Dentistry Uncensored with Howard Farran
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1275 Dr. Monish Bhola on Periodontics, Implants, and Gummy Smiles : Dentistry Uncensored with Howard Farran

1275 Dr. Monish Bhola on Periodontics, Implants, and Gummy Smiles : Dentistry Uncensored with Howard Farran

10/18/2019 6:00:00 AM   |   Comments: 0   |   Views: 135
Dr. Bhola is a Diplomate of the American Board of Periodontology. He received his D.D.S. from University of Detroit Mercy School of Dentistry and his certificate and M.S.D. in Periodontics and Implantology from Indiana University School of Dentistry. Dr. Bhola is the former Director of Post-Graduate Periodontics at the University of Detroit Mercy School of Dentistry and is currently the Director of Advanced Periodontics Institute, a clinical and education center that has locations in Plymouth and Livonia, Michigan. Dr. Bhola is a world-renowned periodontist, clinician and educator with over twenty-six years of clinical experience. His areas of interest include dental implants, oral plastic surgery and advanced bone and soft tissue grafting for teeth and implants. He is the author and developer of the new and innovative LipStaT® procedure for correcting a gummy smile.

VIDEO - DUwHF #1275 - Monish Bhola

AUDIO - DUwHF #1275 - Monish Bhola

Dr. Bhola has been featured in several local, national and international news articles. He lectures and conducts several training courses in periodontics and implantology for dentists and specialists from all over the world and has over thirty peer-reviewed publications in leading dental journals. He is the recipient of the prestigious Bud and Linda Tarrson Fellowship award given by the American Academy of Periodontology Foundation, a fellow of the Pierre Fauchard Academy and a fellow of the OKU Nu Nu Chapter, a National Honor Dental Society.

Howard: It is just a huge honor for me today to be podcast interviewing Dr. Monish Bhola DDS MSD a diplomat of the American Board of Periodontology he receives DDS from the University of Detroit Mercy School of Dentistry his certificate in MSD in periodontics implantology from Indiana University's School of Dentistry. Dr. Bhola is the former director of postgraduate periodontics at the University of Detroit and is currently the director of advanced periodontics Institute a clinical and education center that has locations in Plymouth and Livonia Michigan Dr. Bhola is a world-renowned periodontist clinician and educator with over 26 years of clinical experience his areas of interest include dental implants oral plastic surgery and advanced bone and soft tissue grafting for teeth and implants he is the author and developer of the neun innovative Lipstadt T procedure for correcting a gummy smile he has been featured in several local national and international news articles he lectures and conducts several training courses in peridot extend plant ology for dentists and specialists from all over the world and has over 30 peer-reviewed publications in leading dental journals he's the recipient of the prestigious bud in Linda Tarson fellowship award given by the American Academy of Periodontology Foundation and a fellow of the Pierre for art Academy and a fellow of the okay you new new chapter a national honor Dental Society I can't pronounce it so obviously I didn't get invited to that one if should be Google's name especially on ResearchGate very very interesting articles it is just that Monish thank you so much for joining the show today how are you doing?

Monish: Thank you for having me.

Howard: So how's the how's the weather in Detroit right now is it is that entering Fall it started to cool off?

Monish: It has it was in the low thirties today and the trees have started changing color and fall as you know is it's a beautiful season.

Howard: Right so what you've been in periodontics for a long long time, how is it different for you today and then when you were a dental school graduate?

Monish: I think a lot of change has occurred as we were talking earlier in especially in terms of periodontics there's more regenerative procedures that we are teaching our students now more regenerative procedures that I'm practicing on a daily basis especially with implants that change the whole ballgame in dentistry so like I tell my patients we as periodontists and surgeons we are the ones that are building the bone and the soft tissue so that we can provide our restorative colleagues with the foundation that they need for implants so I think implant dentistry broadly speaking is pretty much changed all the specialties in dentistry.

Howard: When did you graduate from University of Detroit dental school?

Monish: So dental school I did my dental training back in India first and then I went straight into my masters so I did my I had to repeat two years of dental school so that was from 2001 to 2003.

Howard: Oh what year did you become a dentist first in India?

Monish: 93

Howard: What time what year?

Monish: 1993

Howard: 1993 it seems to me I graduate in 87 so just five six years ahead of you that seems like periodontics has come full circle when I came out of school was all these procedures to try to save natural teeth right and then the hoopla about implants got so big that people start saying you know it's just so much easier to treat this with forceps and pull it and place the implant and then with the rise at peri-implantitis it looks like we're full back into saying you know what I'd rather try everything I can to save the natural tooth before just treating perio do agree with that cycle?

Monish: Yes that's a very true assessment Howard we always as periodontist we say we are in the business of saving teeth and we've learned the hard way with peri-implantitis you know implants a great replacement for a natural tooth but it never behaves like a natural tooth it doesn't have the periodontal ligament that natural teeth have so even a little bit of inflammation infection can cause a lot of damage around implants so the best thing that we practice now is if we can save natural teeth that's our number one option if for some reason a tooth is non restorable either from a restorative standpoint or from a periodontal standpoint only then do we start recommending implants so you are absolutely 100% correct.

Howard: You know using a bad analogy if there was high school football college football and professional football there's treating perio with a single rooted tooth, a two rooted tooth and a three rooted tooth do you agree with that and where should people listening to you where do you start drawing the line that maybe this three rooted tooth to the four occasion of um I mean that's a whole different ball game than a single rooted incisor.

Monish: Absolutely yes working with you know we have over 200 doctors that refer to us here at our practice and we have a good group of people that are able to take the specialists when it comes to some of these borderline teeth and say okay how much more time, money and effort to be put into saving this tooth and what's the realistic five-year or a ten year prognosis or are we better off going removing the tooth and going with an implant so I think that's very where specialists can be part of that team and we can work with our general dentists and doing what's best for our patients.

Howard: Yeah to me I always tell the and you know I've had dentists associates working for me for 32 years and I always tell them you have to diagnose and treatment plan aggressive enough for it to last five years I mean if this patient is gonna live to be you know 80 years old I mean she can't come in every five years and I saw that first with endo where an insiser would snap off at the gumline they do a root canal build up and post build up crown and then the patient walk in one year later and the dentist today well I tried my hardest and I'd say well one year isn't hard enough I mean so I would refund that money towards a more aggressive treatment plan like an implant and a crown or a three-unit bridge or whatever the patient decided but do you think it's fair to say that if what you're doing doesn't last five years you're not diagnosing and treatment plan properly.

Monish: The biggest factors that we don't take into consideration is our patient you know - when we look at comorbidities or the risk factors associated with giving a tooth a prognosis a lot of times we don't take into account are and how compliant our patients are so absolutely I think five-year is that critical that if I can guarantee that I can save this tooth for at least five years then it might be worthwhile pursuing trying to save the tooth otherwise I think an implant is a better route to go.

Howard: and you know my insurance friends show me they're not they don't like to be very transparent with their data but they'll show it to you if you're lecturing to a group of insurance people I was in Florida and they were showing me that like molar endo like if when they endodontist in five years five percenter extracted and when the general dentists do it in five years ten percent are extracted so if you retreat a molar root canal and at last year I think you know when the endodontist just throws up his hands and says well I tried my best well best isn't really good enough for one year when someone paid all that money I don't know I warranties or something that I think that the consumer demands it because when they buy a car or a refrigerator or a microwave it's gonna last five years and it's kind of embarrassing in dentistry when patients go give somebody a thousand dollars two thousand dollars in a year later their tooth is in their hand so what is them well I wouldn't jump to what I really had fun reading about you as this on this new lips stabilization technique your to talk about that the gummy smile is there are you doing something new with that then then the mainstream?

Monish: Right so this Lipstadt procedure it's it's it's not a new procedure but we've refined it and we've done this in over 700 people now gummy smile as you know howard has multiple etiologies it could be altered massive eruption that's causing a gummy smile it could just be gentle overgrowth it could be a vertical maxillary access or a bony maxillary access so and then of course you could have a hyper mobile lip so we came up with a refine classification and then we modified this technique to do pretty much stabilize the upper lip so that when folks who have a have a high smile when they give a dynamic smile the muscles don't pull they pop off so it's all done intra orally where it's basically almost like a reverse vestibular plastic so now you know it's it's there's a lot of science that went behind this and of course as you and I know there's a lot of art and what we do so we've been able to refine this procedure where it's fairly predictable we can tell and it's a great alternative to folks who don't want to go through orthognathic surgery or don't want to go through more aggressive treatments so here's another tool in our toolbox to help these patients.

Howard: Yeah it's a no or most of these cases women or is it equal men and women?

Monish: It's mainly women you're right because they tend to have more of a higher smile line than men do.

Howard: because they have lower muscle mass?

Monish: Lower muscle mass more muscle mass shot upper lip and it's just what we found generally.

Howard: Yeah on dentaltown I wish you would post if you just do a search for a gummy smile you get many many threads on that and it's it's very very challenging how do you see other people treating this where you kind of look at that treatments say aha they should have done it the way you're doing it?

Monish: You know doing a proper diagnosis because like I said that it could be five different ideologies of a gummy smile and I think most of the time we're where I see patients referred to me is where someone's done a laser or an electro search not realizing that this was an altered massive eruption which also has two different soft classifications and if you don't take away the bone and you don't give these seeds or natural biologic width that tissues is going to rebound back so I think a proper diagnosis of what's causing this particular patients gummy smile is the key.

Howard: I love to Serge that's I think I think of that Star Wars scene where that's a word I haven't heard it a long long time, what are your views on electro surge I mean there's definitely uh is it gone the way of t-rex or is it still being used or what's the status see the electro surge?

Monish: I think that on soft tissue lasers that's dropped so much I don't see but at least once or twice a month I'll have patients refer to where someone ended up using an electro surge so I take most folks tend to use soft tissue lasers now I'm always when I think I probably never see anyone use an electro surge I'm surprised so I think it's still out there.

Howard: So if some but he was listening today that was almost as old as I was and they were still hanging on to their electro surge what would you recommend that they replace it with laser what would you tell them to get?

Monish: There's so many different i think of basic diode soft tissue laser would be a good starting point so you know you can you can do minor gingiva Tamizh with that you can do biopsy soft tissue biopsies with that you can do some soft tissue crown lengthening gingiva Tamizh so I think a relatively spencer diode laser probably would be the way to go.

Howard: Any name brands you can recommend?

Monish: We use the Picasa light in our practice so we actually have four of those that we pretty much use on a daily basis for these minor procedures.

Howard: Picasa light now that was made in your backyard in indiana

Monish: Yes that's true

Howard: Yeah Alan Miller right A MD lasers was Alan Miller dentistry and he was a Hoosier from Indiana so um the thing I believe about electric surge tell me if I'm wrong but they they just caused a lot of post-operative discomfort and when I've been in several offices where dentists said you know I don't have any post offer discomfort of that and you see the assistant and the receptionist roll our eyes and I turn I say well what happened and they go doctor are you kidding me when you use that thing they call back two or three times in fact it was one of the reasons way before the year 2000 that I got rid of the chart because I was finding this problem where people would call up with a problem but they wouldn't pull the chart and enter the note and I kept talking to him talking to him from 87 to about 99 and finally I said you know the only way I'm gonna be able to fix this I'm gonna have to get rid of the chart so we went completely paperless the goal was by 2000 because you had the y2k thing going on back then and all that silly stuff but I the laser actually the the electric surge is what drove me to go paperless because I wouldn't know the feedback of everything like if I did a root canal on you and I see you two weeks later i I want to know if you ever had to call the office and why you had to call the office. So implants that one of the problems a lot of the young kids have is they come out of school and they became a dentist because their moms are dentists and she's all excited to join their practice and then she starts seeing things that don't really jibe with what she's heard in school like mom using electro surge and her going in there and saying now we got to quit doing that the peri-implant disease is a big source of stress because they don't know what to do they you know mom place this implant mom's happy the patient's happy can eat a cheeseburger but she's looking at you know five six millimeters of mushy gums all around here what are your thoughts on peri-implantitis what's causing it, what do you do when do you draw the line that says no this is failed even though you can eat pepperoni pizza?

Monish: Right right no I think one of the things when we started placing implants over 25 years ago we never imagined that peri-implant disease would be an actual entity that we would have to deal with on a daily basis so I think it's it's been a very humbling experience to all of us in you know that place implants and each implant dentistry to dental students and residents and and other dentists was that we never accounted that you know this would actually be an entity and would be widespread so we now realize that how we manage bone and soft tissue around implants is very different than how we did it around teeth A we need more bone and more soft tissue than we ever thought before we actually have a publication we came up with some new guidelines back in end of 2015 that what we thought the distance between a natural tooth and an implant in the aesthetic zone needs to be more than what we thought we need to have an extra millimeter millimeter and a half over the one millimeter of buckle plate when we place implants in the aesthetic zone so I think on our end we've tried to control a lot of these treatment planning aspects to prevent peri-implant disease then of course we know there are risk factors patients who are uncontrolled diabetics patients that are smokers patients with a history of peri-implant disease those are very high risk factors for developing very implant disease in the future and then of course locally cement is been our biggest enemy because we were doing so many cement retain restorations on these implants that even a little sliver of cement going into the sulcus without an implant having a periodontal ligament would just cause this rampant peri-implant disease so I think just in the last two years there are more of us talking about very implant disease of different aspects because peri-implant disease is actually three different entities Howard people don't realize this peri-implant mucositis which is reversible if you catch it early you can reverse before this affects the bone then there is peri-implantitis is the classic bone loss around an implant and then we have a new entity known as retrograde peri-implantitis which is almost like an endo infection at the apex of an implant so I think with these three categories of peri-implant disease today we have stricter guidelines on when to place implants how to place them properly we have stricter guidelines on a restorative standpoint on we try to do more screw retain restorations or if not we use less cement we also do what's known as crewmentable where most labs are now making crowns with a with a screw hole access just to let all the excess cement out and then thirdly I think where the biggest effect is we don't let these patients just get lost in the system we now have new guidelines for a recall or a recare program in our offices so that we see these patients who spend a lot of money and invested a lot in these implants we have seen them now on a regular three or four month basis so that we can identify some of the risk factors and we have them on a strict maintenance protocol so I think these are factors where we've tried to address and manage peri-implantitis now once that infection gets into born Howard it's very difficult to treat it's still very unpredictable anytime we do any bone grafting procedures around these implants that have bone loss it's a 50-50.

Howard: Wow that's um that's not very good

Monish: No no not not at all

Howard: So basically so peri-implantitis I just assumed it's always gonna have a - now it seems like that's where it's going peri-implantitis...

Monish: Yes

Howard: It's always gonna be hyphenated so so basically peri-implant mucositis it's there's no it's not involved the bone peri-implantitis it involves a bone and then you're talking about retrograde peri-implantitis where it's the apex is involved?

Monish: Yeah so you know if we have not done a good job of cleaning and disinfecting these sockets we are seeing these lesions at the apex of an implant show up about one to three years force restorative ly so again the incidence isn't high but it's as high as about 8% so for every hundred implants that I placed today if eight of them are at high risk of developing retrograde peri-implantitis I better change and spend more time in getting these infected sockets and spending more time making sure I get rid of all the infection in the area before I place an implant.

Howard: You know when you go to PubMed and and for a lot of these periodontal papers it's amazing how many of these are all from India and do you think India has is the leader in this type of research?

Monish: No I think two things of course there are about 25 to 26,000 dentists that graduate in India every year you have over 300 dental schools in India and you know given the sheer population because I go back and teach two or three times a year so I'm visiting professor had come a couple of the dental colleges back in India so I think there is that also there is to a certain degree lack of proper education so everyone graduating today thinks it's easy to place an implant but that's as you and I know we've been doing this for a while that's just a small portion of what it actually takes to place an implant properly to maintain those patients to prevent all these peri-implant diseases from showing up so I think it's it's India's at that stage where there are a lot of implants being placed with very little follow up and little knowledge is always dangerous so what I found is there are some folks that practice at the level when it comes to implant dentistry as what we do here but there's a lot of misinformation or a lot of nonchalant attitude where everyone things to be an implantologists and they find it so easy to place an implant not knowing all the other things that we have to take into account so I think it's a combination of all of these factors.

Howard: You know I love love love luxury in India but you know when you fly from Phoenix of New York that's five hours then you have a layover then it's fifteen hours from New York to New Delhi which is right on the other side of Phoenix like 12:00 midnight there is 12 noon here and then we get done lecturing to turn around and go fifteen hours back to New York I mean I so admire you making the trip to do it in person I'm getting lazy and trying to do it by podcasts and online CE it is amazing but when you but in in the United States I I can't vouch for India on this but in the United States the kids are always telling me that all their most of their opportunities to learn about dental implants are provided by manufacturers so it's kind of like they got a pick up manufacturer before they start taking the course or it's it's very connected to dental manufacturers so they're always wondering you talked a lot about trabecular metal implants and they want the guests to say what system they use and what system you know right now believe it or not and you probably will not believe this there are over 400 companies on earth making implants now, making and selling implants she just got out of dental school and she doesn't want to review 400 different dental implant companies when they got a guy like you so what would how would you shorten her list from 400 to 1?

Monish: Right so I think there are several good companies manufacturers that have spent a lot of research and money in developing so I think it really you know being from Detroit Howard I'll use the car analogy there's more than one good manufacturer of cars it ultimately depends on what a person is comfortable with so I think as long as we go with the top five or the top 10 companies you cannot go wrong in terms of the quality of the product but a big thing for me being an educator being in full time academia in the past and now and full time and private practice but we do about two continuing education programs every month at our Institute to me also it's important that which company is going to provide me with the educational support so when we have a full time at Detroit Mercy and we were looking at an implant manufacturer to provide undergraduate implant education to our students we looked at several different companies and then we pretty much at that time went with Zimmer it was only Zimmer now it's Zimmer biomet because they had the best package in terms of education and I think that's the reason why they are in over 33 or 34 dental schools today providing support and education so I think more than just the product which you have several different companies making a good product my answer to this young dentist would be go with a company that is going to support your growth your professional growth so that you continue to deliver good treatment to your patients so it's just not about selling a product but it's about educating at different stages in your professional career because the way we practice implant dentistry today very different than we did even five years ago.

Howard: So your so if if she asks you if I had to pick one system than yours would be Zimmer Biomet?

Monish: Of course however because that's I you know I was involved in teaching with Zimmer Biomed over 13 years ago 14 years ago through the university that's what we use now so that certainly is my personal opinion, my personal bias but it's not I think the important thing is it's not just having a good product but it's having a good support system around that product that can help you excel professionally.

Howard: Yeah so Zimmer Biomed I'm got it up here right now was the fourth leading competitor in the u.s. dental implant market in 2018, the company's main portfolio of implant systems includes t3 3.1 and MMD is aesthetic I love the way they spelled with a Z aesthetic tapered screw vent Accio Tigh trabecular metal and locator you seem to be talking more about the trabecular metal or is that not true?

Monish: That is true I mean our workhorse implant that we use a lot is the tapered screw vent but this trabecular metal implant was introduced about a little over six years ago it's revolutionary in terms of what it can do to speed up the osseointegration process or what we call today's Accio incorporation so the orthopedic division of Zimmer biomed developed this trabecular metal which is actually tantalum in for patients that had some health issues and poor circulation when they were getting hip implants so this allows for more in growth of bone what it's led to in dentistry is where we can use this trabecular metal implants now to do immediate loading so we can give our patients a restoration the same day and then it also has applications where if someone has systemic problem poor bone quality then this allows for more bone to implant contact so it's one of those premier products that we don't use it for every single patient but at least I don't but we use it quite often where folks either require a restoration sooner or they have some health issue such as diabetes or poor bone quality because of osteoporosis or we tend to use this now where previous implants developed either peri-implant disease and we can save those implants so we do this as a revision implants.

Howard: So what percent of your practice it is replacing implants you know like endodontists they'll they'll tell you most of the ended on site and talk to you actually they only actually do four or five root canals a day and most of them will tell you that over half our retreats or as periodontist reach that where half of their work case is replacing an implant?

Monish: I think it's getting there I see at least one or two cases every day and we there are three of us that practice so each one of us sees at least one or two peri-implantitis cases every day so I would say if I was to put a percentage we had almost at about 20% of our practice now is either treating peri-implant disease cases all where we are removing these air plants that we cannot save and replacing them with new implants.

Howard: Is it hard when you look in the mirror do you see besides seeing just another gorgeous smart bald guy do you see yourself as a periodontist or an implant ologists what do you what do you see first in the mirror?

Monish: I think I'm very much a periodontist because we still believe in saving teeth with all the regenerative advances and you know bone and soft tissue grafting we still see ourselves or myself as being a periodontist where I'm in the business of saving teeth but if we cannot then those skills have kind of transpired into me being able to grow good quality bone and soft tissue for future implants so I'm still a periodontist first but I think I'm an periodontist and implantologist.

Howard: You know I could you know on dentaltown you can learn a lot about dentists by where they spend their time what they're focusing on and there's a lot of correlation to money I mean it's one thing to try a new $50 or bonding agent but it's another thing entirely to go spend a hundred and thirty-five thousand dollars on lanap so they see these um they see these cases they hear about lanap they hear all that stuff but they got two hundred eighty five thousand dollars of student loans they bought a practice for seven hundred and fifty thousand what would you say about the need or urgency to spend a hundred and thirty five thousand dollars on a laser treating peri-implantitis?

Monish: It's you know to use an analogy buying a really expensive golf club is not gonna make you a better golfer so to me I think the technology and the science has advanced and we always advocate practicing evidence-based dentistry so I have several colleagues who use the Lanap and they've had excellent results I think ultimately it falls upon us as the healthcare providers we want to do what's best for our patients so I think every case that we see some benefit from a Lanap or a similar procedure others require a more traditional approach others require a more regenerative approach where we can use in a mometrix proteins and different types of bone grafts so I think it's having just one solution for everything out there all different aspects of periodontal disease I think that that's something that we discourage our fellow colleagues from doing so I think having these different and what ultimately falls upon us that our clinical skills and our diagnosis skills need to be good so that we can say what would apply well for this particular patient in this particular scenario so I think it's just that one-stop approach for treating everything with lasers we're not quite there yet.

Howard: So do you did you buy it do you sir do you need it in your office?

Monish: No we've not that use it we don't we don't use it in our because our methods of doing micro surgical procedures now and treating these cases more with regenerative like I said the proteins in the bone grafts seems to be doing well on the same token however I have other clinicians that you know we do have evidence we know it works but it doesn't work in every single situation so I think that's really where we have to be careful.

Howard: Yeah it's a it's a huge expense.

Monish: It is

Howard: and you know Warren Buffett when he talks about investing he says never good you know there's two rules he has that you know I've been listening to him since 1980 because I when I went to Creighton in Omaha Nebraska and he came over and spoke he said I don't want to go into a business where someone else sets the price and here we are in health care where we're government were insurance Medicaid Medicare they're all setting your price and that's capital intensive but you don't get so much of the capital intensive nasteria and they they bring it on themselves you say okay here's a dollar scalpel and they say no I went a hundred and thirty-five thousand dollar laser you say okay you wouldn't need a CBCT where well when I go to my physician and he needs an MRI he doesn't have it in the office he sends me someplace and and they do the MRI and then the dentist decides okay well I might want to take one of these every other day so I want to buy the machine myself and it's like I don't know I'm I mean do you think a CBCT again same questions she went back out of school she's with her mom her mom has a pano machine she keeps hearing CBCT as a standard of care in Perry Oh implants and you know they always draw out this standard of care even though I can't get a lawyer on this podcast to really explain what the standard of care is, it's an art it's not an exact definition they they throw their hands up standard of care I mean that's about as vague as you can get but same question when from a periodontal implant point of view when do you think she needs to own her own CBCT?

Monish: Yeah just depends on how I always say baby steps, yes CBCT technology is amazing we have a cone beam CT machine in our practice and over seven years so do we use it for every single implant case that we do no, if I have a site where I'm not worried about any anatomical structures and I have a good periapical film and I can see all the structures I am NOT taking a cone beam CT for every single implant case but then on the same token anytime we are placing implants where we are close to a vital structure or we have to do more aggressive treatments such as sinus grafting it has been very helpful I along those lines Howard if I may just talk about guided surgery which a lot of folks are now doing they're using cone beam CT technology and having a guide made so they can go in and do guided surgery my only word of caution to some of these younger dentists that just started their career is it's still not a hundred percent science when it comes to guided surgery because you don't know who's guiding your guided surgery is it the surgeon isn't the restorative doctor or is it the lab technician that's guiding your guided surgery. So I think having a cone beam CT has certainly been very helpful do we use it for all no I think we do use it for about eighty percent of our cases and I think a lot of that has to do with the fact that we've gotten so used to having it in our office and it's available it's can be the radiation dose is significantly lower now than what it used to be so I think we tend to use it more from a diagnosis standpoint but is it a standard of care I think you pretty much mention that at the beginning of this question is we don't know we don't know whether it's a standard of care.

Howard: I'll say the same thing about the ask about the pinhole technique that that's the thing young kids they're always hearing about a John Chao and it's pinhole technique it's very um everyone talks about that and what are your thoughts on that cuz how does that compare and to things you're doing?

Monish: Right so you know it's it's a register technique but we've been doing variations of the pinhole for a long time there was the vista technique it was the tunneling technique so just using a slightly smaller incision with a different product where the basic surgical concept is the same so there are lot of similarities and I think again people certainly you know pinhole has really brought a lot of patients where they've seen this advertised and they want their gum recession treated but it's not a one procedure fix all for all different kinds of recession we've seen relapse with this it's a great technique it works well but in the right situation you cannot apply it for cases that have more severe recession or different areas of the mouth or what a patient's bio type is I think we need to take all of those things into consideration.

Howard: I like the way you are succinctly said it's a registered technique so it's it's applying a brand name registering and getting a trademark for a variation of something that's been around a long time is that kind of what you're saying?

Monish: Yes

Howard: and what do you think of that macroeconomic technique where lawyers create laws and trademarks and registrations for a registered technique do you think that helps the industry for marketing and advertising and building an industry or do you think it's are you not a big fan of it?

Monish: No I think it's a double-edged sword right I think we certainly all of us that are and I'll call it loosely in the business of Dentistry we are health care providers first we want to do right by our patients but I think a lot of this is a good business is necessary because that's what helps us innovate that's what helps us grow as clinicians and say okay is there a better technique or a better product out there but the reverse of that also is I think folks need to be smart enough or educated enough that a registered trademark doesn't mean that you know that's the only way of treating certain conditions there are variations so I think I ultimately being in the business of Dentistry I think III agree having trademarks or where people have put in a lot of effort or developed a technique I think is certainly important but we as clinicians need to be educated and know right from wrong.

Howard: One of the podcast that went out today was basically the one on the I talked to the attorney doing the class action lawsuit against smiles direct club Rick Stone and that that's a big deal that the small start Club IPO has been very troubling from beginning but what are the concerns that were thoughts have is that people are getting this when they already have pareo you know they weren't screen properly have you seen this with your own eyes or is this mostly theoretical in your mind?

Monish: We just arresting because practice today so I you know before we started this podcastI was just wrapped up my last patient and this is a patient exactly what you said has periodontal disease and Madrid with localized severe and had one of these these treatment the smile direct appliances main and and then ultimately ended up because it was some issue going to her general dentists who then referred her here so it's not whether that translates into this being an epidemic and more people I I don't know but I certainly see that as a little bit disconcerting.

Howard: So you feel they weren't screened properly and went into this without having it done?

Monish: Yes

Howard: Well I couldn't believe why he would come on the show I mean every attorney won't comment about a case and I'm like why I said him the invitation I said well I'm wasting my time but I got a try but I wasn't thinking as he you know it was like those commercials if you think you have mesothelioma you know contact this firm he was hunting for cases I mean that's the only reason he came on this show because he wants you to email him so you might you might look at that an email in the case because the orthodontist you know it's competition it's disruptive technology but it's the devil is always in the details isn't it right the Devils in the details. Sinus lifts I feel like when I got out of school in 87 that the most successful implant was the longest implant I mean they wanted to go all the way through your head around the moon three times and that was success and so you had to do a lot of sinus lifts all the time but implants now are getting shorter and fatter like I am has the shorter fatter implant reduced the number of sinus lifts that you're doing now versus say ten years ago?

Monish: A little bit because when we look at evidence we know we have enough evidence that eight millimeter long implants today have a very good long-term success and survival rate you know it used to be we would we would the shortest implant we would placed in the sinus was a 13 millimeter implant so today we are okay with eight six people are placing six millimeter short implants but we don't have the evidence that what the long-term survival or success is going to be so we need yes I tend to be doing more crystal lifts, that's the indirect sinus lift it's less invasive we use some special kids we do it at the same time that we place the implants so I see myself doing more crystal lifts today and less of the lateral window the more invasive procedure that I used to do ten years ago so I think it is as short as I'm going to go in my practice based on evidence so if a site needs one or two millimeters or three millimeters of a sinus layer it's fairly routine we do this several times a day today.

Howard: When I get my fellowship in them in the mission institute it was right there in your backyard indeed a great so were you friends or did you meet Carl Misch any Carl Misch stories?

Monish: Yes I consider him as one of the geniuses and pioneers who brought implant dentistry to where it is and you know he's a you unique grad you know a Detroit Mercy grad I didn't know him personally but I met him several times he used to at different times he would teach his part of his lectures and his Anatomy at the dental school so I got an opportunity to work with him and learn from him so you know he's his passing was a big loss to the implant community to all of us because I think he was one of the pioneers when it comes to implant dentistry not what is in the surgical but in the prosthetic aspect as well.

Howard: Yes an amazing man. How's the when we got out of school to get microbiome wasn't even mentioned and no you can't read anything about the get my chrome and I was starting to question a lot of people are like you know like standard statements like I'm you have to get your teeth cleaned every six months has the gut microbiome what do you think of that and do you think what kind of impact do you think it's gonna have on our final understanding of what's going on in the mouth someday?

Monish: Yeah I mean the focus has shifted so much in dental schools we our curriculum has gone up significantly and we still have a four years of dental training so we're trying to fit everything into that then I come across a paper and specially but University of Michigan being in my backyard and that's where a lot of the research went into this is we will see certain aspects of whether it's periodontal disease or peri and plant disease are being attributed to be certain microbiota that we have seen whether it's the red complex of bacteria whether this anything else so I think is renewed interest every now and then that comes into that but in terms of clinical practice and its impact, I think there are several other factors that we have to consider.

Howard: Some people after they've practiced 20 30 40 years when they're sitting in a bar having a beer will say they believe that what they've seen is if you have a lot of cavities you don't have a lot of gum disease and if you have a lot of gum disease you know that that it's either you have a lot of cavities and a lot of gum disease or vice versa do you do you think that kind of speaks to the oral biome do you believe that do you see that yourself?

Monish: I do that's what we see and that's what we've seen and so the biggest factor in and I can speak from a periodontal standpoint that I tell my patients is we cannot find genes we inherited good and bad genetics from our parents there's no fighting that so once you have a gene that predisposes you to certain conditions then of course your diet and your lifestyle and environmental factors and other factors can either up regulate those genes and cause more severe impact or more severe disease so I'm a firm believer you know genetics of course is the biggest factor and then just like what we see we can see patients with tons of calculus and no periodontal disease and then we see youngsters that have a more aggressive form of periodontal disease have absolutely no local factors they have certain specific bacteria but they had to have that particular gene that predisposes them and then I think all the other factors come into play.

Howard: Yeah I did that 23andme and I found out my dad was a short fat bald guy I did not see that coming. So back so what do you think of the University of Melbourne dental school professor Eric Reynolds who just closed a 14 million dollar funding round to create a vaccine for periodontal gum disease how does that idea even strike you do you do you look at a vaccine for pareo and think I wonder when they were gonna do that or it is the same more far-fetched?

Monish: No I think we've heard this over the course of the last you know two three decades there's always been talk of having this vaccine I haven't read much upon this I've heard of it so I guess I'll have to look into it and more detail to have an opinion one way or the other but it's nothing new we've been talking about it but it all came down to you know who has the funding to support making a vaccine for periodontal disease because in the list of priorities of other diseases this was went way down there.

Howard: So you say you give courses to twice a month in Michigan?

Monish: In Michigan so you know what started Howard is a study club so when we transition we meaning my other two associates my wife she's a periodontist as well and my my colleague who was a resident we all taught at the dental School and then when we things got busy in private practice and we transitioned full time into private practice as in our blood so we started a small study Club which is now grown to over 600 members we sponsor all their education this is our you know our philanthropic wing of giving back to the community so we do about two events every month we do a big event once or twice a year we do some hands-on courses so this is evolved into into a into an Institute and you know we are proud Howard when the opioid epidemic hit about two and a half three years ago we were the first ones to have a continuing education course for over 300 dentists on how to manage this opioid over use we were the first ones to talk about human trafficking so it's not just a pareo study club we invit speakers with different areas of expertise to come and lecture to our members.

Howard: Now is that open for people in other states other cities or just more for your local Detroit referrals?

Monish: No it's open to anyone and everyone Howard and we don't charge any membership fees that is we support that 100% it's only is on courses that we do we charge a nominal fee for those hands on surgical courses but all the lectures they are at no charge the membership is at no charge.

Howard: So that's at they'd find everything they need to know about that?

Monish: Yes

Howard: and so the email for more information that is that's the the email you would use?

Monish: Correct there's a link that says join our Institute fill out their particulars so we've had people from other states that have joined our Institute and they'll they'll come once or twice a year and attend certain lectures.

Howard: Do you let Hoosiers in?

Monish: Sorry

Howard: Do you let Hoosiers in from Indiana I mean how how open is your policy I mean are you letting Hoosiers in?

Monish: Absolutely

Howard: You know so you know one of the best marketing oh go ahead you're all about I want what wouldn't you was so when did you go to Indiana?

Monish: 97

Howard: 97

Monish: 97 yeah

Howard: and I'm a kid you know they actually did find out what a Hoosier was it's not even a joke um it was a lady doing a book on the history of railroads that the railroads they laid him five miles a day so you wouldn't slow down and introduce yourself you would just say whoever was building the railroad you'd say I want to I would be one of hoosiers boys and sure enough a man named Hoosier later railroad clear across Indiana but I really wish you'd do an online CE course on dental town you should film one of those because these kids they they you know money's tight and before they fly across the country a lot of these courses are several thousand dollars a weekend and that's my time you had plane fare and staying a hotel so they love the one-hour course online we put up 400 courses and they've been viewed almost a million times we just released another one today but I would love to have an online course from you do you think you'd ever be up for that?

Monish: Oh absolutely, I think I'm doing a lot of lecturing a lot on peri-implant disease so that would be something that I think your audience would enjoy.

Howard: I would love one on the gummy smile so I'm but the guy that does continue education is Howard goldstein so he's ho go but I would I would love to have anything from you I mean I just think what you're doing is amazing and what do you what do you see you know dentistry Uncensored I like to talk about what's what's controversial and what's not I don't want to talk about anything anybody everyone agrees on but some people look at other people's periodontal program and refer to it as just supervised neglect there you got these people you see him every three months you've been doing this on Mrs. Jones for years where could you help her see the line between supervised neglect versus what what event has to take place before we change course and say no we're just not gonna see you every three months you you need to go do something how could you help her because I think the most important thing I want all the dentist to get an A on diagnosis and treatment planning I'd really get an a on your diagnosis to dream plan and all your dental work was a C then to get all this work that's always an a-plus but half the time it's not even the right treatment plan.

Monish: Right that still remains a big challenge Howard and in fact it's funny I don't know if you're aware of this or not but some leading periodontal clinicians implemented a lot of extra effort from their hygiene team and themselves in trying and motivating these patients to see you know what whether their compliance would go up at the best the our compliance rate is only in the 30 or 40 percent of patients that we you know that come back on a regular three months they say so that remains a challenge but the shift that I've seen is again you know I always say education knowledge is powerful you know whether it's educating our peers or educating patients or you know the end consumers what we've seen is it with patients now that are getting implants we are seeing compliance rate in the high 80s and 90s and I think it has to do with the fact that they have invested a lot of time effort and money and a lot of that is not just insurance money but their own money those patients tend to be far more compliant and are coming in on a regular basis to protect their investment as opposed to paranormal disease so I think it's whether we like it or not you know I just like you I travel all over the world and I found the human nature to be the same everywhere you know have different priorities based on you know which country you are in and what culture you are in but human nature is the same and I think when folks tend to invest a lot of money in their treatment they tend to protect that more and we have seen that with implants where we didn't now I think with regenerative again patients who have had a lot of regenerative procedures and surgeries with bone grafting and proteins and where we've had good results they tend to take their health more seriously so you know ultimately at the end of the day I think everyone is responsible for their own health.

Howard: Yeah and but that's not I mean you're right next door to Canada where Canadians will brag all the time oh I just had this surgery and I didn't even have a one dollar bill it's like okay so you don't believe in human nature you don't believe everything economists learned I mean what you're just saying is that when a person has skin in the game they pay attention I mean it just look at dentists the dentists who owned their own dental office take home a hundred thousand dollars a year more than dentists who are associates. I mean humans just don't pay attention until they have skin in the game okay and if you're trying to devise a health care system where none of the people know the price or have any skin in the game because you feel that you have a big heart and this is the best thing for people well you're basically gonna destroy economics and society with your big heart I mean I mean humans are humans and there's just they have to have skin in the game. So another very controversial thing I know you have patients and I know I'm at 58 minutes and you're like well this guy ever shut up and let me go back to work another big controversy is the oral health continuum the the oral health you know what is how does that connect to the rest of body some people are claiming that oral health is related to heart disease, do you buy into all of these oral health claims where do you where do you say yes it's all related and where do you draw a line says I'm not convinced?

Monish: Right we all tend to follow the evidence and the evidence is clear you know there are a lot of associations any you know whether it's very periodontal disease or certain aspects of oral disease or oral health we know it's a risk factor but when I speak on the other hand and I'm a firm believer I believed it all these things contribute but on the other hand our physician colleagues it's one of 20 or 25 different risk factors that their patients have so I don't think we have a direct correlation we have an association we don't have a cause and effect when it comes to heart disease we know it's you know it's associated because just like information anywhere in the body you have more grow inflammatory cytokines and c-reactive proteins that cause destruction but is it specifically someone's periodontal condition is going to lead them to have a heart attack I think that's what we don't know why it certainly is a risk factor and I think if today the population is aiming to be healthier it's certainly good for them to be aware of the connection and if we can eliminate or we can help them eliminate an additional risk factor I think it's certainly well worth it.

Howard: So you're basically saying that the cardiologists that you talked to periodontal disease is one of just 25 different risk factors and that's not a singular thing like that it's for that and the other big debate is is it contagious we you know you have grandma who's being seen every three months for periodontal disease and for five years your in you've never seen grandpa could grandpa be a part of the problem or no part of the problem?

Monish: No I think the evidence is there the evidence certainly says that the acid is contagious but I think again in every individual you know and the analogy to use is everyone who smokes doesn't develop lung cancer so he puts them at a higher risk I think ultimately it comes down to the genetic makeup of that individual whether it predisposes them to have that disease or not but in terms of paranal bacteria condition being contagious we know that yes it's transferred within families.

Howard: So you talking about opioids I'm everybody I've seen the the pendulum go from one in the other when I got out of school we were the bad guys especially oncologist these people were suffering they were gonna die anyway why are they in so much pain because the doctor wouldn't just give her an opioid you know and and so then everybody just started letting him go and now it's coming back but I think that the bigger issue is maybe antibiotics I mean I know so many of my friends that every time they do a root canal it's a pen BK 500 milligram and they say well do you know it can't hurt I'm like I don't know maybe it can hurt and with with gum disease they they see someone with peri-implantitis they do root planing curettage and they just think I'm just gonna always give him a scrap of antibiotics it's the older guy he's always say I'm doing tetracycline because they were taught you know 340 million years ago that tetracycline show up in the gum tissue seven times more concentrated than other antibiotics what's your view of how dentistry is using antibiotics regarding perio?

Monsih: No I think there's an overuse of antibiotics that's led to antibiotic resistance throughout all over the world I think that's a big concern and I can speak from personal experience Howard is the evidence now when it comes to doing for example root canals or implants that if we give our patients a loading dose you know how we do for patients that require antibiotic prophylaxis if we give them a loading dose let's say two grams of amoxicillin with no follow-up the survival rate and success rate of implants is the same as having them on a seven or a 10-day course of antibiotics so I think what the loading dose does is a one-time loading those does not create antibiotic resistance when you put them on antibiotics for five seven ten days that does so that's how the last three four years in our practices for uncomplicated cases when we're doing you know regular implant placement we give them a loading dose with no follow-up antibiotics so you know we found no difference in the rate of infection postoperatively and secondly these patients our population does not build antibody precision. So I think that's something you know would be a good pearl to share with your audiences that loading those are one-time loading those can somehow help us in preventing this overuse of antibiotics that seems to be happening.

Howard: So did you meet your wife is appearance did you meet her and pareo grad school is that where you met?

Monish: We actually met in dental school back in India we were classmates.

Howard: I always every time I lecture notes go I always tell them okay the smartest thing you can do in dental school is marry one of your classmates what do you say to that advice?

Monish: I would say amen to that.

Howard: Oh my god I mean gosh darn I mean who else wants to listen about gum disease and all your dental thoughts and I mean you know I just think it's the smartest thing you do congratulations on that move, in fact if you're gonna do a lecture on dental school I think you should be for dental students on how to choose which classmate that they should propose to first I'm smart of saying. So his website is I hope he gives us an online CE course I want to get the word out more was there anything that you were wishing I would have asked you about Monish that I wasn't smart enough to bring up or?

Monish: No I think we covered a lot of topics Howard and you know to me this is the first time aware of the em to town or recently became aware of it and I would love to can contribute in whatever fashion that I can because I think you know those of us who teach it's in our blood sharing knowledge is powerful empowering our colleagues so that they can provide better treatment to the end consumer their patients I think that's that's the goal so I would love the opportunity to lecture if you want me to do more I would I would certainly be more than happy to contribute in whatever fashion that I can so.

Howard: Well thank you so much I'm the neat thing about a dentaltown it was five years before Facebook and since Facebook's come out we've still grown a thousand new members a month we have a quarter million dentists I think what I think it's basically two reasons on on Facebook everyone knows who you are but you can still be anonymous on some social media sites like Reddit or Twitter but dentaltown I there's got to be a place where someone can post an x-ray and say I messed up and I anonymously want to ask you know what is what is going on here but the and the other thing is dentists seem to have many social media they than that you know have three or four different sites but the the between the anonymity of dentaltown and leaving your own tribe and be able to go to a tribe where we're only talking dentistry we're not sharing pictures of your birthday party and your and all those first things its I just think it's vitally important that dentists have a place to go where it's only dentist's allowed and you can show the worst thing you ever did and all your colleagues are gonna talk to you back from the edge of the cliff and tell you where to go how to do that but Monish thank you so much for an hour your time it was just an honor to podcast you and I hope that rest of your day is fantastic.

Monish: Thank you Howard, it was my pleasure.

Howard: Alright have a great day

Monish: Thank you you as well 

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