it one of those deals where I've noticed in my life nobody has one tattoo they get a tattoo three years later another and by the time they're my age you know they got half a dozen I'd see the same thing with cosmetic surgery they if they get one procedure so so you're saying the key to a good facelift is a great neck lift so when they does so they do the neck they do the face is the brow lift like next on the list starts match you know you want it all to match so if if the lower facial third and the neck is tight and makes them look like the 30 or 35 then you certainly want the brow to match but people everyone age a little differently and some people age in different parts of the face in a different way you know I need a facelift recently on a very young patient who is literally begging me to do the face up for two years and I didn't want to because she was very young she's early thirties and she was a very attractive individual to begin with but she did have some heaviness around the cheeks and finally she convinced me to do it we did a very conservative facelift almost like a mini face up although I don't really like that term but basically in any case so and she just looks fantastic and I was like you know what you were right you know she and she didn't but she doesn't need anything that she was Anita Brown she doesn't need other things she just needed the the heavy cheeks and the heavy mid face to be addressed so every patients a little different but yeah cosmetic surgery certainly the type of thing where patients who get one treatment tend to get additional treatments down the road certainly and I don't think it's because it's necessarily he's digging the way tattoos may be but I just think that usually they're very happy with the results and usually they're of the mindset that if they can change something with surgery they will so they are already a predisposed to being willing to undergo but not you know - time to go surgery and undergo the knife as they say it's for those reasons 

Howard: yeah mental health it's important I just thought it was just so bizarre when I was lecturing in Cambodian and Malaysia and Indonesia where these young beautiful Asian girls would pull their to upper first bicuspids and doing this line back for a year because they put their finger to their nose and chin and if their lip touched they pulled to bicuspid simple guy they did not want their lip to touch their finger from their nose to their chin and I'm thinking okay there's a billion boys in Asia and not one of them cares if your lip touches the line between your nose and chin you're gorgeous you're happy what P is it's just bizarre what people do yeah us to be from the post-op of those patients that 

Dr. Todd Hanna: they look better do you think it would almost hollow them out a little bit it would decrease the support of the lips and the cheeks you know yeah I'm not a fan of bicuspid extractions for so many reasons but 

Howard: I'm sitting there thinking I read a study once that the most beautiful person is someone thirteen years younger than you so and I've seen this in Phoenix because it's a huge retirement community and you'd be an 80 year old woman and the 93 year old man across the street is almost stalking you and taking out the dinner and and all this stuff like that and I'm just looking at these girls and saying okay if you were like the ugliest person that was ever born you start aiming at someone thirteen years older than you and skip all the surgery stuff so there's that let's keep going eyelid surgery do you like those 

Dr. Todd Hanna: yeah I mean it's very difficult eyelid surgery is really the planning meaning knowing which patient to treat which not to and also in the amounts issue that you leave behind versus the amount issue you take meaning it's not about like many cosmetic surgeries it's not about what you take but we leave behind so you know you don't want to overly treat somebody and remove too much upper eyelid or lower eyelid because you can get them problems with closing their eye you give them something called ectropion and some optima logic issues that they can belt ramaya but technically the surgery itself is really very straightforward you know you remove skin some people remove a little bit of muscle as well the the orbicularis oculi muscle and then you close them in pretty much a standard fashion so they're easy surgeries to perform but the technique there meaning it technically easy to perform where they're tricky and they're complex in patient selection it don't make sense now that was 

Howard: very prevent you say cosmetic surgery is about how much tissue you and not take away is that how you said that that is up and what is the shelf life of something like this meaning how long before they would need additional treatment yeah most of these treatments like facelift I left 

Dr. Todd Hanna: it doesn't stop it tick but it does turn back time so meaning you could turn about 10-15 years in many cases but they're still gonna age so a lot of people would say facelifts you know they're good for about ten years and then you need to touch up and that's probably true I think we were last year closer to about 15 years hmm and 

Howard:  is buccal fat pad reduction is that still thing in Manhattan yes one or two years ago

Dr. Todd Hanna: it seems to be more trendy comes in and out of favor it's not a new procedure they were doing that in 80s and 90s when all the models wanted that kind of something look but I'll still treat I've treated a lot of models actually they want it seemed they seemed like components I want that procedure done most often and it could really change John's face if you treat the right patient and you don't over treat them you don't want to hollow people out but if you treat the right patient you can get a great great result so you can show much more definition of the cheekbone you could have a slenderizing effect on the face one thing one thing that I try to do if possible is I try to look at a photograph the patient's parents because there's different types of people with my face and buccal fat some people have the type of buccal fat that's going to atrophy as they get older and those patients if you look at their parents they'll have redundancy around the cheeks and the smile lines in a lab but some people just have genetically cheap chubby cheeks and if you look at their parents and could be you know wrinkled everywhere but L still have chubby cheeks then you know that that buccal fat isn't going to atrophy much over time so in those conditions you could be a little more aggressive and take away a little bit more puffs of fat whereas in the former or the previously stated patient you know that they're gonna have additional atrophy of the buccal fat over time so you go look you treat them more conservatively so there's one little trick but always understand even when you remove small amounts of buccal fat it may not seem like a lot at the time but you're just from doing surgery just from going into the site you're gonna get some strong retraction so fat atrophy so always remove less than you think then you think you're going to want to remove because the end result over three to four months is going to be a really you know could be a really dramatic effect even when you only remove small amounts of fat when a patient says you everyone thinks my face is fat do you say that's ridiculous you haven't met everyone so and so about slimming down the face liposuction face and neck lipo sculpture are you doing liposuction of the face and neck yeah that's procedure actually do more

Howard:  men posting some of these on dental town it'll blow their mind yes and one of the things you can do is when you go to dental town say say you're gonna post a case on liposuction you guys do a search word liposuction you can see pull up and and that's the key reason they don't Allen's a message board just like if you go to the jet propulsion lab laboratory and they do a lot of that work here at ASU they all use the message board format because it's it's an organizational database it's not where as all social medias last in first out and you just have to scroll back so yeah if you got some cases just do a word search and drop it in there and you'll blow their might you're blowing my mind right now so men get why do so many are getting more liposuction of their face the I think meant

Dr. Todd Hanna: you know a lot of men want that chiseled jawline and that's a procedure that they tend to ask for frequently so treated quite a few men would submit the liposuction and jawline enhancement things like that you know the reason the term liposculpture versus liposuction is kind of kind of goes back to that previous troubies phrase about it's more important what you leave behind them what you take right so you don't just want to remove all the fact but you want to be selective about where you can remove fat from to really give an optimal aesthetic appearance so that's why we use the phrase liposculpture but it's basically the same thing 

Howard: in Manhattan regarding fillers botox injectables you're starting to see some states start to have some turf wars where they're like you know who can do this and not have you noticed any of these turf wars and and what are your thoughts on fillers botox injectables I'm she's 25 she's a gorgeous young dentist so she's she loves all things on Instagram and beauty and she wants to get into Botox would you tell her that that's a good idea for her new practice or a bad idea what would you tell her

Dr. Todd Hanna: it goes back to the same thing with implants right like like the landscape is constantly evolving and if you don't evolve with it then at some point you know you're gonna be left behind so things like filler Botox especially Botox to start with but even filler of the face and lip augmentation that's certainly something that someone would a general general dentistry background can learn to do and do well and also you you can you can make mistakes and you can have bad results but for the most part if you if you're using the materials that you should use it's real it's all reversible so you can do give some Botox and you could drop their upper eyelid because you give it in the wrong area but after a few months it's gonna go away right by the time they get in you know the patient's again you know really upset heap goes away the same thing with filler could inject filler into marryin of a bad result but you could also inject something into it to dissolve it if it's a hyaluronic acid right which is what they should be using you can inject hyaluronidase into it and resolve and dissolve it so these are these are procedures that general dentists should certainly be exploring if they have an interest in it and I actually gave a Botox lecture to group of general dentists back in April a friend of mine know shot by Perry and myself gave us lectured at NYU School of Dentistry College Dentistry and you know you can see the turnout was great you can see the enthusiasm so I think it's something that's certainly going to be heavily incorporated into future dental practices and process possibly even dental curriculum in schools

Howard:  well I speaking of online see they come out with on the average dental student had two hundred eighty seven thousand dollars of student loans last year we've put up four hundred online courses on dental town for just eighteen bucks and they've been viewed almost a million times if you've got a lecture from that school that presentation if you have a lecture in your deal man I would just I would I would beg for that I'd walk all the way to Manhattan to get you to put one of those on dental town I'm I'm Howard at dental town I was the first hour but the next Howard was Howard Goldstein so he's Howe go at dental town and he's in charge of the online see he's in Bethlehem Pennsylvania and that's kind of close to Manhattan in it but he's in charge of that and these Millennials they say all the time I want to learn this but some of these weekend courses are several thousand dollars and I learned it on dental town for 18 bucks yeah  I love the how you say the dental landscape is constantly evolving you need to evolve with it I mean everything hybrid Earth's had about five billion species and they're all extinct except for about 15 million that made it to today so if you're not if you're not constantly evolving it's probably not a good long-term strategy so what about chick chin augmentation is that is that more an implant or is that go all the way back to what you were seeing earlier with those what do you that big long word poly urethane custom implant deal absolutely cigar 

Dr. Todd Hanna: so I just did a QA on my Instagram account on chin augmentation because I was getting a lot of questions about it and there's a lot of distraction C as to which treatment patients should get and a lot of it is often because different specialties have different backgrounds and training and comfort levels with different procedures I think that there's three main ways to augment the chin the poly ether ether ketone the peak isn't something that we typically do for the chin because it's it's you don't necessarily need that customizable chin implant most chin implants are silicone and the reason is probably because the anatomy of the chain is a lot is less complex than the cheeks and this the you know the the there's no it's a midline structure so you don't need the same level symmetry as one side for the other you know I mean so it's a little bit different but with silicone chin implants the common one the other two - silicone chin implants one the second treatment is a genie atomy where the chin is actually cut and moved either forward back up or down and the third one is filler which is used for the chin augmentation as well very very subtle okay say that one more time the three main ways it was a silicone implant was one two and three so one is a chin implant usually silicone two is genie Adami which is cutting the chin and moving it into a different position you cut the chin bone and then you used plates and screws to fixate it and the third one is filler injectable filler and would that be silicone - no never I mean they make injectable silicone ever let anyone use it for something like that that would be a dense ironic I said something like Paloma I mean this this is awful some people use Radiesse which is a calcium phosphate or calcium hydroxylated or whatever but I don't use that product and we use hyaluronic acid based fillers and how are you how the chin surgery how do you spell it and Jeannie

Howard:  how do you spell that Jimmy ah to me it's GEN  IOT o my and is that um their shares is that a yum 

Dr. Todd Hanna: is that a common thing or is that a pretty rare it's quite common and in my opinion in most patients the genie atomy gives the best overall result it is also slightly more invasive than a chin implant but the overall result is much better because when you move the chin forward you're also moving the genial glasses forward and attachments to the hyoid bone so if you look at the way the hyoid is suspended almost like a hammock from the posterior digastric shanterrica as you move the chin forward the hi only tends to lift a bit so when you move the chain forward but versus putting you know if you move the actual chin forward and pull the muscles with it you get actually better tightening of the neck tissue as well when you do a chin implant you don't really get that right the other reason why I think it's better is cuz chin implants especially if you don't fixate them with a screw which I do if I'll do them you can get migration of the chin implant and it could erode the cortical bone over the lower the mandibular central cisors I can move I've seen a lot of problems with chin implants and I had to remove a lot of ones that were placed elsewhere ways with the genie atomy I don't see issues with them you know I think I see them very very predictable long-term results with the genie out of me

Howard:  huh so it is your do you think your practice what percent would you say is medical disease related and what percent would you say is cosmetic related medical disease related

Dr. Todd Hanna: I focused largely on reconstruction so there's a aesthetic element to the reconstruction as well so aesthetics is always in mind when you talk about the more elective cosmetic procedures and the medically disease related perceivers I mean and so facial implants would you say you already covered that because it's um you've already talked about you know fillers Jeanne ah to me 

Howard: facial implants what did that miss anything that you've already talked about are there any more because I think the the big exciting thing with facial implants is the customizable peek implant for like cheeks and angle the jaw the mandibular angles

Dr. Todd Hanna: those are pretty exciting because you can you can you can make them symmetrical you can make them completely customizable with the personal surgical planning the computer revision in what software are you using for these that is a software called 3d systems is what I typically used I've tried different systems as well but 3d systems is a lot of current reason you like that one lot and and does that interface with your CB CT CBC T to their to their website is um I know this is a so controversy like houses a question because 

Howard: um I don't think any I don't think the lawyers even know what standard of care means but is a CB CT the standard of care for implant placement in your mind I mean I think so you know

Dr. Todd Hanna: I think not in every case but if you're if you're close to a nerve or something like that I think it's it's silly not to get one if you have access to one do you have a what brand is 

Howard: CB CT do you use okay now why is it that whenever a podcast an oral surgeon are appearing on say always have an eye cat it's just they got all the specialists why wait that to me that seems significant why waited all the general dentist think all the other ones were great but all the guys like you they always go with an idea so 

Dr. Todd Hanna: I looked at the new ones to purchase I think the important things for me is the one that gets the entire skull you know the entire the entire had some of them all we do sections and you have to kind of cut and paste if you want things I was though and I wanted to be able to do like we maximize the virtual surgery on them so in these seven software I know the last when they do that as well so then 

Howard: last but not least was the reason I work we've been doing this day I posted one of your lip lifts and doctoral dentist on terra's IDEs I told me that was your work um so is that kind of a new thing are you doing more of that lips 

Dr. Todd Hanna: an older technique that was kind of repopulated meaning I that's that's one procedure where I'm very selected in the patients that I'll treat with it and I'll tear a lot of patients away from it because you really have to be you really have to pick the right patient otherwise you could have these really kind of bad outcomes but in the right patient the outcomes outstanding what's interesting about that post I think for most of the people that are tuned into dental town is that's not just a lip lift but it's a lip lift in conjunction with a maxillary prosthesis of fixed back side prosthesis so it helps for the restoring dentists to be able to make thesis aim control the lip length especially in elderly patient population where they may have a tropic maxilla and they may have a senile upper lip which is like a long flat upper lip a lot of times they'll have to produce a restoring back to have to make a prosthesis that has a buckle flange and a little sub labial flange just to elevate that lip to get more lip support but the lip lift actually makes it easier for them to make a prosthesis because they don't need as much lip support built into the acrylic meaning they don't need to build up as much acrylic to get the lip support so that's the  premise is that article that that post is based on and I wrote that paper with a prosthodontist friend and colleague of mine named Kathy Nkosi Onix who's faculty Island Tufts dental school and she did the process work on that she did a fantastic job and then a couple faculty members one Patrick Lewis at UAB fantastic surgeon and Daniel Gibbons faculty in Prague prosthodontics at UAB also in Excel individual so the paper you know it's I think it's more related to a lip lift in the dental patient versus just the patient that just wants a lip lifts or a purely cosmetic reasons

Howard:  yeah I you know I notice I'm all the dentists realized when there's see you're watching the news and the person shows their upper teeth and upper gums you know it's a young woman by the time they don't show any upper teeth and that's shown the tops of lower teeth you know they're past 65 but when they're showing no teeth and their lower gums you know they're 80 and so I can see how surgery like that search people would want to start lifting their curtains to reverse gravity yeah someone on dental town I posted is anyone offering kybella an injection that melts a double chin in their practices if so what has been your experience with it at my kybella calm

Dr. Todd Hanna: okay so Cabella it was popular two years ago it was very popular now I don't hear as much requests for it I don't personally love it I think that in patients who just need a very little amount of submental fat removed it can be okay but you're still gonna need two three sometimes four or five treatments and those treatments can be quite you know that can be quite expensive and you also have to do the treatments anywhere from four to six weeks apart so you're talking about half a year you know six eight twelve months even before you don't with treatment in some cases versus just going in and do semental liposuction which is a one and done procedure so you would rather you would rather do what instead of kybella you would rather do liposuction yeah people get very afraid when they hear that because they think of it as a invasive surgery and I could understand that but the reality of what submental liposuction is it's not it's really not what most people are expecting you make a tiny little neck incision under the chin and you take a very small tube and you suction on some fat and that's really basically the long and short of it they're a little swollen they're a little bruised but by ten days they're pretty much good and by two to three weeks almost all the swelling is gone and you're calling that 

Howard: a submental liposuction yeah yeah and so that's just faster more predictable and kybella you're saying that you're gonna have to be on this for a long time before you notice anything 

Dr. Todd Hanna: yeah it's multiple sessions before you get any kind of appreciable result and in the long run it's more expensive and even after Cabella it's not like there isn't any downtime there is you'll get you get a bullfrog appearance of the throat really give a swelling of the cement there when the tissue around the neck and there's some bruising there's some numbness and tingling that that's there most patients get these little lumpy nodules that take a few months to dissolve and break down so it has its downsides too if someone had a very small amount of fat under the chin and just want about and maybe that they're reasonable cannon before but in most cases patients are much better served with submental liposuction in my opinion

Howard:  well that's a that's a pretty intense opinion instead of I guess just taking the pill isn't gonna be it now I want to get you are you so good for time I mean my gosh you're such a rockstar I I don't want to stop oral head and neck cancer um what should these young kids know what I don't understand this walk me away from these thoughts it's like if you take a patient and it's a girl and you turn her upside down the insurance pays for pap smear cervical lights you know all these procedures and they really taking a bite out of cervical cancer I mean it was like fifty thousand a year and now it's down to twelve but you turn that patient right-side up and the dental insurance companies don't want to oral pay for oral screening there is no big media about oral cancer it's not paid for and and we've still been at that fifty thousand mortality the whole thirty years so why do they take all that why does all that knowledge only apply to a female cervix and not a male or female mouth with world had no mouth hit sir 

Dr. Todd Hanna: where I see that most clear what you just described where I see that most clearly is really with my my Medicare patient I take Medicare a because I like the patient population and B because it I found the social responsibility to the population as well so with the Medicare population they come in and Medicare won't cover oral biopsies you know I mean if they say that they do and there are some loopholes but they really don't and these patients they consider them dental procedures and as you know Medicare doesn't cover dental procedures there's nothing dental about a lesion that potentially be a cancer it's their overall health you know I mean it's not a dental issue some medical issue it's both and all you know you will so I agree with you I don't know why but neglect is there but I think it's probably there because it serves as a loophole for the insurance company its meaning if it's in the mouth its dental so they don't have to cover it and you're saying they don't pay for oral cancer biopsies that the Medicaid Medicare get them covered

Howard:  yeah that is so weird how people say they don't think the mouth is part of the body I don't know what part it is so yeah so Medicare doesn't cover dental so for internationalists listeners the Medicare is the federal government for the over 65 and each state has its own Medicaid which was the most confusing thing about Obamacare I mean I don't I don't want to talk politics whether you like it or don't like it but what I don't understand from a business is everybody that was on Medicaid had no idea Obamacare was affecting Medicaid it was a horrible brand mark it was it was like coke coming out with new coke I mean he should have just focused on Medicare because everybody would understood what he was doing but nobody knew out here like in Arizona it's called access no no one knew that access was Obamacare or covered by Obamacare um but oral head and neck cancers really changed with that HPV and again I don't see my homies talking about Gardasil 9 by Merck I don't they say they're not you know because it was related to Michael Douglas and oral sex I mean obviously we're not having that discussion and it's like well you're either a doctor or you're not I mean do you think the people listening to you right now should be having a discussion about HPV vaccine to prevent oral cancer in their chair 

Dr. Todd Hanna: yeah I mean I think that the the best things I've got a list some new ones out I think if you treat them for that you're essentially treating them before prevention of the HPV positive screening or cell cancer that people get into oral pharynx so I think what we're gonna see as the generation 1 big artists will come out like early 2004 ish 6 right and then they started treating teenage women initially for that and then they expanded to offering it to teenage boys as well so I think it's the population grows you're gonna see less floral Virgil hpv-positive cancer the the important discussion the discussion of people have to learn how to have is what we see it in a patient how to educate them about how they got it in a way that's sensitive to the trend the nature the transmission meaning they do gather through certain activities especially when there's a spouse involved that doesn't have it you know that's the part that then the best of discussion I tend to be tricky and there are ways to kind of do that in a way that doesn't send them home in you know not only having a diagnosis of cancer but also in turmoil with their loved water spouse so but you know I think that intriguing the just in getting the vaccine as young adults you're gonna see a drop in the incidence of HPV possible or financial concern for sure 

Howard: um last no I can't can't believe you've gone over my gosh where you're just so nice going 20 minutes of overtime on this show III could go on for 40 days and 40 nights you're so amazing I'm not gonna do that to you I do I'm begging for my homies if you have any of these presentations to put them on online see I mean we we there's two million dentists on earth and we have a digital connection to have them we have 1 million verifiable auditable connections digitally because I'm when I I'm lectured in 50 countries and I can't believe it almost makes me verklempt when some little girl in Somali or Nepal I walked into the dental school Nepal and with a Dean realize it was me she she broke out in tears because she said my god we um your dental town stuff our textbooks are all 25 to 30 years old she told me in her dental school all the donated textbooks were a church in Pakistan and so their Arabic and and and a another church in China so their Mandarin Chinese and they speak Nepalese and but the international language for dentists is English and they just love those courses and we only charge we don't tell anybody but really charge the eighteen dollars in the rich countries not the poor countries and so if you're poor you already know this if you're rich you're like but um no no too delicate for students is that something that you've had that you've already explored reaching the student population or maybe in the future intent explore more for a way to educate some of them in some things that they may not be getting in their school correct absolutely and all our online C courses are free for all dental students anywhere around the world and the most sad comments on them is I'm watching this lecture right now during my dental school lecture yes my brother I'd rather put in my headphones and listen to this online seee course on dental town than listening to the guy talking right now in school they just and also I think there's something they love Millennials love about that our format I mean they they work out for an hour you know committing to an all-day lecture Friday from 8:00 to 5:00 that I mean it's hard to even sign up for it let alone go to it so they like those little hour increments I think that works better with the human mind um what last one at least um what would you say how can we general dentists have a better referral relationship with our oral surgeons what what do you look at us and say yeah I like that and what do we do to you that you say gosh

Dr. Todd Hanna: I wish they wouldn't do that communication you know if you can effectively communicate with anyone that you're working with to take care of a patient so it's gonna be better for patient and the doctors involved always gonna get and have more of a they're gonna be feel more rewarded and they're gonna have a better experience treating my patients so personally I don't choose to work with many different referring doctors I don't shoot I don't cast the white name I choose to work with fewer doctors that I communicate well with be treatment philosophy with so that piece or the treatment for the patient makes sense on both ends you know and then see that I actually like and I enjoy interacting with because if you like so on you enjoy interacting with them you're gonna be more to either some of them that know hey I just saw a patient so-and-so they doing great or what do you think about this and that's what patients get the best care that's when it's the most fun for us so I think you know choose doctors and refers and referring doctors they choose people that you enjoy working with that you communicate well with and that you think similar you have a similar mindset into treatment philosophies and that's the best way 

Howard: by the way that I'm the case you have a he'll plastic surgery video on Instagram when you make a post on dental town it has the icons for media or YouTube so you can drop that right in there I love your videos a huge fan of your Instagram page his Instagram is just dr. calm its Instagram calm for its last doctor dot Hanna do ctor dot Hanna 21,000 followers you're a legend in my mind everyone's mind thank you dr. adonus tears IDEs for hooking me up with this man Todd you're so amazing thank you so much for all that you do for dentistry for oral surgery and thank you so much for coming on the show and talk to my homies today and if you got an online secrets to make man that would be so cool okay buddy have a great day you