Dentistry Uncensored with Howard Farran
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Today's Gum Recession Treatment with John Chao, DDS : Howard Speaks Podcast #101

Today's Gum Recession Treatment with John Chao, DDS : Howard Speaks Podcast #101

7/20/2015 12:00:00 AM   |   Comments: 0   |   Views: 1256

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AUDIO - John Chao - HSP #101

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With traditional methods like gum grafting, Dr. Chao says, "[He] was unable to get the results I wanted. So I realized I had to develop new instruments." Listen to find out the impact his research has had.


John Chao, DDS is a:

•Graduate of the USC School of Dentistry

•Attorney at Law

•Instructor at USC

•Inventor of the Pinhole Surgical Technique



John Chao

(626) 308-9104

Howard: It is a huge honor today, to be having the legendary Dr John Chao who ... everybody's heard of the Chao Pinhole Surgical Technique and there's ... after our first 75 podcasts, we passed over 100,000 views. I'm going to start with the man himself, the legend. I'm a huge fan of yours. There are people right now on their headphones on a treadmill or driving to work who have heard of this a lot, but they actually have no idea what it is. Let's start with the basics. What is the Dr Chao Pinhole Surgical Technique and its also known by other names. Take it away, Doc.

John: Okay, well thanks a lot, Howard. Its a great pleasure to be with you on your podcast and to meet you finally face to face. Thank you for this opportunity. Pinhole Surgery Technique is a new and novel way of treating gum recession. As you all know, gum recession has been so far treated with connective tissue grafting which entails removing a specimen from the pallet and putting it where the defect is and suturing it together. The other variations of that technique are not using the graft from a pallet ... but using other grafts or cadaver tissue to correct gum recession. The pinhole surgical technique is a way to reduce, minimize the post surgical symptoms. The morbidity associated with connected tissue grafting which is considered a typical standard. Because the patients don't really like it, I'm sure you have done any of these yourself, Howard, then you realize that the patients generally, if they have one done, they don't do it again. 

This method that I developed actually calls for no cutting and no suturing and no grafting of any material ... any tissue from the mouth. Basically, through a pinhole in the mucosa, I use specialized instruments I designed for this procedure to effectuate ... to elevate a full thickness flap, removing the tissue from its bony connection along with the periosteum and then detaching the attached tissue from the bone on the roots. I end up with a totally loose envelope of tissue that I can drape from the apical direction to the coronally part of the teeth to then be able to cover the defect. Then without sutures ... how do we do it without sutures. We actually put strips of collagen through the pinhole and then put the strips of collagen underneath the papillae and then also put it under the flap and that stabilizes the flap and just sit back and watch it heal. It heals really fast. The pinhole is gone in one day and when the patient looks at it the same day, when its done, they think its a miracle because there's no sign of surgery to them. Because to us, it looks so swollen. Aside of that, there is hardly any problems with bleeding, hardly any problems with pain and the patients love this minimally invasive procedure.

Howard: How did you invent this? When did you invent it and how many [inaudible 00:04:03] have you seen? How long does this last? Walk us through the history story of this.

John: Okay. Many things happened.

Howard: Did they teach you this at USC? Was it a lecture at USC when you invented this? How did this happen?

John: I was very interested in tissue regeneration and I've taken quite a few courses on it at different places ... not at USC but at CU courses for that. I remember one time I had learned ... taken this course and actually bought this special scalpel that's parallel ... two blades parallel to be able to take a sliver of tissue from the pallet. I took it out and very carefully placed it on to the root of the upper right cuspid and I turned around to pick up the needle to suture [inaudible 00:05:06] have the suture I heard this sound go phttttt. You know that means, right Howard?

Howard: He swallowed it.

John: No. The assistant suctioned it out.

Howard: Oh gosh.

John: I was not about to go to the pallet and take another piece and so I was in a quandary but finally I was able to get some Meladerm from the fridge and I was able to finish the case. That was kind of traumatic to me and so I said, no, there's got to be an easier way. Its got to be easier for the doctor and there's got to be an easier way for the patients. 

I began to study all the different types of surgeries ... searched the literature and it occurred to me that very few, if any at all, procedures allow you to start from the mucosa where the tissue is soft. I approached the [inaudible 00:06:07] where its harder and I realized that that just might be a way to do it and so I began to put incisions at the mucosa of the teeth and I began to see relatively good results. The incisions had to be large and then once you make those incisions, you have to suture them so it kind of pulls the flap back. As I began to narrow the incision, make it smaller and smaller, I realized I could get better and better results but as the aperture gets smaller, I was unable to elevate the tissue properly and get the results I wanted, so I realized I had to develop new instruments and that took ... so the beginning of ... the concept came to me about 2000 and it took me about 6 years to work out the instrumentation to make it work. It was about 2006 is when I was able to formalize the protocol and start recording what I do. The recording then eventually became the subject of my study that I published.

Howard: Now, we put up 307 one hour courses on Dental Town and they just passed 500,000 views. Any chance some day you would put up a course on Dental Town to show this?

John: I would love to be able to talk about it, but this is actually hands on technique. You have to be here and hold the instruments and let me walk you through it. Actually, really, literally hands on and we use freshly thawed cadavers that are not embalmed mounted on the chair to show the doctors how to do this. Now if you follow ... it sounds complicated but if you follow exactly what I teach you in those two days, you should be able to do it quite easily and really incorporate that into your practice.

Howard: How can someone find out about your course? Your website is

John: Yes.

Howard: ... so if I'm driving to work right now and listening to you on my car stereo, if I logged onto, I could find your courses or are they pretty much all where you practice in Alhambra, California which is a suburb outside of LA?

John: Yes. Yes, the headphone training is done in my office. We have 9 laboratories fully equipped with monitors to show the doctors what do to but the lecture part, we go to a ... the facility of a nearby golf course where we do the lecture activity. So we transport the doctors back and forth from the lecture location to my office.

Howard: How many doctors are usually ... what is this course class size limited to?

John: We limit it to about 30 when I can adequately train them myself with my staff. Generally its about 30, little bit more, little less sometimes.

Howard: How much is that class?

John: The tuition is $5,000 for 2 days.

Howard: For 2 days? How much would a patient pay for this procedure? I'm trying to figure out how many cases would a dentist have to do to recoup their $5,000 investment in your 2 day hands on course?

John: That's a great question. In our eyes, terrific, the return investment, terrific. If you use connective tissue graft, you probably can do one or two, maybe three teeth at one time and but with the pinhole surgical technique, its actually better if you do it for large. So you could do 10 teeth. Hypothetically, if a doctor charges $1,000 per tooth to do connective tissue grafting, you could take a case, an ordinary person, lets say within 15 to 75 years old. They generally have multiple sites of recession. You could use the pinhole surgical technique to actually do a [inaudible 00:10:30] for 10 teeth, for 12 teeth. Then you can say, well, whatever I charge, because it takes me much less time, you can charge less per tooth. Potentially, if you do 10 teeth, in round figures, you can charge $10,000. You can say well, it takes me only an hour and a half ... under two hours to do it, so I charge a minimum of $500 per tooth and that would be a $5,000 case.

Howard: Let's start at the very beginning. Let's start all the way at the very beginning. You graduated in 1967. These podcasts are huge and the young kids out of school ... the first 5 years ... they're the earlier doctors that the podcasts help. What causes gum recession? Why do they need this surgery? What causes it in the first place?

John: Well, the ideology is that it could be anatomical. The tooth is just not located in the right place. All of the alveolar process, it could be sticking out. That could be anatomically the problem. It could be that way because of orthodontics ... that's another cause of it or certainly inappropriate brushing ... over brushing, under brushing, neglect, periodontitus. It could be chemical erosion. Its been attributed to malocclusion, [inaudible 00:12:21] ... there's debate about that. There are various causes that would need to be identified but its so prevalent. Actually, its one out of two adults in North America, in fact across the world have some degree of recession.

Howard: I want to ask you about the ... one of the big controversial debates on Dental Town is whenever you say that this recession could be from over brushing, a lot of dentists say, no it has to be abfractions from malocclusion and brushing and grinding because when you look at animals that don't brush their teeth ... that are herbivores, grazing, they have the same abfractions too. Have you heard that or have you read that? What are your thoughts on that?

John: There are valid arguments to go both ways, Howard. As to what causes it, I know this ... that once you have a major surgical correction, you have used the pinhole surgical technique to correct the problem, if the patient continues to over brush the area, you'll definitely lose it. You can lose connective tissue grafts and grafting area ... the patient can also destroy that with over brushing. That I've seen ... that I know is true. What brought it about? It's such a multi-praetorial situation that its hard to say, in my situation, it may be because of over brushing, other situations its not. I think probably some people get recession without over brushing. Some people get recession just because they have teeth, you know, where there's no occlusion at all. Sometimes on the anterior teeth ... open bite and there's no evidence of over brushing and then you have recession. Actually, a quantum study found ideology is about 17% that's unaccounted for ... there's no known ideology to explain why you have that. Its kind of the ideology part of it ... its very debatable, its all over the place. It doesn't change the fact that we have recession to deal with.

Howard: Well, that's the sign of a great mind. When we're little and we're children, we're taught by [inaudible 00:14:45], everything is yes, no, left, right, up, down and the true sign of an educated man is that its multifactorial. You even said, 17%, one in five, we don't even have any ideology. We always know what we know but we never have any idea of what we don't know.

But, back to patients. I want to go back to patient selection. What patient is most motivated to want to do this? Would they be the ones with sensitivity, the recession is causing hot and cold or sensitivity? In what percent of these recessions does have sensitivity and are those the most likely to want to have some correction because its hard to get a patient motivated to fix a problem if they don't perceive its a problem? So talk about case selection and sensitivity in case selection.

John: Okay. Very definitely, Howard, if you have severe sensitivity and you drink something cold and it bothers you and it tempers your eating, then of course, you want that taken care of. People come in for recession correction for different reasons. I think one of the central reasons that I've seen is cosmetic. You have a high smile line, you smile and it doesn't look right. Something like this.

This patient actually came to us ... she was a dental assistant and she came to us with recession and she actually puts her hand over her mouth when she smiles. She really, really feels handicapped as a dental assistant and not to be able to smile wide and be able to help other people with their smiles, so she came to us and so it happened that we were asked in 3 days to be on the Doctors Show, you know, a national show that ... [inaudible 00:16:55] by Dr Oz, the show that goes across the country and so they asked us whether we can do a pinhole surgical technique operation on the patient. We're not going to turn that down and she happened to be there. We had her come in and we took care of her and with the camera on, we were able to do 10 teeth in about 57 minutes. That's on the show ... you can find that tape actually on my website.

Howard: On the Dr Oz show?

John: There are two shows. One is Dr Oz and one is just the Doctors. We were on the Doctors Show.

Howard: The Doctors Show. The Doctors Show, and on your website, is that on ... when you posted that video, is it on Youtube?

John: Its on Youtube also.

Howard: Because that photo you hold up, if you started a thread on Dental Town and said, the Doctor John Chao, yeah, Rocio before PST. PST being Pinhole Surgical Technique...

John: Yes.

Howard: ... you could start a thread and post that as an image and you can also drop in the link to Youtube and it will pull the whole video up inside of a thread.

John: Well, thank you, Howard. I will do exactly that.

Howard: I can put that on an email blast and email that to 85,000 dentists. So that's Rocio one hour after pinhole surgical technique.

John: Now Rocio. We were able to ... and this is 57 minutes later, it looks like this.

Howard: Lift it up a little bit higher. Oh, wow. One pinhole on each side, that's amazing. If you're listening to this right now on iTunes or sound only, you're going to have to log on to Dental Town and see these before and afters. This is amazing.

John: This is the next day ... now this is, okay...

Speaker 3: Six months later.

John: These pinholes are pretty much gone the next day. The patient, when she saw this, she actually cried. Talking about ideology and what kind of patients do come, they come because ... one of the main reasons they come is because they want a better smile.

Howard: Cosmetics ... so that's the main reason?

John: That's one of the main reasons. We come across a variety of reasons. Sometimes they just ... they are actually the best patients you can find. Because these patients come to you ... they say "I'm disturbed. I don't like my gums being receded. I don't like gum recession". They don't even see it. They actually have to hold their cheek up [inaudible 00:19:46] see it and these patients, they know something is wrong. Maybe they've been told by their dentist that they need something done and maybe they were told that they need to be referred for a grafting and they either don't go or they went and didn't want it done. They look up myself and about ... they have a choice of about 850 dentists now who have been trained and they look them up and to go to them for taking care of this problem. Sensitivity is definitely one of them, cosmetic is another. Sometimes they realize they've been having too many fillings done on the same tooth, time and time again. It's people who are aware and concerned about recession are the ones who are really the best patients that anybody can find.

Howard: Now what about sensitivity? What percent of patients who have this recession ... like the case you saw, how many of those people actually have recession and is that a driving force in this surgical technique?

John: You mean the strong sensitivity, Howard?

Howard: Yes, because some people have recession and no sensitivity and other people have recession and sensitivity. What percent of people that have this recession, have sensitivity and do you think that's related to a different ideology like more have to do with brushing and more grinding versus erosion from acid from bulimia or orthodontic malocclusion, the tooth's not in the right socket?

John: Yes. I definitely have a large number of people coming in because their teeth are sensitive and that's what alerted them to the problem but in terms of actually saying, well that is actually the cause ... that recession is directly related to the sensitivity or vice versa, is not that easy to pinpoint because a lot of it is from brushing, I believe. 

I was very involved and still am in TMJ for many, many years. I know what can happen when you brush and lot of times what we do is, we actually check the teeth which are recessed with [inaudible 00:22:22] and then we check all the other teeth and often times, all the teeth are sensitive. Its just not the teeth with recession. I don't have the stats as to how many people ... what percentage of people come in for sensitivity of the roots whether its recession. The sensitivity sometimes ... more often than not, there's sensitivity everywhere. I'm realizing that when we treat people for a recession, we have to look at the crucial factors. 

If we don't agree, that the ideology is not occlusion, that's if somebody has that conviction then, everybody agrees though, that during the healing period ... during the first 6 weeks and then actually the first 6 months, while the tissue is maturing, that there should be no disturbances to the wound. You cannot have a stable wound if the teeth are somewhat moving, even to a very, very minute extent. I do look at the crucial factors as a very important teacher of post-operative care. That I make sure if they need it, bite guards, if their lower interiors I'm treating for gum recession are slightly mobile, I would do lingual [inaudible 00:23:37] or lingual bracing or so on. Occlusion is a very important part of my diagnosis and treatment as far as pinhole surgical technique is concerned. We go through that very, very extensively during our two day course.

Howard: Talk more about that because when a lot of people treat occlusion factors, you hear bite guards, some do them upper/lower, some do them hard/soft, some use the night/tide. What's your protocol in all that?

John: I generally prefer lowers because if I do want them to wear it during the day time, it doesn't hamper their speech as much so just out of long term use, since the 80's, I generally use the lower but if I feel that there is actually mobility in the upper interiors ... I don't want them disturbed then I would put an upper on. I find that patients get along better with the lowers than with the uppers, but that's my personal preference as far as upper/lowers. Then I do make a cast frame orthodic appliances or night guards sometimes because patients don't like the bulk that comes with the acrylics that we made our night guards out of. I use different kinds. Sometimes I'll use something with just a lingual bar with a side saddle during the day time and give them a full bite guard at night. Its all different and I talk about the different ways that doctors can actually address this problem with the [inaudible 00:25:29] during our two day course.

Howard: What do you think about ... some people do an equilibration? What do think of the equilibration versus wearing a lower night guard?

John: With teaching the pinhole technique, I'm just looking at a whole fraction of doctors who hold different beliefs as far as occlusion, but I would say to the doctors contemplating a pinhole surgical technique that they narrow the spectrum ... I narrow my spectrum to the teeth getting the surgery ... the teeth getting the pinhole surgical technique, I look at those. How can I keep those teeth stable during the healing period. If it requires [inaudible 00:26:20], if it requires equilibration to get those out of hyperocculsion, I would not hesitate to do that. As far as equilibrating the whole mouth, personally I don't have a problem with that. You need to know what you're doing, be well trained, you need to know the basics and do your work up properly. Now that [inaudible 00:26:43] is so readily available, certainly do a [inaudible 00:26:42] and to be able to visualize the TMJ from different directions and have a 3D image of that. I don't have a problem with equilibration as a preparatory step to doing pinhole surgical technique, but if you don't believe in eqilibration, then I would suggest that at least take the teeth being surgurized out of hyperocclusion.

Howard: You're also very interesting ... you're also ... you patented this technique and you're an attorney. After dental school you went on to law school and became an attorney and you patented. Talk about that. What made you go become an attorney after dental school from USC?

John: Actually, going back, the thought came to me when I was doing TMJ work. TMJ work lead me into the courtroom, because I was treating TMJ dentists for a lot of patients who had had accidents in the car mostly or even at work and they came to me for treatment, referred by other dentists and even their attorneys and to represent them in their claims against insurance companies. I began to interact with the lawyers and I realized that its kind of interesting. I like the concept and I feel that I was in part with whatever they are actually bringing to the courtroom and to the depositions. 

I got more and more interested so finally I said, "you know what. I'd like to have a broader view of life". Even though, I was not particularly interested in practicing law, I said "well, I need a challenge" ... I was getting in that period of life when you look for something different to do, a different challenge. I finally decided to go to law school for four years ... night school. I kept my practice going and I was doing a lot of TMJ at the time so I could afford to be away from the office. After I finished, I passed the bar in California and then I realized I loved dentistry more than ever. I really don't want to practice law but I like to teach law. I've been teaching dental jurisprudence all across Southern California and also took a position back in ... a few years ago with USC teaching dental jurisprudence to the classes there and eventually, they also invited me to teach ethics. I'm also involved in the teaching of ethics as the co-chairman of the Ethics Department at USC right now.

Howard: Right. You have such an amazing career. You really are an amazing man. When I talked about a online course on Dental Town, you said that this is really a hands on course but the way I see it is this. The biggest financial asset most all Americans will ever have is their house and when grandpa dies and its just grandma and she's on a fixed income and needs more money. An annuity is usually a good thing, she can sell her house to an annuity and then get a monthly payment and they try to ... if she lives to be 100, she wins and if she dies the next day, they win and it all works out. 

To get grandma to do this, its the biggest decision in the world so they run a commercial with a trusted figure and they just try to get her to just call a number and get a DVD and they swear no one is going to bother her and she's just going to get a DVD. They deconstruct the sales process. Then the DVD explains the whole process and all it says is, if you just call this person and tell them where your address is, then they can tell you your monthly payment and so it deconstructs the sales process. I just think a lot of dentists should take your two day course but its so big of a decision to go from I just heard about it to I'm going all the way there ... I think if you put a one hour course on the Pinhole Academy, it will deconstruct this process and they'll sit there and after one hour say "okay, now I'm ready to commit to getting on an aero plane, flying to Los Angeles and spending two days with the legend himself, Dr John Chao and learn this whole surgical technique. I'd like to get that course out of you and I'd like to get a jurisprudence course out of you. I bet that would just be amazing.

John: I would love to do both. In fact, right now we have been doing a webonaut on the pinhole surgical technique on a monthly basis for the last three months already. Your idea is actually very, very good. They need to see actually ... seeing is believing and you have to see this to see what you can do. We don't just show what I do. In the webonauts, we show what everybody else does, the doctors. Such as this case here. This is the doctor ... he took care of this very severe recession.

Howard: Wow, that is amazing.

John: An actual two day course and this is just another one.

Howard: Hold that up a little higher.

John: This is a doctor from Italy.

Howard: Nice.

John: We have doctors from all over the world - Mongolia, Korea, Dubai ... from everywhere coming to see us for the two day course so that they can bring it to their patients. It is absolutely important for a lot of doctors to know what they will be getting. How can they be assured that if they took the course, that they can actually do it themselves and be able to really effectively bring it to their practice and actually be able to draw patients. You know, Howard, this is a very unusual method because as far as I know, there's never been a real coverage of a periodontal procedure that patients actually demand. Whereas millions of people have been exposed to this already. They actually call up and say "I want this particular procedure", by name - "I want pinhole, otherwise I'm not coming". We want the doctors know that the reason people like it is because it is scalpel free and suture free and the public knows that this is much less invasive and they're much more willing to accept this kind of procedure than what they view [inaudible 00:33:49]. 

We do have a whole bunch of people waiting to find pinhole dentists across the country. We even have a doctor, interestingly enough, that called up and say "Dr Chao, take my name off the find a dentist portion of your website because I'm just getting too many patients" and they're calling in from areas too far from me and I really can't service them well. He was getting so many calls that he actually didn't want anymore but generally, the doctors are very grateful, very happy that they do get patients who want this technique and ask for it and these, like I said, are the very best patients in the world. They want good health, they're concerned about the recession which may or may not be symptomatic but they want that situation corrected and they're very sincere and they're willing drive miles and miles and fly from other cities and States to go to the dentists who are trained for this procedure. 

I'd love to share that on the webonaut ... on Dental Town and I love talking about dental jurisprudence and the medical legal aspects of dentistry which I think could really, really be used by a lot of the dentists if they only know the rules of the road, they can operate so much better and be so much more successful, if they only knew. Howard, you asked me about patents. Would you want me to talk about why I patented it?

Howard: Yes, I do. What is patented? Is it the instruments or the whole technique? What's the patent?

John: Okay. I patented the instruments, which is not unusual. Because of my background in law, I was able to dig a little deeper with my patent lawyers at [inaudible 00:35:51] & Gardner and we realized that the law does allow us to patent the method. You're allowed to patent the method that you develop. Just like if you developed software ... a software program that's totally new, you're allowed to patent that. You can patent a method so when I applied for the instruments which also describes the method, I patented the method at the same time. When you patent the method, you have to describe how you use it. Why not patent both at the same time? Now why did I want to patent the method? I knew, once I finished the invention of this technique with the instruments, there's just no way anybody can read a book, can read an article and use instruments which I didn't invent, and try to duplicate the effect. 

I knew that this was not going to be possible and I didn't want the method to fall into hands which may not do good for the patient, in other words, I'm thinking now, this method should be disseminated in the correct way so that patients are really served and not be adulterated by sources that can take it and misname it, misuse it, adulterate it and actually visit harm on the patients. I patented this so that I could have control over the method, over its teaching so that people who are practicing this method can do it safely, competently and get the result that I get. I strongly do not recommend anybody do this method ... do the pinhole technique without instruction because that really puts the patient at jeopardy and puts the doctor at risk for doing the pinhole technique in an unauthorized way. I wanted this opportunity to explain why we patented it.

The other part, Howard, is that, once you're trained to do this, you've invested your time and effort to do this, you should not be faced with unfair competition from those who have not taken the time and the effort to learn how to do this right and try to compete with you on price. We see that happen with implants. How that really went out of control and you can have an implant for $295 to $2,000 and its just everywhere. Its a wild, wild west out there, as far as I can see. What do you think Howard?

Howard: I agree with your point. I'm trying to estimate what the listeners think about the field and I'll bet you a lot of people are wondering, what if I'm not a blood and guts person or how much surgical skill would I have to have? Would I have to be able to ... would you say its a pre-requirement that you pull your own wisdom teeth or you place dental implants? How much surgical skill would an ideal candidate already have before they make the journey to California and see your hands on course?

John: That's a great question. If you know how to extract teeth, not necessarily a wisdom tooth ... certainly that calls for maybe a higher level of surgical skills, but if you know how to extract a tooth, that's the basic skill that you need to bring forth to this course. If I were in a webonaut, I could actually play a tape for you ... we have a tape that runs 7 minutes that actually take care of one recession in 7 minutes, with the collagen, without cutting, without suturing. It is not a real difficult skill to master. 

You can actually be competent at it within two days but its a totally different concept and if a doctor is willing to follow a strict protocol, then I don't see that that doctor is going to have a problem being able to take my course on Friday and Saturday and be able to do it on Monday morning for one of his patients. We have made it so seamless from the method to teaching [inaudible 00:40:35] to the pig jaw to the cadaver mounted on the chair site and go through every part of the mouth where you'd be using the surgical technique and allow you to feel confident when you leave that you can repeat that same situation on a live patient on Monday. I don't see any problem with basically any dentist coming in with a minimum of surgical skill.

Howard: As long as you feel comfortable enough to extract an incisor, canine or bicuspid, you could learn this technique?

John: Yes.

Howard: Now the other million dollar question I'm sure everybody is wondering ... there are nine specialties recognized by the ADA, seven clinical, two non-clinical. What do the 5,000 board certified periodontists think of your technique? Have you heard from them?

John: I've heard a wide spectrum of opinions from them and some are very, very supportive and some are just not supportive. Overall, so far we have trained five percent of the membership of the society of 5,000 periodontists in the last twenty months that we've been giving courses. So more and more [crosstalk 00:42:03].

Howard: Wow, five percent of the periodontists. That's impressive.

John: Yes, we have about 250 periodontists who have been here and been trained and they're practicing the pinhole surgical technique actively and so more and more I see their colleagues are coming around to accepting this new way of doing things.

Howard: Now, a couple more questions. You're a general dentist, correct?

John: Yes.

Howard: Okay, LANAP has been ... I don't even think ... have five percent of the dentists even learned LANAP? What are your thoughts on LANAP?

John: I actually have the millennium machine in my office. I've had it over ten years.

Howard: I'm sorry, first for our viewers, explain what LANAP is and then tell us what you think. Tell them what LANAP is and then tell them what you think of it.

John: LANAP is a laser machine that has been shown by a couple of studies to actually regenerate tissue in the pocket. Its the only laser that actually has a couple of studies, [inaudible 00:43:20] studies behind it.

Howard: What type of laser is it? Erbien?

John: Its a Erbien-YAG.

Howard: Erbien-YAG.

John: Yes, but it has different frequencies on it. You can actually tune it to ... for different uses, you can actually dial the frequency that you want. I use it primarily...

Howard: Have you used the waterlase?

John: I tried it for a few days ... I didn't actually ... that was quite a few years ago and since I had the LANAP already, I didn't actually...

Howard: What laser are you using for the LANAP?

John: It is the ... one model that I bought about ten years ago.

Howard: What's it called, though? Just the LANAP laser?

John: Its called the Millennium. 

Howard: The Millennium, okay. The Millennium.

John: I would call it Periolase.

Howard: It's called Periolase by Millennium?

John: Yes.

Howard: Is that Biolase?

John: No, that's a different company altogether.

Howard: Its the Millennium Periolase, Erbien-YAG and LANAP. Have you been doing it for ten years? What do you think of it? Is it something that you recommend?

John: That's straying out of my subject of expertise. I do like it. Virtually using it in the first few years, I was getting pretty good results. If you follow the protocol, you'll find that what they tell you the results are ... I shouldn't say you but I followed their protocol and I was able to get pretty good results. I do have to say that I have taken a different direction from just using the laser to using the laser along with endoscopy. There is a machine called Perioscope. Its like an arthroscopic type of concept. You put a tiny little lens underneath the gums and you can visualize the pocket and you can actually find where the [inaudible 00:45:26] is. Using a sonic instrument, then you can remove the plaque that way. 

I found it to be advantageous in my office along with the laser so I actually use both to very, very good effect to where I can fix pretty hopeless teeth and to be able to save them for the patient. That's what I do. It does tie in to pinhole because I do require our doctors to know ... to actually not use the pinhole surgical technique where there is presence of periodontal disease or inflammation. We want the gums to be pristine ... we want a really, really healthy situation so that we can get the best results.

Howard: Who makes the Perioscope?

John: The Perioscope is made by Millennium.

Howard: Millennium.

John: Millennium located in ... oh, Perioscope. I'm sorry. That's by John Kwong, a Periodontist in San Francisco. If you look up, you can find Perioscopy.

Howard: Perioscopy is the company. Perioscopy? John Quan? Q.U.A.N.?

John: The company's name is actually Danville.

Howard: Danville. Yeah, they make [inaudible 00:46:51].

John: Yes. They own it right now. Its been through more than two hands and John Kwong is the Periodontist who is heading it up. How do you spell his name?

Speaker 3: John [crosstalk 00:47:12].

John: Kwong. John Kwong. [crosstalk 00:47:17] talk about this so I don't [crosstalk 00:47:21].

Howard: Is he a friend of yours?

John: I only know him through my dealings with him with Perioscope.

Howard: I saw that. That's been out at least ten years, hasn't it?

John: Yes. I had the machine back more than ten years ago, then because of lack of support ... somehow the company was not able to support its maintenance, it kind of died off and then about ... so Dr Kwong then took it over and modified it and improved it and so with the new version ... I had the new version about three or four years ago and its worked out very, very well.

Howard: What percent when you're doing your pinhole surgical technique, when you make your pinhole incision, what percentile do you actually scope up underneath it and take a look around with an optical scope?

John: I have not done that at all.

Howard: You've never done it all?

John: No, I have not done it. For this reason, you have to ... the way you can see, you can see what you need to see under the gums is because there's a water spout that cleanses the lens with water and what I do ... I cannot be pumping water underneath the pinhole ... I thought of it and that's a great idea. I actually thought of it and I couldn't use it because I don't want to introduce something with water into my flap and I didn't want to do that.

Howard: I think its just unbelievably impressive that you've got 250 Periodontists to learn your technique. If that doesn't speak volumes for what you're doing ... that is just amazing. We're 50 minutes down. I've only got you for 10 more minutes. A lot of dentists ... humans, they need inspiration, they need motivation. A lot of it is not just knowledge based. In your last 10 minutes, try to pump this doctor up. Why she should learn more about this? What would her first step be? Would you recommend that she goes to and do you have some of those webonauts already posted on your website? Have you filmed and ... can you see those webonauts or is webonauts something that you just have to see live?

John: We have a lot of videos of patient testimonials, of what I do and a lot of videos on the website. You can find them very easily but in fact we have a webonaut every month and so we do show videos there also. What the doctors will find inspirational and very, very interesting is the patient reaction. Just the other day, we had a Periodontist on our webonaut, Dr Gamarnik from Orange County and he said he's done hundreds of pinhole technique surgeries in the year and a half since he took the course. He was one of the first ones to take the course. He says that this, as a Periodontist, he does surgery, he never gets hugs. Now that he's doing pinhole surgery, he gets all the hugs. He labelled pinhole as a huggable procedure.

Howard: Wow, that is cute. A huggable procedure.

John: Huggable procedure.

Howard: I've never heard that term. I love it.

John: After you do surgery, you actually get hugs. That kind of goes across the board. It's a way that we can show what dentistry can really do. Whether its in the cosmetic zone, in the aesthetic zone or not, you can show the patient ... you can bring the gumline down in less than an hour to where its normal. Even though it looks so swollen, looks so red and without sutures and that is something that they are totally thrilled with. Because they know, looking at that, they're not going to have pain. On the average, our patients take about two over the counter pain pills for what we do, whether its two teeth or ten teeth or sore mouth. It's very, very low in pain. These patients are grateful and if you want to inspire your staff ... to bring a different level of energy to your staff, do the pinhole. I'm telling you, its just so exciting to see and we dentists never get bored. Why? Because patients want to hug us, when patients tell us they are so touched and moved by what we do and the appreciation we get from the patients will never bore anybody.

There's one thing I would like to leave with the listeners and viewers of this program is that this is something exciting. This is something that you can do for your patients. You just need to invest in two days with me and let me share with you my experience and share with you the experience of doctors who sometimes come back. Some doctors now come back to get re-exposed to it because now, since January, we instituted freshly thawed, not embalmed cadavers whose tissue is like real tissue and they want to come back and really learn all the nuances I can teach by just using that. For the doctors that get hold of us, go to Phone numbers are there, the schedule of courses are there and tuition can actually be financed interest free for twelve months. We have laid it out so that you can actually take the course and actually have a return on your investment before you even pay for the course. We've made it very, very easy for doctors to come to us and learn this exciting, nearly painless technique.

Howard: Dr Chao, you and I have practiced a long time and would you agree with this statement that of all of the specialties in dentistry, periodontics has changed the most? I mean, compared to orthodontics or oral surgeons. Oral surgeons are still removing wisdom teeth but they're [inaudible 00:54:15] but don't you think periodontics has massively changed the most?

John: Well, I know it has changed a lot. I know that a lot of what it traditionally does, has been disbursed into the practices of general practitioners such as non-surgical training, a non-surgical approach to treating periodontics such as with the lasers and so on. We see a lot of changes. I don't know orthodontics. Orthodontics is a specialty where a lot more general practitioners are doing it and there are changes in that field. In terms of oral surgery, I think that probably will remain pretty independent. A lot of people are doing endodontics now for themselves especially when they bring microscopes into the practice, they can do more endo. I think all the specialties are beginning to integrate. 

I think the periodontics are certainly, in my opinion, are struggling because they are ... I don't know how to say this carefully ... they have debate amongst themselves as to which direction they should go. Should they go towards emphasis on implants ... should they go ... really, really emphasize or go back, as some people allege, go back to the philosophy of saving teeth rather than putting in implants, so there's a hot debate going on within the periodontics field. I take no position in that, I'm just observing that they have debate, that they have different perspectives on the future of periodontics. 

I believe that pinhole surgical technique or called pinhole gum rejuvenation or lens time gum lipped can be of help to all the general practitioners who want to take up this technique and certainly it would be great for the periodontist to adopt this technique because no matter how many GP's I train, not all of them will come. If I get five - ten percent in the next ten years of the 150,000 GP's, it will be a lot and the rest of the eighty percent of GP's, they will want to refer to periodontists. There is one way for the periodontist to be very, very busy for the next generation is to do pinhole surgical technique and thereby [inaudible 00:56:57] will really revive the business situation with the periodontal profession.

Howard: Okay, I'm down to three minutes with you. I've got to ask a question on ethics. You're a legend in ethics. You teach it at USC? What's the low hanging fruit on dental ethics? How would you subscribe, in a nutshell, and what are the things we should be looking out for?

John: I think the main concern I see, is the lack of understanding of what informed consent means. Its the number one ethics principal in the American Dental Association Principal of Ethics and Code of Conduct. Autonomy ... patients need to know and too often, we dentists get into trouble because we're a little bit too paternalistic and we adopt the old models and we can say to the patient what is good for the patient. The current ethics ... the current accepted principal of health care is that you've got to give the patient social autonomy to pick and choose what is safe and effective. That means, you really have to offer all options whether you like it or not ... whether this is something you do or not ... you should offer implants, whether you do implants or not, you should offer fixed bridges even if you don't feel that this is something that you do well at. Explain all the nuances. For instance, Howard, if somebody is selling a product in the office, the patient should know, according this principal of ethics, that you are going to make money off it. You should disclose that. These are all ethical questions. I think that would keep the doctor out of trouble, most of all.

Secondly, has to do with emphasizing being truthful to patients in terms of how you disseminate information. But I think the main thing is, you can stay out of trouble, you can tell the patient everything the patient needs to know, give them all the options. It doesn't matter whether its the most expensive or not. Even though you think the patient cannot afford it, you must disclose that option. You should also disclose the cheapest option, the most inexpensive option that will in some way serve the patient and let the patient decide based on their own budget, their own priorities, you know, what they want from your dental services. So if there's any advice I can give, I think that would be the overall.

Howard: Dr Chao, what percent of informed consents get thrown out of Court because they say, okay, you said on this implant that it could hit the inferior nerve and the lawyer says, sir do you know what a inferior nerve is? Do you know what a metal frame is and they establish that you agreed to an informed consent of all these Latin terms that you don't understand and throw it out. What percent of the time do you think an informed consent just gets thrown out?

John: Before I want to answer the question, I would say the pinhole ... there is no safer method than the pinhole in regards to the metal frame. To answer this question, the informed consent is not a piece of paper. The informed consent is basically what effort did you take to really explain to the patient in language the patient understands, all the reasonable options that can ... that you need to show in those circumstances. If you just read all the words from the consent, that doesn't save you. You need to show that the patient really understood what you're saying and has responded in a way to show that he or she understands and then finally, the arbiter of whether you have given enough consent is twelve people sitting in the jury of your peers. They will decide whether you have made the effort in good will and the patient has really understood what you're trying to say. A piece of paper will not save us.

Howard: We are out of time for my last question. When you're at a cocktail party, do you tell people you're a dentist or a lawyer?

John: I never tell them I'm a lawyer.

Howard: You never tell them you're a lawyer?

John: It doesn't increase my credibility.

Howard: I tell you what, you're a rock star, you're a legend. This technique ... you can't throw a cat and see someone talking about this technique. I see it all the time, talking about it on Dental Town, social media, everywhere. For you to take an hour out of your day to spend with me is just a true honor.

John: Thank you.

Howard: Dr Chao, thank you so much for what you've done for dentistry, USC, the pinhole surgical technique and I hope to see a course of yours on Dental Town and the pinhole surgical technique and another one on jurisprudence and on that note, thank you for all you've done.

John: I want to thank you for what you've done for dentistry.

Howard: Thank you. Thank you very much. Bye bye.

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