Dr. Glenn van As has a microscope in every operatory. Hear his story of why he got into magnification in a big way.
Electrosurge is officially dead and lasers have taken their place. Dr. van As shares why every dentist should have a diode laser in their office.
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Dr. Glenn van As Bio:
Dr. Glenn A. van As graduated from the University of British Columbia (D.M.D.) in 1987. He is in full time private general practice and acted as an assistant clinical professor at the University of British Columbia from 1989-1999.
Dr. van As has been placing implants since 2009 and restoring them for 20 years. In 2013 Glenn completed his master of implant training year long program in Los Angeles with Dr. Sascha Jovanovic at gIDE (Global Institute of Dental Education) receiving diplomas from gIDE as well as UCLA and their department of continuing dental education. In completing this intensive course, Dr. van As was recognized and selected as the first place top student amongst all of the participants from geographical locations including participants from Europe, N.America, China and Australia.
He is an active member of International Congress of Oral Implantology ( ICOI) and a past member of the Renaissance Implant Study Club here in Vancouver, and has experience both placing and restoring multiple implant platforms including HiOssen, Ankylos, Nobel, and Astra. He has written articles on the role of lasers with dental implants and was one of the first clinicians to begin using HiOssen Implants in Canada.
Since 1997, Glenn has worked exclusively with the Dental Operating Microscope (D.O.M.). for all of his clinical dentistry. Acknowledged as a leader in the accumulation of videography and digital photography captured with the microscope, he has traveled throughout North America and Internationally, lecturing and publishing about the benefits and challenges of incorporating microscopes into daily dental practice. Glenn at present, is an active founding member and a Past President of the Academy of Microscope Enhanced Dentistry group (A.M.E.D.) (www.microscopedentistry.com). He has released three DVDS on microscope positioning and how to incorporate the microscope into daily practice.
Dr. van As is also an active member of the Academy of Laser Dentistry, and he has both standard (Argon) and advanced levels (Erbium-Yag) of proficiency. He holds a mastership in lasers from the ALD. In 2006 he was selected as the recipient of the Leon Goldman award for clinical excellence in the field of Laser Dentistry. Dr. van As was selected as one of the top CE leaders in North America by Dentistry today in December of 2011. Glenn has lectured both in North America and internationally on lasers in dentistry and published numerous articles. He acts as the Clinical Director for AMD Dental lasers.
Dr. van As is in full time private practice in North Vancouver which emphasizes microscopic, laser and comprehensive implant, restorative and esthetic dentistry. His practice can be viewed at www.drvanas.com and he can be reached at email@example.com
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It is a huge, huge, huge honor to be interviewing my rock star idol and mentor Glenn van As in so many ways. You’re Canada’s finest. You are Canada’s finest man and who was that girl, that movie star girl from Canada…Pamela Anderson! Isn’t she from Canada? So you’re the male version of Pamela Anderson and Jim Carrey.
We both graduated from dental school in 1987, even though you look like you could be my oldest son. Glenn, you’re looking great. I’m a huge fan of yours. You’re always at the cutting edge. I wanted to nail you down tonight on a couple of things. If I ask people what your associate is, they always say quality dentistry, case dentistry, I mean your dentistry is rock star dentistry, no doubt about that.
I would say your unique selling proposition is you seem to know a lot about lasers in dentistry, microscopes in dentistry so during this hour I want to kind of pin you down on that and I just want to start with this Glenn. Let me start the first question: I’ve been in 1000 dental offices, I’m 52 and my God, if that dentist in under 35 Glenn they never wear loupes. They just never wear loupes and they really believe that I wear loupes because I’m an old, fat, bald guy, grandpa with a three year old granddaughter and that’s why I’m wearing loupes because I’m old and dumb and senile and can’t see, but Glenn is that really true?
What age would you recommend that dentists start using magnification, whether it be loupes or extreme magnification microscopes- every year 5000 dentists pour out of dental school, these podcasts are listened to around the world- I’ve never seen anyone wear magnification in Africa, 99% in Asia, I think I’ve seen one guy in India with magnification.
Glenn, do you have to be old, fat and bald with a grandchild like me to use magnification?
Glenn van As: You know Howard it’s a great question. One of the things that’s interesting is when I graduated in 1987 in British Columbia less than 50% of people had any magnification at all. Now probably in British Columbia you’re looking at 80-90% and it’s not just older doctors. One of the interesting things we found is the hygienists that are graduating from the hygiene program, they’re being asked to buy loupes at the very beginning when they first start and they’re asking why? I can see fine but it’s not only about seeing it’s also about the ergonomics. Trying to sit upright and save their neck and back so it’s not only about quality of dentistry and precision, it’s about ergonomics, it’s about being able to deal with very technique sensitive materials that we have right now. The magnification helps anybody.
So even a young graduate just out of school, I really think you should start with 2.5 power loupes right when you get in school or just shortly thereafter.
Howard Farran: You know it’s funny I just got off the phone with my dental school classmate Greg Holmes, love that guy, and we were joking about her age and he said I wish when I was a younger kid I would have read the owner’s manual about my human boy a little closer and your head is a ten pound bowling ball and I trashed my neck and starting two years ago, after going to a chiropractor for 10 years with no relief, I started doing hot yoga and I do hot Bikram yoga three or four times a week and it’s all because I completely jacked up my neck. So you young kids who try to do direct vision and turning your head at a weird angle, your spine isn’t going to do that for two, three or four decades.
Glenn van As: You know it’s interesting, my dad was a dentist who graduated in 1961 and part of the reason he retired was he was really getting some severe arthritis in his neck. When he first graduated they were doing stand up dentistry and as time went on he started to wear loupes. I graduated from dental school and started wearing loupes right away, 2.5 power, I was 25 years old and really found that- I’ll tell you the story of how I started to change from loupes to higher magnification.
I actually had a patient come back to see me upset because I missed a canal in the upper first molar and he went to a specialist, when I told him I can’t see anything that’s wrong, I found three canals, he went to a specialist and he had a microscope and he came back and said I want my money back, you missed a canal, the specialist showed me and his parting words were, he said maybe if you do root canals you should invest in a microscope as well and that was in 1996 and I’d been graduated for nine years.
I felt devastated. I thought either I’m going to quit doing endo or actually start to use some form of magnification that’s going to allow me to do molar endo properly. In 1997 I purchased my first operating microscope, I’d been using 2.5 power loupes and the microscope allows you to work from between 2.5 and 21 power and the interesting thing is Howard, you mentioned earlier about India, I just came back from India I was lecturing there on endodontics finding the MB2 of all things, and I was amazed at how many dentists were starting to use magnification in India.
It was much more apparent and there were six microscope manufacturers at this meeting. Six different microscope manufacturers, two of them they were inly exclusive to India so you’re starting to see worldwide an interest in using higher levels of magnification not only just to do better work but to improve your ergonomics so you don’t have neck and back pain like you or my dad have, and to improve communication and documentation.
You asked about documentation and how to do it, I can tell you that I couldn’t do it without a microscope.
Howard Farran: Glenn my whole passion with Dentaltown and everything has been no dentists has to practice solo again. Use names though, you’re talking about 2.5 magnification- I just went this year from 3.8 to 4.5 and added a headlight. When I’m at my friends offices in Ahwatukee where my practice is, they don’t even know how many times they’re reaching up grabbing the light, they do it all during the procedure and you get that headlight and it’s gone. Use name brands on magnification on wearing them and microscopes or are they all pretty much the same?
Glenn van As: That’s a good question. One of the things that you were talking about and it’s an interesting thing Howard, when you look at visual resolution, it’s actually the square- X times Y- so when you look at the number of pixels for visual resolution, let’s say you’re using two times power loupes, it’s X times Y so you’re seeing four times what the naked eye sees. So you mentioned you went from 3.8, let’s say you went from 3.5 to 4.5 times, you go from about 3.5 squared which is about 10.5 to 4.5 squared which is almost double the amount of visual information just jumping that 3.5 to 4.5.
When you multiply, say you have 5 power loupes which is really getting heavy now on your head with the headlamp, but let’s say you’ve got 5 power loupes you’re seeing 25 times what the naked eye sees and over six times what you would see with 2 power loupes.
So companies like Orascoptic or Designs For Vision or SurgiTel or SheerVision, these companies are all making loupes that are more and more powerful because they’re seeing more and more docs going from 2.5 to 3.5 and 4.5 and if you ask them they say yeah, I have one set of loupes that I use for my endo, I have one set of loupes I use for all my exams and they have three or four sets of loupes there because they bought the first one and every time they see the value as they bump up higher.
Howard Farran: Glenn I actually purchased those for all my assistants and all clinical. All my hygienists, all three of my hygienists and all four of my dental assistants, they have to wear loupes and to tell you the truth when I implemented that policy a while back and some of them pouted a little bit and now they come up to me and they go thanks for pushing me because I fought it every step of the way and now if their loupes fog or whatever they don’t even feel like they can see a patient and I have two pairs because I seriously- if I walked in and they said oh you won’t have your loupes today, I can’t see anybody. And then the guy across the street from me has never used them ever.
Glenn van As: And you know if you see some of the patients that come in afterwards you can tell the quality of the work and I think that’s one of the things that I did it for. I only went to the microscope and I have nine global microscopes in my practice, I have nine operatories, I have a microscope in each operatory, so I have them for hygiene, I have them for restorative, I do 100% of my clinical dentistry through the microscope. The reason I did it was not because I wanted to lecture on it, I just simply wanted to do better work. That guy who I missed the MB2 on, I felt embarrassed and I wanted to do better work and it’s interesting when you can see better, you can do better but you feel much more confident about treating certain things. Certain things come up and you go oh there’s a fracture there that I never saw, a crack line in that tooth. Oh there’s decay on the adjacent tooth that I never would have seen had I not had the higher levels of magnification so I’m not suggesting that everybody needs to start with a microscope but I am saying there are a lot of people looking at microscopes now because they love endo, they like cosmetic dentistry, they have neck or back problems or they simple want to document with videos and stills better and so they’re interested in that aspect.
When I went to India and you wouldn’t think that you would see them there, I saw microscopes in India that were $6000 US. They maybe didn’t have quite the same quality as some of the other North American companies like Global and Zeiss and Seiler and Leica but they were nice microscopes that had basic variable features and would allow the dentists to work on a regular basis using a microscope.
Howard Farran: I thought Zeiss was German?
Glenn van As: Zeiss is German but they are worldwide. Same with Global, Global is made in USA in St. Louis and Seiler is also a United States company. Leica is out of St. Louis as well.
Howard Farran: I wonder if they started with the same people then broke into two.
Glenn van As: I don’t know. I know that Global has been around since the 1990’s, they were a company called Stewarts before and they’ve been selling dental microscopes and ENT microscopes for 15 years now.
Howard Farran: I don’t think they would sell me one because Arizona stole the St. Louis Cardinals and now they’re the Arizona Cardinals and now they’re stuck with the Los Angeles Rams so I don’t know if they’ll even take my phone call.
Glenn van As: You know what one of the thing is, they might have a couple of runners or people who are Iron Man there and if they read that you just finished your second Iron Man in record time beating last year’s pace, they may be back on the phone for you and give you a special deal.
Howard Farran: You’re a marathon runner correct?
Glenn van As: I was but my knees are shot now Howard. I may look the same age as you but my knees are actually double the age of yours I think.
Howard Farran: And that’s from running?
Glenn van As: No actually from playing soccer and hockey as a kid and then I tore my ligaments and they’re done now.
Howard Farran: I just took my three year old granddaughter, Taylor Marie, on the ice rink for the first time and she did not like that at all. In fact all she kept saying no, no! When I put her down, Taylor, Taylor she said no! No! The whole event lasted one minute. We spent an hour getting her boots on and getting it all ready and one minute on the ice and she was done.
Glenn van As: See in Canada, the way it is, in Vancouver there’s a lot of rain it’s like Seatlle but in the rest of the country a lot of them during the winter time have outdoor rinks so you grow up learning how to skate on outdoor rinks in a lot of parts of Canada during the winter time.
Howard Farran: But how old though?
Glenn van As: My daughter was just retired, she was an ice dance figure skater and she was at the national level and she started when she was three years old. She retired at 20 or 21 after being at the national level so she was skating since she was three.
Howard Farran: Can you fly her down here to talk to my granddaughter?
Glenn van As: Yeah maybe, you know what the key thing Howard is to dress your kids up in so much clothes that if they fall, they don’t hurt themselves. If they’re warm and they don’t hurt when they fall then they’re fine on it.
Howard Farran: So Glenn, how prevalent is a microscope? Okay so America has about 4000 endodontists. I know there’s no hard figures but what would you guess of the 4000 US endodontists, what percent would you guess have a microscope?
Glenn van As: I would say it’s approaching 90% now in the US. In the US I would say anybody who has graduated within the last I would say 12 to 14 years, it was made mandatory by the American Association of Endodontics in the late 1990’s, early 2000 era they started to make it mandatory that schools taught microscope endodontics so maybe in the 2000’s in that era, anybody who’s graduated from an endo program since then will have been trained on a microscope. So from an endodontists standpoint it’s become the standard of care.
Howard Farran: And to the dentist practicing alone who doesn’t want to remake a decision, can you go through any market share numbers? Did most of them go? Who is number one, number two, number three? For endodontists using a scope.
Glenn van As: Yeah that’s an interesting question Howard. One of the things that I’ll tell you is that it matters where in the world you are and I’ll give you an example, for instance in Germany, Zeiss might be very powerful there, but in the US I would say that Global is very strong. I would say that Zeiss is always still very strong. In Canada when I first started there was nobody else but Global in my area in Vancouver so Global has a tremendous market share in this area. There’s not as many Zeiss users so it depends a little bit on the area.
In the United States I would say that the three biggest ones are Global, Zeiss and Seiler and then Leica is a little bit behind that.
Howard Farran: And where’s Leica out of?
Glenn van As: Leica is a German scope. Very nice optics, they’re very big in the operating room as is Zeiss. They’re big OR microscopes, that’s where their primary focus is, in medicine, but they do have a dental division but it’s a smaller division.
Howard Farran: Okay I can just feel the karma of the questions that these dentists are going to be saying when they’re hearing you. So Glenn, what do you say to me if I say I’m a general dentist and I don’t do molar endo and I refer it all to the endodontist? Is a microscope pretty much only for molar endo in your view or do you use it? What other things do you use it for? You mentioned earlier you put one in the hygiene ops? Why would you have a microscope in a hygiene op? I only have one microscope and that’s above the bathroom and I can’t really explain why I need a microscope but that’s a whole other story.
Glenn van As: Well I don’t have any magnification there Howard, I’ll just leave it at that.
Howard Farran: Why do you have one in the hygiene room?
Glenn van As: I’ll tell you, one of the interesting things is what we find, a lot of dentists who are very interested in cosmetics, they will look at a microscope. Those who are interested in lecturing or taking video are also interested but the number one reason is people who have bad backs or bad necks because with the microscope, unlike loupes, you can sit vertically, sync straight up and look straight ahead so there’s nothing on your neck, no weight on your head to pull it down, there’s no vertical declination you can look straight ahead. So the number one reason that I would say a general dentist gets involved in it is either because they really want to lecture or publish and they want to take videos, or they’re very interested in ergonomics.
Now when you ask me about the hygiene room, why I do it is actually very interesting. I have all my microscopes connected to the televisions up above so when I come into the room to do my hygiene exams, I do a live view and the patient is able to watch as I’m progressing through their mouth so it’s actually an intraoral video camera with real time video that the patients are watching.
I like it for two reasons because patients become educated. They see if there’s a filling missing. They don’t say, they don’t question me and say are you sure there’s a filling- I don’t feel anything, it doesn’t feel like there’s a problem. I can show them with various magnifications from low to high power exactly what I’m looking at. So it’s kind of a cool thing because it is a marketing tool and in my practice when I’m working on the patient I like it because they hold still. If they’re watching, I have a lot of patients who will watch me working on them and if they’re watching and they move a little bit they’ll see they’ll move and they’re out of focus, so they have a tendency to hold really still.
I would say about a third of my patients to half of my patients will watch at some time during the procedure and for hygiene I like it because I do my hygiene exams with the microscope and the patients are watching. They just switch on the source button on the television and they switch from television to the microscope when I’m watching.
Howard Farran: And what’s the chance you would ever create an online CE course on Dentaltown about just that, microscopes?
Glenn van As: You know-
Howard Farran: I mean you have so much free time on your hands, you’re only lecturing in India, married and kids and full time practice, I mean come on you could do that between 2 a.m. and 3 a.m. couldn’t you?
Glenn van As: You know what’s interesting is that I talk to people and I say how many days a year do you practice and they go ah, you know what, I’m lecturing quite a bit I practice about 100 days a year and next year I’m practicing 214 days in my practice so all the lecturing is on top of that. So I always laugh because we’re doing this podcast late at night, or not late at night but after work and that’s where a lot of the lectures and the podcasts. I guarantee that if you want a podcast of an hour lecture on microscopes, I’ll do it for you in 2015.
Howard Farran: Thanks buddy and I’ll tell you that reminds me of dental school. I hate to say anything negative about dental school instructors because they’ve got a big job taking 100 kids off the street and four years later turning them into people doing root canals but it was the part time instructors that only came in on Friday that were just magical because they were keeping it real in the real world and then it would seem like the full time instructors were just so out of touch and it’s the same thing on the lectures area.
It’s the guys like you who are really real, successful full time practicing dentists that just give a lecture of just one real life pearl after the other and it seems like all the people who are professional lecturers, they don’t have a prototype, they don’t have an office, same thing with consultants. Consultants don’t have any ownership. It’s like where’s your practice doing all this stuff? And they just say well I’ve been published 48 times- yeah well do you have any prototype where this shit actually is proven in the trenches and man you are so keeping it real.
Glenn van As: You know what’s interesting Howard, is one of the things that happens if you are not doing clinical dentistry, your cases can not change and you will show the same material year after year after year. So I always admire the guys that I’ve heard once before and when I go and look at their material it’s new because I know they’re still practicing and I always tell them, when I do training for instance on lasers or microscopes I always tell the docs: you may think that I’m lecturing all the time but I just came from my practice, I’m going back there on Monday so I’m telling you what I’m doing on a daily basis. This is not just stuff that I’ve imagined or written up, I’m actually doing it on a daily basis.
Howard Farran: I would say- I still practice too. I saw patients this week. I did a root canal yesterday. It seems to me in my office, pretty much everything I do and use only have about a five year half life. It seems like if you just go back every five years, so the hottest, greatest thing today could easily be gone in five years.
Glenn van As: If you go to greater New York or Chicago mid winter when we go to those meetings and you see what’s coming, it’s impossible when you’re on a cutting or bleeding edge to stay completely current. I’ll give you an example.
About five years ago I had been restoring implants for a long time and I had a number of people who said to me, especially on the lecture circuit, how come you’re not placing implants? So I went and got courses, did some one on one mentorship, for the last five years taking course and bought a cone beam and started placing my implants because I realized the direction things were going was that I could provide those patients in my practice with an opportunity to replace a tooth that was lost with an implant or I could refer them and have them go home, talk across to the neighbor who says my dentist does implants, why don’t you go and see him? He doesn’t charge as much as a specialist and I would lose him.
So you have to have a passion for the profession and you have to constantly want to keep changing. That’s one of the beautiful things with Dentaltown. If you develop a passion, let’s say it’s molar endo, you can go to the endo forum. Let’s say it’s implants, you go to the implant forum and you can read a lot of people will provide you with material that is really cutting edge stuff that you can stay current and get excited about dentistry.
I’m always amazed by guys that are still doing the same thing that you and I learned about in dental school, amalgams, PFM crowns, gold crowns and dentures. To me, if that’s what I was practicing on and I wasn’t able to constantly change and morph and grow, I think it would be very boring.
Howard Farran: When I got out of school people were always saying it’s the golden age of dentistry and now I think it’s really the titanium age of dentistry and what I’m most excited about titanium is one of my biggest pet peeves on dentistry that I’m always trying to get dentists to think about is it seems like most people talk about dentistry as if they were an engineer.
It’s engineering, it’s mechanical engineering yet everything I see in my private practice, dentistry is about biology. I mean dentists will talk about the margin not being perfect and there will be a source of recurrent decay, dude the tooth was taken out by bacteria when there was no margin. I always say when termites go hit a barn in Kansas, do they go where the barn door has a crack with the barn wall and say well there’s an entry point, let’s go in the margin of that barn door? They just eat through the whole wall. I mean all day long it’s like I feel I’m a biologist, I spend my whole life trying to kill gram negative anaerobes and what I love about titanium is Glenn, the bugs can’t eat titanium.
There’s about eight nursing homes in my area that I have to go into seeing 70, 80 or 90 year old ladies that I treated for 25 years and I’m telling you Glenn, when the implants and crowns I did, they’re all perfect but the root canal buildups and crowns I did, about 18 months after their in the nursing home, root surface decay is pretty much- they’re reduced to mush. Are you seeing that?
Glenn van As: In my practice about 16% of my practice is over the age of 80.
Howard Farran: 16% over 80?
Glenn van As: Yeah the reason being my dad was a dentists, graduated and I took over his practice and I’ve grown from a two chair practice to a nine chair practice so a lot of those patients who were patients when my dad started in 1961, they’re still patients in the practice so I have 100 year old patient who last year I did a crown on because she kept buffing the filling out of the front tooth and she wanted a crown so we did a crown on her. When you look at the problems that happen with the older population on their teeth from dry mouth, all the medications they’re on, Alzheimer’s- they can’t remember whether they brushed or not. I’m dealing constantly- I have a consultation with somebody tomorrow who is upset because both the lady who is in her early 80’s and her husband have got dementia and they cannot remember that one of the associates told them to take that tooth out and now they’re upset because the partial doesn’t fit anymore even though that tooth was unrestorable. So I have to spend half an hour trying to say to them yes I understand that, but the reason we did this is because your tooth was unrestorable so it’s a big problem.
One of the interesting thing Howard is nowadays, I find that patients don’t take- they feel entitled but they don’t take responsibility for the props, it’s always the tooth you worked on. So the best job I can do, when we come back to the microscope, the best job I can do to give you the longest time and if I tell them that the average crown, the insurance will pay for every five years, but I did that crown 18 years ago, it’s triple the time then there’s already this relaxation well yeah, okay it’s 18 years old.
So that’s what I’m always trying to do is extent the lifetime of that tooth but I totally agree with you. When the patients get older we’re dealing with a lot of problems.
Howard Farran: Well Glenn I want you to make a comment on something and I’m going to warn you ahead of time, be careful what you say because this is probably the most controversial thing I ever said on a Howard Speaks monthly column. I’ve had a monthly column since 1994 and probably the one with the most viewer hate mail was: when I see 85 year old ladies in nursing homes, they’ll go in and get five class fives and the dentist will do composite and there’s no active ingredient and I say, and the research says if they were to have done it with amalgam or glass ionomer, and he’s going to say well I don’t have amalgam, I’m like okay you’re still doing cosmetic dentistry on a lady with Alzheimer’s, dementia, rheumatism, can’t brush and if you’re a doctor and you’re doing class fives on people who don’t even know the names of their children, an inert plastic composite because you’re amalgam free- you’re not amalgam free, you’re a freak! You’re an extremist and you’re not a real doctor and I called the dentists who don’t have amalgam that they’re not real doctors and oh my God, I bet I got 1000 hate emails about that but I still stand by it. The lady doesn’t even know the name of her own children, amalgam- it’s actually not the mercury that’s bacterial static, it’s not the copper, the silver, the zinc, it’s the tin ion, that’s why we have stannous fluoride in mouthwash and it’s the tin ions flying out of the amalgam that offer some level of bacterial static behavior and that dentist will say yeah where I take out those old amalgams, there’s like black scuz underneath it- I’m like excuse me, is black scuz a species? Does it consume glucose? Does it eat on the life cycle? I mean really, you’re a doctor of dental surgery and you’re biology is black scuz? Furthermore, that black scuz was under amalgam that was 38 and a half years old. I mean really? We’re retreating amalgams because there’s black scuz, you’re not even a doctor when you say black scuz. I think the 4000 pound elephant in the United States and Canada and the very rich developing countries is that there’s just a gazillion ladies between 85 to 100 and all that dentistry we did from birth to 65, we need to rethink that whole thing. You don’t really have to on a man. I mean their average life is about 74 but in America the women are hitting 80 now. That’s on average.
Glenn van As: I have 80, 90 year olds in my practice Howard. I have many 90 year olds and one of the things we see is root caries. When I first started my practice in 1987, most of the patients, if they made it to 80 they had dentures because they grew up in an era where they didn’t go regularly to the dentist and when they did go it was an extraction so many of them had dentures. In fact I remember as guy who came in for his reline for his dentures and he told me, I said how are you doing, he said great, he said I just turned 80. I said well that’s fantastic, that’s quite a milestone. He said if I knew I was going to live this long I would have taken better care of myself. The interesting part was that I started to notice now that more and more of the generation that’s retiring now is 1) living longer, 2) they may even live longer than us because they’ve taken better care of themselves. A lot of the patients are not drinking a lot, they never smoked, they worked but they didn’t work these crazy hours but what I’m finding is that they’re getting root caries and for me in my practice, switching a little the tone of thought, the microscope and magnification is very important but for me a laser on the class fives and using a laser to remove the soft tissue to do gingivectomies, to keep the field dry, helps me an awful lot when I’m putting glass ionomer onto those facial surfaces to keep the surface dry and to be able to get that material in there.
Howard Farran: Let’s slow down that, because what you just said in a minute, a lot of these dentists it would take an hour to explain what you just said. So let’s talk about first of all, explain to people- you’re an ICU lecturing all around the world, obviously Australia, New Zealand, Japan, they use a lot more glass ionomers. They say things like their filling is called a sandwich where they’ll put glass ionomer on the bottom, inert composite on top. When you go into America and a room full of dentists say can anybody explain the sandwich technique? Nobody even knows what you’re talking about.
So Glenn, explain the difference to dentists around the world in every continent, the difference between glass ionomer fillings and composite fillings.
Glenn van As: One of the nice things for adult patients when you worry about recurring caries is that very rarely do you find recurring caries under a glass ionomer because it’s releasing fluoride and so whether you use that in the base of your boxes on class two’s or whether you use it on a high caries rate patient for class fives, it’s really nice material to prevent recurring, so you had talked about amalgam and glass ionomer. I like glass ionomer for those patients where-
Howard Farran: Glenn are you really going to stick to those words? I mean you just said that you don’t- did you say never find or almost never find recurrent decay under a glass ionomer? If that’s true, why would anybody not use a glass ionomer? Because again it’s like if you go to a Gordon Christensen seminar. I mean he always talks about all the wear rates of fillings, this wears at 15 microns, this wears at 20 microns- well my problem isn’t the fillings all wear down. And then they talk about bonding strength, everything is like megapascal bonding and megapascals and the dentist is saying well I want to buy this one, it bonds at 27 megapascals and this one only bonds at 20 megapascals, it’s like my fillings aren’t falling out, that’s not my problem. My problem isn’t the fillings wearing out, my problem is that they’re invaded by bacteria. Hundreds of millions of gram negative anaerobes eat this whole thing out. It’s a biology problem, not engineering problem so again, are you pretty much only doing glass ionomers then?
Are you looking at the CAMBRA caries index?
Glenn van As: We don’t have that. I know in California it’s a big thing. We don’t have that here. I know Kim Kutsch and his group, the minimally invasive people, have looked at caries rates in different people and you know guys like Graeme Milicich from New Zealand etc. are great proponents of glass ionomer. If the patient has a high caries rate, you’re constantly redoing class fives and there’s caries going on and you know the patients who have medications that dry their mouth out, patients who aren’t brushing at the gingiva and they’re at a high risk. The glass ionomer materials are much more able to withstand caries. My dad used to use silicates. You never saw caries underneath the old silicates.
Howard Farran: Why is that?
Glenn van As: Because again, it’s releasing fluoride in there and when you see these materials, the patient is walking out of the office and their already staining. When you take those materials out, they wore quite fast but if you took them out there was very rarely caries underneath them like composites.
Howard Farran: Okay Glenn, there’s a dentist out there saying Glenn, be specific. Can you walk through real quick a class five? Walk through the technique with the brand of a class five on an 85 year old lady with Alzheimer’s that has root surface decay on eight.
Glenn van As: What I’ll do is I use primarily, I really use diode lasers a lot for tissue management and I think that’s one of the key things for me is in many of these patients the caries goes subgingival and I need some form of laser and as you know, that’s probably my primary area of lecturing now, is not so much microscopes and magnification but lasers. So for me the soft tissue laser is essential for removing the soft tissue during a gingivectomy, getting that out of the way so I can see the apical portion of my prep.
Howard Farran: You’re talking about the benefits of removing the tissue so you can see what you’re doing, but when you’re done doing it, that gram negative anaerobe, that number one thing on earth that it hates more than anything is atmospheric oxygen, the atmospheric 20.9% oxygen and when you remove that tissue, gran negative anaerobes, I mean they’re anaerobes, they don’t live in oxygen, they’re not going to go up there and eat with all that oxygen up there so it’s making an environment where it’s going to be hard to fail.
Glenn van As: All lasers are anti-bacterial. All lasers, so when you put a laser inside an endodontic tooth, it kills the bugs. When you put a laser inside a periodontal pocket, it kills bugs. So all lasers are anti-bacterial and so one of the nice things is, not only do you get a low level laser therapy with the laser on the soft tissue, you kill the bugs around there so it gives a nice environment for it and it keeps the class five lesion visible and without crevicular fluid or blood, which is even worse, creeping into the class five lesion so you can put your restoration in. I like Fuji products, that’s what we have in the office, Fuji IX. We like to use that in our class fives in the situations where composite resin on a nice looking lady who is in her thirties or forties, maybe you don’t want to do that.
Maybe in some cases you want to graft but for these older ladies where you’re trying to do something to help them maintain that tooth, glass ionomer is a nice material.
Howard Farran: Okay again, so diode. Diode is soft tissue, carbon dioxide is for hard tissue?
Glenn van As: It’s a good question. In dentistry there’s four different wavelengths and these are four different categories of lasers. Diodes have become very popular Howard because they’re small unit that are in many cases they’re portable and they allow you to use them as a soft tissue hand piece as opposed to electrosurge.
Electrosurges aren’t great around metal so you cannot use them very well around implants, amalgam, gold crowns. Electrosurge always needs anesthetic so you, unlike a diode laser where you can remove small amounts of soft tissue without anesthetic, electrosurge always needs it. You can use a diode laser with pacemakers, whereas electrosurge you cannot use with a pacemaker and finally electrosurges aren’t anti-bacterial whereas diode lasers are.
Diode lasers as a price dropped, well AMD lasers dropped the price of it about six years ago and all of a sudden there was a massive influx because people said I don’t have to spend $10 000 to buy a laser. A diode laser now is $3000.
Howard Farran: You said AMD laser? Is the AM for their unbelievable CEO Alan Miller?
Glenn van As: Alan Miller.
Howard Farran: What is the D for then?
Glenn van As: The D was Alan Miller designs.
Howard Farran: Alan Miller designs and that guy, if that guy isn’t one of the smartest guys in dentistry, I don’t know who is. That guy is amazing and what did he do to the price range? When I got out of school a diode was $50 000. What is an AMD today for a diode laser?
Glenn van As: It’s about $3000 for a 2.5 watt laser. Howard I’ll tell you an interesting story-
Howard Farran: He did that in Indiana.
Glenn van As: It’s amazing. I’ll tell you a story, when I first got my first laser, this is an interesting story, it was 1998. It was an argon laser and that was a large unit. It was 220 pounds. That laser cost me $54 000. It was single op, you couldn’t move it. It did two things: it cured resins, because at that time we didn’t have LED lights so cured resins in 3-5 seconds so it saves you time and secondly what I used it for was it had a cutting mode, a green wavelength that would cut. It was very hot and the laser as the argon gas dissolved and left, you couldn’t use it anymore.
So that was $54 000, we used to call it the Zamboni, the machine for cleaning the ice rinks because it was so big. It was massive. So now you have these little two and a half pound diodes that are replacing soft tissue electrosurge units and they can be used for all sorts of nice contouring, for crown troughing I didn’t use cord last year at all. We always used the laser for troughing around our crown preparations. We use it for class fives, for gingivectomies, frenectomies, tongue ties, we do a lot of tongue ties on kids too.
Howard Farran: How often do you talk to Alan?
Glenn van As: Once every month maybe.
Howard Farran: Will you do me a favor for Alan. I have a dentist probably every three or four days telling me he wishes their certification program was online on Dentaltown as opposed to having CD’s and assistants coming back and saying I don’t even have a CD because I use Netflix or whatever. People don’t have eight-tracks and cassettes in their cars anymore. All that stuff needs to be online. I just want to say one more thing about the electrosurge: I’ve done this about maybe eight times in the last 10 years where a dentist says I use electrosurge and my biggest complaint with the electrosurge is post operative sensitivity.
Dentists will tell me well I don’t get that, you’re doing it wrong. I’m always doing it wrong so then I walk them up front and I say give me the name of just one person you used the electrosurge on last week and the receptionist says oh it was Glenn van As, I remember because he called yesterday wanting a refill on his Vicodin.
And then I’ll call the guy and say does it hurt? He goes oh my God, it’s the worst pain and the dentist: they don’t hear that. They might call back to front and say is this normal, is this normal and office isn’t paperless so she doesn’t want to pull the chart so the dentist never gets this feedback where I actually went paperless in 1999 just because I gave up.
I kept telling my four receptionists, every conversation you pull the chart and you note it, and it just never got done. It was too time consuming so I only went paperless so that when I had the patient come back in I could see the conversations. If they were upset about the financial arrangement or whatever and electrosurge- do you agree or disagree that it causes a lot of post operative discomfort compared to a laser?
Glenn van As: They say that a diode laser has one fifth of the lateral thermal damage that an electrosurge has. The second thing is I did a lecture many years ago and it was a large audience and in this audience was a lady and a young daughter and I thought it was weird that this lady was at the laser lecture that she was sitting in and at the break she said I’m really amazed by your frenectomies and your healing because I do a lot of infant frenectomies and I’m talking three week olds where they can’t latch on and so we do a lot of lingual tongue ties or upper lip ties for very young infants who are having problems latching. It’s amazing how rampant this problem is.
There’s a lingual tongue tie group and there’s 23 000 people on it so when I looked at this lady, she said I’m amazed by your healing. When you showed those seven day healing, she says here, she says to her daughter, show him. She lifts her lip up and it looks so bad and I said oh my gosh! Was that done yesterday? She said that was done one week ago. She hasn’t been at school all week. She said I couldn’t send her to school today so I brought her with me and I was just appalled at what I saw in terms of the amount of thermal damage that had been done just with the unit there.
So that’s the old style. I think with lasers nowadays I think you can do a nicer job, less post operative pain and less risk of any infections.
Howard Farran: I just want to have one thing because I’m always using dentists- dentists are always right and I’m always wrong. My name is Howard Farran and I’m wrong. A dentist in Vegas, I’ll never forget, it was about 10 years ago and he said well you know what the trick is, after you use your laser you just run cold water with your three way syringe and I always flood it with cold water and that gets rid of all the post operative pain and his assistant who’s standing right there said did you use it last week? Did you do that? Got the name, we went up front we called the patient, again completely throbbing. So if you cut your ears off and don’t listen to anybody, electrosurge might be a great idea but it’s not a great idea. In fact would you declare that electrosurge is done in dentistry?
Glenn van As: Yeah I will go on and say electrosurge does two things well, it cuts gross amounts of tissue faster than a diode laser and secondly you don’t need safety glasses for it but other than that you can’t use it around implants, you can’t use- if you are doing any implants and you have to do soft tissue remodeling, if I’m talking to you today and one of my patients phone in and says oh my crown came off but it’s not bugging me on my implant, it was cemented. I’m going to come back and see you tomorrow. By the time they come in tomorrow the tissue is so closed around the abutment you cannot get the crown back on. I don’t know how you’re going to get that on if you don’t have a diode laser. You cannot use electrosurge.
Howard Farran: And by the way that mouth tissue is the fastest growing tissue in the human body. You said originally four lasers, but then you talked about diode. So let’s go to two, three and four.
Glenn van As: Other lasers include a CO2 laser and those are either completely soft tissue or there is a new hard tissue laser from a company called Convergent that is a CO2 laser. I have not used it, it is a big unit but those lasers, the CO2 lasers, the soft tissue ones are fast cutting and oral surgeons like them because they’re fast.
The next laser is a Nd:YAG laser and like the main laser that people know about that one is the PerioLase and it’s used for periodontal therapy, they’re big proponents on Dentaltown and they’ve got a large user group that are very fanatical about using their product and their protocol for LANAP- it’s laser assisted new attachment procedure and that LANAP protocol is with their laser only.
And then the final laser which I’m using a lot is a hard tissue laser, it’s called the Erbium laser. One of the best known companies is BIOLASE and I’m using a BIOLASE iPlus and it’s a laser that can be used for cutting soft tissue, bone, tooth- it’s kind of an all tissue laser.
Howard Farran: Are you friends with the owner of PerioLase?
Glenn van As: Yes. Bob Gregg.
Howard Farran: Bob Gregg. He’s in Colorado?
Glenn van As: No he’s in Cerritos, California.
Howard Farran: Okay and that’s the one with the adorable wife that’s always with him?
Glenn van As: Yes.
Howard Farran: You know my problem with PerioLase is if you really want to learn more about it you have to commit and go and buy and I just meet so many dentists that do it and love it and just praise it and just say it’s the greatest thing and that’s what I call the low hanging fruit, but it seems that the next level they want more information to get into this and their system of information is like well once you’ve bought and once you committed and then we’ll train you on it. It’s like I wish there was a more intermediate amount of information because I think they’ll get a whole other tier of dentists if they can see and understand more before they buy.
You know dentists, their engineers, scientists, physicists and a lot of them need a lot of information to buy and it seems like most of their information you have to cross an economic barrier or purchase before you- is that a fair statement or do you think that’s not true?
Glenn van As: Yeah I think it’s fair, I think one of the interesting things Howard is that in the last few years their market has been primarily periodontists. They have almost a quarter of the periodontists in the US now own a PerioLase and why that is, is because the traditional market and when I graduated the periodontists were trying to save teeth. But as implants came into practices and collective tissue crafts became more commonly used, periodontists focus changed from trying to save teeth to implants. I knew periodontists who told me they were placing 1400 implants a year and now they’re only placing 400, 350 a year.
You know why? Because all the GP’s are learning how to place implants so many of the periodontists now are looking and saying okay my chairs are empty, I’ve got to start looking back and trying to see alternative mechanisms for trying to keep patients in my practice. I’m going to try and save teeth. So PerioLase, they’ve really focused on periodontists. I think once that gets exhausted and it sort of hits critical mass where 50% of the periodontists have bought them, now you have to look at where am I going to move next and really for those who have a high number of periodontal patients in their practice, it is a very good laser. 90% of teeth, 90% of the pockets will shrink by 50% in one visit.
If you’ve got an 8mm pocket and go to 4, and it’s from the bottom up, bone fill, that’s pretty impressive. So 90% of the pockets in their studies, and again I’m not a spokesperson for the company, 90% will go to 4mm.
Howard I will say, because I do work with BIOLASE, I will say that BIOLASE also has their deep pocket therapy that they’re promoting and it is using side firing tips to not only remove calculus and remove the inner wall of the pocket, but they can use their laser as well to clean the root surface and they’re also getting tremendous results with their laser periodontal therapy. They maybe don’t have a few well researched studies that the PerioLase has, but you can do periodontal therapy with a hard tissue laser and get nice results.
Howard Farran: Well you know it’s funny because since I’m 52 and graduated in ’87 I see this business strategy déjà vu again because remember when Branemark from Sweden? When he first started teaching implants in America he’d only teach oral surgeons and if you knocked on the door and you’re a general dentists, shoo get out of here!
Now he’s 85 years old in Brazil, I was emailing his wife the other day and they eventually realized that the market is going to general dentists and now more general dentists around the planet place more implants than any specialist.
I want to pin you down to something- there’s a lot of kids in dental school. One of the biggest questions dental students ask me is there’s nine specialties that the ADA recognize. They just added a new one a few years ago, oral radiology because of the advancements of 3D, CBCT’s.
I’ve got to ask you and I hope there’s no periodontists listening to this, but what would you say if your daughter was a senior at dental school and she said dad, I think I’m going to go to the perio grad school and spend three years being a periodontist. You said it was the end of electrosurge, are you kind of seeing the end of perio? Would that be the least defensible of the nine specialties to go into? I mean I tell them to go into oral radiology because I’ve got a CBCT and Glenn, I’m telling you it’s like getting a microscope and looking out in the universe and three quarters of what I’m seeing is dark matter and I mean I’m not- we were three dentists the other day and we were looking at a CBCT and there was this one huge structure. Three of us didn’t have a clue what it was. No idea. So I always put them in a Dropbox and send them to Dale Miles who is an oral radiologist just so I don’t miss something.
So I think CBCT is good but what would you say to your own daughter if she said dad, I think I’m going to be a periodontist?
Glenn van As: You know, it’s interesting because as a specialist, the traditional way that general dentists worked is they dealt with things that they dealt with commonly, so for instance they did a lot of restorations, they did extractions but if it was a difficult patient, medically compromised or difficult procedure they might refer them. You’re seeing a lot less of that now because once the recession hit in 2008, people were trying to keep patients in and I know for instance in Canada, where I live in Vancouver, some of the practices on average have 500 patients so how can you survive with 500? You’ve got to make sure that you try to keep that patient in.
So you’re not so likely to refer that patient to the periodontist with the risk that the patient is going to go to another general dentists and not come back to your office. So I think all specialties are suffering. I don’t think only perio, I think all of them are suffering and they’re all having to learn new things so I see orthodontists that are doing other things. They’re doing laser frenectomies. I see endodontists who are placing implants. I see prosthodontists who are placing their own implants and not just restoring them? Why?
It’s all because as their traditionally general dentists have started doing more and more of the procedures and becoming kind of a jack of all trades, they’re referring less and less. So I don’t know if it’s only perio, I think pedo is still strong because there’s still a lot of kids that require special treatment but orthodontics, general dentists are taking a lot of the ortho as well so it’s not just perio.
Howard Farran: My favorite specialty is the pediatric dentists. God bless them. If I had to do that Glenn I would quit and work at McDonalds, third shift. I mean oh my God but I want to tell you something about endodontists. I have a MBA from Arizona State University and they just beat into your head that 80% of all decisions come down to price and in MBA school, anybody can get a MBA because if you walk into any multiple choice test and just put price on everything, you’ll probably get and 80 on your test and get a B, and I have seen too many times that I have sent a patient to an endodontist and they’ll just retreat and then when it fails a year later they say well I did the best I could. It’s like well you also took $1000 from him, or $1500 and it didn’t even last a calendar year. I only send patients now to someone who can say well I’m not going to retreat this, I’ll make my $1500 by pulling and placing an implant.
I want that endodontist to be able to make the same amount of money pulling the tooth or retreating the endo and when the only way that they can make their money is a retreat, there's too many retreats done that don’t have a meteorite’s chance in hell of surviving.
Glenn van As: 100% agree.
Howard Farran: So be leery of the endodontists, you know if your only tool is a hammer everything looks like a nail and if the only way you can make money is to retreat a root canal- that scares me. Do you agree with that or is that too harsh?
Glenn van As: No I agree. I think one of the things too Howard is, I think it was the journal of the American Dental Association this past year, there was a study that came out that showed that the actual failure rate amongst general dentist for implants was 19%. So they were showing that sometimes the pendulum may have swung too far, that we’re taking out teeth that we really should be trying desperately to save and we’re taking them out and putting implants in and the failure rate- there’s a guy named Maximo Simeon and he’s from Italy and he’s talking about the tsunami of peri-implantitis that’s coming because there’s so many GP’s taking weekend courses and putting implants in.
So you kind of have to find a balance between those teeth which you can treat and those teeth which you can’t treat and you know one of the biggest things that I’m dealing with now when I’m on the lecture circuit Howard is peri-implantitis and laser treatment in that and using hard tissue lasers like the BIOLASE iPlus to remove granulation tissue around implants, disinfect the implant surface to allow for regrafting and opportunities to save the failing and ailing implants.
Howard Farran: One of my favorite sayings is that the mind is like a parachute, it doesn’t work until it’s open and one of the key words, one of our listeners might not have heard is you’re not calling it periodontal disease, you’re calling it peri-implantitis and a lot of people are always talking about that, oh there’s some gum disease around it still, you know what gum disease around natural teeth is very different than around a titanium and you’re calling it peri-implantitis so Glenn will you talk about the difference between periodontal disease on a human natural tooth versus peri-implantitis and how they’re different and are they treated differently?
Glenn van As: It’s a great question Howard. One of the things that- I always joke Howard, you know what the difference between an ailing and a failing implant is?
Howard Farran: What?
Glenn van As: Well the ailing implant is one that you did and the failing implant is one the guy down the street did. The reality is when you look at the gingival fibers around an implant, those fibers typically are not horizontal like they are on Sharpey’s fibers on a tooth. They’re vertical so I always tell the patients if you get a popcorn kernel stuck in a natural tooth there’s a defense mechanism to prevent it from going down. Same with a crown, if you had a little bit of extra cement stuck in on a tooth, it won’t go down halfway down the root surface. You get a little bit of cement stuck on an implant and you can push it halfway down the tooth and get a lot of problems.
So when you see implants, you see not only mucositis problems which are not a lot of bone loss but gingival inflammation, those can be cleaned up by simple methods. Non surgical methods. But when you look at failing implants right now with bone loss, once it gets beyond 50%, doesn’t matter what you do, you might as well extract the implant and start over again and there’s a lot of effort now looking into how do I get rid of the granulation tissue, how do I disinfect the site because it’s got so many threads and you need- the hard tissue lasers is able to disinfect the thread completely and allow you to graft material back on so there’s a lot of excitement over lasers like the BIOLASE, the erbium lasers for disinfecting implant surfaces in a surgical manner on implants.
So it’s really something that’s I’m lecturing a lot about right now and it’s an exciting topic.
Howard Farran: Do you think that bacteria, the bugs around a failing implant are the same as the ones around a failing tooth? Do you think perio and peri-implantitis bugs are similar?
Glenn van As: I don’t think that they’re similar but I do think that when it happens around an implant the machine surfaces are rough to aid for osseous integration but what happens, those same rough surfaces are very difficult to keep clean once the bacteria get on them so they just start to travel down and I think the bacteria that you have for peri-implantitis, I don’t think they’re going to be the same bugs that you find for peri-implantitis but the mechanism is much more aggressive and you see a lot more of it than people want to admit and I always tell people if you’re not sure, press on your implant, on the buckle surface. You’ll be amazed how many times you get something coming out of the sulcus and the patient says I wasn’t even aware that was happening.
The microscope, when I have that hooked up and they press on it and they see the puss coming out, I had one today, she was literally crying. I didn’t do the implant, she had this implant done and I pressed on the buckle and I said you see that white stuff coming out of the gum, she said yeah, she said I get a bad taste from it, I said that’s actually infection that’s draining out of your bone.
Howard Farran: I’m always listening to you trying to predict what 1000 dentists questions might be around the world. You said implants have different surfaces for osseous integration. There’s somebody out there thinking well which implant do you use? What surface did you go to? Did you get a HA coded implant? What name brand and what surface does the wise Glenn van As pick for himself.
Glenn van As: You know I used to use ANKYLOS a lot, which is a Dentsply product and I liked it, it had really nice bone maintenance because of the way it was and guys like Bill Shafer on Dentaltown use ANKYLOS, small 6mm ANKYLOS implants. He does amazing stuff with the sinus lift and short implants. I used to use ANKYLOS a lot but I felt from a cost standpoint it was though to compete and restorative standpoint it wasn’t the easiest to restore, so I went to a lower cost implant, there’s a number of them out there, things like Implant Direct, Bly Sky Bio is a big supporter on Dentaltown but I use a product called HIOSSEN. It’s a Korean company, it’s a less expensive product.
Howard Farran: Spell it.
Glenn van As: HIOSSEN. It’s the sixth largest implant company in the world. Number one in Asia and a lot of the countries because it’s a very similar surface to Straumann but it’s probably a third of the price of Straumann so I’m able to compete on price, we talked about price and comparing myself to periodontists. I can’t compete on experience with a periodontist who’s placing 1400 implants a year. I might place a couple of hundred. I can compete on price and I know my limitations when excessive grafting needs to be done or vertical augmentation needs to be done, you know where that’s going.
Howard Farran: Glenn I’ve got to ask you, the guy who really started implant revolution, wouldn’t you say that was the guy- I just said his name- doctor Branemark in Sweden, and he named it Nobel Biocare because Sweden is the Nobel peace prize and all that stuff and then Straumann is from Sweden.
Glenn van As: Switzerland. Straumann is from Switzerland.
Howard Farran: Oh Straumann is from Switzerland. I always get those S’s mixed up. I’m sorry to all the people from Switzerland. But why do you think the largest dental company in the world Danaher just paid 2.1 billion for Nobel Biocare when it’s one of the highest cost people and they also already owned one you just mentioned, the Implant Direct. What if they own the low cost Implant Direct, which Glenn van As says low cost, why would they own that and then pay 2.1 billion for Nobel Biocare? What was your theory? Only Danaher would know but what would your guess be?
Glenn van As: Well I think when you look at a lot of the specialists, they’re loyal to the big three, and the big three being Straumann, Zimmer and Nobel and they’re loyal to them because from a surgical standpoint they’re placing implants, dentists will say I don’t care what implant you place, you place an implant for me. Make sure it’s a good one, so they’ll place those and a lot of the specialists will get a good deal on the implants but the restorative dentist has to pay full price for the restorative fees.
So a lot of times the patient comes back from the specialist and says I paid X amount of dollar, and he says how much more am I going to need for your restorative aspect? So a lot of dentists are looking for alternatives now. 1) Keep the patient in their own practice and do the implant themselves, 2) get a lesser priced implant. So when you look at Danaher I think they’re looking at primarily the specialists. The people that have continued to use Nobel because I do know that these big companies are struggling right now because more and more of the general dentists are switching to lower cost implants in an effort- patients don’t ask you what implant you use. They don’t ask you if you’re placing Straumann. Nobody does.
They ask you one question, the same question you talked about with the multiple choice in the MBA- they ask you how much do you charge for an implant. Because it’s not covered by most insurance plans. Do you know there’s 400 implant companies in Italy?
Howard Farran: 400 implant manufacturers in Italy?
Glenn van As: Italy! Yes! 400! And there’s 1000 implant companies worldwide. They all work.
Howard Farran: So Glenn you just said they all work. Glenn are you saying that titanium is titanium and an implant is an implant and if Implants Direct sells it for $100 and someone else sells it for $200, $300, $400 they’re all titanium screws? Are you going that far?
Glenn van As: I’ll just say that the surfaces are different but all implants will osseous integrate to a greater extent. Now if you took Straumann, maybe their success rate is 97%, maybe one of these lower price companies the success rate is 96% or 95%, but it’s not 75% or 35% so the difference is less. The differences between these companies are in the restorative capability, their service and support, their education, their commitment towards education so those kind of questions are the questions on the differences between implants but they all work.
Now some people have a real preference for one implant system over another. I like HIOSSEN’s system because it has a SLA surface and they are doing some pretty cool things with some of their surfaces like BMP2 they’re going to start coding them.
Howard Farran: Bone morphological protein.
Glenn van As: Yeah they’re going to start coding them with that so you might find in the next year that these products are coming out and they’re finding in Korea that the products they’re loading at four weeks, because patients are always saying how long before I get my crown and if you tell them it’s going to be three months before I can load that tooth, a lot of them are like can’t you do something earlier?
Some of these implants companies are looking at methods to try and get loading earlier than 12 weeks.
Howard Farran: Well Glenn I can’t believe we’re out of time. That was probably the fastest hour I ever spent in dentistry. I just want to say that in all seriousness, I’m not blowing air, you are one of my biggest rock star mentor idols of all time. I’m a huge fan of your 7314 posts in Dentaltown. You’re a legend in so many people’s minds- probably most dentists, if you say name a dentist in Canada, they’re only going to say you, the great one, Glenn van As. Thank you so much Glenn for putting me on. It’s dark, you did an hour at the end of the day. Bless your heart, thank you so much.
Glenn van As: Hey Howard let me conclude by saying one thing: I started on Dentaltown in about 2002 and I started because it was nice to have communication with other likeminded dentists about various topics. I want to thank you for that. I’m going to tell you that the most amazing thing that I never knew would happen is how many people I’ll meet on a lecture circuit and they will say one thing to me: they say I read your posts on Dentaltown. It’s like I knew who you were before I even met you and that has happened to me 100 times if not more and that’s because you started a web forum where no one dentist ever had to practice alone, and where you had the opportunity to share information in a collegial fashion and get information about anything you want about dentistry, be it practice management or clinical techniques and really you were the visionary that saw that and you built a tremendously successful web forum and I want to thank you for your efforts.
Howard Farran: Well thank you. We should start the mutual admiration club because I love you like a brother. Thank you so much Glenn for an hour of your time.