Dentistry Uncensored with Howard Farran
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1337 Mastering Periodontology with Dr. Homa Zadeh : Dentistry Uncensored with Howard Farran

1337 Mastering Periodontology with Dr. Homa Zadeh : Dentistry Uncensored with Howard Farran

1/21/2020 3:00:00 AM   |   Comments: 0   |   Views: 143
Dr. Zadeh is a diplomate of the American Board of Periodontology. He received his doctor of dental surgery degree from the University of Southern California (USC) Ostrow School of Dentistry in 1987. He has completed post-doctoral clinical education in Periodontology and earned a PhD degree in immunology from the University of Connecticut, Schools of dental medicine and medicine in 1992. Dr. Zadeh is internationally recognized for his clinical and scientific expertise. He is the author of numerous peer-reviewed publications and book chapters.  He served as the president of the Western Society of Periodontology in 2017.  Dr. Zadeh directs the VISTA Institute for Therapeutic Innovations with blended educational pedagogy and directs the Southern California Consensus Symposium. He maintains a private practice limited to periodontology and implant surgery in Southern California.
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VIDEO - DUwHF #1337 - Homa Zadeh


AUDIO - DUwHF #1337 - Homa Zadeh


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Howard: It is just a huge  honor today I cannot believe I'm podcast interviewing one of my idols he's your idol he's the periodontist for periodontist Dr Homa Zadeh my gosh DDS PhD he is a diplomat of the American Board of Periodontology and implant surgery he has served as tenured associate professor director of the post doctoral Periodontology as well as chair a parrot ontology section at USC Ostrow School of Dentistry he graduated from the University of California Los Angeles with a degree a BS degree followed by a dr. dental surgery from universe USC Ostrow he completed postdoctoral clinical training and Periodontology as well as a PhD degree in immunology at the University of Connecticut also known as that's UConn right UConn School of Dental Medicine Dr Homa Zadeh has lectured nationally and internationally in over 30 countries at prestigious conferences on topics ranging from aesthetics to minimally invasive periodontal implant surgery as well as tissue engineering he served as president of Western society of Periodontology which is the largest regional Periodontology society spanning the 16 western US states and Canadian provinces he is the innovator of the visa technique recognized around the world is one of the most effective methods for the treatment of gum recession he's also innovated many concepts and devices which have been patented and developed into products and clinical use in many countries Dr Homa Zadeh has direct to the laboratory for immuno regulation and tissue engineering called L ite a USC I was gonna do it but I was busy that day and I forgot my PhD in immunology which is a scientist guy I mean his resume it goes on for 40 pages he has an extensive publication track including over 60 publications in reviewed journals and numerous book chapters he serves this editorial reviewer for many scientific journals he served as a chartered scientific reviewer to the National Institutes of Health and chaired a scientific panel at the NIH Center for scientific review he served as director of USC international period-- ology and implant symposium I mean I got is there anything you haven't done meeting Howard Ferrand is complete now if you just if you just drop-ins add a Z ADH I was like today in fact I need my today's dental I did one name is a days dental cuz I knew he'd sue me so I called it today's dental but you just just drop his name in dental town and you have questions are I mean this is a comment for you I'm someone's posting about tunnel grafts first post what would doctors a day do I mean that's just what they I mean you like say they that you're the you're the periodontist that the periodontist listen to you so so first of all thank you so much for coming in and honor to see you I have to say out of all the ten specialties I got a school in 87 I mean what's really changed in pediatric dentistry silver diamond fluoride what's really changed and I mean so many of the professions haven't really changed much periodontics I mean my god it's it's crazy when I get out of school it was all these periodontal surgeries it was taking four Cashion's and doing route this and that and all that and then about I don't know five ten years out of school people said you know how you treat pareo with forceps let's just pull them out and place it with titanium after ten years of that they're like yeah that didn't really work like I thought it would and now the pendulums all the way back to being a parent on us again I would have to say I think you're especially changed more than all the others would you agree or disagree well

Dr Homa Zadeh:  first of all thank you Howard for having me here it's an honor to be here and pleasure to join you I applaud what you're doing I think it's a great service to the profession you're right that Periodontology has had the most amount of innovations because I think there are more periodontist who are doing research and I think keep an open mind and adapting to knowledge as it comes along and you're absolutely captured that encapsulated very well that the pendulum has swung and I look at the way I treated periodontal disease we started out with periodontal therapy and then we became so enthralled with dental implants and we then discovered all the problems that go along with that so that really taught us a lesson that we shouldn't jump on the bandwagon we shouldn't abandon the tried-and-true type of procedures that we have known for many years so I think for me as a paradise my passion today saving teeth is really we have discovered that he'd have something that you we have not been able to capture in dental implants yet the ability to you know heal themselves the ability to maintain themselves I think that's there's no replacement for teeth at the present time

Howard:  you know you gotta remember a quarter of my viewers are still in dental kindergarten school and the rest are all under 30 I mean people are age they're not into podcast or Instagram or snapchat they're they're you know they're so you're talking to kids and it's very stressful for them they only became a dentist she only became a dentist because her mom's at us and she comes out of school she's read how many chapters and how many books have you written I mean yeah she's read all this stuff and now she's working with her mom and her and it's stressful because her mom started to treat pareo with extractions and placing implants and now she's looking at him and five years later you know a third of them have peri-implantitis around them and the mom saying well well Frank are you having a problem he's like no I can eat a bacon cheeseburger you know I have no problems no pain and then her mom says no problems no pain and then there's these people talking about the oral health continuum and some people are saying well you know they're finding periodontal pathogens and Alzheimers of the liver that you know all this so like that and she she's talked to her she she doesn't know what to it's her mom the patient's not having pain some people say well you know every morning this when I turn on my coffee pot the Sun comes up but I didn't cause it it's a correlation and a lot of these diseases that you're saying or associated periodontal disease are correlations they're not cause effect and she's trust well what would you what would you say to her she's 25 working with her mom so I'm careful hey 

Dr Homa Zadeh: you are absolutely right that we shouldn't jump into conclusion always I think we have to be very careful in how we interpret information you're right that when we're looking at many associations they don't always pan out into causality and I think the tendency for people is to draw conclusion too quickly so yes we have a great deal of evidence to look at the correlation between paranal disease are many systemic diseases and perhaps we will find at some point correlation between peri-implant diseases and systemic diseases and not all of it has really panned out in the form of a causality some of them we've have more evidence for but the reality is that inflammation and infection or key aspect of many different disease processes so there's no question that regardless of any of that we as Dentist our main job is to control infection and inflammation and we're gonna be dealing with that where they were dealing with parallel disease whether we're dealing her implant diseases we're whether we're dealing with caries we have to put that as a center of what we do in dentistry 

Howard: when you're talking about causality um do you know the dentist's out there by you Paul O'Malley yeah you know Paul Ali from great University Owen I talked to him I Paulo Malo from O'Malley no no um when I was a freshman at Creighton I went over to the dental school and he was a freshman at Creighton dental school and I had eight sticks on my occlusal z-- and molars and he did eight ACLU's amalgams and by the end of the year all my hair started falling out and I was wondering can I still go back and sue him just look at him right now look at mr. got all his hair how can he make me go bald there are 30 years later sporting his hair so um they come out of school and a lot of people are saying you know the people who represent dental schools they're lying with statistics they always put on in their website that the average dental student has $284,000 students come on you run a dental school why are you lying an average 20% of those kids their dads paid for dental school I'm another five ten percent somebody paid them the military is something else when you look at just the kids who have student loans it's more like four hundred thousand dollars run that and then they come out of school they're four hundred thousand dollars in student loans but and they're told you want to be you want to be a periodontist you need to buy a hundred and thirty five thousand dollar LANAP laser you need a hundred thousand dollars CBC T you're gonna need a hundred thousand dollar chairside CAD CAM and she's like dude if I make three purchases I double my student loans so this is dentistry and sensor we don't talk about what everybody agrees on so I'm gonna hit your heart first cuz I know it's it's channel conflict for these guys when these guys are prestigious periodontist they don't want to have people come up to me and say why did you trash-talk something on Howard's transcenders but I'm gonna ask you point-blank do I need a hundred and thirty five thousand dollar LANAP laser to be a periodontist like you

Dr Homa Zadeh:  let me ask you if you want to be Kobe Bryant you go buy Kobe's shoes and you become Kobe Bryant so just because you find some tools it's not always going to improve you out cause that's the number one thing I think the most important aspect for a dentist is the decision-making skills I think today that is by far the most important thing that you can do for your practice is to improve your decision-making skills by acquiring the information so I think if we are focusing more on information and how to make decisions we're going to be much better dentist and buying tools and gadgets to improve our outcomes not all of those gadgets and tools are going to improve the outcome of our patients the first question we have to ask is this going to improve what we're doing for our patients is going to improve the outcome of our treatment if it does then we pursue that unfortunately many people will look at how can I amortize this particular piece of equipment over the course of the treatment to make more money for that means from a business standpoint that's one way to look at it but I think as looking as clinicians I think that may not be the most effective way to look at how we can be better healthcare professionals

Howard:  healthcare I think is a bad business to go into because when I went to Creighton at Omaha with Paul O'Malley who went to Creighton the my gosh Warren Buffett the Oracle Omaha was in there and he'd come over and he talked to the business class and he said never go into a business that needs big capital investment and someone else that's your price never gonna have business so what do we do we go into expensive healthcare and insurance companies set the price so you really wanted to be a dentist had to intentionally walk into that storm and one of the things that I can't get my mind around is the the oral surgeons when you go in with four wisdom teeth they pull all four at once when I I don't know when I'm gonna get my quadruple bypass but I'm sure it's sooner rather than later I don't think they're gonna do one bypass a month they're gonna do all four at once so someone comes into my office and they have a mouthful of gum disease I always think for me I want to treat you like I would treat myself I wouldn't have all four quadrants and spend two three hours and do the whole mouth because I'm trying to I mean I don't I don't know how to flush half a toilet but the insurance company said no no no you you can only do you you can only bill us for one quadrant at a time or two quadrants at a time you can't bill for all quadrants at a time and it's like god I I I don't know to me doesn't set but you would know the research you would know the immunology you you got a you're a double doctor I'm actually about half the doctor would it be a better outcome if I did full mouth root playing curettage to flush all that out today and or is the interns gonna be right I should do right side left side two weeks apart

Dr Homa Zadeh:  there is some level of evidence that has done with full month dis disinfection type of treatment there's research done in Leuven University by mark Warren and who has shown that for math disinfection is a more effective form of treatment you're correct that if we're dealing with an infectious disease it doesn't improve the situation if we're doing one area and time at a time and we're leaving part of the infection behind as we're cleaning up so it's just like if you're going to be doing the you know clearing roach infestation in a house you cannot do one bedroom at a time and then have all of the infestations remain in other areas so I think we have to look at one aspect is the insurance but I think insurance is still a choice in u.s. I think we still do have a choice because we can inform our patient what is in their best interest we still have an opportunity to give them what the best way of treating that and it will be up to the patient to make the decision in some other countries is not always a choice I know I have some friends in France that even as private dentists they don't get to decide the government actually gets to set prices and they have to abide by that you don't have the option of opting out of these insurances because the government actually decides how the prices will be for implants and other types of procedures so I think we still have a choice here in this country I think we still have the opportunity at these present our patients what is in their best interest and if they want to utilize their insurance that would be one way to look at it but at least they should know what is in the best interest which is basically one-time treatment usually my patients appreciate it when you try to do all of the work in one session whether it's scaling route planning whether it's doing surgery they don't want to go through at multiple times yeah when I had my

Howard:  I've only had one surgery as a vasectomy I told him do both at the same time I did not want to come back again but so so let's say on the debridement deal I'm you remember I'm old school I graduated 87 I still got a lot of mine same year same years you 87 and you still got your hair that's just not but it's a wig be honest it's a wig that's a wig and I had plenty of amalgam so that disposed there so Paul O'Malley I'm still gonna sue Paul he's in southern cowboy you so you can deliver the lawsuit for Ringo Mayer but but there's a lot of boys a lot of my friends which you know local alcoholic dentists that drink too much that after every four quadrants of replaying curettage they still say I give them around to touch cycling because cycling show up in the curricular tissue seven times more concentrated than penicillins and buh-buh-buh-buh-buh and then and then the guy drinking next to him say well you know what I do it and at the end if it's a deep pocket I put in a pareo chip or I put in this or that um how much of that so so succinctly after four quads root playing here Taj all at once is there a need for an antibiotic or is that silly and do you ever put local perio chips and Menaka cycling's and do you use any of that stuff well Dr Homa Zadeh: the tetracycline type class of medications they've pretty much lost their antimicrobial effect ofthis because of the overuse but especially by the colleagues in dermatology they put patients on many months or years so there's so much tetracycline resistant that as anti microbials they're not so effective they there were some efforts to try to take advantage of tetracycline other ability which is to inhibit the enzyme collagenase to prevent tissue degradation so that's the other side of tetracycline medication where you can use low doses of them to reduce the tissue breakdown and that also seemed to be a nice therapeutic there people were put on these sub antimicrobial doses of tetracycline class medication but they also did not seem to pan out in the long term we were enthusiastic about it but it didn't work out so the answer the question about antimicrobial therapy do we really need to have antimicrobial therapy on top of mechanical debridement not in most cases in in most cases where we have an abundance of local factors we have mineralized biofilm calculus and plaque and and there's abundance of that by just eliminating the mass of the biofilm we can usually be very successful in patients which have not a lot of calculus they have pretty good hygiene but they still have had a lot of breakdown they those are patients that we use to call aggressive periodontitis now the terminology has changed these patients can benefit from that because a lot of these bacteria can get into the tissues so adding on top of that antimicrobial therapy systemic can be helpful in conjunction with with with the full mathis infection and so one way is to do it bacterial testing to figure out but most of those bacteria respond to a combination of amoxicillin and metronidazole in patients were not allergic to that so that could be a therapy to to combine adjunctive systemic antibiotics with full mastis infections in younger individuals who have had severe form of attachment loss but have not don't have a lot of local factors like lacking calculus and that we can address with the planning so those are the patients that we give systemic antibiotics

Howard:  I did not know that question to bring up a nightmare in my life you said the antibody plus metronidazole mm-hmm I took my four boys scuba-diving one time right and we came back and something was wrong with her GI so we had to go to the bathroom send it to a lab in Minnesota and they came back and said you all have a parasite mm-hmm and they put us all on pen BK metronidazole for 10 days and cured us up but I'm is there um are you doing salivary testing is that a part of your protocol too because you're not getting the easy pareo cases I mean you know we it's like the pediatric dentist you know they sew or is that oral saliva testing is that part of your our material or not really

Dr Homa Zadeh:  it is for select number of patients vast majority of patients do very well just by scaling route planning and and mechanical debridement for select cases if it's food to also take the saliva sample to look for the bacterial composition it's a very simplified form of diagnosis because most of those bacteria we don't even know who which they are there are hundreds of different type of bacteria that could be present anytime the DNA testing will only check for you know a handful of them so I would only use that in certain cases where the patient has aggressive forms of periodontitis have have a great deal of of attachment loss and we want to kind of monitor the bacteria make sure that we can see at least the known pathogens and track them before and after treatment to make sure that we've suppressed their numbers with our treatment so I would say maybe less than 5% of cases we use microbial sampling

Howard:  when you and I got out of school the they were improving implants like putting a che coatings on it you know they thought that would be better and so the question is peri-implantitis how real is it and does any implant surface better for preventing it than others I mean I notice all the h8 coatings are gone okay so does the does the does the name brand Nike Reeboks Puma implant I have less pure implant itest and the one made that I buy by mine at Home Depot or the you know 

Dr Homa Zadeh: well peri-implantitis and could have prevalence depending on who you ask and who you believe and the peri-implant diseases come in to two varieties one is peri-implant mucositis which is the equivalent of gingivitis and periodontitis which is the equivalents of Perry periodontitis so they peri-implant mucositis could be as in as much as 80 percent of the implants that's just inflammation that pair implant mucosal peri-implantitis which involves also bone loss depends on what are your criteria for defining bone loss how much bone lasts you accept the threshold has been anywhere from half a millimeter our bone loss to define parent plant eaters up to three millimeters or more so currently depending on what classification you agree on I would say that the most reputable percentages that are out there is about 10% of the implant have the severe form of parent plant itis that's about the from Fahrenheit to Celsius no I like it so so yeah because everybody likes to light with statistics in exaggerated so you're saying true periodontal disease around implants but re-implant itis is probably ten percent about ten percent and that's actually any length of time are you talking about like after that's that's actually very similar to periodontitis we know that about half of the population has periodontitis but the severe forms of periodontitis isn't about ten percent of the population very similar to periodontium plant itis that may be about 40 percent that the implant have some form of peri-implantitis but the severe form that could affect the function about so we're talking about prevalence at any given time not you know incidence so usually peri-implantitis starts somewhere around year three to seven years so somewhere in that time range it starts and then it can progress over time but the key is early diagnosis and don't think about implants as you know as the final treatment that we don't need to follow them up just like our and periodontitis patients that we have to follow them up peri-implantitis patients need to be followed up in a regular basis and

Howard:  I see Parian implant itis I've seen as two words one word Perry - implant itis what's the u.s. see I mean I know we're Hillbillies out here in Phoenix but what how would you SC do Perry 

Dr Homa Zadeh: the definition the most reputable definition right now is by American Academy paired ontology European Federation of Periodontology they had the most recent classification definition anybody who wants to look up the diagnosis all that's called the American Academy of Periodontology yes they can go to Peri. org and under peri dot org you will find the latest classification the latest you know actually there's some very good papers in there that you would see that define practical way of diagnosis of param  plant itis in a clinical practice also they have periodontitis diagnosis clinical day-to-day diagnosis so go to perry org you'll find their classification of periodontal diseases and perry implant diseases and you'll see a series of papers in there that have very clear definition of these diseases and some guidelines for diagnosis and treatment I'm still just trying to get the - a that is their proper way so Perry so you said all that just to say - but I just want to give a colleague's an opportunity to do information yes Perry org and what's also great you know 

Howard: what I love about Perry org the most is um you know the women in Phoenix they're all on Pinterest they are the moms are on Pinterest and so I on Pinterest I'm at Howard friends right and so many of the perio home care instruction so many of those things are all memes from Perry org and I just tell I just bought my iPhone right there at the chair and I you say what do you want because I like Pinterest easiest because you can separate your picture albums by pareo and boy if it's a newborn mother so that was gonna be my next question so periodontal disease again she's 25 she's hearing all this about teratoma associated heart disease how's our relationship I love the way you cleaned up peri-implantitis to bone loss severe whatever do you think there's when somebody has this severe gum disease do you think there's any diseases that are yes this is causing that disease or do you think at 20:20 we just don't know their correlations are causal we're just not sure 

Dr Homa Zadeh: well the reality is that periodontal disease is a very multifactorial disease there are many different forms of periodontal diseases there's not just one disease and the same is true with many other systemic diseases they have many factors you take cardiovascular disease you know many people know they you know let's say cholesterol as one of the risk factors but you cannot have cardiovascular disease just with high cholesterol you need on top of that inflammation so inflammation goes at the heart of many diseases including cardiovascular disease including the diabetes type 2 diabetes you know you cannot have just diabetes by high sugar you need inflammation at the heart of it so inflammation can come from many sources in the body one of them is oral cavity and paradol diseases are one form of contributing that inflammation to the systemic overall health so I think the key word in in many of the long term stand diseases is inflammation and and periodontal disease can be one of them so yes cardiovascular diseases diabetes these are ones that very highly correlated with periodontal diseases and I think if we want to control any of these long-term diseases controlling inflammation is really key and one aspect of it is controlling oral infections including perdón

Howard:  I am so glad you came here today because this morning my mom emailed me and she wants to come out in February and she's the only thing that inflames me so so so you're saying to stop inflammation tell mom no I just saw you over Christmas you're not coming out here causing more um another but back to implants is there is there is there some implants that are better than others regarding future peri-implantitis the surface 

Dr Homa Zadeh: yes absolutely so there is quite a bit of information on that the short answer is that every single implant surface is amenable to peri-implantitis okay every individual implant surface so many people has amenable to peri-implantitis yeah that was the that wasn't a mucosal no this you could have pair em you could have developed bone loss okay in relationship to the implant so they mindset has been that with Machine implants which were original implants that we had these machine implants they have smoother surface they didn't attract bacteria as much so we did not have as as as higher peri-implantitis with those that is true that machine implants have about ten percent lower percentage of peri-implantitis but the reality is that they have you know less integration in the up front as well so you can take your pick you want to have more complications initially lower chance of integration you can use machined implants but if you want to have better integration you use any of the rough surfaces but down the line if you have exposed rough surfaces that predispose the to peri-implantitis so out of all the rough surfaces every implant company wants to make their surface the best that there is but the reality is that what appeals to the host to it to attach to the implants and us you integrate the same factor appeals to the bacteria bacteria love to attach to the same surfaces so by making our implants rough to attach to the bone they also makes it more rough and the bacteria love it too so that increases the chance of parent plant itis now we do know that specific surfaces have more propensity for parent plant itis there are some specific studies that have identified very specific implant surface you know modes of of roughening to higher incidence of parent plant data so out of so maybe we don't mention their by name but you look at the literature and you can look at the literature we need to start making cocktails yes just needless to say that I will just say that there are different ways of making implants rougher there they if you look at some of the systematic reviews that have compared they have identified the implants that have been roughened by there and you know anodized ations system okay to have higher incidence of parent plant either so anodized surface is one way of making the implant surface is rough and that's what has been associate with higher incidence of parent plant bone loss okay now the new thing is to say okay let's forget about titanium let's go to zirconia because they're Konya is not amenable to parent plant itis you know we don't have evidence for that many of the zirconia manufacturers are trying to make that as the main point and there's not enough evidence to say forget about titanium now with zirconia you won't have it as a problem the reality is that we don't know enough about zirconia to make a widespread recommendation to everyone now to switch to zirconia and we can't you know say that we're gonna have less complication we need much more evidence before making that recommendation to people so my recommendation is to stay with what we know about rather than going with the more unknown well dentistry is an art and a science and the oral surgeons tell me they hate glass or cone iam implants they don't like working with them I mean are you hearing do you know any that love them well you know zirconia has some pluses and minuses as econia is a nice surface the reality is that many people will say well if you are concerned about metal let's go with a metal free zirconia if you look at the periodic table you have titanium right below titanium you have zirconium which is basically right below that in the periodic table so so zirconium is also a metal so to say zirconia is metal free I think that's just a little bit of a stretch so it is er Konya has some benefits but also there is a possibility higher possibility of fracture and I think we don't know enough about long-term studies with zirconia to know that you're gonna use it on a large number of our patients

Howard:  I'm sorry I'm on Google so and I click the periodic table the first three were ads so I'm still trying to find though so titanium was 81 or show me it's Rob right below that in the periodic table is 81 titanium yeah that's not item 22 what what is TI ot okay so so the same titanium is the same one so that's right there in the periodic table 

Dr Homa Zadeh: so it's the exact same thing right so you see next to that is vanadium and VPM these are all used in some of the newer alloys that they're trying to develop yeah and 

Howard: I see that with people that um I'm a big water fluoridation guy and they don't like the fluoride but it's like okay well you know right Arnie fluorine is chlorine if we take that out now your kid dies of cholera and and now the swing pole they're all coming by and they go down one more they say well you need to get a chlorine it's all toxic let's replace it with bromium right it's like we're in this we're in the same column of number 17

Dr Homa Zadeh:  I'm trying to say metals are bad but just to say every metal is good or every metal is bad you know there's a clearly a difference between titanium as a metal versus mercury as a metal or chromium as a metal or nickel I mean there are different metals that have different by reactivity so we have to not and

Howard:  I love it when they Alan but they're honest people though because they come in they say I want metal free it's like well I least they're honest because they're driving metal free cars or flying metal free airplanes there's no other metal in their house there there is it's like when you went to that global warming summit it was so interesting to see all the movie stars flying in their in their jets burning ten thousand gallons of kerosene an hour on the way to the global warming and what do they want to talk about to use a metal a metal straw okay so get back in your Learjet um so um this this is a pet peeve of mine tell me if I'm if you tell me I'm absolutely wrong I'm wrong but it doesn't make sense for me when I see I'm in a dental office and they've seen grandma every three months for peri Aziz for ten years and they've never seen bad and now I say well what if what if you saw her every three months for an STD and she's had it every three months for tenant what do you originally say hey we need to check grandpa we know can you treat someone for penalties every three months for 10 years with ever seeing their spouse when they're sleeping with them right so there is this

Dr Homa Zadeh:  there is clearly some kind of familiar aggregation of periodontal diseases partly because of genetics partly because of exposure so exposure doesn't always equal disease so if you're exposed to the disease you have to have the genetic susceptibility on top of that to be predisposed to that so yes there is a higher you know communication of that so there's horizontal and vertical communication of some of the paradigm pathogens but you need also there the host susceptibility to go along with that so yes the answer is that you do need to examine all members especially if you have a younger individuals who has periodontal diseases and it's likely that they have a familiar aggregation of that there's a genetic predisposition for that so other members of the family should definitely be examined so this could also be a practice birth builder to bring in more members of the family to examine to look for that

Howard:  I think the low-hanging fruit of where there's opportunity is and you know every dentist four years of college four years of dental school they all got A's and math calculus physics I mean the dentist's Envy they're the only ones in Phoenix you know the difference between a sign in a cosign I mean they're  so smart and they um yet so I look for well where's the big they're not into agreement that that's what dentistry is so it's so explain to me this you lined up 25 dentist five dentists refer patients routinely for crown lengthening or may even do it themselves and they've done to their whole life and the next 20 they've never they've never referred anybody for crown lengthening to a periodontist and they don't do it themselves to me there's got to be something wrong have you noticed that phenomena of course what do you don't Dr Homa Zadeh: know won't hurt you so yes absolutely there are many and basically undiagnosed periodontal disease and the practices so you know when you see the patients who have had all these restorations that are either subgingival and causing increased bone loss because the crown lengthening was not done or because you have recurrent caries because the margin was so sub gingival that they couldn't capture a good impression so crown lengthening could be very important but if the dentist is not pursuing that you know they wouldn't know why the case failed why did they end up with a recurrent caries it's just because they weren't able to capture the impression because they were all the way into the biologic width and they weren't able to capture the good impression so I think a lot of that goes on but people don't realize while the cases are not lasting as long as they should be because they didn't really set up the cases properly 

Howard: um I think it's hilarious out here in Phoenix where they're now they're advertising that Colgate now has a toothbrush that connected to your app and we're just trying to get them to not smoke meth while drinking Mountain Dew but the million-dollar question is that Dentist asked is is do I treat periodontal these better with an ultra sonic toothbrush connected to an app versus my old oral be manual tooth brace with with Crest toothpaste

Dr Homa Zadeh:  well the reality is that there's no evidence that one form of tooth brushing improves outcomes in terms of where they use the power versus a manual brushes any differences however if you can have some kind of a motivation or behavioral modification by using an app and just like your Apple watch can remind you to get up and exercise I don't know if it actually translates into basin's people exercising more but if if there is some benefit in that I think there's nothing wrong with that 

Howard: you know what got me to start going to the gym regularly and I'm not even kidding right there on Mill Street by ASU they open up a bar called the gym even spell the right gene Who I am and it's like I am now going to the gym so there's um there's a lot of people talking about some of these procedures and they have names almost like Nike or Reeboks the pinhole technique and you see it there and there you actually see a trademarked and then someone else was saying they were doing a pinhole technique and I was like well you can't say that that's trademark I'm so so explained the pinhole technique why is it trademark does it go by other names and what is that all about because I'm just I'm just asking you the most common questions I see on social media

Dr Homa Zadeh:  I see so there are different modalities for treating gingival recession defects okay and their most common way is to reflect the flap place a graft and coralie advance the flap then you have the tunneling techniques where you don't make the surface incision and a flap instead you create the tunnel so one way to create the tunnel is to go through sulcus of the teeth and another way is to go through the vestibule now there are different techniques to go through the vestibule of the of the teeth one is to use a pinhole which basically uses instruments or puncture through the vestibule to create a movement of the tissue their technique I've been working with is called Vista that's also vestibular incision that creates a tunnel for Colonel advancement so I'm obviously biased about that technique in terms of benefits of that for being able to currently advance the tissues and achieving route coverage the reality is that we haven't had side by side comparison of these techniques to decide the effectiveness of of these different techniques but I can tell you that Vista definitely as a completely biased individual has many advantages for treating gingival recession in the sense that we create a small incision in the vestibule gives us more maneuverability to be able to loosen up the tissues to currently advance but also a key aspect of it is is rigid fixation of the gingival margin by bonding the gingival margins with suture to teeth so that's really goes at the heart of this procedure to currently advance and bond each sutures to teeth so then it creates a very stable gingival position during the healing so the gingival attaches to the new location now if you contrast that with pinhole pinhole basically if you look at the publication's there that was in 2012 they showed that it's a procedure that does not utilize sutures for me personally I think having the suture is a very important aspect because if you don't stabilize the gingival margin with some specific sutures there's more chance of the movement of the tissue during the healing and more chance of relapse

Howard: so this Vista that's what that's that means an Italian war means site or view in Spanish means literally until I see you or more simply see there so what so talk about what is the Vista oh it's 

Dr Homa Zadeh: Vista Institute for therapeutic innovations that's okay this the Institute is my Institute where we teach various and continue education courses but Vista as a procedure is an acronym for vestibular incision subperiosteal tunnel access so that was my next guess right that was my very next guest so that's just a cranium okay so you're gonna I'm gonna remember speak slowly so Vista stands for what vestibular incision subperiosteal tunnel incision subperiosteal tunnel and yes access so access so that's the a 

Howard: so that's kind of like is that kind of okay but that describes gingival recession 

Dr Homa Zadeh: so we use vista for many different types of use it for parallel plastic surgery procedures including treating gingival recession you can use vista for treating pair implant recession we can use vista for tooth extraction to manage the dehiscence around those areas we can use vista during immediate implant placement to monitor the facial area for soft tissue augmentation or bone augmentation we can use vista for gbr for bone augmentation for a denture asite there are many different applications of vista but the most common is to treat gingival recession around teeth or mucosal recession around implants so

Howard:  so that's so your website is learn vista calm yes so the websites learned vista calm and I know how to tell you what this means because I mean I already knew it I met this tubular in in subperiosteal tunnel access did I say right perfectly and who who is going so go to learn vista calm and what or you know the problem with dentist is there they their practice alone when I started in town it was the goal was that no Dentist whatever I practiced solo again right so she's on an hour commute to work I hope she driving to work cuz I if she's on the hour the treadmill just get off its just stop it it's hard for me to focus when I know you're on a treadmill who but she doesn't know who's going to your courses and what are they learning because I know they're successful and by the way I got a hand to your Southern California consensus suppose iam is February 6 and 8 I mean you have the 2 4 6 8 10 12 14 16 18 20 22 24 biggest names in perio or are in dentistry I mean that's a that's amazing 24 speakers from 7 countries so time when you first start with them because the dental town no one practice alone why why are her homies flying out to Southern Cal to go to Vista learning 

Dr Homa Zadeh: as I mentioned the beginning the most important aspect of improving our outcomes is not to buy a piece of equipment or gadgets the most important is to improve information so I think that's the most effective way is to get information from reputable sources I think and you know anything that we can do to improve our information I think that's the most important so at our Institute we have courses that use a blended learning where we have half of the material online but that but you know you still need to be in person there to do some simulated exercises to give some feedback to make sense of procedures to meet face a face to discuss their clinical procedure so we have any courses with hands-on component life surgery so colleagues come from all over the United States and some also from foreign countries to basically hone their information and their skills about some of the important information and and procedures in dentistry of course Vista is the technique that a lot of people come to learn but we have many courses in conjunction with other colleagues with other periodontist prosthodontist and other colleagues on that but I thank you for mentioning about the Southern California consensus symposium that's coming up in a couple of weeks and February 6 to 8 just as a way of for your followers for the Townies I have a promotion code if they want to go to that website learn this outcome if they want to what's the promotion is Towny so if they if they use a promotion cone a code of Towny they get $200 off of the registration and we're in they register at learn visa become that's correct okay so I'm at Lauren visa so I go to registration so I go to registration yes so then when you put in the promo code Tony you got $200 off of the registration and $50 off of each of the hands-on workshops so ty just I just typed in town eNOS said if you're a townie you need proof that you're still a licensed dentist so so so the where is that it's gonna be in Woodland Hills California it's it's the symposium is in downtown at the LA live right across from Staples Center so that's at the JW Marriott in LA live that's where the symposium is located that's a larger event and so so that's Los Angeles 900 West Olympic Boulevard that's downtown LA that's downtown LA right at the Staples Center at LA Live you know I I know that many colleagues like to get the education from you know online and I think that's good but still we need to be have in person major events like this to see our colleagues Network listen to some of the top speakers in the world for me I attend a lot of these I give lecture in many of these type of events but also I attend them for me the most important part is that when I attend an event like that I get inspired I get energized I gonna go back to my office and treat my patients with a renewed energy because you see some of the people with the you know that are the top educators in the world and you definitely can be inspired by what they're showing in terms of the outcome so what would you say is the theme of your symposium our theme is trends in clinical dentistry so we have some of the people who are the trendsetters the thought leaders for coming in to give their presentation and the format for us is is a bit different that we have the lectures from these speakers coming from all over us speakers several of them come from Europe and  Asia and when they come to this they  participate if their lecture but we have these prolonged panel discussions where we put pose important questions to them and we really put them to the challenge because we want them to just say how as how it is and  we actually put people with the opposing philosophies just so that they can and kind of clarify it for their participants about the point of view so I this is the first year that I do this as a Southern California consensus symposium prior to that I ran the USC periodontal implant symposium up and for 16 years so this is a new venture for me and to do it as a non university but a private event because that really allows us to rethink and reimagine not have some of the restrictions and and to be able to do a world-class educational event 

Howard: I'm gonna my job is to get you to make the most dentists mad I'm gonna ask you I'm gonna ask you the ones that I'm so we had Carl Mich on here and Carl Mich really I loved him because he would he would always tell you what he thought he never he never pulled any punches if he didn't but he said that the drawing blood there was no research that he said that was art it was voodoo was necessary I got friends that said my god I ate that they the way they draw make the putty they just love it so some people are saying well there's no research for well we learned from the New York Times last year there's no research for floss I'm urban yeah I'm thinking about so so do I need to draw blood and spin it and all that stuff or do I not 

Dr Homa Zadeh: well one of the individuals who will be at this symposium is Professor Gannett II was coming from Goethe University in Frankfurt he's one of the originators of the protocol he's done probably some of the most significant research into the biology of the platelet concentrate and blood concentrates in this area yes there's a lot of poor research in this area but there's also a lot of great research which has demonstrated clearly the importance of blood concentrates and what it can do for us in any kind of surgical therapy

Howard:  so you're saying Carl mesh on this show was spreading Mich information well you know what did Harlow it was Carl Mischa information did he catch that mission information there were many different kinds of a blood concentrate the first generation of blood concentrates where Carl Misch was talking about the PRP and their platelet rich plasma that was the first generation that required you to use an anticoagulant and then draw the and then it was a very cumbersome multi-step procedure that required you to coagulate it using thrombin so it was a very complex procedure and many of the research that was that was platelet-rich plasma so PR P stands for platelet-rich plasma so that was the first generation of that basically a lot of the research was done by Robert Marx and in an University of Florida and  he did a lot of great work in that so I think it's not fair to poopoo all of that research because they did find a lot of benefits for PRP but when they put it into specific tasks for example would it make more bone in the sinus they didn't find it because it doesn't do miracles when you expect things from it we know that it does when we use this platelet concentrate you can find many different benefits first of all you have improved control of inflammation so I use it for routine D and I can tell you just aside from the research there's far less inflammation far less edema I think the bruising that we were seeing with the major surgical procedures it's almost gone away when we're using these acceleration of healing and you know reduce inflammation these are things that have definitely be found do you find more bone not all that this research has found that consistently do you find more periodontal regeneration there's some evidence that actually shows that yes there is some additional clinical benefits of using it for periodontal defect do you find faster healing yes that we can say conclusively there is faster healing of the mucosa when we using it is there less pain yes there's a lot of good research to show that where using the platelet-rich isolates they see a lot of improved pain experience from the patients so anybody who's interested in that professor Kennedy is spending a whole day of going over all of the biology of this and the clinical benefits of using it in the regenerative environment and he can actually distill the important evidence that we have from some of the weak evidence because there's a lot of poor research evidence in this area as well 

Howard: I'm going to ask you a softball question this can get you in trouble for anything who police's if your general dentist who places the implant better a periodontist or oral surgeons

Dr Homa Zadeh:  I think that's a generalization I think that you know they you know what whoever has the best information I think actually ends up with better outcomes I think the decision making is the most important aspect of it the actually technical aspect is not as hard as the decision making of when to treat how to treat what  material to select how to sequence it so whoever has the best information will have the best outcome and it may not be in any specific specialty as a general rule I think whoever and also has better maintenance program afterwards to maintain these patients over time will actually have better long-term results so I think that's what you want to go on

Howard:  so that's February 7th and 8th yes every seven days that's just a one two three weeks two weeks bummer um who is your target market for this symposium is it who who which one of my homies listen that is the best this is for I mean is it is 

Dr Homa Zadeh: anybody who wants to have up-to-date information because we believe that you know you have to get information to every you know discipline and every clinic clinician out there so we have some restorative presentation we have some surgical presentations some scientific presentation and we have a hygiene day so anyone in clinical dentistry could benefit from this 

Howard: how crazy am i that because you have a PhD in immunology I mean III think that is so darn cool but I see these all on fours and I get the business side of it because Americans want instant gratification I mean when I pull into McDonald's and there's three cars in front of me I get so mad sometimes I flip a u-turn and go across street to Burger King just to spite them right and I'm looking at that it's like okay they had a full mouth of gum disease they pull all the teeth place the implants to me I'm thinking well shouldn't you pull all the teeth and put them on a rinse and some antibiotics and at least give it a day for all the pigeons of owls to die and then I've read papers I say no Howard because that that P gingivalis to be living in your tonsils and be living in your mouth but I I don't know I see the the worst gum disease cases and you know I know I know everybody talks about all on four but remember clear choice doesn't even do 18,000 arches of all and for a year the most common procedure is not all on four it's all on none it's a full denture and you you see how many full dentures are done for a Rio on foreign America what would you say a hundred to one so but when you you see those people with full mouth gum disease and you pull all those teeth two weeks later it's fresh pink carpet everything's beautiful it's a it's the miracle of healing I tell people all the time they're sick and they're like ah you know I don't know if I'll ever get over it I say you know for 30 years I pull out a tooth you leave this big hole pus infection whatever and they come back two weeks later brand-new pink carpet everything's her but it seems to me if peri-implant Titus is a problem wouldn't why would you want to pull do pull all the teeth and place the implants the same day wouldn't it be better if you just waited two weeks to let the new pink carpet come in with no gum disease or am I out of my mind 

Dr Homa Zadeh: so treatment in general it's about risk assessment we have to do a risk assessment on our patients to find out who are at the highest risk and assign treatment according to their risk and decide on the protocol the problem is that when you know all we have is a hammer everything looks like a nail and that's really the approach that I think is the wrongheaded approach when it comes to some of the centers who are treating this who basically look at every patient who gums in and say okay I learned this particular modality everybody who comes in I use a cookie cutter approach on everyone so I think in general to what your treat and referring to I prefer not to name all on four I think that's a really terrible name because it emphasizes one thing which is for I think the general concept of that is using a combination of axial implant straight implants and in conjunction with tilted implants I think that's a valid concept that can work very well the concept of immediate loading that's a concept that works very well but we should do risk assessment on our patients and that's your you actually hit the hammer with nail because what happens is that many times we have a patient who has hated to go to the dentist has been phobic and and sometimes I have patients I have some friends who work in some of these clinics that are working as a male to do this kind of treatment and everyone who walks into the door the problem is that these people come in they think that they hate to go to dentist and they're bled to believe that if they extract their teeth that's the end their problems once they place implants and they will never have problems again and that's really the misinformation that they're that they're giving to these patients so the concept of you know immediate loading on even on patients who've had history of periodontal disease is valid but you're correct we don't need to do that on every individual if somebody has a very poor hygiene if somebody who has not demonstrated that they're capable of doing something better to jump into a treatment of extracting all the teeth and do this complex treatment on them and not go through the effort of disharmony whether or not they be able to maintain it I think that's a you know really not doing doing a disservice to that patients so you're correct that maybe those patients we need to step it back a little bit go through some some oral health in health instruct or hygiene instructions make sure that they're capable physically to maintain these if they're not able to maintain they're gonna lose them we have I think we're opening up a future epidemic of of these large reconstructions that are going to fail and we're going to have a lot of disappointed patients and because of the fact that they're not properly treated or followed 

Howard: so what's the difference between she's listening to you now and she's saying well should I go to your Vista Institute where it's classes with you or should I go to the Southern California consensus suppose I am February and 6-8 on your website five reasons to come to the Vista Institute world-renowned faculty with passion for teaching number two updated evidence-based knowledge on import and clinical topics number three cutting-edge practical techniques guidelines and protocols number four simulated exercises to elevate clinical skills and provide feedback number five live surgery demonstration to allow observation and clinical inflammation and number six free beer free beer free beer so what would be the difference between going what's the difference in the Vista Institute and going to your two days Southern California's consensus suppose I am what would be the difference here and to the thirty thousand Denis who or members the FAA Academy of General Dentistry you know they have to take 500 hours of clinic but to get your mastership it's six hundred more hours and four hundred hours of that has to be hands-on what percent of your Vista Institute courses qualify for MA Gd hands-on to get your ma Gd okay 

Dr Homa Zadeh: so the difference between a symposium the symposium is when we have these twenty-four experts who are coming from all over the world the top experts in the world you have them in one place in a two day format that they're sharing big concept ideas so when you hear about these big concepts they basically open your mind to things that we may not be thinking about we see what they're doing we can get inspired by them we also have an opportunity to see a large number of our colleagues who network so it's a different setting where we look at big picture ideas but we are really looking at them more in general form to kind of you know get us started but then when you come to the Vista Institute you coming for more in-depth information on specific treatments for example if you want to learn the Vista technique you will come in they say basically one day of the material is online so it's basically available with on-demand access and the other day is is is basically more clinical descriptions and hands-on and live surgery so this is a much more in-depth training which gets you prepared to be able to implement those things in your private practice so that's a year toward clinician so all of the courses that we have Vista Institute will include at least two to three hours of of simulated exercise hands-on workshops a day but they also have a lot of information clinically relevant so you can implement them in your clinical practice so those are geared toward people who want to have much more in-depth information to be able to implement the full protocol in the practice um how would you CLA let someone how did you SC let someone in from UCLA I still can't figure out I mean it aren't those like oil and water I mean I I know I didn't think anybody I didn't think anybody from USC like anybody from UCLA but you but there are they working together now you promised me our your life I'm an hour of 15 minutes I'm so grateful do you need to run run run or can I do anymore over time it's up to you know the honor is all mine you have some you've asked some great questions you open the a lot of important topics in our clinical field I think you're doing great service for the profession I think you're really and bringing some important information to light and and keeping a lot of the colleagues and you know up-to-date with information so I want to thank you for that well thank it's only the only thing I do is for some reason I get people like you to come on the show but um sinus list I just real quick um when I got out of school the best implant was the longest one I mean they they wanted to go all the way out the top of the head around the moon three times and back down and now the implants um I like them better because they're getting shorter and fatter and I like anything shorter and fatter is sinus lifts going away because the shorter fatter implants you're not gonna have to go into the sinus as much or is that more dream boating okay so nothing is going away I think the key is that as doctors we should be using a decision tree to decide the best treatment for a given individual so I know that that's the approach many colleagues who love to do sinus augmentation every patient who walks into the door gets a sinus augmentation those who love short implants every patient gets that the reality is that we should have an expanded armamentarium so in our toolbox we should have many different tools that we can utilize based on the specific needs of the patient you are correct that there the evidence has clearly Howard: demonstrated that there's no difference in the length of the implants so short and long implants perform very well one of my areas of research has been to compare in clinical trials randomized studies of a short versus long implants we actually found that the short implants have a little bit less bone loss around them yeah so you're saying short and fat is better short works very well not not fat necessarily because you know we used to think maximum titanium volume so we're thinking actually shorter and narrower because we don't want to take more bone out to put more titanium in

Howard: but that's why they're confused there's two dental schools in the valley here we got a chi still in Mesa and we have Midwestern and both when I walk into either one of those schools they say they go the the periodontist they don't make sense and I say why and so do anything to say bone and then over here on the all-on-four they're shaving down the bone they said 

Dr Homa Zadeh: well we need room for inter it's like how do you how do you worship bone and then shave it all off or on four so there's a time and a place for all of them each of those respective therapy to resect the bone to place the implant into base it's a great treatment but for the right patient saving the bone is also great treatment for the right patient so rather than saying this or the other we have to have a decision tree to side when would be the best way to use easy to make that what do you know something an online seekers you should make for devil town we had today are actually at the rest of society period exactly that we went through the whole decision tree to talk about exactly at all of those points but well I'm happy I

Howard:  I think it'd be the best marketing because I'm what pinky did is they and the Dawson Institute they said okay we have five one week courses that's  a big jump to go from an ad in a magazine or a Flyers or tweet on Twitter to a week so they made a one-hour course for each one of their weeks and said it was the best marketing they did so many people when they do a one-hour core we put up four hundred courses on that on time they've been beat over a million times so I advanced nation but I only want your course on there just because seriously would add so much for stage to the course just a couple more questions now the big thing is natural path natural medicine natural everything what do you say to the holistic dentist who are treating periodontal disease with with probiotics Pro dentists bio geisha cultured care probiotic gum pry bar fly revite and does you do you think do you think that's bleeding edge leading edge here now and why is there no aloe vera I don't understand this how could you be a naturopath without aloe vera 

Dr Homa Zadeh: integrative medicine is really a great branch of medicine because it integrates many areas and and looks at some of the traditional medicine along with complimentary medicine and and by comparison integrative dentistry is also great when we are integrating different aspects of what we know from the traditional dentistry but also we're bringing some alternative treatments but we have to be very careful and you know there's a difference between utilizing some of the naturopathic information that we have and that may have health versus doing voodoo dentistry or voodoo practice so I think there's a fine line between that so I'm all for complementary medicine complimentary dentistry many areas years ago we did research on hypnosis to show how hypnosis can actually change your physiology it changed your immune system it actually can change a lot so there are many areas where we can find information that Dr Homa Zadeh: that these could be useful but also there's a lot of unfortunate areas where you know people are using treatment without evidence if someone showed me that they're taking people to take out all of their titanium implants and they're doing all of this other stuff and they put in zirconia implants in them I think this could really get out of hand but if it's motivated by something other than what is in the patient's best interest so you say out of hand wouldn't it be out of mouth clear is there are you are you the man or is doctors a day are using any laser in your office Picasso lightly is there any soft tissue lady do you have any need for a laser Laser is also a tool that can have some benefits there are definite benefits if you using laser you can have better visualization to perform scaling route planning you can and there are some limited evidence that you can have better outcomes on your implants now laser what it does not do magic right so there are some people who are basically over you know promising what laser is capable of doing so I have no problem with laser as a mode as a tool but you know unfortunately again some people are abusing laser and using it for something other than improving outcomes for our patients

Howard:  two more questions and I'll let you guys swearing on I'm we're down to the deal um as a periodontist not as an implant on an implant surgeon as a periodontist is there any advantage to bone grafting an extracted socket you know you pull a tooth yeah your name is there any advantage that that also comes to risk assessment yes there's clear evidence that by placing bone graft in the extraction socket socket grafting you can minimize or reduce the magnitude of the dimensional loss that comes after tooth extraction so that part is very clear but what comes along with it is a delay of healing anytime you put any biomaterials in an extraction socket you're going to delay the healing so there's a pro side of reducing that the shrinkage of the of the Ridge but there's a downside of delaying the healing so you have to weigh the you know pros and cons to say would you benefit more from reduction of the volume volume loss or would you you know gain more by having faster healing by not putting a graft material in there so what comes down to them the most important decision aspect is measuring the thickness of the buccal bone if buccal bone is less than a millimeter thick you're gonna lose a tremendous amount of bone so I would advise in those cases to graph the sockets because if you because if you don't you can have as much as 50 to 70 percent shrinkage of that bone bone versus if you have a thick bone which is more than a millimeter of that buccal bone thickness those ridges are very stable and they don't need to be grafted so that's one thing that you can use as a this making process to decide whether to graft or not to grow 

Howard:  I had the best bone grafting technique in the world mine's better than them all you know I used for the bone graft mother-in-law bone and it worked so so what is the what it would again you know you go to McDonald's for a Big Mac frying it coke if I wouldn't her colleagues go to your Vista Institute for therapeutic innovations what would be the hamburger prego what what are the three most reasons you see students go in there what way are they going there 

Dr Homa Zadeh: well number one reason if they want they want to come because they wanted a Vista technique I think that's where is used for mostly treatment of gingival recession and treating mucosal recession around implants okay so that's the number one reason that people come in they don't get a garden right right so that's so people who want to learn to treat gingival recession or treat the mucosal recession around implants those are the most common reasons where people come but they're also the second type of courses that we have are for treatment of adventurous patients for immediate loading kind of cases that which you said I hate to work use the word all-on-four but it's basically a treatment of immediate loading on those but also people come to learn regenerative therapies regenerating bone augmentation in you know different areas of the mouth so those are the three types of courses that we have

Howard:  let me tell you something it's in two weeks it's February 6 and 8 it's in Los Angeles my god but I can assure you I've been in this business for 32 years those are the 24 most amazing speakers from seven countries all in LA I mean that is a hell of a deal and how much is it how much is the course well for its 695 dollars but if you use the promo code townie you save $200 on the ridge yeah and

Howard:  by the way there's no commercials did you did you give me any money for this it will come later oh but Suzy no one's no one's ever they don't no one's ever given me money to be on the show and i I've I've been trying to get you on the show for four years and this was a dream come true like say my my periodontist every period honest I know this is there man and if you're a dentist and you don't know that you're periodontist worship this man go because if you don't know this is the man you might not know some of these speakers coming here but my god you're a legend in my mind you're a legend if you google your name on dental town I mean like say I started this program with this is that this is the most common way I see your name on dental town someone's talking about a coronal tunnel graft and it's just like what is what is he today say I mean didn't you say your first name is just homas a day thank you so much it was just an honor to podcast you today alive in the studio thank you so much it's my honor thank you very much for being and you know inviting me here and thank you for everything you do for their profession same back at ya


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