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VIDEO - Dennis Smiler - HSP #79
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Knowing how to perform a
certain task really well is not enough to be considered a master. To
master anything, learn the theory first and then the practice.
Dr. Smiler graduated from the University of Pennsylvania, School of Dentistry in 1964. He attended Boston University, Graduate School of Dentistry, earning a Masters of Science degree in 1968. Following an oral surgery internship and residency at Roosevelt Hospital, New York, he returned to California in 1969, establishing his oral surgery practice. Dr. Smiler has published numerous articles in dental professional literature and contributed to periodicals and text books. He lectures extensively and participates in symposiums both domestically and internationally at universities, academy meetings and implant conferences. He maintains a private practice in Encino, California.
www.smiler.net
(818) 995-8601
Dr. Farran: It is a great honor today to be interviewing a legend, Dr. Dennis Smiler. We're both here live at the 11th Annual MegaGen Symposium in New York City at the Grand Hyatt. This is fantastic. Thank you so much for giving me an hour of your time.
Dr. Smiler: You're welcome.
Dr. Farran: You have every honorary thing I know. You're an oral surgeon. You're a diplomat of everything. I want to add to your question. This is late April. Next month 5,000 kids are going to graduate from 56 dental schools in the United States. They know that implants are exploding. Should they be thinking about adding the placement of implant to their curriculum? If they're 25 years old, should they be thinking some day they'll be placing implants like you? What advice would you give them?
Dr. Smiler: I think it goes without doubt that they're going to be placing implants. The future of doing implant dentistry really rests with the general practitioner. The proviso to that is that you have to have that general practitioner that stays within their comfort zone and stays within their experience level. If you've interviewed people like Jack Krauser or Mike Pikos and those of us that have started doing implants back in the late '70s, there were times we went to meetings where people wouldn't sit with us because that was voodoo.
Now this has become the the sate of the art. The problem is that in most dentals schools, you get a smattering of a little education in this, a little education in that. They train you 90% of the time for what you might do 10% of your time in practice. My advice to a young graduate is to pick a few post-graduate courses for the academy meetings and gain the experience replacing implants. When they do, they should stay within that comfort zone.
Dr. Farran: Be more specific. If you just graduated next month for the last 5 year sand you said, "Some day I'm going to place my first implant," where exactly, specifically would you start?
Dr. Smiler: If I'm just graduating, I'm probably going through a whole period of just anxiety of where I want to set up that practice. The idea of where I want to be in 5 years is a little bit difficult but like most things in life, you end up with a 5-year plan. You sit in front of you a compass and a map to decide where you want to go. If that's what you want to do, then it's a matter of finding the educational programs to do that.
I would join places like the American Academy of Implant Dentistry, the International Congress Oral Implantologists, where you run into colleagues that are very happy to share that information. Then pick a mentor. That [should do 00:03:43]. To become excellent in any field, to become a master in an field, you first have to know the theory. After you've digested the theory, that leads you then to practice.
Then you have to combine the theory with the practice to decide what cases you can do, how to stay within that comfort zone, treat the patients and then with time you become a master but only by developing the time and effort for the educational courses. Many of the implant companies will provide you with courses on how to do their particular implant which is fine. Most implants in the present-day market work.
I'm specifically more involved with 1 or 2 implant systems that I think are excellent but when you do the implants, you have to stay within the biologic limits of the patient. If you fall outside of that, that's when you get into trouble. For the new graduate, it's a matter of finding a mentor who knows not only the easy way of just drilling a hole in the bone but to also understand the how, when, how that you want to do this.
Dr. Farran: Let's back up to the very beginning. I think the biggest difference between, and I placed my first implant in, what, in 1997 to now is you and I grew up on 2-dimensional X-ray. When we'd have the pan out and things we had an inch of bone. You'd flap it back. It was like a little piece of paper. Now there's 3-D X-rays. Has going from 2-D to 3-D affected your implantology career?
Dr. Smiler: The simple answer is yes. If you go back to that dental student that's graduating, I sit here with a smile because going to dental school, we didn't have high-speed units. When we did third-molar extractions, we did it mallet and chisel. I graduated a little bit beyond the time where we had covered wagons. After that, everything took off. In the beginning when you and I were doing implants, it's true, we had [peri-apical 00:06:00] X-rays. We had panographic X-rays which were 2-dimensional. Then enter the scene with CT scans. Then that graduated to volume-metrics CT scans.
At this moment, using a CT scan for diagnosis and treatment planning is not state of the art but in practice, it really should be the state of the art for every dentist that is doing implants because it gives you a 3-dimensional picture of the receptor site, the quality and quantity of bone and the anatomic structures before we do any surgery. It takes the guesswork out of most of this.
Dr. Farran: Now for the dentist that's been out there 5 or 10 years that is thinking about buying one of these machines, they're a huge investment. Are there any particular machines that you like or anything you like more than others?
Dr. Smiler: Ogden Nash had a poem. The difference between men and boys are the price of their boys. When I first ...
Dr. Farran: I like that.
Dr. Smiler: Wanting to be the first on the block, I did get a CT scan with a flatbed CT scan and almost led to divorce that we spent $200,000 and some for a scan but it so influenced the way we practice. The idea that having a CT scan that will increase for the doc, for the dentist, a revenue stream is going to pay for that scan in a very short period of time. What type of scan to get?
Let's see, I've used a lab tech machine. I've used the [I-tech 00:07:44] machine, the ICAT. You just have to be familiar with that. I wouldn't rush out to do it because once you make that type of capital investment, it's not that you can't change but the problem of reinvesting that type of revenue to buy another machine is ridiculous. I certainly would do my homework.
Dr. Farran: You practice in LA.
Dr. Smiler: Correct.
Dr. Farran: Whereabouts in LA? That's almost a country.
Dr. Smiler: It's in the San Fernando Valley area. It's out of practice also and in west Los Angeles which is outside of Beverly Hills for a while.
Dr. Farran: Now what if a general dentist in that area wanted to send you for just a CVCT? Do you charge a referring dentist for a CVCT or is that something you do for your referrals? Has that ever come up?
Dr. Smiler: No, it does come up. There's legal questions about that, the star clause?
Dr. Farran: The star clause?
Dr. Smiler: The star clause?
Dr. Farran: Is that California law or ...
Dr. Smiler: No, it's a national law so that if a private practitioner is setting themselves up to take CT scans for another entity, there are certain requirements they're going to have to fulfill. I would do it as a courtesy. We would do that as a courtesy. I think more to the point is that you want to find a surgeon that you like to work with, a surgeon that you have a relationship with. Now anything in life, whether or not it's selling insurance, selling houses, doing implants or finding patients, it's all a matter of relationships.
The first thing I would do is make sure you have a good relationship. When I was very much into private practice when we had our study club that ran for over 40 years, dentists would then take my courses. They would come to me and ask me to put these implants in. I would look at the case with them. I would say, "Dr.," whatever their name is, "you don't need me. You can do this case and be well-trained. Get more experience. Stay within the comfort zone."
What most people don't understand is that axiom that rising tide raises all ships, so that if you have a referral base that you've developed in talking to the specialists now and you've helped them understand what they can be doing, not only will they send you more patients but more patients are going to be becoming aware of implants, which they are now. More patients are going to want to require implants. Then there are definitely surgical procedures that really should be left if not to the specialists by themselves or to the GP that has a great deal of experience.
Dr. Farran: I want to ask you about something that just happened recently. You don't have to answer any of these questions if you don't like it, if they're too politically incorrect. What do general dentists think when they see one of the largest dental companies like [Danner 00:10:49] buy a low-priced implant system like Implant [inaudible 00:10:55] and a high-priced system like [Novarca 00:10:54], if you're certain that all implant systems basically work, why would a company buy a Mercedes at a low cost? Is there that much difference in the value, longevity?
Dr. Smiler: To go back to your question of being politically correct, I come from Los Angeles where everything is politically correct. We can't even go into a bar now without buying a drink and calling it a politically-correct entity. To your question, quality usually is the same as what you would buy not necessarily for the expense but let me give you an example. You can go to the outlet stores and go to Neiman Marcus. The clothes that they have at a Neiman Marcus outlet store is not the same group of clothes that you're going to find at Neiman Marcus.
If you go and get an implant from a knock-off company, you have to make darn sure that all those parts and pieces are going to fit properly, that there's going to be good connections between the abutment and/or the implants, because what you're doing, what the clinician is doing, they are really taking the patients money and they're providing a service but you have to be very careful that the service you provide is absolutely excellent. You want to start off with excellent parts. I don't drive a Mercedes but if I did, I would certainly wants parts and pieces to fit the Mercedes and not something that I would get from a third-world country.
Dr. Farran: We keep hearing a lot about ... I guess the Holy Grail of the implant dentistry would be immediate load. How nice would it be to just place the implant and put the tooth on top? Will you talk about when immediate load is ... What percent of the implants you place are immediate load? When is that an indication or when is that not so much a good idea?
Dr. Smiler: Immediate load is a nice little catch word that's put out by the various implant companies in order to sell product. At the other end of that product is a patient. That patient has bone and has an implant. There is just a biologic phases of healing that you cannot circumvent. Immediate load does work but you need certain parameters. You have to have an implant that is initially stable that stays stable. You have to understand that stability of the implant is not the same as having an implant osseointegrated. As a matter of fact, if you have just a conical-shaped implant that you place, you place the implant on Day 1, in 2 or 3 weeks that implant is less stable than the day you put it in.
The reason for that is that the biology is such that you have these osteoclastic cells. These are vacuum cleaner type of cells, multi-nucleated giant cells. They come in. They clean up all of the microscopic debris between the implant and the bone. That space opens up. Then over the ensuing 2, 3 or 4 months, however it takes, then that quality of bone becomes integrated. If you have an implant say, for instance, the MegaGen system with that type of thin design, that resists loading and you can measure this, that it maintains its initial stability over the 30 or 40 weeks, then it is stable while it is becoming integrated.
Now the second or third phases of this is that that implant cannot be under load that is beyond the physiologic limits of feeling. If you put the implant in and you immediately put it under full load, then you retard the healing of bone. You may have immediate placement, immediate load for aesthetics. I'd be a little bit careful of placing an implant complete for immediate load, say for as single crown restoration. If you're doing this with a bar system over denture where you have a number of implants that are maintaining a bar and the restoration rests on that, that might be a different story.
Dr. Farran: Given your practice or maybe not your practice but a typical oral surgeon, are you mostly doing single implants to replace a single tooth extraction or are you mostly working with removable dentures and doing multiple implant cases? What percent is full-mouth implant removal, fixed reconstruction versus single tooth replacement in the American market today?
Dr. Smiler: I think in the American market today the single-tooth implant would be endodontic failure. It might be the younger population where you're losing 1 or 2 teeth, somewhere in the neighborhood of say 20, 30, 40 years of age. As you get up to about 50, 60, 70 when patients are coming to you with loss of teeth and loss of bone, that becomes more of a specialty type of practice. The only reason for bone to be there is to support the teeth. When the teeth are extracted, the bone slowly melts away.
Now most of the patients then that come with almost fully-dentureless mandible or maxilla would have to have replaced 5 or 6 implants. Those implants can usually be done as immediate load but there are some provisos with this. My father was a carpenter. In fact, I use the same instruments he does but I do just smaller bits of the mouth but this is not rocket science. All we have here is a beam or struts and a beam that set upon those 2 struts. What you need to do in implant dentistry is to avoid stress on the implant. Stress is then transmitted to the bone. The bone then resorbs.
You might end up having failure. If you're going to avoid stress, you have to either decrease the force that you have on the prosthetic design, the implants or the bar system, or you increase the design of the implant, the surface area, either by putting in many more implants or by having an implant that is wide or long.
We now know that the diameter of the implant is more important for conserving bone than is the length of the implant. If you place implants strategically in an arch form to decrease the amount of deflection that you would have on a beam between implants, then you've increased the amount of implants. You've decreased the stress. You'll end up with more success.
Dr. Farran: Are you using software to help you pick the placement of the implant, the length and width of the implant?
Dr. Smiler: Almost all of the implants that I now do are done with information we gathered from the CT scan on a software program. What is important about this is that whatever implant system you're using, and most of us have our favorite that we like to use, the proviso is that we need to have circumferentially around the implant about a millimeter to a millimeter and a half of bone. If you don't have a millimeter and a half of bone circumferentially around the implant, that implant puts stresses on the cortical bone at the crest.
The bone is very thin, has a very poor blood supply and is the first type of bone that is resorbed. My admonition is that no matter what implant system you're using, don't pick the implant for the amount of crown that you want to place. For instance, on a molar you want to put a wide-diameter implant. Those days are gone. You want to place an implant that relates to the quality and the quantity of receptor bone. You're looking at the bone width and the quality.
An interesting story is about 25 years ago placing implants when I did not know what I was doing, I put small-diameter implants in to support bicuspid and molar teeth. The patient comes back. On the contra-lateral side knowing now what we got from our scientists that were doing finite element analysis and our research people saying that we should put in wide implants for the load, we put in wide implants.
The bone around the wide implants fails because we encroach on that cortical plate. The reason that the engineers didn't figure this out is because on their analysis, they were using this all as if it were [cancellite 00:20:39] bone and didn't take into account that we have that thin cortical bone. Stay with the axiom of maintaining that millimeter or millimeter and a half circumferentially around the implant. You'll be okay.
Dr. Farran: Back in the day when we started, all of the implants were covered with HA. All of that was starting to come off. Is the days of coated implants gone? Is it more about shape than coating?
Dr. Smiler: No. It's both. I'm sighing because one of the best coatings that we had on an implant was a high-quality, hydroxylapatite coating on an implant. The phrase there is high-quality, one that had a high crystalline structure, one that was adapted to the implant. We had bio-integration. That was an excellent coating. That went by the wayside mostly because of trying to develop the studies in which we were able to have machines that would give us a good, thin coating that would be biologic. It got us into the titanium, into the different various amounts of coatings. What you're looking at now is the development and coatings on an implant with a roughened type of surface.
The reason for the roughened surface what you'll find with, for instance, the MegaGen system, is that when you place this in the bone, one of the first things that happens is that you get these collagen fibrils that attach to bone. If you don't have a roughened surface, these fibrils then and during healing detach from the surface. The problem is that these fibrils are a pathway onto which your cells and the osteoblasts go in order to form bone. You need that as a web. The surface of the implant, the type of surface that we have, is very important.
Dr. Farran: When you have a place that is drawing blood and centrifuging, can you talk about that?
Dr. Smiler: Yes.
Dr. Farran: In what percent of your cases? Is that something routine, just under a special needs or ...
Dr. Smiler: Drawing blood and spinning the blood down is a very, very simple process. I would recommend that the general practitioner and the surgeon out there who is a periodontist that they do this almost every case. It has advantages when you're bone grafting. It has advantages also around and in placing implants. There are a number of doctors that have used PRP, what is it, platelet-restored plasma, restored platelets, that are very, very good. There's a number of docs that use PRP. Then they say it doesn't work at all.
The problem is they're asking the wrong question, that the platelet practice of spinning this down and gaining that only acts on the cells. If you place this in an area say, for instance, in the skin where it first started, it works very well because you have lots of cells. If the practitioner is using this or now what I use is concentrated growth factors and you place it in an area that has a lot of cancellous bones or a number of cells, it works.
If you place it in an area where there is mostly cortical bone where you have very little cancellous bone, therefore, you have very diminished amount of cells, it doesn't work as well. That's why those of us that are doing a lot of bone grafting know that if we graft in the maxilla where there is a large amount of cancellous type of bone, our success goes way up. If we're grafting in the posterior mandible where the cancellous compartment is less and we have more cortical bone, our success goes down.
It has a little bit to do with the practitioner. It has a little bit to do with the material we're using. It has a lot to do with the receptor site. To go back to your initial question, when we were talking about CT scans, the other thing that the CT scan does is give us a quantitative measurement as well as qualitative of cancellous bone versus cortical bone. The more cancellous bone, the greater your success. Not only does it give you a measurement of what diameter of implant to do, it also tells you what type of bone grafting procedure you're going to do.
Dr. Farran: Is there any CT scan, 3-D X-ray machines and software that you like? If there's a dentist out there ... My motto is of a [dentaltown.com 00:25:48] no dentist has to practice solo again. I know there's dentists out there listening saying, "Come on dude. If I was going to buy one 3-D X-ray machine, which one would you get?"
Dr. Smiler: I think I would get something like the Vatech machine. I think that's an excellent machine.
Dr. Farran: The Vatech
Dr. Smiler: Vatech, V-A-T-E-C-H, I think.
Dr. Farran: Who makes that?
Dr. Smiler: I don't know. I have no idea. A lot of times if you ask me what kind of instruments we use, you have to ask my nurse.
Dr. Farran: Right.
Dr. Smiler: They just give it to me. I don't [crosstalk 00:26:18] ...
Dr. Farran: Right.
Dr. Smiler: ... but the important part here also is the software package. Many of the implant companies come with their own software package. The software that I prefer is one that comes from Anatomage. I think that is probably one of the more excellent software packages out there.
Dr. Farran: Now that's just the software. Are they affiliated with the 3-D machine, Anatomage?
Dr. Smiler: No. It's not that they're affiliated with a 3-D machine. The raw data that every CT machine uses is called D.com as the suffix, D.com. That's the raw data. Any machine is going to give you the D.com raw data that you can then take and put that into any software package that you want. Now there are different softwares that give you greater or lesser bells and whistles to use. That's why I like the Anatomage program.
Dr. Farran: Do you know the owner of that or where they're at?
Dr. Smiler: I think they're in the Sacramento or San Francisco area.
Dr. Farran: Is it because everybody talks about that on [inaudible 00:27:31], Anatomage.
Dr. Smiler: Do they?
Dr. Farran: Yeah. It seems like one of their favorites on [inaudible 00:27:33].
Dr. Smiler: It's one that I use almost on every case.
Dr. Farran: I should track them down and do a podcast with those guys. Back to this general dentist. I want to go back to something. This general dentist is trying to work. He's got to extract 29. What should he be thinking about if the patient someday is not getting an implant? Today it's just an extraction but some day he may get an implant. Should a general dentist by routinely bone-grafting extraction sites if they're going to go back later and replace them? Talk about what we should be thinking about when we pull an individual tooth to help increase the chance of receiving an implant later down the road.
Dr. Smiler: The simple answer is yes, every time. Now what happens is is that as soon as you take out a tooth if yo don't restore the bone or get something in there, you're going to immediately lose height in with the bone. You will have less bone in that site a week, 2 weeks, 3 weeks later, than you had initially. What you are able to do at the time of the extraction is put in a graft material that's going to not only preserve the sit but also give you back new bone. A socket graft is the simplest, easiest, least expensive way to preserve the bone. The efficacy of forming new bone is superb.
Dr. Farran: Then you're in California. Would Delta Insurance cover a procedure like that?
Dr. Smiler: I don't know.
Dr. Farran: You don't know?
Dr. Smiler: I don't know.
Dr. Farran: What would you grafting with? Talk about different products, from low cost to high cost.
Dr. Smiler: The easiest product that I think one could use that is very inexpensive is a product of calcium sulfate. It I think runs about $60 to $80 maybe in a $2,000 package. It's somewhere around that price. In a small socket area like a lower central incisor, you could use the calcium sulfate material. The nice thing about this material is that you can mix it with saline or mix it with an aqueous antibiotic and form it almost like a putty. You could form this material in doing third-molar extractions and greatly reduce the amount of dry sockets that you might have because it helps form a [crosstalk 00:29:58].
Dr. Farran: Who makes this putty?
Dr. Smiler: DentoGen, OrthoGen, I think is the manufacturer in New York, no, Jersey, in New Jersey.
Dr. Farran: OrthoGen.
Dr. Smiler: They also have a product called NanoGen which is calcium sulfate and has nano particles in it. It retards the resorption of the material. It's an important concept. If the graft material resorbs too quickly, it doesn't stay there as a matrix to form new bone. If you use a calcium sulfate material or any material that resorbs very quickly, for instance, say in a sinus graft and come back 3 months later, you'll have no bone. You need a material that's going to stay there, slowly resorb and as it is resorbing is going to be replaced by the patient's own bone.
Dr. Farran: Speaking of resorbing, do you use resorbable sutures or do you use [silk 00:30:58] and have them come back and take them out?
Dr. Smiler: Let me spend just another minute or two with the grafting.
Dr. Farran: Please. I'm sorry I interrupted.
Dr. Smiler: No because there are a couple concepts here. In my practice, I prefer to use a graft material that resorbs. I do not have advocate a non-resorbable material. I want the material, the matrix, to resorb and then be replaced by the patient's own bone. The other problem that doctors get into when they're doing socket grafts is that they pack the material in too tight, almost like they're doing a amalgam restoration. If they put in so much of this material, you reduce the spaces between the particles so you don't have any space left for angio-genesis, for nutrient supply to come into the graft.
The technique is to have a loose compaction. More is not better. You want a very, very loose compaction. If you have a socket that's open, now you can use a membrane on top of that, if you need to. There are enough collagen membranes that are out there or the one that I use is that I'll draw blood, use concentrated growth factors and press the little area and make it into its own membrane and use that.
Dr. Farran: Now do you have any of these procedures filmed on videos so any dentist could watch you do that?
Dr. Smiler: Yes. I've given all of the videos that I made, a number of them, to I think it's called View Medica. If they go onto the internet and they just knock in Smiler or View Medica, they'll see a number of videos.
Dr. Farran: How long have you given those videos?
Dr. Smiler: Oh, I think about a year ago, 6 months ago. It's been up on the web a number of times.
Dr. Farran: Any chance you can talk to those guys and see if we can put them on Dental Town or ...
Dr. Smiler: Not only that, I can just send you both the videos and you can put them on Dental Town.
Dr. Farran: I would love that. I would absolutely love that.
Dr. Smiler: Easy. Now if you go back to your question about the sutures, the best suture material, I think, is one that is non-resorbable. It's mono-filament that is very little in tissue reaction. That's the good news. The bad news is that if it's non-resorbable, you have to take it out. The other bad news is that these materials are usually very stiff, almost like fishing line. If you take that type of suture and you put it in even with a very, very small knot, very often the patient may come back with a small ulcer where they have some irritation.
If you're using resorbable material like Vicryl or gut suture material, you have to remember that it resorbs via an inflammatory reaction. If you have a patient with good oral hygiene that can keep the hygiene down, make sure that there's very little debris around the implants, then you can keep that suture in place for 10 days, 2 weeks. Most often, patients don't do very well with hygiene. Then what you have is a lot of debris around where your sutures are. My preference is a non-resorbable suture, something like maybe a 4-row Ethicon or Prolene and make a very, very short knot.
Dr. Farran: One of the things a lot of the dentists have a hard time putting their hands on is the people who most likely need an implant are also usually the ones that most likely shouldn't have one. They're smokers. They're obese. They are diabetics or alcoholics. They don't brush. They don't floss. They don't go to the dentists.
You've seen 30-year follow-ups. Obviously, if you're a hygienist, you're never getting any implant and you brush, you floss or you're ... You do everything perfect but it ends up the people that land on your doorstep, they're not perfect. How do you risk somebody who shows up if they're a smoker, a diabetic? They're an alcoholic. They don't brush and floss or they're hillbillies and probably grew up in Kansas. How do you determine whether they're a candidate or not?
Dr. Smiler: The first thing I need to know is they came into the office. 90% of them are candidates. Otherwise, they wouldn't be in the office. I think for the young doc and for the experienced doc out there, there has to be that dialogue that not only is the patient thinking whether or not they want that doctor to do the case, the doctor has to think, "Do I want to do that case?" Now I have to tell you, I've been in practice 45 years, so there have been some times where we've ended up with medical malpractice cases.
In every case if I think that, I would have Jiminy Crickett sitting on my shoulder going, "Don't do this," but we have our own ego. We can do everything. The admonishment I would give to the young practitioner is that it is not your job to do every case. Patients who come in who are diabetic, who have AIDS, who are under cancer treatment, have some other metabolic conditions, these are relative contra-indications how well are they controlled? You have to do this in concert with a physician.
Certainly these are patients over the years I've treated, even patients who smoke. We have a huge informed consent that they sign, 3 or 4 pages, which outlines their diagnosis, their treatment planning, what we suggest for treatment, the alternatives. They don't have to do implants, so you have to tell your patients the alternatives. There's a large paragraph also on smoking. Now even though they sign and even though they promise they're going to be good for their diet and they promise that they're going to end up and do better with their hygiene, a lot of times they don't.
Dr. Farran: Every time they don't.
Dr. Smiler: The important thing is is that they come back and it is our fault. They will not take responsibility for it, which goes back to the original comment that you have to do an evaluation and take that patient that you want to do. Young doc, you want to go after the low, low-hanging fruit. You have a cardiac surgeon that goes in and does cardiac surgery. The patient lives for 5 years. The family gathers around at the funeral and says, "Thank you, doctor, for keeping the patient alive, our father, our cousin or whoever. We certainly appreciate it."
In dentistry, the doc does a crown and bridge restoration and it fails them 5 years. They want their money back. Again, it goes back to pick that patient that you want to do. You'll slowly learn what cases are within your comfort zone and which cases are not. If that doc, young doc, going out into practice is going to meetings like this, they have to go to 3, 4 meetings a year. It will turn out that if they go to a meeting, they listen to the various speakers, if they pick up 3 or 4 pearls at a particular meeting, it's worth going to. Every meeting that I go to, there are a few pearls that you pick up.
Dr. Farran: What percent of general dentists in America ... There's 30,000 specialists, like 10,000 orthodontists, 5,000 oral surgeons. There's 120,000 general dentists. What percent of those general dentists are placing implants today, like just 1 a year or more?
Dr. Smiler: I think the last statistic was less than 10%, ...
Dr. Farran: Right.
Dr. Smiler: ... something like that.
Dr. Farran: 90% of the people listening to you right now on iTunes, YouTube and Dental Town, they're not going5 to ever place 1 implant but one of the things they're always wondering about is what is the deal with this sinus lift? What if the sinus [inaudible 00:39:08] is only 2 millimeters about? Just talk about sinuses. When you lifted that sinus and put a bunch of bone there, is that going to hold? Is that going to work? I'm talking about from the diagnosing and [trim biting 00:39:20]. Does this looking at a bite wing ...The tooth's been done forever, it's all the sinus, how good of a site is for an implant?
Dr. Smiler: Got it. Now let me go back to right before that when you were talking about that dentist just placing a single implant and just getting started with that. A dentist who is placing, for instance, there was a study done on this, say less than 10 implants a year, their patients end up having more post-operative patients than say someone who is placing 100 implants a year but then if that patient is on prophylactic, surgical antibiotics 2 hours before you do a surgical procedure, the post-operative, inflammatory, infectious reaction are almost equal.
It's a multi-factorial process of whether or not you're placing 1 or multiple implants. I would recommend in my practice and I would recommend to anyone out there that that patient receives surgical prophylaxis. If I have someone that comes in just for a simple extraction, that patient will receive either 2,000 milligrams of penicillin or 600 milligrams of Cleocin, say 2 hours before we do the procedure. I have the antibiotic going through the system before I make the bone cut.
Now depending on whether it's a simple surgery, that's all I'm going to do, this surgical prophylaxis. If it's a compromised patient like we talked about before with a metabolic disease or someone who is on chemotherapy, someone who's diabetic or in a case where you're only placing a few implants a year, for a complicated surgical procedure, I may keep that patient on antibiotics for a longer period of time. For instance, in the sinus lift.
In the sinus procedure, and we started doing the sinus lifts back in the late '70s, early '80s, I think the first paper I wrote on the sinus lift was about '79, 1978, if you have about at least 5 millimeters of alveolar bone, the magic number being 5, if you have 5 millimeters of alveolar bone, then I would suggest you have enough bone to put the implant and do the sinus lift at the same time. If you don't, then I would do the sinus lift procedure, wait 3 or 4 months and then put your implants in.
Now depending on the graft material that you're using and the ancillary material like stem cells or concentrated growth factors, in 3 to 4 months when you're facing the implants, this is not bone. It is turning into bone but the biology of bone is that it's going to take 40 to 50 weeks for that bone to become mineralized. You could put the graft in. This is now on your patient that has say only 2 to 3 millimeters of [alveolar 00:42:35] bone. Put your graft in. Wait 3 to 4 months. Put your implant in.
Wait an additional 6 months. Now your bone graft has healed for 9, 10 months. Your implants within the graft is healing about that 4 to 5 months. Remember that that interface is a very immature, woven bone. You have to treat that bone very gently with your restorative procedures to turn that into a more dense, [inaudible 00:43:07] kind of bone. The axiom I would suggest is the phrase, "The slower I go, the faster I get there.
If you try to do things too fast, like putting implants in in bone that's very less of alveolar ridge with a graft and if you have a failure, now you've lost the graft. You've lost the implants. You have a patient that is not very happy with you. I would back off and say, "Let's do this slower and make sure we have the success."
Dr. Farran: Now I want to go back to diagnosing [trim biting 00:43:43]. Again, the people who need the most implants have the worst condition. We're reading that if you lost them due to gum disease, you're more likely to have peri-implantitis. Will you talk about gum disease and how it's different around teeth versus implants and what a general dentist should be thinking about when you're losing 2 teeth because you have gum disease. You still have a full mouth of perio. Are you a candidate for 2 implants there or do we need to remove all the teeth? Talk about peri-implantitis.
Dr. Smiler: Let's go back. When I was in dental school in the early 1960's, we had courses on perio-props where everything we did was the art of save teeth. We developed the prosthetic procedure to try to save marginal teeth. That's all changed because if you have a tooth that's marginalized, that's loose, it's almost like a hydraulic pump of organisms, endotoxins, going into bone. The point is you'll have less bone in that area next week than you have right now.
The process is changed so that we don't do as much perio-proc trying to salvage marginal or failing teeth. We now take those teeth out, do a socket graft, preserve the bone. Then you complete the implants and do your prosthetic reconstruction. You have to remember that periodontitis is a disease of cementum. Titanium doesn't have any cementum around it. Once you take the teeth out and you clean up the mouth, implants do very well on those patients that have had periodontal disease, providing they have oral hygiene, they are not metabolically compromised. They do very well.
Dr. Farran: Your confident when a person has generalized periodontitis that's been on 3-month recall for the last 10 years, loses the 1 tooth, that you can place an implant in between 2 teeth that have been needed to have 3-month recalls for the last 5 years.
Dr. Smiler: Again, the operative word there was confident. The short answer is no, I'm not confident. If they have generalized periodontal disease and all we're talking about is a single tooth, you have to remember that as soon as you purse your lips together, you have a closed environment. Your loose tooth that you're taking out may be in the upper right quadrant but you have gross periodontal disease on the left side. That patient is now laden with bacteria once they close their mouth. That patient has to be cleaned up. You need to do debridement. You have to salvage the teeth that can be salvaged. You have to remove the teeth that cannot be salvaged.
Dr. Farran: I always wanted to ask you about some of these systems we're seeing today ... Following up on the perio, some of these systems we see today where people will put in 4 implants, so connect them by a bar, some people don't think those are as hygienic and easy to clean as other attachment systems, balls, something more [cleansable 00:47:06]. Will you talk about if a person is a perio patient or there is some removable denture systems that are more cleansable than others? To me, that's a big factor.
Dr. Smiler: I think hygiene, postoperative hygiene, is extremely important. On those patients, my recommendation is that we do a bar system over-denture appliance where you would put in a number of implants, connect that with a bar and then do the ... That would be a primary bar. Make a secondary bar that fits on top of that primary bar and do the prosthetic reconstruction on that secondary bar. What that means is is that when that is in the mouth, it is firm and stable. The patient can chew corn-on-the-cob and spare ribs without a problem.
In the evening, they can take out the appliance, brush their teeth, brush around the bar, brush around all the implants, put the appliance back and go to sleep. Then in the morning, the same thing you and I do is go in the morning. We brush our teeth. They would wake up. Take that system out. Brush. Then put it back for the rest of the day. That works.
I think where we end up with the compromise is where the patient wants to have something that is non-removable. We try to make a space between the prosthesis and the gingival portion of the alveolar ridge. They have difficulty cleaning. If they have difficulty cleaning, then they develop inflammatory reaction. The sulcus around the implant becomes traumatized, endotoxins from bacteria, loss of tissue, loss of bone, loss of the implant.
What we're supposed to do as clinicians is to give the patient what they need, not necessarily what the patient wants. Everyone wants to go back to what they looked 20, 30 years ago. I would love to go back to what I had 20, 30 years ago but you're not going to do that. Be careful of the patient that comes in with pictures of how they looked when they were in their teens or 20's and say, "This is what I want you to do."
That's not going to happen. You have to decide what the patient needs. If the patient's wants are way askew to what the patient needs, then I would say run. Don't do that patient. It's going to cause you trouble.
Dr. Farran: If the person lost all of their teeth from perio and they were already [inaudible 00:49:43], would you really put your foot down and say, "You need to have a full implant removal solution," versus if they, say, lost all their teeth from decay and saying, "I want to have a full-mouth reconstruction of implants fixed?" Where do you weigh in on a patient if they could have 6 implants [inaudible 00:50:03] and 2 fixed bridges that never come out versus no, you've got to be able to take these out and clean around them?
Dr. Smiler: Again, it's a nice question but it goes back to initial treatment planning. It's just not a matter of what the patient wants and that you could put the implants in. The best tissue around an implant is attached, keratinized tissue. If you have a healthy patient, a nonsmoker, with a lot of good, attached keratinized tissue, I'd be more apt to put the implants in and let them wear a fixed case.
If it's movable mucosa, the hygiene is not as good, they came to me with a lot of periodontal disease, my suggestion strongly would be a fixed removable type of pivotal appliance.
Dr. Farran: Are you still doing many skin grafts to get more attached gigiva?
Dr. Smiler: We do, yes. We do some skin grafts but I'm not doing as many.
Dr. Farran: Why is that?
Dr. Smiler: There are other ways of doing this. Even with skin grafts themselves, I wasn't that much in favor of doing skin. One reason was is that we end up not only taking the skin but sometimes the hair follicles and the sebaceous glands. Back in the '70s, I wrote a paper on doing a dermal graft where we took the dermis which is [inaudible 00:51:24] potential, placed that into the mouth. Then what we ended up getting is new tissue.
You could use some of the synthetic materials. You could use the [palato-grafts 00:51:35]. Periodontists are adept at doing palato-grafting. We've used the membranes of concentrated growth factors to do that but it's all a matter of treatment planning. What is the quality of the recipient tissue that will determine that?
Dr. Farran: You and I got out of school during the late '80s [inaudible 00:52:01]. Now there's 9 with CVCT, [inaudible 00:52:05]. Would you say that the most changing specialty would have to be periodontics? Don't you see a lot less periodontal surgery and a lot more just going towards extraction and replacing with an implant? What are your thoughts on periodontists? Is that a good thing, a bad thing or ...
Dr. Smiler: If you talk to some of my periodontal friends that we've been doing implants for a long time, they tell me that their practice in periodontics is going down. They're doing more implants. Implants I think is saving the specialty of periodontics, [periodontotics 00:52:49]. In today's market for that general practitioner that we talked about earlier, I wouldn't make any decisions about a specialty until you're in practice for about 3 to 4 years.
There are too many nice things and too many new things that are going on within dentistry that change is so fast that will help make that decision for you. If I practice surgery the way I did 20, 30 years ago, it would be antique to what we are now doing.
Dr. Farran: I just want to let you know there is a lot of dental students that love these podcasts. They're really into podcasts the most. What would you say to a junior or a senior dental student who thinks that maybe he wants to become an oral surgeon like you? What would you say if your own son or grandson was saying, "Should I become an oral surgeon too or just be a general dentist or a family dentist?" What are your thoughts there?
Dr. Smiler: Hmm.
Dr. Farran: Would you do it all over again?
Dr. Smiler: Hmm. It's going to take a thought here for just a second or two.
Dr. Farran: You bet.
Dr. Smiler: I tell you why. Just a little bit, a while ago, I said that we're trained in the school of 90% of what we do 10% of the time. That really is what we do in surgery. I trained in New York as a surgeon, a maxo-facial surgeon. It was very exciting when I was in my 20's.
Dr. Farran: Manhattan or the ...
Dr. Smiler: In Manhattan.
Dr. Farran: Wow.
Dr. Smiler: If you walked through Central Park at night, I always took care of you the next day. That was a nice practice because it made you feel like you were really doing something. That type of trauma of fixing up faces that somebody that fell in front of the subway train or someone who got shot gets old very fast. There are docs that love it. To them, I say, "God bless. Go ahead. Spend your 4, 6, 8 years. Go into that type of a practice."
That doctor as a maxo-facial surgeon belongs in a large practice, a trauma center, a hospital, but if you're doing office spaced practice, you have to think about how many truly [orthonathic 00:55:14] surgeries you're going to be doing. Most of that is going to be dental alveolar. If I were graduating today, which I think was your question, I'd love being a general practitioner, handling not only the prosthetic phase of this but getting adept at surgical procedures that would stay within my comfort zone.
At the time that I became a surgeon is because I hated prosthetics but when you're involved with implants, you needs to know more prosthetics than I ever learned when I was in dental school. Today, I'd like that general practitioner who picks out a course that they want to follow. If it were implants, I would just devour classes and courses and become ... Get yourself a mentor to help you. Stay with that. I think that's exciting.
Dr. Farran: Why don't we get some of your videos up on Dental Town?
Dr. Smiler: It's a easy thing to do.
Dr. Farran: Do you have any lectures too?
Dr. Smiler: No.
Dr. Farran: There's no limits. Let's do some where you just upload your Power Point. Then you call on the phone and do a voice-over or ...
Dr. Smiler: No, I don't think I have had anyone tape lectures, although we'll be lecturing tomorrow. If you want to tape that, that's okay.
Dr. Farran: I would love to. You said something that I'm going to follow up on, [orthonathic 00:56:43] surgery. A lot of general dentists, a lot of them get nervous when they send a kid to an orthodontist and the orthodontist says, "To do this right, he's going to need orthodontal surgery. We're going to have to advance the mandible or [inaudible 00:56:57]."
People start getting nervous about [inaudible 00:57:01] and is this overkill. What are your thoughts on orthognathic surgery? If your granddaughter had a weak chin or too much of a gummy smile, would you let her have orthognathic surgery or would you say that's too many complications and too much risk?
Dr. Smiler: I would have to do orthognathic surgery in a heartbeat. It's not a question. The question is who would I have them do it? There are a few surgeons around the country that I admire that I think are probably some of the finest maxo-facial surgeons, not necessarily in California but there might be 1 or 2. That's who I would have them do it.
Dr. Farran: Name them because this guy wants to know in the podcast. Right now he's in Parsons, Kansas. He has no one. They'd put him on a plane or the bus. Who would you go to? Are you doing it?
Dr. Smiler: No.
Dr. Farran: You're not doing it?
Dr. Smiler: No.
Dr. Farran: Who would you say ... If he was in Parsons, Kansas and you were a dentist[inaudible 00:58:00] and you don't want someone to botch that up, who would you fly him to?
Dr. Smiler: Let's back up a second. I used to be a private pilot. In order to take passengers, I would have to fly at least 3 or 4 hours a month just to become current. Back in the '70s or '80s when I was doing 2 or 3 orthognathic cases a month, that was fine to keep my proficiency. If I were the last maxo-facial surgeon around and there was an emergency [inaudible 00:58:32] or a sagital split, I guess I could muck my way through it, but that's not the point.
I want to go to someone who's experienced. The first thing is I would pick the doc that I think are the most experienced. Usually, the nurses in the operating room knows who the doc to go to. There area couple docs in California. One of the finest maxo-facial surgeons I've ever met was Dr. Wolford, Larry Wolford, who's in Texas who I would send anyone to.
Dr. Farran: Which city in Texas?
Dr. Smiler: I think Dr. Wolford's in Dallas or Ft. Worth. I'm not sure.
Dr. Farran: Spell Wolford.
Dr. Smiler: W-O-L-F-O-R-D.
Dr. Farran: That's a good source because at least I'm sure, if anything, that he would give a recommendation to someone somewhere also for your ...
Dr. Smiler: But if you're in a smaller town or wherever you are and someone recommends orthognathic surgery, there are a couple things I would suggest. That decision has to be made at the beginning of treatment of the patient. If the patient is a candidate for surgery and ortho, then you have to do the ortho first, then do the surgery and then go back and fine-tune with the orthognathic.
The problem is is that if you're thinking about surgery, in most cases the orthodontics is in the opposite direction than if you're not going to be doing surgery, that you are augmenting the compensations so that the dentition of the mandible reflects the mandible, the dentitions of the maxilla reflects the maxilla but they don't necessarily mix in 3 planes of space but then when you do the surgery, they all mesh together.
If you're doing orthodontics and then the orthodontist says, "This is going to be doing surgery," that most often gets to be a problem because the movement of the teeth is in the opposite direction than if you were to plan surgery to begin with. I would be very careful about that.
Dr. Farran: That's the old axiom there. If you're going to get a A in anything in dentistry, get it in the diagnosis and treatment way.
Dr. Smiler: Yes. Diagnosis, most important.
Dr. Farran: It is. It's absolutely the most important. Everybody is in so big of a hurry to learn how to do something they forget that deciding whether or not it needs to be done is the far bigger decision.
Dr. Smiler: That goes to doing implants. It goes to taking out third molars and wisdom teeth. If you do extractions, the best time to take out a wisdom tooth is someone who is in their late teens or early 20's. If I have a patient that comes in that's 50 and 60 years of age, that bone is harder. It's more dense bone, more cortical, not cancellous. I'm going to say, "I don't know. Do I really want to do that case?"
Dr. Farran: [Inaudible 01:01:33] your practices, implants versus [inaudible 01:01:35]?
Dr. Smiler: When I started doing implants it was at the time where the dental alveolar portion of it was decreasing and the orthognathic surgery was decreasing, as well as trauma. Very quickly, up until the time that I had recently sold my practice, implants were probably about 90% of the revenue.
Dr. Farran: Unbelievable, so you sold your practice.
Dr. Smiler: I sold my practice almost 4 years ago, 5 years ago.
Dr. Farran: Are you still going in there now?
Dr. Smiler: No. The office is not there but I'm still practicing and still teaching. We're still running lots of courses, didactic, model courses, life surgical courses. One of the surgical courses I teach is that either in Minnesota or in California if you have a license to practice, I'll take 6 doctors, 6 dentists. We provide the patients. The dentists then gets to do the surgery but my job is to select the patient for the skill and expertise of the doctor. They spend 2 or 3 days doing surgery, as well as diagnosis and treatment planning
Dr. Farran: Where can the listener get more information about that?
Dr. Smiler: If they go to my web page, go to Smiler.net, they'll find out all the information about what to do for workshops, for lectures and for live surgery.
Dr. Farran: You're a legend in my mind and everyone else's. Thank ou so much for spending an hour with me. It was fantastic.
Dr. Smiler: My pleasure.
Dr. Farran: All right. Thank you very much.