The official Blog of www.PasadenaPeriodontics.com

2012 year of collaboration!

2012-01-25T11:22:00.000-08:00

This year's theme for our practice is collaboration.

This concept in dentistry is evolving as the role and depth of each specialty change over time. The term "interdisciplinary dentistry" connotes the same thing except it makes me picture the patient being passed from specialist to specialist and sometimes getting lost on the way back to the dentist.

To get the best results in dentistry today a team approach is needed. This doesn't mean each patient is being seen by each specialist, but that the best of each specialty's deep knowledge is being used when developing decisions.

From a periodontist's perspective there are 3 key disciplines that are considered to create the best treatment: periodontics, prosthodontics, and ortho. When a case is seen through the unified vision created by these three perspectives on treatment it leads to planning that is truly A to Z.

Here's our first meeting for the year: Feb. 22, 2012.... talking about abutment selection in posterior implants.

Periodontitis treatment without cutting and sewing?

2011-12-03T20:57:00.000-08:00

Just got back from 3 days of intense training with the LANAP protocol. This is a way to treat gum disease with equal or better results than regular gum surgery, without the side effects of pain, long-term sensitivity, and lost tissue. The secret sauce is a laser that is specific for treatment of gum disease.

The LANAP protocol is another way we are practicing the best in periodontics in Pasadena, CA....

I can't wait to reveal the whole Smile for Life protocol that is in place in our office...we will be talking about this on Weds in our Holiday CE course!

Sneak peek at a section from "The Book of Periodontal Diagnosis and Treatment"

2011-11-29T20:28:00.000-08:00

Here is a draft from a section in my book about periodontics for patients... obviously there is still too much jargon, but here's the work in progress...

Periodontal disease is present in almost all adults over 40. The main way of measuring periodontal health is through measuring the periodontal attachment to the tooth. Periodontal probings combined with recession measurements gives the overall attachment to the tooth. We also look for bleeding as a sign of inflammation in the tissue. Although bleeding does not correlate very well with active bone loss, repeated bleeding of the same site over multiple visits can be a sign of periodontal pathology of some kind (calculus, deep restorative margin, root fracture etc). The critical probing depth is 4mm. This means that any area 4 mm or less would lose attachment when root planed, whereas scaling deeper than 5 mm you can expect an improvement in attachment level. In general, probings less than 5 mm should be treated by non-surgical scaling and root planing. When a patient has generalized 5 mm + probing, the traditional treatment is to do scaling and root planing, allow 4-5 weeks for initial periodontal healing, and then reevaluate whether surgical therapy is needed for remaining pockets.

Usually careful scaling and root planing results in reduced probing depths, and avoids the need for surgery in many sites. Periodontal surgery has 3 goals of therapy: thorough cleaning of roots, removal of granulation tissue, correction of anatomic tooth and bone defects (either by recontouring or addition of bone), and creation of cleansability. Briefly, periodontal surgery consists of reflecting the gum tissue away from the neck of the tooth to see the bone and root surface. When inflammation is present, it creates unorganized scar tissue that needs to be removed. The underlying bone is examined to see if a bone graft might build back lost bone, and any rough or irregular edges are smoothed. Finally the soft tissue flap is adjusted to create a new seal around the teeth. There are 2 general approaches to periodontal flaps: resective and regenerative. Resective flaps remove some tissue and bone to enhance cleansability, but may cause more sensitivity and more tooth to be cleaned. Regenerative flaps seek to regrow lost parts of the periodontal tissues: bone, periodontal ligament, and cementum, and result in less recession and sensitivity, but require more costly materials.

A recently introduced laser-enhanced periodontal therapy combines the scaling and root planning steps with a laser surgery. This therapy is called LANAP (Laser Assisted New Attachment Procedure), and data from 7 years of documentation shows very promising results. In this protocol a specific laser is used to remove diseased tissue and bacteria in the periodontal pocket wall. After the laser removal of diseased tissue, the tooth roots are cleaned with ultrasonic and hand cleaners. Finally a fibrin blood clot is induced with the laser. This protocol achieves the pocket reduction of traditional periodontal treatment, but instead of recession and tooth sensitivity, there is regrowth of bone, cementum, and periodontal ligament onto the previously disease surface. It is much less invasive because there is no suturing and no gumline incision. Patients like it because it is more comfortable, and a one-stop solution. I like it because we can treat in 1 step instead of 2, fewer negative side effects, much more confortable, and it allows me to get my patients back to regular dental care sooner.

In our practice we embrace the move towards less invasive, more comfortable periodontal treatment. LANAP and regenerative periodontal surgery represent clear advances in periodontal treatment. For more information, please contact the office for a treatment discussion and exam.

Mustache month for men's health!

2011-11-16T10:49:00.000-08:00

At the risk of scaring off patients, I'm growing my mustache during November to raise awareness for men's health. Did you know:

*1 in 6 men will be diagnosed with prostate cancer in their lifetime
*A man is diagnosed with prostate cancer every 2.2 minutes
*1 in 2 men will be diagnosed with cancer in their lifetime
*24% of men are less likely to go the doctor compared to women

Why mustache? Think of the manliest men in history: Burt Reynolds, Tom Selleck, Salvador Dali (?), etc. A properly groomed mustache is the height of masculine. The picture above is my wife and I from my 2009 holiday mustache party, but 2011 will be even better.

Sonicare Diamond-Clean

2011-11-09T13:16:00.000-08:00

I met with the representative from Sonicare today to see the latest and greatest. I've used and recommended sonicare for years.. very thorough but gentle. The new diamond-clean sonicare is the next generation toothbrush. High on style, it looks like the lovechild of Apple and the old-Sonicare. Bristle design is new, with more bristles. Early data shows it may clean more efficiently...TBD. Check it out...

http://www.sonicare.com/professional/dp/OurProducts/DiamondClean.aspx

Seeing periodontal disease in 2012

2011-11-07T14:23:00.000-08:00

To be frank, periodontal disease measurement is fairly limited. We use a probe to measure the attachment of gum to the tooth. We check to see how loose teeth are. We look at x-rays to see the position of bone around the teeth. Now there are 2 technologies that allow us to look at periodontal disease in real-time:

1. 3D x-rays: Dental CT scans see bone and teeth in real-time vs. a 2D x-ray that shows the accumulation of bone loss or decay. 3D xrays show us the exact location of infection, the exact anatomy of the bone. This allows very precise diagnosis and no guessing.

2. Bacterial DNA testing: the cause of gum disease is bacteria invading the gum tissue and surrounding bone. However, did you know that 99% of the bacteria in the mouth are normal residents? There are a few species that are clearly pathogens causing the majority of bone and tissue destruction in the mouth. Previous methods of detecting which bacteria are present was very tedious and difficult. Now we have a simple test that detects the DNA from specific bad bacteria. We test 2 times: at baseline, and after our first stage of treatment to ensure that we are getting the microbiological result we want...elimination of bad bacteria and cultivation of the good.

To paraphrase a mentor of mine Daulton Keith " What you can see, you can do!"

Another gummy smile case...

2011-11-03T22:01:00.000-07:00

Check out the difference on the 16 year old girl who had just gotten braces off. We timed the surgery so the gums would be back to normal in time for a school dance...

3 tips from your periodontist to keep your teeth...

2011-11-01T21:40:00.000-07:00

Three things that benefit almost everyone:

1. Don’t forget to floss! Most gum disease starts between the back teeth where cleaning can be more difficult.

2. Choose morning or night to do a super daily cleaning: floss first, then brush for 2 minutes, and finally rinse with a gentle anti-septic or fluoride rinse.

3. Invest in an electric toothbrush. For most people an electric brush gently cleans the teeth and gumline more thoroughly than a manual brush.

Gummy Smile no more.

2011-11-01T20:17:00.000-07:00

Did you know that underneath extra gums there are beautiful white teeth? Here is a classic case of a young woman ready for her first post-college job, and wanted whiter teeth. Her astute dentist knew that they key to her smile makeover was not just white teeth, but proportioned teeth.

We did lengthened the teeth with a combination of a laser and microsurgical bone reduction. She reported taking 2 doses of pain medicine and couldn't stop smiling.

A true case of Tooth in a Day

2011-10-31T10:36:00.000-07:00

You hear implant-tooth-in-a-day advertised on the radio and TV. Is it hype? Most of the time yes. However there are times when we can remove the tooth, place the implant, and place a temporary the same day...usually in the front of the mouth. Here are pictures of this case sequence:

Picture 1: Pre-op. The front right tooth looks OK, but is actually cracked in half due to a problem with an old root canal.

Picture 2: The broken tooth

Picture 3: The temporary tooth on the implant 2 weeks after the tooth was removed

Picture 4: The final crown on the implant

What's up with $399 Dental Implants?

2011-10-31T08:40:00.000-07:00

(Above: failed implants referred to our office for removal...all implant knock-offs)

Squeezed between billboards promoting weight loss surgery and new cars I recently spotted an ad for $400 dental implants. Radio also has numerous promotions for tooth-in-a-day or walk in with teeth, walk out with implant teeth offers. This makes for a market that creates confusion for patients and would-be consumers of dental implants. This post will dissect the $400 implant.

Implant Quality: There are dozens of dental implant companies that sell implants in the USA. However many of these companies are copies or "clones" of othe successful implants. Since these smaller companies do very little research or development, they are usually 1-2 generations of implant design behind the major companies. In the many implant complication cases referred to us, we have seen a higher rate of problems in the "clone" implants...even though they look very similar to the major implant brands. An additional concern is that as smaller implant companies come and go there is a risk of being able to get parts compatible with these numerous implants. To summarize: I would not put a clone implant into my dear mother (no research, no track record, little data... no way!). To be clear, innovative companies that approach implant dentistry responsibly with research and education provide quality and service are doing very well, while implant companies that compete only on price are not a good fit for our practice.

Peek behind the price curtain: The major implants retail to dentists for $320-400 depending on the brand and specific implant. Some of the clone companies (most from Korea, Israel, USA) are selling for $150-200 / implant. The discounted implants are discounted, but have some higher risks as above.... would you want a discounted hip or knee implant? How would you feel if your dentist was charging you the regular price and giving you a cheap implant knockoff? The consumer needs to know that all implants are not created equal, and they should ask what brand is being used at a particular office.

Here are some implant companies that have a good track record and lots of data: Zimmer Dental, Straumann, Biomet/ 3i, Keystone, Biohorizons, Astratech Dental Implants, and Nobel Biocare.

Keystone Dental Meeting was great!

2011-10-26T07:03:00.000-07:00

Keystone meeting summary - Boston, MA

Well friends I am returning from this weekend in Boston a changed man. This 2-day meeting was sponsored by Keystone Dental, and featured Dennis Tarnow, Stephen Chu, and Monish Bhola. The education was cutting edge, and I am changing some implant protocols as a result. Over the next couple weeks, I’m going to summarize the top pearls I brought home.

Let me just comment a little on Keystone as a corporate personality. As implant companies go, they have a much larger footprint than their actual size. They have almost successfully jettisoned the lifecore legacy implants renova, stage-1, and prima. Prima will be the second tier implant until people try and convert to Genesis. The company’s CEO is a likeable, down to earth Frenchman Pascal Guinn who is an engineer by training, and seemed as into the course content as the rest of us.

The strategic alliance with a few noted clinicians Tarnow’s group and the Nevins group are going to help extend the brand exposure quickly to North America and the Europeans that contribute the COIR and IJPRD journals. The coprporate henchman at the private equity group Pincus Warburg have allowed Keystone to grow in the poor economic environment while other implant companies are taking bridge loans or being bought up by other dental suppliers. So I’m inclined to like Keystone’s start-up approach to the industry. They are not shy, and are making waves in a crowded pool…some of those waves are from the heavyweights that are struggling to stay afloat in lean times.

Zimmer Soft Tissue Graft Video...my case

2011-10-24T15:28:00.000-07:00

Check out this video that Zimmer produced and is distributing globally. I provided the case and helped direct the illustrations by Zimmer's great graphic design team. I think it's an accurate, brief example of how we do soft tissue grafting....

Ending recession!

2011-10-24T14:43:00.001-07:00

I can confidently say that I can end most recessions...(the gum kind) in one of 3 ways:

1. Lowering the existing gumline to its previous position. This is great because it is minimally invasive. Most of the time we need more thickness of gum tissue, which requires adding gum thickness. That leads us to our 2 other options..

2. Connective tissue graft: see previous posts for before and afters. Keep in mind that although we are transplanting gum tissue from the hard palate to the recession area these surgeries have very little discomfort... especially compared to old-timey periodontics

3. Gum graft substitutes: I use Dermis allograft on cases with extensive recession, or for patients that are hesitant to have the roof of the mouth affected. The other material available is Dynamatrix, a special growth membrane made of collagen that can promote gum growth.

To finish up with this post... look at the case above and tell me which technique did I use? This is an almost perfect result, and was accomplished with Dermis. Thanks for reading.

San Gabriel Valley Dental Society

2011-10-24T09:02:00.000-07:00

SGVDS Summary

Tuesday night was an opportunity to hear from one of my first surgical mentors, Alan Felsenfeld. He presented at the San Gabriel Valley Dental Society to a packed house. He covered “peri-operative” patient management. The really practical standpoint that he presented can be summarized by a couple pearls:

· Know your patients.

· Have good reference materials like drugs.com to refer to the zillions of medicines patients are taking

· Antibiotic prophylaxis is still very confusing, but defer to MDs when requested. However most antiobiotic prophylaxis is not evidence based.

· No epi for pregnant patients (2^nd trimester of course! And only necessary treatment + prophies)

· Pain management is accomplished day 1. This is why our patients are given their first pain medicine dose close the the end of the appointment, and are encouraged to dose at regular intervals for the first 2 days…don’t wait til it hurts!

Connective Tissue Grafting regenerates new tissue over recession!

2011-10-18T22:41:00.000-07:00

This is the result after connective tissue grafting the significant recession on this canine. The important take-aways from a case like this are that even significant mid-root recession can be covered. Doctors often question what a successful graft probes after healing. Well if you look at histology you find new connective tissue fibers connecting into the root surface. The probing is like a healthy sulcus 2-3 mm. Note the nice new band of keratinized tissue...where only mucosa existed before. Try that with a free-gingival graft. This nice woman took pain medicine for 2 days...which is about normal for a 1-tooth gum graft. Next I'll show some dermis graft results.

Not your Aunt Mabel's gum graft...

2011-10-16T16:07:00.000-07:00

This is a nice 2 week result from a connective tissue graft. The patient is 17, and you can really see the quick healing after minimally invasive gum grafting. The patient reported taking extra-strength tylenol for 2 days...then she was back to usual club soccer and full time highschool life!

Gum grafting is so much easier on patients with my combination of new techniques (less invasive and more effective), technologies like PRGF, and sedation if needed. No more Aunt Mabel lost 15 pounds after her gum graft stories.

This week feels like a good week to detail the difference between the different gum grafting techniques, so look forward to gum grafting blogging.

---Joel Henriod

Implant Spacing Diagram

2011-10-12T09:51:00.000-07:00

Here is a diagram I created in 2009 to simplify what the research says regarding implant spacing. Here’s the method behind the numbers:

7 mm: occlusal space minimum. You need room for abutment axial height and restorative materials.

1.5-2 mm: tooth to implant. This spacing is necessary for bone health

3-4 mm: implant to implant: space for cleansability and bone maintenance. Remember there is limited papilla between implants..

2 mm: implant apex should be at least 2 mm away from neurovascular bundles!

Osteohealth – Geistlich Bombshell

2011-10-11T10:06:00.001-07:00

The rumors from a week ago were confirmed this morning as I received an email today which informed me that Geistlich is firing Osteohealth as distributor. It looks like Geistlich wants to go direct to dentists instead of using a distributor.

In my opinion this may be the beginning of the end for Osteohealth. Here’s why:

· Gem-21: Innovative product that is very expensive at full price, and is a niche product used in only 10-15% of my bone grafting cases.

· Mucograft: Innovative membrane that may be used as alternative to autogenous free gingival grafts. However the material is delicate and “technique sensitive” (read hard to use). I’d rather stick with proven Dermis or autogenous tissue

· RTI’s Colla-products sold as Heli-plug, cote, tape etc. are now commoditized within the market. Take your pick and buy from Zimmer, Ace, Salvin, Osteohealth, etc.

Here’s what Osteohealth needs to do: Fight the court battle. However, if someone doesn’t want to do business with you you can’t force them. I would immediately look at rebranding a similar product line of sintered xenograft (Nu-oss). I would look at rebranding some membrane products like the identical membrane sold as RTM collagen (Ostegenics) or Mem-Loc (Biohorizons), or rebrand the RTI product sold as Biomend (Zimmer) and Ora-mem (Salvin). That’s a lot of work to pick up a portfolio that doesn’t distinguish you from anyone except the use of Gem-21 and the new Sprix.

Another option is to look at some novel biologics in spine and orthopedics and try and bring it to dental. Time and FDA intensive while the company is on life-support.

Here are some more risks: the sales force could easily be eaten up by other companies that are in growth mode, or looking for a sales force that can speak dental (hello Medtronic). The litigation could choke off sales of the main product line until the company runs out of money. There are a lot of bad scenarios.

The strength of the company is in its relationships with surgeons and dentists around the country…leverage these relationships for a chance at survival. Osteohealth needs to look at their core identity and figure out who they are without Geistlich products...this should also serve as a warning to companies that depend on licensing someone else's product for 90%+ of sales. Very vulnerable position.

The management needs to move fast, or there won’t be an Osteohealth left soon.

Pikos course summary

2011-10-11T08:59:00.000-07:00

Dr. Miller and I had the opportunity to attend a bone grafting seminar with Michael Pikos in Tampa, Florida a couple weeks ago. It was great to spend 3 days in live surgery and lecture with a man I consider a close mentor. We’ve spent time at various seminars and in cab rides to and from meetings, but this was a front row seat on how Pikos has such an incredible track record of success and safety. I recommend his continuum to any dentist, oral surgeon, or periodontist who is ready to take implant treatment planning and bone grafting to the next level. Here is the website: http://www.pikosinstitute.com/

A couple pearls we brought home:

· A great antibiotic cocktail for sinus grafts

· Tricks for hemostasis

· Expanded uses for our PRGF protocol

Pasadena Periodontics Blog Relaunch!!

2011-10-10T20:43:00.000-07:00

This blog is our way of reaching out and making showing cases, summarizing courses we give, and being a good citizen in our local dental community.

Last week was full of teaching and CE:

Monday - Zimmer University. I spent the afternoon in Carlsbad training new Zimmer reps on regenerative materials in dentistry. We explored bone graft materials, membranes, biologics, and the myriad techniques available for ridge augmentation in dentistry today. The Zimmer Institute set-up proved once again to be an amazing way to teach dentistry. I've done about 10 courses there, and it is very streamlined. Here a schedule of courses at the Zimmer Institute http://education.zimmerdental.com/zi.aspx

Tuesday - Terri Oto from RTI biologics. Terri went through each RTI product that Zimmer carries: puros, copios, and dermis in EXHAUSTIVE detail. By the end I was saying "Uncle!, I won't even think of using another biologic..." Clearly the tutogen process is the gold-standard, and I trust my patients with this responsible and meticulous company. Read here about RTI and tutogen : http://www.rtix.com/safety/sterilization-processes/

Wednesday - Ziv Simon @ the Burbank Dental Lab Advanced Training Center. This evening lecture is the fourth in a series of five. I'm priviledged to participate with the other 2 faculty, Dr. Vahik Meserkhani and Ziv Simon. Ziv taught hard and soft tissue augmentation in implant therapy. Meticulous photos and cases, and waterproof rationale. Check out the remaining courses at the ATC http://www.atccourses.com/index-4.html

Thursday - Salt Lake City Evening Program by ME! I spoke to a group of 30 oral surgeons, periodontists, and GPs on advances in bone grafting. There was a clear excitement regarding the curV membrane that Zimmer launched last month. We have 7 cases since we began with the early market launch of this unique membrane. More on the curV in another post.

For some reason the week was full of Zimmer events. Wierd how the chips fall. This month I look forward to another packed house in our CE series in the office Oct 26, and a visit to Boston for a 2 day course with Dennis Tarnow....