Dentistry Uncensored with Howard Farran
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328 Oral Biofilm and the Systemic Connection with Gregori Kurtzman : Dentistry Uncensored with Howard Farran

328 Oral Biofilm and the Systemic Connection with Gregori Kurtzman : Dentistry Uncensored with Howard Farran

3/8/2016 5:49:02 AM   |   Comments: 0   |   Views: 473

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VIDEO - DUwHF #328 - Gregori Kurtzman




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AUDIO - DUwHF #328 - Gregori Kurtzman



This episodes’s discussion:

1. Research linking oral biofilm, formally referred to as plaque, with systemic conditions such as cardiac disease, diabetes, pulmonary disease, etc.

2. New look at periodontal disease and how to manage it long term with regard to biofilm

3. Biofilm resistant to traditional methods both in-office and with home care to elimination and what can be done to eliminate it and maintain elimination


Dr. Gregori Kurtzman is in private general practice in Silver Spring, Maryland and a former Assistant Clinical Professor at University of Maryland and a former AAID Implant Maxi-Course and assistant program director at Howard University College of Dentistry. He has lectured internationally on the topics of Restorative dentistry, Endodontics and Implant surgery and prosthetics, removable and fixed prosthetics, Periodontics, and has over 450 published articles. He has earned Fellowship in the AGD, AAIP, ACD, ICOI, Pierre Fauchard, ADI, Mastership in the AGD and ICOI and Diplomat status in the ICOI and American Dental Implant Association (ADIA).  Dr. Kurtzman has been honored to be included in the “Top Leaders in Continuing Education” by Dentistry Today annually since 2006 and was featured on their June 2012 cover.  

Check out Dr. Kurtzman’s article in the March 2016 edition of Dentaltown Magazine


www.Maryland-Implants.com


Howard:

It is a huge honor for me to be podcast interviewing a legend in dentistry, Gregori Kurtzman. Greg, seriously, I mean I don't think I know anybody who’s been published 450 times, has a thousand posts on Dentaltown. You are a legend to so many. Let me read your bio just in case you didn’t catch one of his 450 published articles. Dr. Gregori Kurtzman is private general practice in Silver Spring, Maryland and a former Assistant Clinical Professor of University of Maryland, which is the first dental school in America, and a former AAID Implant MaxiCourse Assistant Program Director at Howard University College of Dentistry. I just love the name of that dental school, Howard University.

 

 

He has lectured internationally on the topics of restorative dentistry, endodontics, and implant surgery and prosthetics, removable and fixed prostho perio, and has over 450 published articles. He has earned fellowship in the AGD, the AAIP, ACD, ICOI, Pierre Fauchard, ADI, Mastership in the ADD and ICIO, and diplomat status in the ICOI, and American Dental Implant Association. Dr. Kurtzman has been honored to be included in the top leaders in continuing education by Dentistry Today annually since 2006 and was featured on their June 2012 cover. You put up one of the most legendary Dentaltown courses on core buildups, post and core, understanding the ferrule, which I still don’t think half the dentists in the United States understand. You always see them with these flap preps and they try to think they’re going to get everything with a big post buildup, but …

 

Gregori:

No, they don’t even want to use post in those cases, that's the problem.

 

Howard:

My God, you could lecture for 40 days and 40 nights and still edumacate me on A to Z. Thank you for joining me today, Greg. How are you doing?

 

Gregori:

My pleasure. Great day today, it's beautiful weather, it's not snowing anymore. I’m happy.

 

Howard:

Is it finally warming up there? What is this, the 7th now, February 7th? This is actually Super Bowl Sunday. Are you going to watch the game?

 

Gregori:

My girlfriend will force me to watch it, I’m sure.

 

Howard:

Yeah? I am a embarrassingly NFL addict, and I know it's crazy but it's just my little thing that I allow myself to indulge in. What did you want to talk about today? I’ve seen you've been talking a lot about … well, you could review your Dentaltown CE course at the beginning if you want to or the end, but I know that you've been doing a lot of research linking oral biofilm, formerly referred to as plaque, with systemic conditions such as cardiac disease, diabetes, pulmonary disease. It seems like you've really been into in perio a lot lately.

 

Gregori:

Well, I think it's really the link that attaches a lot of stuff and it really makes or breaks what we’re doing in dentistry. They’re finding over the last 10 years that there’s a big link between perio biofilm, what we used to call plaque, and systemic issues like you touched on. I think that everything is finally coming together how the mouth is really interconnected. I’m not sure, you probably graduated dental school about the same time I did, I graduated in ’86 and we were still …

 

Howard:

I was ’87.

 

Gregori:

Yeah, we were like sort of still tooth mechanics back then. You didn’t go past the back of the throat, you didn’t concern yourself pretty much with anything in the body. Now we’re finding there is a big connection there.

 

Howard:

Well, even in 2016 you go to a bar and you’re sitting there with five dentists watching sports eating a cheeseburger and they still talk about dentistry like they’re mechanical engineers. They always talk about the wear rates of fillings, but I don’t see my fillings wearing down. They always talk about adhesive bonding strength. My problem’s not my fillings falling out, it's we’re biologists. We build bonds and they’re eaten by termites, and it's all about biology and oral … we’re physicians of the mouth, we’re not mechanics.

 

Gregori:

Absolutely, I agree with you. What really it’s the bone and the gums that hold everything in whether it's natural teeth or implants and if you don’t preserve that, if you can’t and the patient can’t, doesn’t matter how beautiful that filling is, how great that crown is, it still fails.

 

Howard:

Well, when you’re reading this research and we’re reading it and I mean obviously 1,000 years from now almost everything we know now is going to look silly. I mean one of the most exciting things I ever did was I bought the first three books autographed and signed by G.V. Black who is the father of dentistry in America and Pierre Fauchard from France 200 years earlier, but you’re reading what the smartest dentist knew a century ago and you’re just like, “Wow, they had no idea.” You know it's going to be that way 100 years, but right now you see when you say perio is linked to heart disease or whatever, the research fanatics are in there saying is correlation, causal, no, yes, no. It just makes sense that the whole body is all working together.

 

Gregori:

Well, they’ve done a ton of research that's been published in dental journals, medical journals, basically linking the bacteria that is in the biofilm in the pockets to cardiac problems. They find it in heart and arteries, they find it in the pancreas, they find it elsewhere in the body, and it's those specific bacteria we only find in the mouth. They find that those patients who don’t have severe oral issues don’t have those severe diseases. There is definitely, it's not a casual relationship, it's definitely been linked in the literature. Look at it this way, 30 years ago when you were in dental school, what percentage of that information has changed in that time? I’d say probably 80% of what we were taught in dental school is no longer valid today. Things have changed drastically, and you say 1,000 years, I think in 20 years things are going to change drastically that anything we learned in dental school no longer will be valid.

 

Howard:

Well, you know what I find interesting reading 100-year old dental books and 70-year old dental books is those dentists knew they would see a sickly person and jaundice eyes, I mean just they spill on detail and a whole mouthful of pyoria, and they would pull all their teeth and they would document how the person just looked and felt much better as soon as they got all that infection out of the mouth. I’m like, wow, now it's 100 years later and they’re starting to say, “Yeah, those bugs in the mouth are making you sick.”

 

Gregori:

Yeah. Exactly, but now we have the literature and the proof to back all that stuff up, it's just not somebody’s opinion. Remember tooth worms, we learned about tooth worms in the 1700 and 1800’s, they believed that's what caused tooth decay. They found, well, that wasn’t true because they didn’t know anything about bacteria. Now we’re understanding bacteria does a lot more damage and does more stuff than it did years ago that we’re aware of. The key is, is the difference between planktonic bacteria and biofilms. Planktonic bacteria is just bacteria floating in your blood system or in your saliva. That's easily killed, the body can take care of that, but when you group it together in a biofilm it's very resistant, up to 1,000 times more resistant to antibiotics. It controls the environment to protect itself and that's what causes a lot of the issues and we’re just now starting to understand that.

 

Howard:

How are you managing? I mean you lecture and write on everything, how are you managing your perio patients today differently than back in 1986, and how are you managing perio around implants?

 

Gregori:

Well, what I used to do basically is I follow what we were taught, I scale and root plane, I put them on home care which is basically brushing and flossing and hoping that they’re brushing and flossing, and then get them back every three months. I found that a lot of these patients it wasn’t getting better or it was pretty much staying in a …. I wouldn’t say it would plateau, but still get bleeding and still have issues, bone would still disappear, and it really depended on the patient’s particular resistance. Some patients the bone melted away no matter what they were doing and others it didn’t. I started looking for better ways to do this and I actually stumbled on using the Picasso diode laser when I’m doing my scale and the root planing.

 

 

I run that through and kill the bacteria as much I can, scale it, and run it through again to clean up the tissue. Then I’m putting them on what we call Perio Protect trays with a 1.7% peroxide gel. I’m putting them on this three to four times a day for usually four to six weeks. I get them back, I check, if there’s no bleeding I start cutting that down to about twice a day, get them back on a three-month recall, and I find that we’re seeing less bleeding, we have higher patient compliance. The patients are saying that everything feels better. I’m not seeing the tissue receding anymore, I’m not seeing bone loss, and I think it's made a big difference.

 

Howard:

Now these are like the Perio trays, you make like a suck-down bleaching tray?

 

Gregori:

No, no. You really need a custom tray and it has to be through the Perio Protect people. What you do is you send a full charting of the pockets and they custom design this so that there’s a seal around each tooth on that model. It's not like a regular custom tray, we need to basically create a seal so when we force the peroxide gel down into the pockets it stays there and creates basically a hyperbaric oxygen chamber because we need contact …

 

Howard:

What's the website of Perio of this place?

 

Gregori:

It's PerioProtect, P-E-R-I-O-P-R-O-T-E-C-T.com. PerioProtect.com. Basically you send them a full charting either impressions or good study models and they basically then customize that tray to fit that particular patient’s pockets on each individual tooth. A regular bleaching tray is not going to create the seal you want. You have to be able to force that stuff down into the sulcus. The problem is our natural reaction is that we’re producing fluid in the sulcus or the pocket to force bacteria out. If we basically try to irrigate something in there or use a bleaching tray that sulcular flow just pushes everything right back out. We need a special tray, the Perio Protect tray, to force it in there and hold it in there for the correct contact time, which is about 10 minutes.

 

Howard:

Now would that tray be better even for bleaching? Because I know when Rod Kurthy started his core bleaching system, if you really looked into that I mean 99% of what he was talking about is the attention to detail to making the tray.

 

Gregori:

I haven’t used it for that but it probably would because it would seal the bleaching solution onto the teeth better. The key is we don’t want to force that bleaching solution into the pockets. It may be that the bleaching solution would be forced into the pockets and cause an issue. One of the interesting side effects of using the Perio Protect and the 1.7% peroxide is we do see a little bit of whitening of the teeth, not a lot but a little bit. The patients I’ve used this on when they come back for recalls they say, “Hey, I noticed that my teeth are a little bit brighter.” That it's a good side effect.

 

Howard:

Who’s the founder of this Perio Protect and where are they out of?

 

Gregori:

They’re based in St. Louis and it's Dr. Keller.

 

Howard:

St. Louis, Dr. Keller. From Keller Labs?

 

Gregori:

No, no, different person. He’s a dentist and he basically …

 

Howard:

Dr. Keller, K-E-L-L-E-R?

 

Gregori:

Yes. Yes.

 

Howard:

How long has he been doing this?

 

Gregori:

He’s been doing this for I believe it's a little over 10 years.

 

Howard:

Well, let's get him on the show. Is he your buddy?

 

Gregori:

We can talk to him.

 

Howard:

Yeah, yeah. Email me howard@dentaltown.com and CC Dr. Keller. Slow down, Spanky, what's in that tray, one point …

 

Gregori:

It's a 1.7% hydrogen peroxide gel.

 

Howard:

Why do you like that as opposed to chlorhexidine gluconate?

 

Gregori:

Well, the problem with chlorhexidine is that it works on young biofilms but if you have a mature biofilm or one that is nutrient starved it has no effect on the biofilm whatsoever. The good thing about the peroxide is it's sort of like an onion, peels layer by layer of the biofilm off, getting to the bacteria and then breaking those down. Also the bacteria that's in these biofilms is anaerobic so the peroxide basically liberates oxygen changing the environment, making it really uninhabitable for the anaerobic bacteria so we’re able to change everything around.

 

Howard:

Now when you said you use a diode laser, I want you to slow down on the diode laser because these dental students are walking out of school with $300,000, $400,000 in debt and they see a perio LANAP laser but that program is 125, 135, and you’re talking about using a Picasso diode laser which is what, 2,500? How much is …

 

Gregori:

You’re talking for the Lite, I believe it's $3,500 for the Picasso Lite from AMD Lasers which works adequately for this. They do have a full Picasso laser which is higher wattage. If you’re doing surgeries and stuff, that's a little better. That one I think is 5,500. The $3,500 Picasso Lite works great and you don’t have to spend a lot of money to be able to do this stuff.

 

Howard:

Explain again the name of the 3,500 versus the 5,500 and what …

 

Gregori:

It's the Picasso Lite from AMD …

 

Howard:

Lite, L-I-T-E?

 

Gregori:

L-I-T-E.

 

Howard:

Okay, Picasso Lite, and what does that not do that the $5,500 does?

 

Gregori:

The new one has 3 watts of power where the full Picasso has 7 watts. The only difference you’re going to find is if I’m cutting very fibrous tissue I need more wattage in those cases. For the average dentist what they’re doing the Picasso Lite works adequately well.

 

Howard:

Then what's the value proposition of upgrading from a 5,500 7-watt Picasso to $135,000 LANAP which includes the training?

 

Gregori:

Well, I mean they’re basically indicating what the more expensive laser, they're indicating that they’re getting bone growth and some other stuff. They patented the LANAP procedure and the name. I’m not using that type of laser in my practice, I think I’m getting very good results. I’m seeing improvement especially when I’m combining it with the Perio Protect trays.

 

Howard:

What type of laser is the diode laser versus the LANAP?

 

Gregori:

One’s a Er:YAG and the other is a diode. The AMD lasers are diode lasers and the Millennium laser which is what they’re using for the LANAP is a Er:YAG laser.

 

Howard:

Then the Perio tray gel is a 1.7% hydrogen peroxide H2O2?

 

Gregori:

Yes.

 

Howard:

You’re doing this if they have periodontal disease around natural teeth or peri-implantitis …

 

Gregori:

Implants.

 

Howard:

… around implants?

 

Gregori:

Yes. See, the problem is biofilm sticks to everything and what happens is your body sees this insult in there, it sends white blood cells, and the biofilm is able to actually deactivate those white blood cells. After about three days the cells [light 00:14:58] themselves killing themselves, releasing all the enzymes that they intended to kill bacteria with and that's what leads to inflammation and bone loss. If we can get rid of the biofilm we don’t have to worry about it destroying the white blood cells and then causing the damage in the bone and soft tissue.

 

Howard:

I’ve had a breakthrough this last month with a patient where I’m sympathetic to gaggers because I’ve got five sisters and a brother, and me and my sister [Kaleen 00:15:27] are the two gaggers. The biggest problem we have when we’re brushing it's just our gag reflex. I’ve never been able to brush 15 minutes. I brush for like a minute at the beginning of shower and a minute at the end, but anyway, I told her to get an electric toothbrush and just dry brush because Trisha O'Hehir was the hygienist who been saying forever that it's not the toothpaste, it's the brushing. She always promoted dry brushing. This lady came in and she just massively, finally after … I mean I think she’s been a patient for 18 years, and it massively went down.

 

 

She got an electric toothbrush, put it by her nightstand, an alarm goes off, she just sits there in her bed dry brushing with an electric toothbrush. She does it before she goes to bed. Now she’s doing that every morning and night with an electric in her bed without any toothpaste, she can brush for a long time without gagging and it made a huge difference and I’m really excited about that. Have you heard of the dry brushing people techniques?

 

Gregori:

Well, yes, but you also have to realize that people are lazy, they’re not going to brush for long periods of time. Studies have shown you really have got to brush three or four minutes, nobody does. Everybody brushes for a minute or less. If you use an electric toothbrush it's more effective than hand brushing whether it's wet or dry. You say I can’t increase how much time they’re going to brush but if I increase the efficiency in that period of time we’re going to get a better result. I think home care is great, it really helps with a lot of the stuff. The only problem is those toothbrush bristles can’t get more than 3 millimeters down in a pocket. If you have a pocket that's 4, 5, 6, 7 millimeters or deeper we can’t get down there to clean it with any floss, toothbrushes or anything else. If you give a patient an irrigator and say, “Here, I want you to use this,” they don’t use it.

 

 

Are you going to spend 20 minutes irrigating around every tooth? Nobody does that. We really need something that increases compliance for the patient make it as easy as possible. I have a perfect example. I have a patient in my practice who’s in a networking group I’m in, and he comes in and he says, “You know, I know I’ve got a perio problem. I just don’t like brushing. I don’t like doing this, I don’t like doing that.” He’s got pocketing, he’s got bleeding. I said, “Let's put you in the Perio Protect trays.” I got everything cleaned up, I used the laser, got him on a recall. I say, “Well, you’re using it twice a day now. How is it?” He goes, “It's not that bad. I put it in, I drive to work. I take it out when I get to work. I do the same thing on the way home. I got my two times a day.”

 

 

I say, “All right, we can cut down to once a day.” He goes, “It's not that bad. Actually it's such a habit now, it's so easy to do. Why don’t I just keep doing twice a day?” I said, “That's great. The more you do it the better.” The compliance I find is very easy with these, but it all adds in. You still have got to use a toothbrush and floss.

 

Howard:

You’re using the Picasso Lite 3-watt for disinfecting pockets but the 7-watt you would be doing pocket elimination …

 

Gregori:

No, you can use the 3-watt for pocket elimination too. Where the 7-watt comes in, if I’m uncovering an implant and I have very fibrous tissue, I can’t get enough wattage sometimes out of the 3-watt laser to cut through very fibrous tissue. I find that the 7-watt works better in those cases. If I’m doing a peri-implantitis treatment where I have to disinfect the implant surface, I want to use the higher wattage laser. The 3-watt laser works great for bacteria reduction in the pockets, you breathe into the pockets after scaling. Pretty much 90% of what the average general dentist is going to use a 3-watt laser works perfectly.

 

Howard:

Just not to beat a dead horse but let's beat a dead horse, this is dentistry uncensored, we know that for every person using a diode laser, three are using an electrosurge for the same thing. What are your thoughts?

 

Gregori:

I’m really glad you brought that up.

 

Howard:

Really?

 

Gregori:

I’ll give you how I started practice. 12 years I used a monopolar electrosurgery and I found that I had a lot of inflammation, a lot of tissue shrinkage, the patients had discomfort for a week, two weeks afterwards no matter what wattage I set it at. I moved into bipolar electrosurgery which is now off the market. I used that for about 12 years. Then I started moving into diode lasers. I find that with the diodes I can use that around metal filings, amalgams, crowns. I can use it around implants with no negative effect at all. The problem with the monopolar is it's a circuit. If I get anywhere near an implant it's going to pick the path of least resistance which is through the implant than through the body and I could see deintegration, it's been reported, I’ve never seen it myself because I don’t use them around implants, you deintegrate those implants.

 

 

Monopolar electrosurgery, no matter what anybody says, the literature shows, and [Wallace’s 00:20:01] article was key in this, we cannot use those around implants. Metallic fillings are the same way. We’re going to grab right through that metal, fill in their crown.

 

Howard:

Just between me and you, what percent of the American dentists are still using an electrosurge anyway?

 

Gregori:

I don’t see as many advertisements for electrosurge anymore. I think the big company is still [Elmen 00:20:24]. I think some of the other smaller companies have really phased them down, they’re not selling much. It seems like there are a lot of companies selling some form of laser. As the prices come down you’re talking price-wise if I’m going to go out and buy something, what it's going to cost me to buy let's say a Picasso Lite is almost what it's going to cost me to buy a Electrosurge unit. Why not use something that's safer and gives me a better result? I get no tissue shrinkage with the laser. A lot of cases I can probably use it without any anesthetic or maybe just some topical. I can’t do that with monopolar electrosurgery.

 

 

If I’m basically going around something and I want to remove some tissue and take a crown and bridge impression, with monopolar I had to wait two weeks because I’m going to get some tissue shrinkage. I don’t get that with a laser, I could take the impression immediately.

 

Howard:

Let's go to back in the day scaling and root planing around teeth, and I still get questions all the time, do you scale and root plane the titanium implant with peri-implantitis? Do you use any metal instruments when you’re cleaning around peri-implantitis or?

 

Gregori:

I prefer to use a plastic instrument. They do have plastic tips that fit onto ultrasonic [and pivot 00:21:31] surgical tips. The key is if you put metal to metal whether it's a titanium tip on a Cavitron or a stainless steel one, it's still going to gouge the metal. If you have a rough surface do to gougings you’re going to have more plaque trap there. You really basically have to be really careful on these.

 

Howard:

Well, what about all the other things that people are using for perio? They put perio chips, [H docks 00:21:58], some just use systemic antibiotics. Are you doing any of that local [crosstalk 00:22:04]?

 

Gregori:

I was. I’ve moved away from that. The problem with the perio chip that I didn’t like was it was like putting a wet noodle into a pocket, it just it was hard to get in. if you refrigerated it, it was easier. What we find, as I mentioned, chlorhexidine doesn’t really do much to biofilms. Antibiotics, remember what was the string one, was like a rubber band you had to put in there, those things are impossible to get in there. They went into the pocket [not after 00:22:27] after a day or two. Acticin, some of these others that you inject in, they tend to get a little on the expensive side because they’re really designed for specific sites not the whole mouth. Most patients coming in have like multiple sites so it's a fortune for these patients to pay of this stuff. As we’ve said, biofilms could be up to 1,000 times more resistant to antibiotics so if I put an antibiotic in there, it's not really doing anything.

 

Howard:

I see them talking about they’ve discovered this [inaudible 00:22:54] was telling me that they discovered that now fungi, candidiasis is in that plaque matrix making it even more impenetrable to the … so it's kind of like [inaudible 00:23:03] take advantage of a fungus [crosstalk 00:23:07] making it more impenetrable. Go ahead.

 

Gregori:

They found in the literature actually a lot of sinus infections were actually fungi related. We were treating sinus infections with antibiotics and it turns out a lot of these are yeast and other fungi that are in the sinus. That's something we’ve tended to push aside and ignore because we focused on bacteria, but as you said, they do have an influence also, and a compromised site everything sets in.

 

Howard:

[Ryan 00:23:34], we’re doing a podcast coming out with a local rhinologist, a local ENT. Basically the story is and I’ve heard it several places that now that endodontists are getting CBCTs and dentists are getting CBCTs that a lot of people you think they’ve had sinus allergies for the last 10, 20 years have a failing root canal into the sinus and these rhinologists get in the sinus exactly what you said, candidiasis, plaque, just long term chronic infections. A lot of these they’re surprised … You’ve got a cat too, we’ve got …

 

Gregori:

I’ve got four of them.

 

Howard:

You've got four cats? My God, I’m so jealous, I’m only half the man you are, I only have two. What's your cat’s name?

 

Gregori:

This is [Zippy 00:24:17]. We have [April 00:24:20] and we have [Belly 00:24:22] and [Bear 00:24:22].

 

Howard:

It's so funny, my [Mimi 00:24:23] only wants attention when I’m staring at someone else on the computer. Then if I wasn’t talking to you she wouldn’t talk to me but since I’m talking to you she has to get in my face. These rhinologists are saying that CBCT has been a game changer in sinusitis because they just had no idea how many of these were odontogenic origin. A lot of these dentists listen there’s need to start … I think we’ve reached a point where we’ve got to start asking do you have sinus problems because a person will just say it's something in the air, it's something blooming, it's something whatever, I’m allergic to this or that, but you’re a dentist and you've got to rule out odontogenic origin. Are you hearing this too?

 

Gregori:

Yeah, I do hear that also and it’s interesting because being in the D.C. area we’re in allergy central because everything grows here. Everybody here has allergy issues, that's not a problem. It's funny, I had a patient came in some years ago and he had tooth number 2 endo treated, endo retreated, and it still wasn’t right. He was missing 3, 4, and 5, and wanted implants there. Then he brought a cone beam in with him and I’m looking at the cone beam and I said, “Here’s why it's bad. You have a lesion that you can’t see in a regular x-ray that we could see in the cone beam that it basically is up in the sinus.” His answer was, “I had it treated, I had it retreated. Let's just get rid of it and put an implant in there also.” We are seeing a lot more of the cone beams especially with sinuses and other things that we really weren’t aware of before.

 

Howard:

What else did you want to talk about? Do you want to talk about perio or do you want to switch subjects?

 

Gregori:

Well, we could stick with perio for a little bit.

 

Howard:

Okay, what else do you want to edumacate us on, on perio?

 

Gregori:

I think that things have changed a lot. We have to realize that there is a connection, especially in our older individuals, they’re really prone to aspirating plaque in biofilm into lungs and that's why a lot of them have respiratory problems. Maybe those senior citizens once you put them on like Perio Protect trays to prevent this and improve their overall health. Diabetic patients, same thing, it's like we know there’s a big link between perio and diabetes, and if we basically control the perio, the diabetes get better. We’re not going to eliminate the diabetes but we can make it better. Prostate cancer we’re seeing a big interconnection with biofilm, colon cancer, preterm birth weights, early pregnancy issues, there’s a lot of things that are interconnected with the perio and the mouth. I think that we really need to start focusing more on stopping those tooth mechanics and really be healthcare providers.

 

Howard:

The hygiene department really is the lifeblood of the dental business. I mean having these patients come in regularly is the lifeblood. I mean it seems like any time you see a dentist, if they’ve got two fulltime hygienists and then the dentist has two chairs, 80% of what they’re doing comes out of just retained, seeing these hygienists every checking to hygiene hour and 20% emergencies and new patients or whatever, and it just seems like that's the foundation of the biggest most successful dental family practice I see, not whether or not they become implantologists or start doing ortho or become a cosmetic dentist or a sleep doctor.

 

 

All these other things which are all cool, but it just seems like 80% of all the very successful family practices is just four chairs, two hygienists, the dentist works too and then an overflow emergency fifth room operatory. Just focusing on 2,000 people and really taking care of them is the basis of a really successful dental office.

 

Gregori:

Absolutely, absolutely. Just before we move on to another topic, next month in your magazine I do have a article coming out on oral biofilm and how to treat it in the Dentaltown magazine. I wanted to mention that.

 

Howard:

Thank you so much for writing that. Any listeners that want to write article, a lot of people are confused, they think that I have something to do with it. I don’t, I have Tom Giacobbi, he’s been the editor. He’s worked for me since 2000. I think he’s amazing. You can email him, tom@, is it tom@dentaltown.com or tom@farranmedia? Do both of those work, Tom? Yeah, yeah, tom@dentaltown.com or tom@farranmedia.com, but Tom Giacobbi, I was CC’ed on some of those emails. That was an amazing article, so thank you for doing that.

 

Gregori:

My pleasure. Well, as you know …

 

Howard:

Will I be Article 451?

 

Gregori:

Well, actually I’m almost at 500, so we’re pushing it.

 

Howard:

You’re pushing it.

 

Gregori:

Yeah.

 

Howard:

What else is hot and what's not?

 

Gregori:

We could talk about lasers a bit. I think that lasers are really changing the way we’re practicing. I think the diode laser has come down a lot in price. It really is affordable for all practices. How many times do you have root caries and you can’t get that tissue out of the way or it's inflamed, diode laser it's easy to trim the tissue and you don’t get any bleeding or very minimal bleeding, and you’re able to treat the caries right there. I think that makes a big difference in how we practice. I haven’t used cord in years because I just hate it for crown and bridge impressions. I run the diode around that and I get a nice open sulcus. I don’t have to worry about the tissue shrinking. It just makes crown and bridge impressions much easier.

 

Howard:

You are you using 3-watt Lite or the 7-watt one?

 

Gregori:

I have both of those in the practice so it just depends on what room I’m in.

 

Howard:

It doesn’t matter which one?

 

Gregori:

No. Well, if I have like a lot of fibrous tissue I’m using the 7, but most of the time I’m using the Lite or I’m using the 7 set at a lower wattage.

 

Howard:

You just opened up a can of worms because you said root caries so I’m going to hold your feet to the fire on that. I always felt that's the 4,000-pound elephant in the room that no one talks about, is that we take care of these people for a lifetime. The men are lucky, they just walk away and drop dead, but the women just keep living and living. They live five years longer than men, and the nursing homes are pretty much all women, and they’re getting a root surface cavity a new one every single month they’re in the nursing home. After your grandma’s been in there a year, she’s got 12 root surface caries, and I’m telling you, I’m in Phoenix which is a big retirement area, and dude, those are hard to manage. It seems like they’re like brush fire. What do you do when you get 82-year old grandma and she comes in, you saw her six months ago, she’s fine, and now she has five root surface caries?

 

Gregori:

Well, part of that is dry mouth issues, they just they’re not able to keep clean. Putting those patients on a neutral brush on sodium fluoride or something in trays is going to help limit that. You said an 82-year old patient, well, last week I had 100-year old patient came in on a lower premolar with root caries so it had turned into a root canal. She’s missing I think three teeth in her entire mouth, but she’s in pretty good health for 100 years old. I say, she goes, “Isn’t there another alternative?” I say, “I could take the tooth out.” “Well, I don’t want to do that.” We did a root canal on it. The root caries which wasn’t there three months ago now is basically was right into the pulp. We do see those problems, and as you say, we’re seeing it more in females because they tend to live longer. I’m not sure if women have more dry mouth issues than men do, but they tend to be on a lot of medications, older populations, and it contributes to dry mouth.

 

 

Basically we’re seeing a lot more of that stuff as people are living longer and longer. Like you said, it's like they come in, you come back six months later and they’ve got a whole mouth hole where they didn’t have it at the prior visit.

 

Howard:

Back to when we started this conversation talking about mechanics versus biologists, I mean I still see most root surface caries being treated with just a inert plastic composite straight out of Ivoclar or 3M, but you’re seeing other composites like Pulpdent, you’re seeing GC, where they’re trying to make a filling material that tries to become more bacterial static or have some mechanism to fight these bugs. Do you believe those mechanisms are more successful than just a straight resin in a composite?

 

Gregori:

Well, I don't know if you know Gene McCoy who’s the big abfracture guy, he’s in San Francisco. Gene has been studying abfractions for like 30 years, and I think that I sort of learned a little bit from him that a lot of the stuff, the tooth flexes, and I found that when I was putting hybrid or nano composites basically on the root surface they tended to pop out or they reabfractured or [we got to keep 00:32:54] a gingival margin. I really moved away from that and went into flowable composites which had a little bit more flexture. I’ve used glass ionomers, and the thing I like about the glass ionomers, and you mentioned GC, they have a new product called EQUIA Forte which is a stronger, you could actually use it for Class 1’s and 2’s, but it's got fluoride release. We’re going to decrease the chances of getting more decay around those margins, plus it stays in better.

 

 

The problem is a lot of people advocate, “You just don’t have to prep these things very much. You just clean out the decay and we’re going to bond it in there.” I find that I’d rather put some mechanical retention too because it's belt and suspenders, I want to make sure it doesn’t pop out. I find that I’m having fewer problems when I’m putting a little bit of mechanical retention in as well as trying to rely on some bonding.

 

Howard:

Do you think these filling materials like glass ionomers and stuff out of GC and Pulpdent, do you think these things have a statistically measurable effect of having less recurrent decay or slower to get recurrent decay than something inert?

 

Gregori:

I believe so because they’re releasing fluoride and the fluoride recharges itself. If we have fluoride there are less likely … you have to realize decay results from calcium ions being pulled out of the tooth structure. Well, fluoride ions can take up the same kind of biomolecular spot. It takes more acid to pull the fluoride molecule back out than it did calcium. If we have fluoride in the area really are fluoridating that dent and surface, we’re more likely to see longer progression or less problems down the road due to future decay. A lot of this also is like dry mouth issues, you get rid of the dry mouth or manage that they have much fewer root caries issues.

 

Howard:

I know you've lectured in too many countries to count. You’ve lectured all over the world. It seems like every time I see you on Facebook you’re from another country. Why do you think glass ionomer is more popular in Australia and New Zealand and Japan than the U.S. and Canada?

 

Gregori:

Well, I think Japan because a lot of these products are developed in Japan. They’re pushing the [inaudible 00:34:59] out there. I think that we see a lot of materials used in countries not in the U.S. that are easier to place. Glass ionomers are easier to place because we don’t have to bond them in, they’re self-bonding. I think from that standpoint it just they really grasp those things. Here we have a tendency we don’t want to look at any research outside the United States, it's not valid unless it happened here, and we have a tendency to move in one direction. I think we’re opening our minds and looking at more stuff these days and I think the glass ionomers are good materials. They’ve gotten better over time. The initial glass ionomers were very weak materials.

 

 

They were good for a liner but they really weren’t good for anything else. Now they have stuff that is really abrasion resistant that really holds up long term fairly well.

 

Howard:

I think the internet is a massive game changer, because I know when I started Dentaltown magazine in 1994 every single dentist only read a magazine from their country. Then when the internets came out it was really not even till like maybe, Facebook started in what, 2004, and it's probably about 2009 before you really start to, when the first time in their life, it didn’t matter they were in Romania, Poland, or the U.S. saying, “Hey, did you hear about what this guy said in Argentina?” I knew that was going to be just a massive game changer because we’re going from our own tribe to a global tribe.

 

Gregori:

Absolutely.

 

Howard:

Yeah. I really think it's just a huge game changer. I still think that some of these companies like GC’s one where they sell the exact same product under several different names in several different countries, and I think that's got to stop.

 

Gregori:

Well, part of the reason for that is what they call grey market materials. What you’ll do is you’ll buy a product in let’s say Romania for $25 where that product sells here for $100. What they do is they import it into the United States some small distributor and sells it over here. They basically have no control over that stuff. What they do is they name it different things in other countries so you know if it's the ABC material you’re using here and they’re trying to sell you the BCD material, even though it's the same company you know it's not the same product, didn’t come here. The standards for manufacturing may be different in other countries. That's why they basically rename things in other countries. It's funny …

 

Howard:

My God, I can’t believe I didn’t figure that out until you explained it to me. I mean when I can’t figure something out I usually go with, well, money is the answer, what's the question, and it was money. It was geographic price discrimination where they sell things for a lower price in poor countries and a higher price in richer countries, that's why they do that.

 

Gregori:

Well, you've been to India, haven’t you?

 

Howard:

Yeah.

 

Gregori:

I mean look at what you pay for a dental product here, you think they could afford to pay for that same product that same price in India? They can’t.

 

Howard:

I know Indian dentist in the United States as they go home and visit family, and take a big, empty suitcase and buy $1,000 worth of stuff in India and then they bring it back and it would be 10,000 United States.

 

Gregori:

Absolutely. Next time you’re going overseas let me know so I can give you a suitcase to bring back stuff.

 

Howard:

Yeah, and American pharmaceutical companies are the worst, these pills $10 a pill here they sell for 50 cents in Shenzhen.

 

Gregori:

Well, it's funny because I had a friend who was doing a lot of Botox and used to be able to get it from Canada for like a third of the price that the material cost here, and now FDA has basically said you can’t ship the stuff into the U.S. It's like it's the same exact product from the same exact company, it's just that they sell it a lot cheaper outside the U.S. because they’re greedier here, the pharmaceutical companies.

 

Howard:

Well, we’ll talk about that. There’s some big threads, there’s the big thread right now going on Dentaltown about grey market, black … I think the name of the thread’s Grey Market, Black Market, Yellow Market, What's It All Mean? Did you want to weigh in on that? What does it all mean?

 

Gregori:

Well, and there’s a difference between grey market and black market. Grey market means the ABC company has made a product, they selling it in another country, somebody buys and brings it in here, sells it, marks it up, they’re making a bigger profit. Black market means that they’re basically taking that product and they’re making something similar to it, it's not the exact product, and they bring it over here and they try to sell it as that product. With black market products you have no idea what it is. It might say it's whatever the product is but it's not exactly that product. With grey market, you’re usually assured it's about the same product, but the companies over the last 10 years in working with the companies their big problem is the grey market and black market products.

 

 

I can understand from a profit standpoint they’re having issues, they’re more concerned with the black market products because if you’re used to using the ABC product and you get a box and you think it's the ABC product it's a black market and it's not the exact same product, you go, “God, this was horrible, I had horrible results. I’m not using this product anymore.” What happens is they lose your business. They’re more concerned with the black market stuff than the grey market stuff.

 

Howard:

Interesting. It's not just a rich country problem that we’re paying more for something sole identical in Brazil or India or China, when I go to very, very poor countries one of the problems they have is one guy bought the country’s distribution rights to a product and then he just marks it up 100%. They go to these international dental conventions to buy this stuff half off and then sneak it back into their country just because the distributors mark it up 100%

 

Gregori:

Well, it's interesting you mentioned Romania. I was in Romania lecturing a few years ago, and a friend of mine who’s a dentist there who does a lot of implants, we’re talking and he says, “What would it cost to have an implant placed and restored in your country?” I said, “Probably about $4,000.” He says, “You know what it is here?” I go, “I don't know.” He goes, “$800 total.” I go, “Really?” He says, “We can’t afford to buy an implant that's a name brand like Nobel or one of those that cost us $300 and then have to pay for the abutment head and the crown on top of that, there’s no profit margin. We can’t make anything. We have to buy something that's $150, that has the abutment head included so we can basically then get a crown made for another $50 or $75 and still be able to make some money on it.”

 

 

Some of the big companies couldn’t understand why they can’t break into these smaller countries or these poorer countries because the economics sort of say, well, we can’t sell an implant there for $300, they don’t understand that. The economics just doesn’t work in those countries. That's why some of the big implant companies are not selling in a lot of these smaller poorer countries because they can’t mark the thing down to it.

 

Howard:

Danaher has really playing the GM route where GM’s got like a Cadillac and then they got a Buick, it owns Chevy, and Danaher owns the high end Nobel Biocare and the low cost Implant Direct. They’re serving two markets under one company.

 

Gregori:

Well, one of the companies now, a very large company I won’t mention their name [crosstalk 00:41:58] …

 

Howard:

It's Dentistry Uncensored, mention their name.

 

Gregori:

Dentsply. It's interesting, this is before as they were getting ready to buy ASTRA, a Korean company called DIO. I said to them, I said, “You’re combining everything into one?” He goes, “No.” I go, “Why?” He goes, and it made perfect sense, “We’re keeping DIO separately so we can sell that implant that's a lower cost implant in other countries that we can’t sell our other implants in because they’re too expensive. What happens is if we combine it into one, somebody is going to say why do I want to buy the ASTRA implant or the [Zyde 00:42:30] implant, I’ll get a DIO implant, the same implant for less money. They basically were smart in how they compartmentalized that.

 

 

I think Danaher has done the same thing, they’ll never combine Nobel and Implant Direct because they’re going to two different markets and if you have them under the same roof what happens is people say, “Why should I buy the Nobel implant? I’ll just buy the Implant Direct, they’re selling the same thing. They’ve got to be similar quality.”

 

Howard:

Who started ASTRA? Was that Niznick? Jerry Niznick?

 

Gregori:

No, no, no. Niznick basically sold and became Implant Direct.

 

Howard:

What was Niznick’s first implant company? Was it Core-Vent?

 

Gregori:

It was Core-Vent and then Dentsply he … Jerry was kind of interesting, he had Core-Vent was two companies, manufacturing and distribution. Dentsply bought distribution. Five years later they made him buy it back really at a discount because the price of the distribution had come down a lot. He couldn’t use the Core-Vent name anymore so he formed Paragon. He had Paragon Implants, and then Zimmer bought that. Then what happened is he had to stay out of the business for I think it was five years. He stayed out of the business and then he came back in and formed Implant Direct and eventually Danaher purchased that.

 

Howard:

That five years is about up and rumor has it he’s going to be back.

 

Gregori:

Well, that five years was 10 years ago. He was back in and then basically Danaher had an agreement with him that after five years he basically was out of the business again. My understanding on the agreement, I could be wrong, is that he cannot come back into the business or his family for a long period of time because they basically didn’t want to have to deal with the issues.

 

Howard:

I think that long time is over now.

 

Gregori:

No, not this one.

 

Howard:

I hear he’s back, I hear he’s back.

 

Gregori:

There’s some suits and countersuits going on but we’ll see what happens.

 

Howard:

Well, I emailed him the other day and he says, “Just give me a little more time.”

 

Gregori:

We’ll see.

 

Howard:

He says, “I’ll come back and do a podcast and tell you what's next.” I don't know what it is, maybe it has nothing to do with implants.

 

Gregori:

I haven’t spoken to Jerry in a while so you may have more information than I do at this point.

 

Howard:

An amazing man. What next? What else do you want to talk about?

 

Gregori:

Whatever you want.

 

Howard:

Well, I really want you to go back and talk about that Dentaltown continuing education course you put up because … and by the way, that was in 2010, dude, it's 2016, are we going to have the honor of getting another course from you?

 

Gregori:

I’m sure we can do something.

 

Howard:

You know why our courses are exploding now is because now you can take an online CE course on the Samsung and as far as the iPhone Apple told us they kept making a few changes but the iPhone online CE should be released. Now that these dentists, there’s 210,000 members on Dentaltown but 40,000 download the app on their phone and once they start taking online CE on their Samsung it exploded. The iPhone is right down the corner. When people log on to Dentaltown from their app, it's about 80% iPhone. I’d love to get another course from you. I want you to go back and talk about your 2010 course, Core Builds, Post and Core and Understanding Ferrule because I think a lot of dentists believe that … you’ll hear them, they’ll just say, “Well, if I don’t have any retention I’ll just put it on with Panavia because I know that won’t come off.”

 

 

When some dentist doesn’t have any retention and he says, “Well, I’ll just use Panavia,” I don't think they understand the ferrule, I really don’t. I also don’t think they know when to post and not to post. Can you address those two deals? What is the ferrule and is this crown going to stay on from … and then I also want you to just go over some issues on here for a nice podcast saying that he doesn’t like these resin cements. He says they don’t show up on x-ray and bacteria and biofilm, [a gentleman 00:46:21] he wants people to go back and use the zinc phosphate cement that shows up on x-ray and kills bugs. Answer those 49 questions.

 

Gregori:

Okay, question number one. Basically a ferrule is a vertical band of two structure that the crown wraps around. It comes from the barrel-making industry, and that was a circumferential band that held the [slats 00:46:42] and the barrel together. If we look at it from that standpoint, the studies have shown that we need at least a 2 millimeter high ferrule around the entire tooth in order to prevent lateral tipping and force that crown off the tooth.

 

Howard:

You’re saying ferrule was the name of the metal wrap around the barrel?

 

Gregori:

Yes, that's where it comes from.

 

Howard:

Really?

 

Gregori:

Yeah, it just basically is ferruling the barrel all together. Basically what we have to do is we have to have this ferrule there. The problem was that when we went to dental school we weren’t using adhesive cements to everything else, whereas adhesion dentistry came along people started developing this attitude, I can glue everything together. I can use Panavia or whatever and I’ll glue everything. [That we’re going to have 00:47:22] two flat surfaces and it's going to stay on forever and it doesn’t. The problem is that we’re moving away from engineering and we’re using materials that are not designed to be used the way they are. Panavia is a great cement, it's a phenomenal cement but it's not going to hold a flat surface to a flat surface long term.

 

 

This is more critical in the upper anterior because of the tipping forces or the direction when your lower teeth meet the upper teeth, it's not in a long axis. We have to do is we have to have a ferrule around the tooth. We also want to maintain as much tooth structure as possible. If you look at when rotary endo first came out that we use in very wide files or 08’s, 10’s, 12’s in diameter in order to basically blow at as much cervical tooth structure, they weaken the tooth and that's basically why it broke. We’ve moved in the direction we’re using 04 and 06 tapered files, we’re maintaining as much cervical tooth structure as possible to maintain a stronger tooth or a base as we can. The question is when do we use post, when do we not use post? I still use post, I use fiber post. I don’t use them all the time.

 

 

If I have let's say a tooth that has just a filling and a [closal 00:48:30] filling and both marginal ridges are intact, I will just fill it up with composite when I’m done with it and that's it, I’m done with the restoration. If I’m missing one or more marginal ridges, I’m putting a crown on that. I’m not a big believer, inlays I think act like a wedge in a piece of wood. Onlays you can do but the cost of having onlay labwise versus a crown is about identical, so I’d rather put an all-ceramic crown on the thing and really hold it together. When do we use post? If I’m missing enough tooth structure that I really need to retain that core better, we have to realize the post only holds the core in. It really I don't think strengthens the tooth very much. If we put a post in there, a fiber post we’re able to bond to it.

 

 

Now what I believe, even though these posts are silanated when we get them from the manufacturer, you really need to resilanate them to get a better adhesion to it because what happens is your resin cement is only going to stick to the resin part of the post, not the glass fibers. What we do is I silanate it, I put an adhesive on it, I light cure that now I have a better bondable surface. I like to use a self-etch resin cement like Panavia is a good example. I place that into the post prep, I make sure my post prep is not bigger than the final endo file I used so I’m not blowing up more tooth structure to get a post in. I’m multi canal teeth, I’m putting one post to each canal to really pin that core in, and I’m basically then bonding everything in using adhesive dentistry, then putting a crown on top of that. Now if we get to what [Carl 00:49:59] said about cement, I have to agree with him …

 

Howard:

I’m sorry, you didn’t name what type of resin post. You mentioned the cement was Panavia, but what brand of the resin post?

 

Gregori:

There’s a lot of good posts in the market. Most of the companies, tapered fiber posts are tapered fiber posts. I don't think there’s a lot of difference between company to company. GC makes good posts. There’s a lot of different companies that make good fiber posts, there’s not a lot of difference. I haven’t used a metal post in years. The reason for that is when you overload a tooth with a metal post the stress concentrates at the tip of the post, that's when you fracture the root. When you have a fiber post and you overstress it, they tend to break coronally up above the cervical, so we can restore that tooth by putting a bigger post in if we need to. I’ve seen a lot of failures with metal posts.

 

Howard:

Just one question, if that root canal failed and you sent to endodontist, what's he think about the metal post versus the fiber post to try on a retreat. Does that factor in to …

 

Gregori:

Well, usually it's a metal post and the tooth fails, usually you’ll extract the tooth because it fractured a root. Where I haven’t really seen any fiber posted teeth fracture roots.

 

Howard:

Can like …

 

Gregori:

I’ve seen [crosstalk 00:51:10].

 

Howard:

I’m sorry, I mean can the endodontist get that fiber post out or?

 

Gregori:

Yeah, the restorative dentist can. All you do is you take a pointed diamond and you go down the center of the post a little bit, then you start working hand files down. Because you've got to realize a fiber post is parallel fibers of glass, so all you’re doing is working down between those fibers till you get past the post and you laterally widen it to remove the post. It's not that hard to get fiber post up.

 

Howard:

Okay. Then you were going on next.

 

Gregori:

Well, what Carl was saying about cements and everything, I have to agree. When I first started implant dentistry, everything was screw retained, and then basically everything moved into [inaudible 00:51:54] retained because they didn’t have a lot of techs that were really good at doing screw retained and general dentists wanted something that was easy that was similar to crown and bridge on natural teeth so that's the direction they moved in. Then when we started doing a lot of immediate loading, we moved back to our screw retained stuff. I’d say probably 90% to 95% of my implant restorations are screw retained. Part of the problem with that is I don’t want cement down in the sulcus which I can’t see. Using cements like Durelon, zinc phosphates, and stuff like that worked very well.

 

 

We can’t see those in the x-ray, we need retention with our implant crown, we don’t need as much retention as with a natural tooth because usually the walls are a lot more parallel so we get better retention. We really don’t need to use really strong resin cements. God forbid, I’ve got to take that crown or that bridge off, if I use a resin cement I’m not getting it off, I have to cut it off. If I use Durelon or another cement like that, they’re not as retentive, I can tap that thing off and do whatever I have to, maybe tighten the screw in the abutment head or whatever. Because even with torque wrenches screws get loose.

 

Howard:

How big a problem is screws getting loose?

 

Gregori:

I think we still see …

 

Howard:

Or where you've got a patient on your schedule. I mean …

 

Gregori:

Well, I think we still see it occasionally. I think a lot of this probably is occlusion related, because you basically you tighten it down with a torque wrench, you say, “I know that's tight.” Then the patient comes back a couple months later and says, “Something feels loose.” I have a screw retained implant crown in my mouth number 31 and every couple of months it gets a little bit loose. My friend tightens it down with a torque wrench and everything’s fine but I guarantee I chew ice, I do other things, I’m hitting it at really weird angles and it eventually gets it loose. Even if you check the occlusion it may get loose over a period of time. One thing that we really ignore with implant dentistry is we check the occlusion when they come in and we put their prosthetics in, and then we never check the occlusion again.

 

 

We really should be every recall checking the occlusion because things change. Things shift, patients start biting a little differently, so we want to basically keep maintaining the occlusion pattern that is ideal for that situation and we need to check that periodically.

 

Howard:

Greg, why do you think my mom says I have a screw loose but I don’t even have an implant? I don’t …

 

Gregori:

Well, I’ve known you for years and I’d have to agree with that.

 

Howard:

I don’t have a cemented or a screwed retained implant, I have neither. You just opened up another can of worms, you said the word occlusion. I swear to God when you're on Dentaltown the occlusion debates go around the clock since 1998. The big occlusion deal now is neuromuscular or classic Pankey Dawson occlusion. Do you have any thoughts on that?

 

Gregori:

I’m more of a Pankey follower than I am a LBI follower. I think that …

 

Howard:

Well, that just gives away your age. All that means is, I agree, that just means that we’re in our fifties or sixties.

 

Gregori:

Yeah, yeah, I guess so. I think that patients have occlusal patterns that some of them are not pathologic. I had a patient came in to me some years ago and she was an upper lower partial and she said it was the most uncomfortable thing she had ever worn. They had just made it for her and they basically using neuromuscular got her into a bite pattern that she said didn’t feel comfortable. It's like she basically was very eccentric in how she bit. I made her new partials and I’d made her in the bite that she was comfortable with and she said, “This was perfect. It felt comfortable, it felt natural.” We have to look at those things and I think that the neuromuscular people put too much emphasis on that stuff that it works in some situations.

 

 

Nothing works in all situations, so we have to have lots of different tools in our toolbox. I don't think that controversy is ever going to go away. You going to get two schools of thought, they’re never going to agree on what one principle is.

 

Howard:

You opened up another can of worms, you said partials, and I drove three hours south of Phoenix to Nogales, Mexico which has the largest partial past frame. There are a lot of labs. A lot of times you think you send this partial up the street and this man’s making in your lab, but a lot of these end up in Nogales, Mexico, where they do 1,000 per day. You go in there and these lab guys have worked there as long as I’ve been in dentistry, 30 years, and when 1,000 partial impressions come in, 9 out of 10 don’t have one rest seat cut, nothing, it just says partial. What are your thoughts on that, 9 out of 10? I’ve seen this with my own eyes. What would you say to that?

 

Gregori:

Well, I think it really comes to how you were taught in dental school. I was taught that we were prepared … we had actual wax and cast on partial frame so that was part of it, we were taught to do our rest seats and everything else and to specifically state on the lab slip this is where I want to rest, this is where I want to clasp. I find that a lot of dentists just take an impression and just send it to a lab and say make me a partial and no regard to exactly how the design is. Now you have people that are maybe, you know, don’t have a lot there. Waxing and casting [stuff 00:57:05] but they’re not really well trained dental technicians that are basically going to just, I’ll design it the way I think it should be, and they really don’t have that training. I think that we have to take a more proactive stance in how we’re designing these things.

 

Howard:

I’m on the lookout. I want to find someone that will build me a course on just partials because the lab techs at the other end they throw out their hands like, well, what do they want me or how come, you know, that no rest seat, I mean couldn’t they just taken a football and made a rest seat. If I put a rest seat here it's going to occlude the other tooth. I think it's a real issue.

 

Gregori:

Where I find it's funny when lab techs tell me that ones that are based in U.S. that a doctor sends them something and says, “Make me a partial. Put the rest seats where you think they should be and I’ll modify it in the mouth on those teeth to fit it.” Now what you’re going to do is you’re going to try to get rest seats to be the same shape in the mouth when you go to deliver it. It's kind of backwards and it's really a lazy approach. Better to construct those before and take the impression, now you get something that intimately and perfectly fits that arch. It's a challenge with partials.

 

Howard:

It's fun being out 30 years later and looking at all the prediction went wrong because they literally like told us in ’87 that partials and dentures were just going to go extinct. When you look at the number of units of partials and dentures it's actually increased significantly in the last 30 years and they said it was going to go to zero. Another thing they predicted in ’87, I walked out and bought my first Cerec 1, that their labs were going to go extinct and it’ll all be CAD/CAM. The labs did go from 15,000 to 7,500, but it seems to me, well, what’s your status on CAD/CAM? Do you think in 30 more years labs will be gone? We’ve gone from 15,000 to 7,500, do you think that's linearly or do you think it's a pendulum, it’ll swing back? What is Greg’s view on a CAD/CAM versus an impression and send it to a lab?

 

Gregori:

Well, first of all we’re seeing more partials and full dentures, and I think that the direction before the economy tanked in 2005 was we were seeing fewer because people had more and more money and they were willing to go for implants and stuff like that. Then the economy tanked and people start saying, “Well, I can’t afford $30,000, $40,000 for implant restoration so I have to go with something less expensive.” Then they start moving back into full dentures and partials. The economy is still kind of teetering, up and down a little bit so people are not spending what they thought they were going to spend. As far as labs go and CAD/CAM, I find that most of the labs these days are using CAD/CAM in the lab versus nobody is waxing and casting anything anymore.

 

 

Of course a lot of restorations have moved to monolithic zirconia, so they’re basically using it after that. If you look at a lab the biggest expense they have is labor. If they can decrease their labor they can make more money and actually charge a little bit less and do more restorations to draw more customers in. What happens is we can train somebody who is just graduated high school or college or likes to play video games and train them how to design these things virtually on the computer, and then meanwhile I mean we’re paying them less than we have to pay a trainee technician who’s going to wax and cast something. I think the direction has moved in that direction. As far as in-office, I don’t have in-office CAD/CAM, so …

 

Howard:

You don’t have a Cerec?

 

Gregori:

No. Just I don’t have one in my office. I want to look at something and say, this is best material I think for this particular tooth, and I find that a lot of people who have Cerec to make that lease payment, everything has to be a Cerec restoration, and I don’t want to basically do that. I think the price has come down considerably and I think that it's moving in the direction. I don't think it's ever going to replace, like they talk about intraoral impressions, that’ll never replace in our lifetime regular impressions. Because you’re going to get maybe the upper 50% of dentists are going to say, “Yes, I’m going to go for this.” The bottom 50 are going to say, “I can’t afford this because I can’t charge enough to make the payments on this.”

 

 

I think we’ll still see impression materials, I still think we’ll still see stuff going to the lab and having them do stuff. I think that we’re going to see the labs move more and more in the direction of CAD/CAM because it's just easier them, they get more consistent results this way. They’re able to turn things around faster. I think that's the direction things will keep going.

 

Howard:

I’m sorry we’re out of time, we’re already one minute. Can I go overtime with you on something?

 

Gregori:

Yeah, go on as long as you want.

 

Howard:

We said that when you go to a lab that does 1,000 partials a day, 9 out of 10 don’t have a single rest seat, just says, upper partial. There’s 5,000 periodontists in the United States and every one of them tells me that 10% of the dentists do 90% of the crown lengthenings. What's your thoughts on that? Is crown lengthening, has the market spoken, it's really not necessary because some of these older dentists will you, well, you know, if it invades a biological [I mean where 01:02:27] that's going to do crown lengthening itself. It’s going to be puffy and bleedy for a year then the bone will recede and the crown will lengthen itself. Other people say that's crazy. What's your rant on that, crown lengthening?

 

Gregori:

I’m glad you brought that up.

 

Howard:

Really? That's the second time you said that.

 

Gregori:

I don’t believe in osseous crown lengthening at all.

 

Howard:

You what?

 

Gregori:

I don’t believe in osseous crown lengthening at all and the reason is that if I have let's say tooth number 4, these osseous crown lengthening, I have to remove bone from 3 and 5 too in order to get a general ramp that's going to maintain itself. The problem with that is I’m compromising two more teeth to save that one tooth. In the days of implants now where we could do certain things so readily and easily and more predictably, why not just take that tooth out and put an implant in, then I don’t have to compromise the other two teeth. In some cases hyper orthodontic or [hyper op 01:03:20] that tooth to bring up more root if the root is long enough so that we can now basically get the ferrule we need to be able to put a restoration on it. I really am not a big believer in osseous crown lengthening at all. I think we’re seeing less and less of that being done because of implants being as predictable as they are.

 

Howard:

Okay, my final question, let's say 9 out of 10 people who email me howard@dentaltown.com about the show, whatever, they’re just probably within five years out of school. Ryan and I just went and talked to the local dental student chapter last Saturday or Sunday. I want you to weigh in, I’m going to throw a bunch of questions at you and just give me your opinion. Some of them are scared. They got $300,000 to $400,000 in student loans. Some of them think that 25 years from now we’ll all be working at McDental’s, we’ll all be working for corporate dentistry. They got $300,000 in student loans, when they grow up they want to be just like you. They’re asking what direction? I mean you got your AGD, your AAIP, your ACD, your ICOI, I mean you got every damn diplomat fellowship known to man.

 

 

You are old enough to have a child walking out of dental school. What would you say to your own daughter if she walked out of dental school today with $350,000 and said, “Dad, am I just going to be working for a chain? Are the golden years back in the seventies and eighties when you and Howard got out of school? Did I screw up becoming a dentist with 350,000?” That's my question? Greg, did I screw up graduating dental school with 350,000 student loans? Where do I go now? I’m 25 years old.

 

Gregori:

I think the days of opening your own practice cold are long gone. I think that there the best approach is, and I don’t really think corporate dentistry is a good approach for the average dentist because you’re basically working in a mill where you have to crank things out as fast as possible as much as possible. I think going and working for somebody who’s an associate, finding somebody who let's say says I want to retire in the next five to six years. I want to bring somebody in and over a period of time get them up to speed and transition the practice so you’re buying the practice over a period of time, I think that's an ideal situation. It's funny because a friend of mine’s daughter she graduated a year ago, she wanted to go into oral surgery.

 

 

He’s a dentist, she wanted to go into oral surgery. She’s doing a one-year IV sedation residency. She got accepted into a perio program. I kept telling him, “Tell her to just be a general dentist. Send her to CE and let her do this stuff.” These days general dentists do so much, there’s not a lot of reason to become a specialist anymore. General dentists are doing more endo, more ortho, more other procedures, implant placements than a lot of the specialists are, so why spend another three or four years and more money to become a specialist when you could take CE? The problem is you graduate with a $350,000 debt you can’t afford to take a lot of CE. Areas like Dentaltown where you can pick up knowledge and it really doesn’t cost you anything or cost you minimally is really the way to go.

 

 

When we graduated dental school, you and I, we had a license to practice dentistry. Well, things have changed, techniques, materials, everything has changed so much that you now when you graduate have a license to learn dentistry, because they can’t teach you everything there is in dental school in those four years, you really have to take CE in order to really build up your knowledge base, and you also have to realize that it's going to take a while to build up your speed and stuff, that you’re not going to make a fortune when you get out of school. When I was teaching at Maryland, it was interesting, I talked to the seniors getting ready to graduate and I said, “What are you expecting?” They said, “$90,000 a year, four weeks paid vacation.”

 

 

I went, “What, are you … you’re not going to produce $90,000 worth of dentistry your first year, how are you going to get paid that? You don’t understand, you don’t get paid vacation time. You’re on a percentage of production. You take a day off or a week off, you’re not making any money.” They don’t understand that. When we lectured, at least when I graduated, you made like 40%, 35% of whatever you produce working for somebody, and at the end of the year you had $35,000 you made and you thought you were a king. They don’t understand that. They figure, I’m a doctor now, I should be making big bucks. They don’t understand that things have changed. You have to really produce in order to be able to make any money. I don't know if you’re finding the same thing.

 

Howard:

Well said. Well said. Greg, seriously I’ve been to so many of your lectures, your courses, I’ve been your biggest fan my entire career. I just want to thank you. You have 1,000 posts on Dentaltown. Thank you so much for all that you've done for dentistry, thank you so much for all that you've done for Dentaltown, and thank you so much for spending an hour with me on Super Bowl Sunday.

 

Gregori:

Sounds great, thank you for having me.

 

Howard:

All right, Greg.

 

Gregori:

Don’t forget the article next month on Perio Protect.

 

Howard:

All right, fantastic. All right, take care. Bye-bye.

 

Gregori:

Bye-bye.

 

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