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1349 The Changing Field of Periodontics with Dr. Brian Gurinsky : Dentistry Uncensored with Howard Farran

1349 The Changing Field of Periodontics with Dr. Brian Gurinsky : Dentistry Uncensored with Howard Farran

2/6/2020 3:00:00 AM   |   Comments: 0   |   Views: 143
Originally from Dallas, Texas, Dr. Gurinsky attended the University of Texas at Austin and then received his Doctorate of Dental Surgery from Baylor College of Dentistry in Dallas and completed his residency in Periodontics and Dental Implants atThe University of Texas Health Science Center in San Antonio.  He currently maintains a full time private practice in the Denver and Centennial areas.
https://www.briangurinsky.com
VIDEO - DUwHF #1349 - Brian Gurinsky

AUDIO - DUwHF #1349 - Brian Gurinsky

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Howard: it is just a huge honor for me today to be podcast interviewing Brian Gurinsky DDMS he was born in Dallas Texas and attended college at the University of Texas at Austin he continued his education at Baylor College of Dentistry in Dallas which is now Texas A&M where he attained his doctoral dental surgery following graduation dr. Brian Gurinsky beyond a three-year residency in periodontics and dental implants on completion of which he earned his certificate and periodontics from the University of Texas Health Science in San Antonio dr. Brian Gurinsky has extensive research experience and has published and presented his findings in a number of papers and presentations he was a lead researcher of a new soft tissue graft material utilizing amniotic tissue and is being sponsored by astra tech to research implants and smokers dr. Brian Gurinsky is the past president of the rocky mountain society of periodontics and currently serves on the Executive Board of the Metropolitan Dental Society as treasurer he's consultant for the Colorado State Board of Dental Examiners he has also been named a top dentist last five consecutive years and top implant surgeon by top dental surgeons dr. Gorski on the editorial advisory board for two dental journals and is a product evaluator he's a clinical associate professor in the Department of Surgical Dentistry at the University at Colorado School of Dental Medicine as one of the few board-certified periodontics periodontist in Colorado he provides a comprehensive periodontal care and a professional and caring atmosphere using the most up-to-date methods and materials I mean I could go on and on and on by the way your new dean of the dental school don't know the new dean of the dental school Nancy or uh Denise Kassebaum yeah she was my teacher at UMKC Dean for a few years she was in for a bit and now 

Brian Gurinsky: she's been full-time for a number of years she is that did you see her often I see her about once or twice a year her husband who's a recently retired dentist was in my study club so I said I would see him all the time in here a little bit

Howard: she was so cool man III knew she to a different job even as a student she would always answer any question from a research base we use hands like do you think that's a cavity between 3 & 4 and she'd start quoting research I thought wow this woman is on a different level than me but it's unbelievable I'm you know I tell everybody that of the UM when I got a school there's only nine specialties now they're ten but it seems like you know they take pediatric dentistry the only thing that's really been hot is and changing as maybe silver diamine fluoride I mean into Donna's I mean everything seems pretty much the same specialty for the most part except for yours periodontics my talk about an hourglass of sand just turned upside down once and then back over it seems like when I got out of school it was all periodontal surgery and then that was 87 and then by 95 to 2000 people just started saying you know the best way to treat this is with forceps and pliers pull the teeth and put titanium in and then they did that for ten or fifteen years and now I'm back where I started where you're back to like periodontal surgery so it's it's kind of so do you agree or disagree

Brian Gurinsky:  I agree and I think you always see shifts in the pendulum but I kind of saw this coming ten years ago when it seemed like everyone was wanted to jump on dental implants and you know when plants are great we do them but they're not fail-proof and I think we're learning that now that they're fraught with issues and problems and maintenance issues and the periodontal patients that have periodontal disease don't all sudden get cured because you sticks unka titanium in so I'm hoping that in my specialty we see more of a shift going back to trying to save teeth treat things conservatively I hope so 

Howard: um you are so publish you're so accomplished I mean you've written so many articles for dental town and they're  all classics aesthetic crown lengthening functional osseous crown lengthening I mean I mean you're just a legend but I wanted to start with a tough question where the percentage of people who have gum disease or pérignon seized I mean you read stuff in the mainline press it says you know 2/3 of Americans have gum disease you see it with peri-implantitis you see you see the quotes all over the board and it's like what if someone asks you what percent of Americans have gum disease and what percent of implants are failing from peri-implantitis what would your numbers be

Brian Gurinsky:  well it depends if we include gingivitis as well I mean your device technically is a disease but if you include that you're talking 85% of the population has some form of periodontal disease I think at least half 50 to 60 percent is what we're hearing says true periodontitis where bones involved now if you look at implants I mean maybe 9 out of 10 implants have some form of peri mucositis maybe it hasn't affected the bone but the numbers are maybe even more staggering than it is with periodontitis in natural dentition

Howard: so what it what is it's a 2020 you can finally see clearly now with your 20/20 vision what has got you excited in pérignon us today that wasn't there when you walked out of pareo school 

Brian Gurinsky: it's hard to pick one thing it would be tough the materials are definitely changing we're looking we're using some materials that I've been excited about I started in research about 12 years ago on an amniotic material initially we were looking at using it for route coverage for seizures and then kind of morphed into a product for a membrane over bone to do more type of GTR or gbr type stuff in the product to be just innate inherent products of alamut's placental tissue a myung tissue as growth factors and proteins and things that are gonna increase and boost the healing and so I think we're looking along those lines any product that offers embody the ability to to do what it wants to do but maybe at a heightened response or a better way as opposed to putting some inert material that isn't living or doesn't have any bioactivity so that's what one newer materials products that I think help the body heal better and then along those lines we started doing about eight years ago one nap or doing laser procedures to help the body do what it wants to do just like the materials we might use trying to do things from a more minimally invasive angle I guess you could say so anything that we can do with less pain less morbidity is what we should be looking at and moving in that direction and as you mentioned I think a lot of the fields in dentistry and things in dentistry haven't really changed all that much I feel like what we're seeing in pareo is a shift towards doing things more minimally invasive whether it be through tissue grafting treating periodontal disease there's so many different new techniques materials modalities I think we can be more conservative and ultimately patients have less pain and a faster recovery um you just said blood nap-nap has a big roots in Colorado that's correct mostly because one of the top researchers the guy that really spearheaded it was retina and retinas in Colorado and so there are a lot of Linares here in Colorado and what dr. Jana had done his research was kind of kind of went against the grain for periodontics we're so in tune to everything's gonna have a research we got to see the day that we don't just jump in anything till there's histology and we kind of go overboard and so the paranormal community kind of turned a blind eye on poo-pooed a lot of this stuff until dr. youngness research and he got involved and so we were really how are you saying that dr. what dr. ray you know why you KN a he's kind of I why you KN a he's a he's a kind of a legend imperio he's been doing research with bone and synthetics forever and he's a very well respected very well known periodontist and so we were kind of lucky to have him he used to run the program at Ellis do when the hurricane said he came to impact Colorado and ran the graduate program paradox program here and has just remained here and does a lot of research for millennium 

Howard: so I want you to talk about that a little more because when these kids are dropping $100,000 a year for a dental school Allen app is another hundred thousand a CBC T's another hundred thousand dollars so so since it's a hundred thousand dollar investment will you spend a little more time on it what do you think of um 'ln app 

Brian Gurinsky: well it's not it's not a hundred thousand dollars anymore that was probably about six years ago I think it's clustered up 130 or 140 now I worry that it's getting priced out of the market and you know if you're not gonna it's a one-trick pony you really for Perry out there's other lasers that do more hard tissue and soft tissue but the Slater's which i think is the best for soft tissue but it is just for Perry out so there are a lot of general dentists to have it but it's expensive it's  a lot of money when I look at buying products from my office I either think what I'm buying is gotta have some type of ROI on it or it's got to be a lot better for the patient so when I first was a practice the first thing I did was I bought a existing practice the first thing I did was I put in digital x-rays I thought old film x-rays were just not what I wanted now did I see a big ROI on buying digital radiography no but I knew it was better for my patients in long term maybe maybe I started recouping that was less buying less film and chemicals and all that what happened yeah but that's what I have to look at we're not buying some is it isn't either gonna be better for my patient or is it something that's gonna help me be more efficient and more profitable and do

Howard: you where is the pendulum now between the periodontal disease treatment where when we get into school I mean you could have lower molar to the through for case involvement and they would do a Hema section and they come back to me and I do like two little premolar crowns on it and then that all that stuff just died I mean the first casualty of ever titanium implants was actually the apical acting right Rafael if you look at Delta dental insurance claims I mean that nothing went extinct and then and now it's coming back where do you think it is now on paid oral surgery versus implants I think it is

Brian Gurinsky:  I think depends on who you ask and what type of philosophy that person has I am on the extreme side I would say of being a conservative periodontist where we really try to hang on to teeth we will keep teeth that have fur keishon involvement and areas that I think a lot of my colleagues will take out and place implants and we can certainly justify that through the literature on why that might be a good decision to do that but I'm gonna kick out of keeping teeth it's a challenge it's fun to keep teeth I would like to try to keep my own teeth so there might be areas that are kind of in the gray area but areas I think that we can maintain for a long period of time but the patients motivated so we still tunnel teeth with class three through four caissons we still do root imitation semi sections when I think it's called for when I think the patient will be compliant and can maintain their teeth unfortunately most of the patients that we have they're just not that patient are you trying to

Howard: go back there's an institute for advanced laser dentistry and they talk a lot about fighting gum disease and you talked about Lynette and I wanted you to be clear just because it's a hundred and thirty five thousand dollar decision if she was um if she was 25 she got out of dental school she'd say she does five years as an associate she's opening up her own practice she wants to be high-tech would she be thinking about whether a hundred and thirty-five thousand dollar l'adapt laser is a good good decision 

Brian Gurinsky: because it depends on what her practice demographics are does she see a lot of older patients see a lot of patients with periodontist I assume you're talking about a general practitioner right right I think it depends on what the patient makeup is she in a new area a young area where it's a lot of yuppies and maybe not but I think if it's an older existing pre-existing practice with a lot of pre-existing pareo patients then which might be some benefit it's  a hard to justify it takes a long time to recoup that amount of money so if I was a younger dentist looking to buy technology I'm a GP it wouldn't be the first one I'd rush out and get what would be the first one you'd rush on get oh maybe a 3d printing machine or a or CAD CAM device 

Howard: you know why those young dentists don't see a bunch of old people where they don't needle an app it's because I think when they're when they're just babies see 35 and under they they're always on Instagram and snapchat and all this stuff and not know 135 and unders got gum disease needs implant on Instagram and they hate direct mail because they think it's pollution but the people that I know crushing it in implants they always run a dollar bill sized ad that says dental implant 999 because they know that all these people are coming home from the paradise oral surgeon where the implants like 1250 1400 1500 and they know no one needs one implant you know everybody's come in multiple and the the other guy I know I mean he'll denture world or affordable dentures built their entire industry on an advertising says all extractions $99 because affordable denture says I mean come on Brian do you need a tooth extracted you might even know do you need one tooth extracted I think zero teeth extracted I know same here no one needs one tooth extracted when someone comes in for that $99 extraction they need like six extractions four quadrants arute playing heroes those guys that do that 99 dot that $999 implant they go well you know if you were gonna place like say one implant on replacing a central incisor on a beautiful girl with a highlight like yeah III need big money but your average implant is multiple implants especially if they're in retirement communities like fini and whatever but they say yeah the $99 extraction and the $999 implant it's gonna attract somebody that needs five to fifty thousand dollars with a dental work you know I mean so if you're if you're a young girl and you're doing all your advertising on Instagram I mean you know the Instagram people aren't getting immediate so so I want you to UM help hope these young kids they're hearing all about the oral systemic link and and my gosh they were associating these bugs with just everything and a lot of them say to me you know every morning when I make coffee the Sun comes up is that a correlation is that it cause of fact there's they're saying periodontal disease everything from Alzheimers whatever what are you convinced that this gum disease P gingivalis that it's any are you convinced that it's the oral systemic linked to anything specific

Brian Gurinsky:  I definitely think there's a link the question is is it a link or is there a causality in addition to that but I think if you look at all of the different things that we're seeing a link what do they have in common it's all inflammatory disease so I think there's paranoia's eases inflammatory disease I think if you if you look at that and you compare these diseases that are inflammatory in nature well I do think there's only and I think it's not so much the bugs that we are we were taught that you gotta eradicate this bug and he got eradicate that but I don't think that's necessarily right I think what we need to eradicate is inflammation that whatever whatever way we can do that and so I think if we can eliminate inflammation or reduce inflammation instead of trying to get rid of the red complex of bugs that I think we're better off but I definitely think there is a link because all the links that we see from periodontal disease other systemic diseases they're all inflammatory in nature

Howard: well now I want you to weigh in on the biggest controversy I ever did and that is on the great karl mesh his little brother Craig & Karl would not Carl would do smokers and Craig wouldn't and smoking is a huge inflammatory disease so you learn and she's young she learns in dental school by the periodontist said these are the people that you don't do implants on and one of them smokers and also but then in the real world you're vegan yoga instructor isn't the one that has gum disease it's always your uncle Charlie with a pack of cigarettes and a beer in his hand so what do you do between how do you justify the ideal and the reality listen we all gotta make a living

Brian Gurinsky:  so if you're if you say you smoke one cigarette a day you're not getting an implant the patient's either gonna lie to you and tell you they're not or you know I have too many implants and so what I was taught and residency was the dirty little secret is if you get below half a pack a day you're probably okay most of the problems we saw over half a pack a day and we tell you a frank discussion with the patient listen if you smoke you got about three times higher risk that these are gonna fail there's still have a high success rate but you have a higher chance of these not taking so I think you know you got to mitigate all those those factors and in Colorado it's not just smoking cigarettes it's the other things that people smoke here so you got I mean real specific when you say a patient of the day and I say hey do you smoke he goes no no I smoke gross and I said to use marijuana oh yeah marijuana I think or I put it in a bomb like god smoke I said you'll that's I when I say smoking I'm referring to anything that you put in your mouth I'm not talking about serious and so I think most people assume we've dug and just cigarette so we have to be specific in Colorado but I think you've got to figure out what is your line on what what you're gonna treat and we know this muggers don't heal as well but to say that you're not going to treat anybody doing anything that that smokes some you know it's going to be hard to make a living 

Howard: does you've for the international listeners were you were like this first or second state that legalized marijuana you an organ or we were first you were first yeah so do you and and how many years ago is that

Brian Gurinsky:  I think it's going on five or six down

Howard: so Arizona's voted it down every time and you're our neighbor so to international there's a place in Arizona called four corners my grandkids love it you can put your foot down and be stepping on Arizona New Mexico Utah and Colorado but now that it's been there five years did that have a material dental impact and did you see any dental impact with your eyes after five years of legalized marijuana not from an oral standpoint but my office is downtown so we see a lot of people that have come to the state and into the city because of the legalization of marijuana people that the most saver uses the works that have come here and so I we deal with that but as far as the mouth goes 

Brian Gurinsky: no and when they looked at marijuana and the deleterious effects of marijuana they found none however I should say what they found one and it was para donald Z so this only correlation was marijuana to pérignon sees all the other things that it might do didn't show up medically

Howard: so so marijuana increases periodontal disease that's right 

Howard: well then I'm gonna quit giving it to my grandchildren I did not know that I use it so certain there's certain ways that are worse than others ah yeah it's a it's interesting stuff I um tobacco was actually discovered by the Native Americans in in North America I mean our our indigenous people figured out smoking tobacco I wonder where they figured out to smoke marijuana was that also indigenous in America I don't know that is interesting so um so when and so but back to that oral health continuum this is a question we get all time in dental school she reads this oral health continuum she doesn't want a bunch of inflammatory someone a bunch of inflammatory disease all these things go bad and there's peri-implantitis but it's completely symptomatic and it's on your uncle Bubba and he so go to eat a double bacon cheeseburger and he has no pain he loves his implant and she's looking at you know red bleeding hamburger around it we're where does she actually have research to say I know it doesn't bother you but this this is a systemic this is an inflammatory issue this has got to come out and redo it or or would you just start putting him on like three month maintenance and really doing the old-fashioned periodontal disease 

Brian Gurinsky: we would the problem is when you start losing bone so having just bleeding gums around it isn't the end of the world but once we start seeing bone loss so it goes from a peri because itís to a peri implant science is when it starts to become a problem now where do you cut the cord and say alright it's got to come out that's that's up to each practitioner some people say if you have more than a third of bone loss you take it out I think it depends on where in the mouth it is and it depends on the patient and what their recall schedules been like but we gotta train like periodontal disease we have a lot of the same paradigms even though it's different and we don't really know how to clean them adequately we still have to use a lot of the same things we know about periodontal disease and intervals of cleaning we got to apply those to implants and unfortunately it's the same problem I have with  gum disease I have a pair implant Isis then hurt they don't sometimes feel a need to get treated and to undergo an expensive procedure that will hurt so it's a tough sell

Howard: so the Native Americans in America have figured out smoking tobacco but it was the Chinese that figured out smoking marijuana so at least we got one attitude right America Merck you got one attitude we're doing pretty good um so more more back to periodontal implants again there's 400 now dental implant companies just registered in Italy only just the country of Italy was seventy five million people and fifty thousand dentists has four hundred implant companies because they just it's a big industry there titanium is a big industry so so many people were making titanium parts but but when you go to the Clone meeting there was like 275 implant companies so she's 25 she wants to learn how to place implants she ain't got time to figure out 400 different implant companies are you agnostic or as a periodontist are there is there an implant or certain implants that you think are special than just saying titanium titanium titanium 

Brian Gurinsky: well is it yes my answer is yes I think there's a big difference between the s1 and the 50th best one maybe not a huge difference as far as survival rates but I have other beliefs on that item as a specialist I'm expected to use a premium implant so I'm using the more high-priced implants because that's what my referring base wants they don't want me using a knockoff but I'd like to use a premium implant because I know those companies are gonna be around some of the fly-by-night companies I don't know where they'll be in a year I don't know if you'll be able to get restorative parts for those companies or if I'm patient goes from Denver or to somewhere east coast or west coast that's far from here I want to know that it's gonna be easy for that patient to find a practitioner that can restore that or handle it as opposed to wondering what the heck is this kind of implant so so I think there's a huge difference in survivability I don't know I think that long term if there's issues we're gonna have a better chance of correcting those and in working with the implant if it's a if it's a premium Empire you

Howard: um she doesn't know what premium implant mean she's a third or a fourth of my listeners are still in dental school what is a premium implant well it's one of the main companies there's probably four or five companies that have listless Lea little is the

Brian Gurinsky:  premium implant companies for Robin noble care sitting in straumann and Abu Bakr dents fly Zimmer bio horizons I would say those are probably the top five the five biggest they probably have ninety percent of the share and there's some other clone implants that are very fine that are good implant directs of the world those kinds of companies and Noble biocare and implant directors owned by the same company and Vista sorry

Howard: I know no Baba who got recently bought I was Danaher did buy it but Danaher spun off kind of like when we were little Siemens owned Sirona and then the new CEO said we're over weighted in healthcare so he spun off Sirona and the building didn't move is still right there in Austria at the same building but it was no longer part of Siemens and Danaher said we're over weighted in a healthcare and they spun off the whole dental division is called Invista and VI sta so you're saying the premium dental implants was straumann who's made a bunch of mergers and acquisitions they bought out neo dent out of Brazil they bought others you said noble bio care which is also implant drug and visa you said DENTSPLY Zimmer 3i what was and then the other was bio includes Astra and ankle Mo's Frieden and and buy a license now is owned by Henry Schein they bought that does atom does that change anything in your mind or 

Brian Gurinsky: not really not really we're still doing what they did same sales force for the most part and so so now you're a periodontist

Howard: so you said you need to use a premium dental implant and does a general dentist need to use a premium dental implant or would you recommend that she did 

Brian Gurinsky: well I still think for the same reasons I gave you that it's important to use a premium implant if the companies go out of business or the patient moves but if you're because of finding replacement parts mostly in research and yeah but if you're a general dentist and you're looking for a more cost-effective solution maybe you want to lower your prices below what the specialists are charging then I think you you look to consider a clone type implant that's going to be half the cost on the on the surgical side and your store departs probably  a little bit less as well so that I found where me I would probably look at everything where am I going to get trained and where were you get trained do they have are they teaching you want us different specific implant system that you felt comfortable with I think they all work and the principles are all the same it's just what's gonna be around the longest 

Howard: so I know you're an intense science dude but I know that you're aware that there's people between here Phoenix and Colorado I'm better what am i a 12 hour drive from you 12 hours Denver to Phoenix for me oh I love that drive I just love it but anyway um so here's the reality of patience in between us on especially when you get around Sedona so they say things like you know if you put a gold ring on your finger there's no tight ain't there's no staining but if you put a base metal you know how you get that green staining around your deal and there's just a lot of anti metal people and they're starting to not want any metal in their mouth and I always ask him do you fly metal free airplanes do you drive a metal free car you know you have a metal for a mile but anyway they're crazy but there is some dentists believe in this and pushing ceramic implants so my question is is there any evidence that at a seven and a half billion people that some people actually indeed do have a metal allergy to these dental implants metals I have you are you interested in ceramic implants you think there's a place for that what would you say to her 

Brian Gurinsky: there's a place for and we placed a few the patient the last place that I paid the last patient I placed one on and a true allergy to titanium we took the four main implants that we knew she had allergies we took the four main implants that I use she taped him on her arm that this is where doctor want to do she taped him onto her arm and within an hour she's breaking out to these and some of the company said this is our ceramic implant straumann furnaces this is our ceramic implant well it does have metal in it she's aged still out of reaction the only one she didn't have her action was one that was a pure coating implant that was pure pure ceramic implant I afraid to tell you that a year and a half after we placed that she lost that implant but that was the only one she'd never true allergy to so I've had two people three people maybe in my career that have had a true allergy to titanium so I think there's a place for it but I think the public hears ooh metals bad or they watched what was the endo movie about the roots the root problem whatever when they watch something like that and they get in their head that I can only have a ceramic implant I have to have it so I think if the public is clamoring for something yeah company's gonna come out with it but I always worry about your point and one's got metal everywhere but I worry about long-term data how are these things gonna handle in 10 12 years and I don't think I think jury's still out on those 

Howard: Wow that is uh that is amazing um we you I asked you you said it wasn't the first thing you'd buy and you said you weren't to buy something so there's three parts to an intro scanner there's a scanning design milling or you you place a lot of implants are you using old-fashioned impressions polyvinyl siloxane polyether and pure gum or are you starting to scan well we've been

Brian Gurinsky:  we've been scanning for eight years we you have we you scanned body so if the referring Dentist wants us to scan for them will scan the implants send it to the lab that they want and they get the crown above it in their office without having to t

Howard: ake impressions without having to take up chair time question what's your scanner ID row okay as skin so you know it's funny I'm cuz i taro is owned by line technology which owns Invisalign so people doing you know Invisalign what that I taro but you're a periodontist what why did you pick a taro well never

Brian Gurinsky:  I was talking earlier about what I think is better for the patient or at Devon ROI it wasn't the ROI that I bought this thirty thousand dollar machine I thought that well I thought it would it would help boost referrals because we could do all that work on the front end but I thought the patient would like the wow factor and they do they like the wow factor not having to put all the stuff in their mouth you show them what their impressions show up digitally and manipulate it and they like that and I kind of geek out on - I think it's pretty cool myself but we could still do the same thing probably with PBS now if you ask the labs they'll tell you that they they have a few it remakes with the digital impressions but do I you do it a lot no because we don't prep crowns and we're not doing Invisalign so I have a real small initial and I can use it unfortunately another so back back to that the skinny so you like the scanner or you you're designing milling did you you send that to well as a periodontist are you just placing implants or do you actually use much lab work not very much no in these cases we're placing the implant we asked referring to a ste one stamp patient back to do traditional impressions or would you like us to scan and we've got some that like as a scan and some that don't I think this a lot of the furring offices perceive that it's gonna cost them more in their lab bill if we scan it which is probably the opposite on the lab have a few less labor it's less labor-intensive so a lot of times those those fees or less if they scan it so the only negative is if you want to for do a custom shade and you need to use a local lab so that there's fewer options from local labs that are they gotta buy the lab the software from white arrow which is pretty costly so the bigger labs tend to buy it and so the smaller ones don't some of the one the guys it's just kind of a mom-and-pop type lab they're not investing in the software necessarily fried taro 

Howard: I asked you about what nap and but what's really confusing to the kids in dental school um there was a dental seminar this Friday Saturday in Phoenix and there I saw a bunch of dental students from HEC La Mesa and midwestern and a couple different times the kids were asked me there's been the old one app and the new lip app so there's an app and lip app okay lipet la pap that's the LA yeah that's for peri-implantitis protocol okay so what's what's the map and what's lapel lapel so when a piddly 

Brian Gurinsky: refers to just treating teeth so laser-assisted attachment protocol no special protocol thank you and we'll put this laser it's just peri-implantitis protocol so one out and it's kind of the same Howard: protocol or is it really a different protocol oh it's pretty much the same protocol but there's less energy it's a shorter procedure just because you can't have too much energy hitting the metal surface of the implant another thing that every day asking about is um the pinhole technique the pinhole surgical technique so you're a periodontist is that a patented special procedure or what do you know about the pinhole technique

Brian Gurinsky:  I know careful what I say so I don't get documents sent to me from industry uncensored all right good well I was for last several years I was teaching a two-day hands-on tissue grafting course for DES so we go through the gamut of all different techniques all different materials panel was just one technique there's really nothing new or revolutionary about it it's a it's a tunnel we talked about tunnels decades ago and the guy who I kind of think it was the father pareo Plastic Surgery at Allen who was the best at what's his name Pat Allen out of Dallas

Howard: okay and please tell me he wasn't a Cowboys fan this team it's funny for my five grandchildren or in Dallas I mean or in Abbeville Texas okay they're all they're all they're all Dallas Cowboy friends I can't get any of them to be an Arizona Cardinal but anyway

Brian Gurinsky:  so Palin you think it was the father of periodontal no I kind of consider him he what maybe he wasn't the first but I consider him to be the the best at it he's just an credibly gifted surgeon really a man he was the one that really started talking about tunnels and that was I was learning about that in my residency 20 years ago and so it's not really a new technique the difference is it's a tunnel that's the insertion point is in the vestibule and then you tunnel from up there where it's a traditional tunnel comes through the sulcus traditional tunnel is actually more difficult and then with pinhole instead of harvesting patient's own tissue they're using dissolving collagen material really a college of barrier caught up in strips and placed into the into the sulcus so there's nothing being harvested which makes it easy for person doing it and julienne their description of it doesn't require it being sutured so I as a periodontist I'm not a big fan of it I think there's very few cases that really are indicated for it you've got to have a decent amount of care a nice tissue for it to be successful and not a real shallow sulcus which frankly a lot of those cases are they're being done for aesthetic reasons but not for functional reasons so if the patient wants a once roots coverage and they've got ample amount of keratinized tissue they often don't need gum grafting they just needed probably position flap and so I think there is a very small indication for it but you got to know and when to pick the right cases to do it so it works well so there's a lot of marketing behind it as winds probably doesn't surprise you okay

Howard: I've been I've been giving this advice for 30 years and please feel free to tell me that you completely disagree and unplug your headphones and storm out of the room um a lot of dentists they always ask me they always say I need to learn a pareo hygiene program I need to learn the soft tissue management program I I bought that my mom's practice and I got these two old hygienists and and I'm taking all these courses on you know fillings and crowns and root canals and cosmetic dentistry and and what course should I take and I always say well I wouldn't take any course I would go find the periodontist you refer to and have him come down and have a lunch and learn and gives you a the exact criteria like okay we're gonna see these because one of the big critiques about a general dentist hygiene programs is supervised neglect you but you've been seeing grandma every three months and until you put her in a pine box and just lower into the ground and so I always say that it's the periodontist fault because you know if the crown doesn't fit it's the lab man's fault if the hygienist does something wrong it's the periodontist fault i I've never done anything wrong in my entire career but III went to periodontist and he does it for us he gives my hygienist exact protocol of when you just keep doing this or when you change course and do that and I don't have to get involved in any of the debates about it Rustin and chips and so we check her referred is that still is that what most periodontist will do or is that not really what they'll do anymore

Brian Gurinsky:  well I think that's a great protocol to have Oh miss Emory referring dentists has their own idea what their protocol should be and so some offices they don't want to refer out and so they're gonna push their hygienists a clean and scale Andrew plain and do things that probably need to be treated surgically so I think it depends on who that is if the dentist says what's the ideal time to get it treated I just gave electric couple days ago in our our convention and it was titled when do I need to send to my periodontist and we talked about this and what the parameters are and we've got research that tells us that we're only effective cleaning so gingerly 23.7 six millimeters now that's the research we all know that we can do better than three point seven six millimeters my hands are special yes the best you're ever gonna do is six point two one that was when they spent twenty minutes on a tooth they stained it they then they flapped and they saw you only got to about six point two so we're just we know we're not very good anything six is about as good as we're gonna get so if it's greater than six millimeters it's probably gonna end up treated but the gist of my my talk this weekend it was you can't just treat the numbers you got to look at everything it's a bleeding that's do they come back every three months how they had six millimeter pockets for 30 years and they had surgery 31 years ago when they were nines and tens and they've been fives and sixes sense and haven't gotten worse you gotta look at everything but I think every hygienist has an idea of what he or she is reaching the point of where they're not effective anymore and every hygienist has a different probably a different number based on their experience level but every dennis is gonna say keeps shoving some arrests and in here or keep scaling it until they get to here and then with then we have to send it out so there's some economics behind that I'm sure what about when 

Howard: you say when you clean some general you can't see I mean anything else up gingival is a Stevie Wonder cleaning now they have the the perio scoop what do you think do you think the perio scoop has changed all that or not really

Brian Gurinsky:  I think the periscopes awesome but full disclosure I don't have one the imperial scope is super cool you can see what you're doing much better now that it's it's a little takes a little time to learn how to see what you're seeing underneath it but you're still charging surgical fees to use that so I think it's great for cleaning it would be nice to use that in conjunction with other things maybe even it'd be great to use it with one app when you're doing stuff blindly I think it's awesome but it's an expensive machine it takes to learn there's a learning curve to using it so are you as a dentist going to use it or you can have your hygienist use this the hygienist that's using are you gonna train your hygienist your Center for training and as you I just send a bump around from office office is it is a modality that you're gonna keep training each hygienist you bring in every year or however often you have to bring in new by jenis but there's some things behind that where most dentists I don't think we want to do it themselves as aperi to us we would probably use it ourselves and I think it's I think it's a pretty awesome piece of technology but I don't have it right now and

Howard: um you know she wants to learn implants but she tells me and I heard this is weekend twice like I don't know I mean I want to learn to place implants but I had $400,000 student loans I bought a practice for 750 I'm thinking I'd have to get a c.b.c t-that's a hundred grand my god by time you get done going to Jamaica or Dominican Republic it's just if what would you tell somebody four years out of school you know they did their dental kindergarten they've been out for four years they got down the block to tackle the past the reception a cleaning a filling exam and they're ready to start going next level they want to learn you know implants how would you coach her to start that journey

Brian Gurinsky:  I think first of all the younger Dennis really should focus the first several years on being very very good at bread-and-butter dentistry and to money over so worried about place doing veneers and implants and Invisalign and they forget making really nice crowns to in really beautiful fillings I think first I need a master that after that and they think they want to place implants then they need to take implant courses too hands-on courses different Continuum's because if you're going to place implants and you need a large surgery and you need to learn how to use bone grafting materials and membranes how to suture properly it's not just doing a platypus procedure and placing an implant and then handling the failures when they come you need to be comfortable doing all those things and it's not just placing implants it's learning how to make flaps and design your flaps and it's more than just screwing a screw into bone you've got to know all those other things so I think if you're going to do that you need to commit to understanding surgical principles first and then finding out that dental curriculum or the or the continuum that fits what you want to learn 

Howard: and the news is it's really feeling with a lot of them really trying to convince Americans at an electric toothbrush is gonna be I mean there's so many I mean there's quip and sonic hair and oral-b I mean there's just so many of them and now they're attaching them to an app and you know I practiced 32 years in Phoenix I'm just trying to get my clients to not drink Mountain Dew after they smoke meth it may it may be different in Denver but but but the bottom line is succinctly is an electric toothbrush statistically significantly better than manual to prevent

Brian Gurinsky:  it is it is but the question is is it better because of how the brush works it probably is or is it better because it stays on for two minutes so they did a study a number of years ago and the average person when they use a manual toothbrush presses for 30 seconds so if you just brush with a regular toothbrush for four times as long as the average person does so two minutes would it be better with the electric toothbrush still be better I don't know maybe but maybe not a whole lot better so I think most of what's better matters it's just horses you brush for longer

Howard: um there's a you know how there's these and by the way are you agnostic to any toothbrush I mean I was looking at um I'm trying to see what the okay I'm gonna say there's this one article out there's a Chicago Tribune had an article out and it was comparing get clip oral be burst oral care Philips Sonicare is when you talk about implants you talk about the premium dental implants is there a premium electric toothbrush that you think is significantly better than a standard lowest cost electric toothbrush that you'd get it at Walmart

Brian Gurinsky:  I think probably the sonic here it's gonna be the two best ones Lana care or the oral beat yeah I think those are the two best once I have my personal preference but I think those are the two best ones and they're probably gonna be better but again it goes back to if you took the cheapest battery operated one versus a sonic hair and brushed for two minutes with both of them or you did a split mount design in your brush for one minute on one side with a battery operated one and then one minute on the other side of the sonic hair would you see a big difference I don't know that you would the companies will tell you otherwise but I don't know that you would 

Howard: is it there isn't there a big an electric what is it one of those companies in Colorado water I think they're based out of in cholera yeah water water pick that was one I was thinking you know what I yeah Fort Collins Colorado you know what I liked about the water pick is that you know when I got high school you told someone to get a water pick if you told a man to get a water pick his wife was gonna smack you because he made this big mess in the bathroom now there's water everywhere and they finally made it to where you can carry it into the shower yeah I mean water a water pick and the shower is perfect but it's not a great idea in front of your your mayor so do you like water pick how do you like that for cleaning 

Brian Gurinsky: I recommend patients get water picks all the time I'm dealing with very outpatient stuff so they got a lot of bleeding they've got bigger spaces in between their teeth I love water picks around implants if they're not used to liable level I think they're great but I also know that most people buy human aid they sure have about a couple minutes and most of they're gonna spend on their teeth so if they give me two minutes I'm gonna tell brush and floss and be done with it if I tell you you got a now you gotta use proxy brushes and now you gotta use a water pick and now you got to use this rinse they're probably not gonna do something so if it's something they're not going to do it whether it be probably the water pick or rinse as opposed to brushing and flossing and that's own

Howard: water piks owned by church into white uh they bought that for a billion dollars they also an arm and a hammer I thought that was our hammers funniest thing this book is Armand Hammer his autobiography in search of us I and I don't own Arm and Hammer baking soda his entire life everybody just every time I introduce Armand Hammer everybody assumed it was for his baking soda company but Armand Hammer owns water flosser maker water pick they paid a billion dollars for that do you think that was a good buy and do you think I mean do you think that's that was a good deal I don't imagine a billion are just being a good deal for anything but I guess they probably looked at the numbers more than I know their marks coming up with newer things they just came out with this water this water pick fusion where it's a toothbrush with a while or pick built inside and and as you alluded to they've got they've got either a portable one or one you could take it to the bathroom so I mean I guess if they gave a billion dollars I sure seems like a lot of money for a one-trick pony yeah well the thing

Brian Gurinsky:  I am was worrying about is you know they got the army hammer toothpaste they bought Waterpik and then the New York Times comes out right after they bought this and said there was no evidence for flossing it was basically 

Howard: so so we I'm in Phoenix Arizona I mean they still tease me about that I had I had an 80 year old woman put her hand on my shoulder like two days ago she goes I know you still say it even though the New York Times said it's all just it's all you know crazy talk what would what do you think about the fact that New York Times said that if there was no research to show is that actually true and we're just fine don't flush your tea get rid of all the floss be good for my business 

Brian Gurinsky: I think it's silly it's just kind of like the people that don't think that water fluoridation is a good thing maybe there weren't the great I haven't been the greatest designed studies to prove that that flossing isn't helpful but anecdotally I can tell you I can tell when patients awesome when they don't when they walk into me Italy so I think it's laughable that it came up and it's me that we shouldn't be flossing 

Howard: so then what about okay so they bought Arm and Hammer and they already have a toothpaste we're talking about electric versus manual do you think any toothpaste are more preventive to not decay not streptococcus mutans but P gingivalis do you as a periodontist do you like some toothpaste more than other

Brian Gurinsky:  no never so that is a that's probably 

Howard: um so back to the boomer versus millennial you know I always joke with the the Millennials I would say I go to when I when I'm lecturing I say to the I say how old are you and she said I was 25 and I said when I was your age I was 28 are you married yet divorced but they they go they go become a dentist about a quarter or a third of the time some relative their mom their dad it's a very family business in dentistry at least a quarter of everyone in dentistry has got a blood relative in there and they're seeing things to me that I'm their old boomer dad like me does pareo splints and then she just came out of midwestern says there's no research for that well yeah the only real benefit for pareo splints is for patient comfort that's that's true that's what our studies have always shown that it's only for patient comfort okay I don't think they don't strengthen the team well explain explain what we're talking about - the one quarter of the kids and dental school okay we're talking about 

Brian Gurinsky: so we're talking about so for those quarter of the kids who gone through ortho I bet a quarter of them have a bonded lingual liar in their mouth same kind of principle it holds the teeth together keeps the teeth from shifting so if you're a pareo patient you got mobile lower teeth then way back when we used to split teeth and we still split teeth because we didn't want every time patients bite down on it it would hurt we don't want the teeth moving so we split them all I have teeth splinted all the time in fact if I'm trying to regenerate bone whether it be through a graft or a laser procedure I know for the studies also that if there's mobility of my wound or mobility of my tooth then I got a much much more decreased chance of that happening if there's movement so if I can eliminate the mobility that I know I've got a better chance of bone coming back so there are benefits to it but from what the studies say yes it's for comfort it doesn't it doesn't necessarily strengthen the teeth but it allows sometimes a procedure or a general procedure to catch up and then potentially strength of the team that makes sense 

Howard: okay now I want to get you in a lot of trouble my goal here is to get your license taken away and beyond the the evening Denver news the when I there's a lot of guys like myself who when they see an infectious mouth you know the oral surgeon numbs up all four quadrants they like to numb up all four quadrants and debride the whole mouth and do everything and then while they're numb I I did this the other day I had a 3-hour patient and I numbed it all up I'm doing the scaling the root planing removed sixteen I mean it was just an infectious disaster and so the oral surgeon numbs all four up and then he's in a medical dillon building with eight general dentists and the other seven general dentists a their whole life well i can't name up all four quadrants so let's just do right side left side because i know you won't come back for the other appointment and I don't want my treatment plan exceptions case to be too high so we don't do same-day dentistry and we don't do four quadrant dentistry we just design everything by intent so that nobody gets done and I saw this lady and she came in she was in pain I had the time I was in a day I never ball four quadrants through scaling we were playing pull sixties all that but anyway long story short um united concordia and dental insurance companies they say well we're not we're not we can't pay for quadrants the same time it's like dude i want i want the united concordia guy to go get a bypass and a quadruple and they do one valve a month for four months i mean so just talk about that why it just seems intuitive that if i just blow everything out of that now pull out the six hopeless teeth that are non restorable you know let's let's just let's get all the bad stuff out wouldn't that be better therapy their right side left side 

Brian Gurinsky:  yes and i just saw most college we just pulled out scaling a root planing now that said i don't do it a lot mostly because of me i mean in the insurance  comes and says vici you can't do it but me i don't like doing it and I'm pooped out after I do it and I don't know what I do as good of a job if I'm spending four hours doing one big procedure but does it make sense it makes way more sense way more sense but

Howard: but do you admit that dental insurance companies a lot of them will not pay for that 

Brian Gurinsky: yes that's probably what keeps us from doing it most I'm the one that frustrates does this actually comes in and they need scaling root planing here and maybe so here and then the rest are mouths okay so all right well I'm not just gonna clean for teeth I'm gonna still do aerial maintenance or cleaning at the same time while I've got you here but yeah they won't pay the additional amount they only pay for stealing here it's feeling here and so I we've got to do it for free or you play the game where you do this the perio main its first and then you come back in the couple days later and do this isolated scaling root planing it's silly that we have to play this game 

Howard: you know you're in Colorado which is a famous for a lot of things I mean they they they they new water fluoridation that was it was brown teeth in Texas Colorado you had how huggens the most famous anti amalgam guy but some people are saying that the modern-day people who are saying and I know we talked about this earlier that you got to get your cleanings every three months to prevent Alzheimers that that's a little to how huggin II what would you what would you say to someone well first of all did you ever know how Huggins or was that before the time so he was the biggest anti-american and let me just say this for the record because I get asked his thought about amalgam matter you know there's a big difference between you don't like mercury you don't like amalgam you don't do amalgams you don't want to Malcolm versus what I never understood is the second opinions like okay he thought the amalgam should be removed out of your mouth okay but the case is always twenty-five thirty thousand dollars it's like okay how did we go from we need to get these eight amalgams out of your mouth to thirty thousand uh so so that's why I always called and more because it was like the guys who get the TMJ thing so you got TMJ you have you have all this stuff and I'm like what I'm not so sure but the treatment plan was always to crown all 2018 you know it's like I bought an TMG a machine to justify the need to crown every single tooth in your head so you know if you were telling me that you didn't believe in amalgam and you think they should come out and you took out 9 m OD amalgams and replace it with 9 MOT amalgams I I'd probably believe you because that I don't want to do I don't want to place 9 m OD composites I mean I the worst thing in my life is when I look at this schedule and I'm walking in the room and I have to do a quadrant of m OD composites on two to six I mean that's just an hour of flippin work and you know the you know there's just nothing it's just hard but when you say you don't like amalgam but it always translates to full mouth kind of bridge for you know 28 crowns I don't trust the dentist but some people are thinking that if you get if you mention Alzheimers during a three-month recall pitch that you're kind of crazy well what would you say to that specifically

Brian Gurinsky:  well I think it goes back to the inflammation thing so I don't think you could draw the link and say if you don't come in every three months you're gonna get Alzheimer's no but what you can say is that we know that people that had periodontal disease at a certain age have a higher risk factor for it or there were more people that had it can't say that it causes it but if hey if it's me well I don't want to take a chance I don't want to take a chance of having pancreatic cancer edie rheumatoid arthritis obese all these other things that it's putting one more log onto the fire so the things that I can actually affect not my genetics things that I can actually change my behavioral patterns why would I not do that so that's my attitude I can't say that you're gonna get it if you go to Queens every six months as opposed every three months but I know that there's a smaller chance of it and I have healthier mouth which Lisa potentially fewer systemic problems why would I not do that what's the downside

Howard: last and final question I'm trying really hard to get you in trouble is the probing frequency a lot of a lot of dentists eight look you know you do you need an exam once a year and these hygienists on these people on three months recall I why are we probing them every three months you know but but some people it's a big debate a lot of older people say no you only do an exam once a year when we probe once a year so the other six month cleaning or every three month cleaning there's no probe or exam so the question is succinctly probing frequency and I know it's different for you because you're a periodontist in advanced cases but what would you say to probing frequency 

Brian Gurinsky: we don't probe every three months we Pro if they have if they're getting of teeth clean four times here will comb twice a year and sometimes once insufficient depends on what's their history if they've got implants that I'm not I want to probe more frequently than once a year so I could pick something up if it's going south they have a history of having advanced periodontal disease or refractory disease I want to know regular I don't want to wait a year to find out of some going on I don't think you need to do it every three months I think that's probably more than it's necessary but maybe try see here's is appropriate end do you for the record 

Howard: do you have allen app I do you do and you would you would wreck yea or nay that on a bra if you were a parent on us would you a or net yeah but I mean to other periodontist so so I mean there's a different paradigm seeing a general dentist yes I would and what

Brian Gurinsky:  if you're talking to general dentist I don't know I don't I think it depends on the makeup of their practice they'd have to have a lot of area to justify doing it I don't know that most general dentists are gonna see enough pareo to justify that that type of investment the company will kill me for saying that but I just don't know that they'll do it it was 

Howard: my final last question last question last way I think I'm on my fourth final last question I'm just one phenomena that I never can understand is uh when I go out my friends and Phoenix that are dentist which you can just assume they're all functional alcoholic no eating cheeseburgers it seems like it seems like for everyone dentists who routinely refers for crown lengthening procedures for dentists have never done it one time in their life yeah how do you have all these guys that live in the same country same dental school same initials we would you say it's about one guy does cramming things is the 80/20 rule 

Brian Gurinsky: maybe the 1090 rule okay

Howard: so so that does that mean that it's wrong I mean that doesn't exactly how do 90 percent of dentists go their whole career without doing this and the other 10% can't live without it so what what is the height of that I don't know

Brian Gurinsky:  we see a lot of teeth that have had crowns that they bleed constantly because there's biological wit thing and the patient just thinks it's gingivitis listen the world's not going to come in if they don't get a ground unlike that but yeah so if you violate the pilot with that maybe a little more sort and they bleed more but I think the bigger problem is if you don't feel like you can capture that margin so gingival III your impressions or get a good margin and you're kind of to working blindly and if you feel like you need to see that margin which I would then get a crown lengthen so you're working equal to the margin even if you don't believe in the biological thing at all you got to keep that dried so you get a good impression and let me let me just give you one recommendation the

Howard: kids a lot of times I've seen you you get really really stressed out because you are you just look to the impression and your stress cuz it's not gonna have you want to reimburse what you're running ten minutes behind and all that kind of stuff you know what the old guys do you walk in this room and you say you know what this is it's too much blood and infection I'm not even an impressed a let's get a temporary on this you need to go see the periodontist you need that blah blah blah blah so man when you're when you're mad you're running your legs you got a really you don't need to reimburse maybe if you send it to your periodontist for a crown lengthening then next time you get it back there's a firm layer a pink rubber carpet and all this is gone so your your self-imposed stress thinking it's you and your impression didn't make it and what it is is you just need to yeah most dentists they don't want that patients incur that seeger the extra costs and so they bust their butt to get a better crown or a better crown margin and work when the bloody field make your life easier make it so that you're not having to deal under those circumstances all right well on that note man it was a thank you for writing so many amazing articles interdental town you're the most viewed periodontist article writer on dental town I've been one to get yellow so for all four years you're a legend in my mind and so many people's minds thank you so much today for spending our at my home hey thanks for having me I appreciate it was fun alright have a great day 

Category: Periodontics
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