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Esthetics of Periodontics with Roberto Rossi, DDS : Howard Speaks Podcast #128

Esthetics of Periodontics with Roberto Rossi, DDS : Howard Speaks Podcast #128

8/26/2015 2:00:00 AM   |   Comments: 0   |   Views: 696

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Which general dentists are most proud of their implant work? Are periodontists the only ones consumers should really trust for implants?

Stream Audio here:

AUDIO - Roberto Rossi - HSP #128

Watch Video here:

VIDEO - Roberto Rossi - HSP #128


Most general dentists in the United States DO NOT place implants. Find out why general dentists in other countries place a lot more, and discover the beauty in doing it right.

Roberto Rossi is a DDS, and a specialist in Periodontology and implant dentistry. He is an active member of the Italian Academy of Esthetic Dentistry.


Speaker 1: It is a huge honor today to be interviewing my first guest from Italy. How cool is that. Roberto Rossi. How bad did I butcher your name? I want to hear how an Italian says it in real life. 

Speaker 2: That was perfect.

Speaker 1: That was perfect? Oh hey, well, you're too kind. And you're in ... there's nine dental specialties in the United States that are recognized by the American Dental Association, and I have to tell you that your specialty, periodontics, has probably changed more than any of them. When I got out of school twenty years ago, it was just all surgery, quadrant surgery, and they were trying to do everything to save these three maxillary teeth and now it's just gone into implantology. Would you say that a periodontist is now an implantologist?

Speaker 2: Well, I would say that I agree with you that periodontics has changed a lot in the past twenty years. Actually, the periodontist is probably the finest person to place implants. Because it has attention to the soft tissues ... to the patella and to cosmetics, of course.

Speaker 1: That is true. Oral surgeons get blamed that they put the implant where the bone is, so they're blamed for being bottom-up implantologists. The person restoring it thinks it's crown-down, that you start with where the crown has to be and are you going to cement or retain screw this? And then you're addressing probably the number one complaint of all anterior aesthetics with implants. What is the gum tissue going to look like around these implants? Is there going to be dark spaces? Is there going to be gaps? That's very hard.

Speaker 2: Implantology has changed a lot because if we look at the early works of Brånemark, nobody really paid attention to aesthetics. Implant dentistry evolved into cosmetic and aesthetic restoration, so the way we do it now is very different from the way it was done twenty years ago. Probably, what's going to be in the next five, ten years we do again.

Speaker 1: How long have you been doing it? You got out in '92 and it's 2015? 

Speaker 2: I'm sorry?

Speaker 1: How long have you been doing this? Since 1992?

Speaker 2: Oh, 25 years. Yes, that's correct.

Speaker 1: 25 years. So tell me how it has changed in your life.

Speaker 2: In my life it has changed that ... honestly, in the beginning we were just doing it as it was done in the beginning. With little technology, with the knowledge of the anatomy but without all the evolution of technology that we have nowadays. With cone beams, with the implant navigation system we can actually see ... navigate through the human anatomy and put the implant safely and in the best prosthetic position. Knowing already where the soft tissue, the bone crest, the abutment are going to be. It's a big evolution. 

But, it's the same thing if we think 25 years ago we only had [faxes 00:03:13] we wouldn't even dream of having a conference call from Italy to California or to Arizona. It's the same thing for everything as in the world.

Speaker 1: How many dentists are in Italy?

Speaker 2: Oh. We have so many dentists. Just like in everywhere in the world.

Speaker 1: But, how many would you say?

Speaker 2: I would say about half a million?

Speaker 1: 500,000 in Italy?

Speaker 2: Absolutely.

Speaker 1: You're probably talking all Europe because there's only 150,000 dentists in the United States. I think it's 50,000 in Italy.

Speaker 2: Maybe 50,000.

Speaker 1: What I'm trying to get out is out of those 50,000 dentists in Italy ... which is the number I hear how many there are ... what percent of them place implants themselves?

Speaker 2: Nowadays, probably seventy-five percent.

Speaker 1: Okay, seventy-five percent. That's the same number we hear in Germany and in Korea. Why do you think, in The United States, only periodontists like yourself and oral surgeons place ninety percent of implants and general dentists in America probably only five percent have ever placed one implant in their life? You're talking to mostly general dentists in America right now.

Speaker 2: Well, probably because of the issues with the lawsuits in the United States. So, insurance issues and it is more risky to place implants in the United States because patients are more willing to sue the dentist and if there is any problem to go to the lawyer right away. In Europe, actually, it is not like that. Things are changing, also, but the general dentist can place the easy implants and the [companies 00:04:57] help the dentist to become more and more aggressive, showing certain procedures are easy to perform and they're predictable. Everybody got invited to place implants. 

Speaker 1: The CVCT. There's a big controversy around the United States where if you're an oral surgeon and you've placed 10,000 dental implants ... the majority of them do not like surgical guys. They say, hey, you need to be a surgeon. You don't need a surgical guide, you need to learn how to lay a flap, see the bone, place the implant, and doing it ... just snapping on a surgical guide and placing a drill-bit through a hole, that's not a surgeon. It works fine when everything works fine but if you have any problem, you're not a surgeon until you learn how to lay a flap. 

I'm going to ask you, because who you're really talking to right now is probably five to six thousand general dentists. Probably 80 percent of the United States. They're thinking about placing their first implant. My question to you is address the biggest controversy. Will you recommend that they use a surgical guide? And again I'm sorry, I need to preface this question. In the United States 95 percent of crowns and implants are done one at a time to replace one missing tooth. Only five percent are quadrant full mouth dentistry. 

We're talking about missing a first molar. You would have a second bicuspid in front of it, you would have second molar behind it, you have mesiodistal landmarks. If you laid a full-thickness flap you'd have buccal lingual landmarks. My question to you is, for that first implant that this person is listening to on their way to work today, would you go surgical guide or would you say, no man, suck it up buttercup, and become a surgeon. Learn how to lay a flap.

Speaker 2: That's cool. Well, honestly, I teach in dental school and I teach two private courses. I would say that it's always, the real things is in between the lines. I would say that if you're starting to place implants the best thing to do is follow protocols. If you don't know about the anatomy ... you don't know how to approach the crest of the bone, it's always best in the beginning to open a flap because you want to make sure that you have the bone underneath. Even if you have the made the cone beam or see the scan and you can read the anatomy pretty easily. 

Otherwise, if you are already a little bit of experience, nowadays I think it's must less dramatic to the word implants, flapless. If we have the knowledge of the anatomy and we know where we're going to go, it's much easier to place an implant. Within five minutes, with a stencil, and in a very safe way.

Speaker 1: I think you're very smart, because one red flag a person is not intelligent is they're always an extremist. Every great historian always says moderation, moderation. You just nailed it, buddy, you said, "The truth is in the middle." All surgical guides, no surgical guides, that's not real. The truth is in the middle. 

I also think it's very interesting that you came at it with an answer first from the patients point of view, and the patient's point of view is ... I remember when I got my diplomat in the International Congress of Implantology, way back in the day. Went through the Misch institute. You would lay these monster flaps. I mean, unbelievable. You dissect out the metal frame. The post operative swelling and discomfort ... it was a major surgery. So, to sit there and think you could just go through the tissue under ideal situations ... the patient would have to love that. 

Speaker 2: Actually, in Italy we have a way to say that. Is, "Grande lembo, grande chirurgia." So, big flap, big-time surgery. Today, it's not anymore like that because the good surgeon is the very minimalistic, is very skilled that handles the soft tissue in a very delicate way. We have diagnostic things that allow us to do it in a very way delicate, if not actually painless way. 

Speaker 1: The next question I want to ask you is another huge controversy in the ... for dentists all around the world. My favorite meeting in the world is actually every other year in Cologne, Germany. The big, what is it, the IDF meeting?

Speaker 2: IDS.

Speaker 1: I'm sorry I said IDF. IDS meeting, and loved that thing. I've lectured at it before in a booth, but my ... they had 145 different implant companies with a booth selling implants. My whole motto with using the internet now iTunes and YouTube and podcasts and all this is, 'So that no dentist will have to practice solo again.' Right now you're talking to a dentist on a treadmill and how is she supposed to pick? She doesn't want to own five systems, she wants to own one. What would your first ideal, recommended implant system for a general dentist be if you were only going to buy one of those. 

Speaker 2: I started with the, at the time, Branemark system. That was probably the oldest, and the one with the largest documentation in the world. 

Speaker 1: He just passed away last month in Brazil. 

Speaker 2: Yeah. No, Professor Branemark died about five, six months ago in Sweden, not in Brazil.

Speaker 1: Well, he was living in Brazil.

Speaker 2: No, he was in Sweden. His home.

Speaker 1: When he died?

Speaker 2: Yes. 

Speaker 1: Okay.

Speaker 2: He died in his home, yeah. Basically, everything that followed up after Branemark's system is companies trying to follow an idea and put some new ideas into a pot. New designs, new surfaces, new prosthetic advancements, and of course we know that in the implant world now probably twenty, thirty main companies that rule the world and hundreds of small companies that are trying to make a product that looks like, and probably also works like, but as a surgeon I will always try to stay within the first five, six important lines. They're the ones that have a history. I know the companies there ... although nowadays, these companies are buying each other. One company is being bought by another company, by another company. It's a world in evolution, I'll say in this time..

Speaker 1: What are the ... you said there's top six. Is that what you just said?

Speaker 2: Well, there's five, six companies that everybody knows about.

Speaker 1: Go ahead and name them in order of which one you would buy first.

Speaker 2: Nobel Biocare, for sure. 

Speaker 1: That's the one that Branemark started. That use to be called Branemark but now it's Nobel Biocare.

Speaker 2: Then the second one, for me but I think it's nowadays the first, is ITI  Straumann.

Speaker 1: That's Switzerland?

Speaker 2: Yes.

Speaker 1: ITI Straumann out of Switzerland?

Speaker 2: Yes. Then we have all the American companies. Dentsply, Astra from Sweden, Biohorizons ... so many. All of them are reasonably good. I cannot say that one is better than the other.

Speaker 1: What's the Dentsply implant system these days?

Speaker 2: What do they call it? They have different lines. There is no one line. But, in different countries they have different names. 

Speaker 1: I can remember back in the day when they used to have that core ... what was it?

Speaker 2: Yes, Corevent. 

Speaker 1: Was that the one started by Jerry Niznick? 

Speaker 2: Yes, exactly.

Speaker 1: And then they bought that from Jerry Niznick, and then when it ...

Speaker 2: [crosstalk 00:12:57] has changed, and the name and the shapes have changed. Now it's a completely different company. 

Speaker 1: Biohorizons was the one started by the American Carl Misch.

Speaker 2: Right, and it went through different names. It was BioLock ... not BioLock, it was Minimatic. Then it became [Class 00:13:17] implant and now it's Biohorizons.

Speaker 1: What do you think about the low-cost leader, Implants Direct?

Speaker 2: There are many of those. It's like ...

Speaker 1: What do you think of the Korean one, Megagen. 

Speaker 2: I know all the Korean companies because I work as a consultant for most of them. They're all very good companies. I would say they put a lot of attention to their research. They cooperate with a lot of universities, but their limitation is all the universities they work with are Korean. They produce just a lot of work. They're not yet very well-connected with the international universities, and they're starting to open up to the world. They're doing quite a good job because they are very intelligent people and very hard-working and they have good engineers that do with engineering on the implants.

Speaker 1: What system do you use personally, and what system are you teaching the dental students? Also, do dental students in your dental school place an implant by themselves before they graduate? Or is it only something post-graduate dental students do, study how to carry out oral surgery?

Speaker 2: I work in the post-grad, so the students that I handle are already dentists. Yes, they can do implants in the dental school and they do all kinds of implants, so depending ...

Speaker 1: What percent of the dental students who graduated from your dental school this year, just graduated, do you think placed an implant by themselves while they were in dental school?

Speaker 2: Maybe twenty percent, thirty percent of them?

Speaker 1: 20 to 30 percent. What system are you placing and what system are they placing?

Speaker 2: They can use either Nobel or Straumann or any of the other systems that we named before.

Speaker 1: Yeah? I'm surprised you're not recommending an Italian brand. You're Italian. Is it the [crosstalk 00:15:17].

Speaker 2: We have very good Italian companies. We have Sweden and Martina that became very popular. Nowadays they're selling all over the world. Even the United States is becoming one of their targets, so ...

Speaker 1: What's the name of the Italian company?

Speaker 2: Sweden and Martina.

Speaker 1: Right. Huh. Very good. You mentioned a cone beam. Same thing, what cone beam do you recommend? Are they all the same? Are some easier to figure out? I remember when I got mine, my gosh, reading it was hardest thing but back to this individual dentist, what cone beam systems do you like?

Speaker 2: Actually, I don't have one because I [audio 00:16:09] clinic just a few floors below my office. I send them to the audiologist to do the cone beam. All kind of the cone beams nowadays are good. There is no one that is better than the other. The last generation are all more or less to the same level. All of them have their self software that helps the dentist to really see and play with the images. 1d, 2d, 3ds. I wouldn't say there is one that edges the other out. It's all more or less the same. 

Speaker 1: Okay. Walk this ... this girl is driving to work right now and she's got about forty minutes more to go to work ... how would you recommend making a surgical guide. Is this something you would take a CBCT and you would export the file on Diacomm to a lab and they would make the surgical guide? Or would you recommend that she take some impressions and makes it herself? Go through your surgical guide for replacing a molar.

Speaker 2: Well, for me doing it through an implant navigation system is probably the safest way, because you can play with it. I can actually put the implant. I can move the implant in three dimensions. I can see the kind of prosthetic abutment I want to use. With cut-cam, now, I can already design the final restoration at the same day that I am doing the planning. It's a big innovation.

Speaker 1: It's really changed a lot. It makes me want to start eating less fatty food and live longer and see what happens in the next twenty-five years. 

Speaker 2: You have to also be very familiar with using the computer because I noticed that many of the colleagues,  especially ones of the old generation, they're not very computer-friendly. It's more the young people that are really fast and they grew up with a computer. When I work with older dentists they always have a hard time to accept this kind of evolution, but it's there so we have to.

Speaker 1: I think the way human minds are hardwired is fear is bigger than greed. You want the greed of learning how to place an implant, but fear is bigger. They say that when apes and monkeys are in the jungle and they're really thirsty and they see water. The greed of getting a drink is huge, but they see two crocodiles sitting in there and that's overwhelming. That's why when stock markets crash the ten biggest crashes are much bigger than the ten biggest gains. The young kids ... I watched my three year old granddaughter, and this has happened twice, to where nobody can figure out the TV remote. We're all doing it. She just walks right over at three years old and figures it out because she has no fear. These young kids ... I got out of dental school in '87 and we didn't have computers. In fact, the first computer I bought was the year after my practice opened. It was an old Intel 286. 

The guy told me that if I upgraded, and right out of the gate bought an Intel 386, it would be so powerful I'd never have to buy another computer the rest of my life. What a joke. I've had to replace it every three years forever. Back to this dentist place in the first one. You talked about implant systems, you talked about CBCT, you talked about surgical guides. What is the easier, low-hanging fruit cases that should be in your mix of your first ten implants? What would be the opposite of that? What would be an implant case where you say, no, don't do that until you've done a hundred, or two hundred?

Speaker 2: The implants in the aesthetic zone, because before patients were not ... patient without one tooth, they just wanted to have that tooth back. Now, they come to the office with a magazine with a pretty lady smiling and they say I want this. But, they don't understand that it's not just the implant. It's not just the crown. It's the bone, the kind of re-absorption that we have, the soft tissue, the periodontal biotype, the thickness of the gingiva, the position of the gingiva. There are so many issues related to it that if you take it one step at a time and you have outweighed all these factors you may get to the endpoint with an excellent result. But, if you cut corners and you don't take everything into consideration you may have a bad result.

Speaker 1: What would you like to talk about? I don't want to be leading this interview all the way with questions. What's making you passionate? What do you think you could tell us now that people who have placed hundreds, and to the periodontists and oral surgeons listening to this. What's making you passionate these days?

Speaker 2: My passion has always been aesthetics. Probably, the fact that dealing with periodontally involved patients, the fact that patients have lost bone ... they've lost not only the bone but the soft tissue so they have these teeth that are moving forward, they're opening up spaces. Something that is not really pretty. always really challenged me to do something that would bring the situation back to normal. I think what I always loved was to look at the aesthetic aspect of both periodontology and implant dentistry. That is the daily challenge, the daily pleasure to go to the office. Not something to help people, but to enjoy. Solving a situation and bringing it back to normal. 

Speaker 1: Now, I would be everyone's ideal patient because I don't show any teeth. Let's talk about the hardest case. A woman. All seven of my crowns are gold because I'm a dentist and I want them to last forever. I can't get an American woman to go with a gold crown for anything in the world, even though they have gold on their ear, nose, lip, belly button, ankle ... they have gold on almost every body part but I can't get them to go gold, even on a second molar. One time I had so little clearance, and it was so far back there ... I have about five full gold crowns on upper second molars on women who don't even know it. Because I'm just like, "I can't do this," and she doesn't get it and I put it in there and if she ever figures it out I'll re-do it for free. I still see them about six month recalls, and I always grin from ear to ear because I've got this beautiful gold crown on it ... max 32nd molar and she doesn't even know it. 

But, let's talk about that case where you got that woman ... I've read that women have 27 percent less muscle mass than men, so their lips go up higher. They show teeth and gums. Let's talk about that girl who has an upper incisor tooth. She lost it, and you've got to go to implant. How do you handle the tissue on something like that?

Speaker 2: Well, the gummy smiling is the challenge of the periodontist and the dentist because anything that is seen so-so is okay, but something that is seen big-time, it becomes ... you have to be as delicate as possible to make it invisible. When you have a patient like that, the first thing to do is to make sure ... The way I do it nowadays is that I build the frame, and then once the frame is built I put the painting into it. I pay attention to have the bone and the soft tissue exactly the way they're supposed to be. The last thing I think about is the implant. The implants come in a second time. I do my regenerative procedure, the ridge preservation, the ridge augmentation, the bone graph, the membrane, the connective tissue graft, anything that is necessary to reset the situation.

Then, I'm going to the navigation systems. I study and I plan my case in the computer because I want to see before I go into the surgical phase that the tooth will come out with the correct emergence profile, with the proper crestal position. Then I just do my guided implant surgery and I place a temporary crown that is designed by the computer or by the technician to have the proper anatomy for that specific situation. That's it. [crosstalk 00:24:44] ... condition we move on with the final restoration.

Speaker 1: Let's go through your bone graft procedure. Let's take a hypothetical woman. She's pretty, she's got a high lip-line and she asked to remove number eight because she had a root canal build up in crown and it's fractured. When you remove that number eight crown on the tooth. Had a root canal. Maybe a post fractured. How do you bone graft? You don't pull the tooth and place an implant the same day? Is that what you're saying?

Speaker 2: No. The assessment is very important. One of the key factories to do a previous assessment of the situation, because there is a recent publication that I like to quote when I do my lectures. There was this study that was in Brazil that evaluated the thickness of the bottom plate. Three millimeter, five millimeter, seven millimeters from the bone crest. On two hundred and fifty patients, the very scary finding was that below the bone crest ... fifty percent of these patients had a bone crest that was less than half a millimeter thick. 

We cannot put an immediate implant on the bone crest that is less than half a millimeter thick. In this kind of situation, we need to do a bone graft, which we call nowadays a ridge preservation technique. We cover the graft with a resorbable membrane and possibly connective tissue graft. Sometimes we do it just a connective tissue patch from the palette that we stitch there with micro sutures with a microscope so that everything is covered and will heal eventually. Then, six seven months later re-evaluate the situation. We do a new cone beam. If we are ready, we have the bone, we have the soft tissue, we move on with implant.

Speaker 1: Let's name names. You said you used a resorbable membrane.

Speaker 2: Yes.

Speaker 1: What do you use?

Speaker 2: I work with an Italian company in this case. I use everything Italian because I use biomaterials that are made in Italy. They're collegenated bone graft material, porcine origin, that seems to work just great. The only problem is they're not available in the United States, so I can't ...

Speaker 1: They are if the dentist just emails you and you ship it directly to his house. Trust me, nothing that the customs of the United States, they could ever find bone-grafting material. But, I say that tongue-in-cheek. Let me ask you this question, what about harvesting the patient's own bone for bone grafting. I know dentists who will go back in the wisdom tooth area and lay a flap to pull a wisdom tooth and then a [inaudible 00:27:31] burr and pull out a plug there. Also, have you seen the new Megagen grinder where you take the extracted tooth, throw it in there, and it pulverizes it instantly to about three hundred, what do you think of that?

Speaker 2: I don't know, absolutely.

Speaker 1: Do you think that's a good idea, or do you think those are bad ideas?

Speaker 2: The gold standard in bone grafting is always autogenous bone. Anytime we have the chance to collect bone from the own patient is always good. The problem, as you know, is the quantity. Sometimes we need to harvest a large quantity of bone. We should do a sinus lift. You don't want to take all the bones from the ramus and have to put it [inaudible 00:28:10]. So, the use of bio-material is helping the dentist to make the procedure less morbid for the patient, because the patient has to be [using 00:28:20] only one side. Anytime we can collect bone from the patient himself ...

Speaker 1: But on that Megagen tooth pulverizer. A tooth is not bone, but do you think a tooth is an acceptable bone grafting substitute? Or would you say you don't think so.

Speaker 2: I wouldn't do it.

Speaker 1: You wouldn't do it.

Speaker 2: It's a different substance. As a periodontist, when I aim for regeneration, if I graft bone I want to find bone. That is a big issue in the periodontal work because among the many bio-materials you know we have bio-materials that are bio-mimetic so they act like original bone and actually transform into bone. But, we have many bio-materials that are just fillers. We put them there, they integrate in the area where we place them, but they are still there. If you go back five years, ten years, fifteen years, I think you'd still find the particles of this product. From the periodontal point of view, I like to do regeneration. For me regeneration I studied in school was new bone, new connective tissue attachment, new cement, and new everything. Something alive. I don't like to use something that is just fibers encapsulated or integrated into a situation but is not alive and available for me. 

Speaker 1: I would say one thing to the kids out there. We have a ton of dental students that listen to these podcasts. I'm fifty-two years old, how old are you, Roberto?

Speaker 2: fifty-two, same.

Speaker 1: We're the same age? Then how come you looks so damn much better than me?

Speaker 2: You look okay.

Speaker 1: Maybe I should start eating more Italian food. A lot of times young dentists ask me, what are your major regrets? My major regrets are jumping on things new. I'd asked you that question about the Megagen. It sounds like you and I are going to sit there and take a pass on it and let the young kids jump on this and we'll talk about it five years from now when you got some research. I got out of school in '87 and the cosmetic dentists were telling me to do these old icore grounds and cement them with Durelon. There's a difference between bleeding edge and leading edge and by the time you're fifty-two, especially guys like me who stand behind everything I do in my office and I'll warranty everything for free. 

When I try something, and the Targus comes off the Vector or the Dicor breaks or this or that or whatever, I'm going to eat these things for free and so at fifty-two years old, when I see those things I always say, "Oh, that is so cool. Why don't you try it? Why don't you study it and come back and talk to me in five years?"

Speaker 2: I pretty much agree with you, because I always do things after other people have assessed that they work. 

Speaker 1: Oh my god, if you want to make money ... because think about this in your line. Let's say you do ten full-mouth rehabs that are fifty thousand dollars apiece. Two of them fail, and you got to redo it for free. Or let's just say one of them failed. That fifty thousand dollars, well, that's not just one case. Of those fifty thousand dollar rehabs, you might have only made twenty thousand on each one. So when a fifty thousand dollar rehab fails that's one loss, and then you'd had the profits of another two or three cases, so you would have been better off just doing six cases that worked. The one thing you want to do in dentistry, is you want to diagnose and treatment plan aggressively enough that it's going to last five to ten years minimum, so you can warranty it. To do that, you've got be more conservative. 

Those young kids, I love their passion. It's like when my grand-daughter comes over. She runs around like a tornado. I wish I had a fraction of that energy. It looks like she's hopped up on some drug or something. Those young kids are all passionate. They want to dive and everything and just, like, whoa, slow down. There's 2 million dentists in the world, I don't even know how many dental schools are in the world. There's 56 in the United States. Do you know how many there are in Europe?

Speaker 2: Oh ...

Speaker 1: There's got to be 100.

Speaker 2: Many.

Speaker 1: Yeah. Let those guys look at all that stuff. I want to ask you, you're a periodontist. I want to ask you some other questions. And by the way, when I'm asking these questions it's not so much that they're my questions they're ... I'm trying to predict and estimate what a broad spectrum of five thousand listeners of different ages all trying to ... but, a lot of them wonder, okay, well if this tooth is coming out from periodontal disease those bugs are there. You're a human, Roberto, you weren't born with p gingivalis in your mouth. You picked it up somewhere. It's got to be a contagious bug. If this bug caused a tooth to fall out, now you're sticking an implant in there. Is that going to be the same cause of peri-implantitis? Talk about that.

Speaker 2: I want to tell you a funny story when we start this topic because I had a patient, it was probably the second or the third patient that I treated twenty years ago. This patient had a missing number eight, in the United States, and he lost it because of periodontal disease. It was not just placing the implant but was doing a bone graft and placing the implant with a concept of 1992 to 1993 that the implant had to be palatally placed. I place my implant and the patient, who's a businessman, disappeared for a number of years. 

He came back about 15 years after and said, "After 15 years I think your implant is failing, so we have to take a look at it." "Okay," said, "Come back to the office." I took an x-ray and the implant was perfect. The bone crest that was regenerated was there. Same level of 20 years before. The tooth beside it periodontal disease and was dangling. It was not the implant, it was the other tooth, the other central tooth. 

The very strange thing what you said is you take a tooth out and you put an implant in a patient with periodontal disease, I agree with you, we shouldn't do that. We should first always assess periodontal disease. If somebody loses teeth because of periodontal disease, you first have to do causive therapy, antibiotics for mouth infection is what we do these days. Once the periodontal disease is completely under control, then it begins a new life for this patient so you can start placing the implants. The situation are so different, for me, every patient is a different island, so we can not generalize the concept because this guy had a tooth beside an implant. The implant was not affected at all, but the teeth were going everywhere. The bacteria were bad for the teeth, but were not bad for the implant. Another situation, we have no teeth anymore, just implants and we see peri-implantitis, how do you explain that?

Speaker 1: How do you explain it?

Speaker 2: We know a little bit about it. We know that the bacteria flora changes from mixed aerobial, anaerobial, to completely aerobial in the moment we extract all the teeth. So when we have poorly dental patients who have a completely different situation, a mixed dentation and when the teeth are still there. But we have to pay attention to the soft tissue. The soft tissue becomes an issue in patients that are fully dentures, so we cannot just place the implant where the bone is, but we have to place the implant in the proper position and with the soft tissue all around it, because we know from the recent study that everything's started to move alike.

So gingivitis, which is mucositis on the implant, is what leads to peri-implant disease. That implantitis is a big problem, simply because many of the implants that have been placed have been placed without paying attention to the soft tissue.

Speaker 1: You said something very interesting, that you have dentation, if you have teeth, then your mouth had aerobic and anaerobic bacteria, those that live in oxygen and those that don't live in oxygen, but once you've pulled out all the teeth you now longer have an anerobic environment so you only have aerobic bacteria. Does that explain much difference in success rate of fully dentulist implant cases versus mixed dentation implant implant cases?

Speaker 2: Right. Absolutely. But the fact is also that we never take into account that, for instance, in patients with no teeth anymore, we can place the implants and we can still have peri-implant disease, sometimes because immunitory deficiencies, because nobody talks about the way periodontal disease works. Sometimes it's just a bacterial infection, but sometimes it's not a bacterial infection, it's the body that does not know how to defend from normal bacteria, because of immunitory deficiencies. 

Speaker 1: We don't have that in America because we get all of our nutrition from McDonald's. We get all of our vitamins in our french fries and ketchup and  Coca-Cola.

Speaker 2: Sometimes we lose focus on diagnosis, which is a very important thing. For me, when I see a young patient in the late thirties with severe periodontal disease, my first question is, "What happened in your life in the past five, six years?" You will have an answer that she got divorced, the father or the mother died, or she had somebody ... there was a trauma in her life. Because a patient that young, with that much periodontal disease, can only be that either she had the wrong bacteria, that can be, otherwise it was just an immunitory system that did not work and for a period of time just turn off completely and the body was just left alone against normal bacteria that became pathological.

Speaker 1: Roberto, I'm going to ask you, were you born with p gingivalis?

Speaker 2: Absolutely. 

Speaker 1: Do you think you were born with it, or do you think you picked it up after you were born? Do you think you had that bug when you were inside your mother's womb?

Speaker 2: No, no. That is not the fact, because we are born without teeth, so we get the bacteria in the mouth after we are born. When I was a student, we were doing DNA [probing 00:39:22] on the periodontal bacteria. We were putting our paper points into the sulcus and sending them to Sweden or to the university that were doing the bacterial evaluation. One day one of my friends from Sweden told me how many strain of bacteria do we have in the mouth. How many do we have?

Speaker 1: I'm guessing three hundred and fifty.

Speaker 2: Okay. If you look into a sample, how many bacteria you think you're going to find?

Speaker 1: In just one sample?

Speaker 2: Well, you sample pockets in one mouth in three, four, five-

Speaker 1: You mean how many different species, or how many total?

Speaker 2: No, no. How many different kinds of [inaudible 00:40:12], Selenomona, staphylococcus, everything.

Speaker 1: I wound say three fifty.

Speaker 2: Right. If you do a sampling, you will find them all, because they're there. The thing that they exist, doesn't mean that they are pathological. They become pathological in the moment that they grow, and in a certain site, they develop something. If you're looking for the lactobacillus, bacilla set in [inaudible 00:40:40] that now has a new name, you'll find it, because it's there. Maybe it's one, two or three, or three thousand, but you will find it there. It's not the issue. The issue is that we should make the diagnosis early enough to prevent the bacterial infection to spread in the mouth.

Speaker 1: I think this is going to be the most exciting breakthroughs of the next ten to twenty years, because the most famous zoo in the United States is called the San Diego Zoo, and it has forty-five hundred species of animals on display, and they're saying from the mouth, all the way through the digestive, all the way out the back door, that thirty foot of intestine has about twelve thousand species. There's three times more animals on display, bacteria, fungi virus in the San Diego Zoo, and there are some people around the world that even think your digestive gut bacteria is affecting your mouth bacteria, so if someone was eating the wrong foods, or different foods, and had a different bacterial gut microbiome, that that could even affect their mouth.

I want to ask you one more question on [inaudible 00:41:52], then we'll get off it. When you're repelling someone, when you're trying to get rid of or control someone's periodontal disease, you mentioned the word antibiotic. What antibiotic do you use, and a lot of questions we get is there's a lot of companies that sell little chips of dense antibiotics that they put into the pocket. Do you like systemic antibiotics, and if so, which one, and do you evr use localized perio chips or Arestin or anything like that at the site? Can you talk about that?

Speaker 2: When I was a student, Harvard University was doing with Ray Williams, most of the biggest study on the use of tetracycline course. At that time were placed in the pocket that were actually having periodontal problems. Now we know that the antibiotic help to control the periodontal disease in the early stage, when we make diagnosis. We need the antibiotics because the bacteria are on the root surfaces, with calculus, but they spread in the soft tissues. 

The bacteria control of the infection with antibiotics is important also for implants. Not because on the normal patient with no issues, probably not. But in the periodontally involved patient, that becomes very important. All the antibiotics, as we know, from amoxicillin, tetracycline, metronidazole, they're all in a way working towards sterilizing the situations.

Speaker 1: If you're placing an implant on someone who has had periodontal disease that is now under control, when you place the implant on that person who three months ago had periodontal disease and you're doing your protocol, would you prescribe antibiotics at the time of implant replacement?

Speaker 2: Absolutely. Although certain studies show that there is no effect if the patient is sterilized so there is no more periodontal disease or there is no infection active at the moment, there is no benefit or damage to give antibiotics to the patient.

Speaker 1: But you still do it anyway? You still do it?

Speaker 2: It doesn't hurt.

Speaker 1: Back to those chips, not for an implant, but when you're getting someone's periodontal under control, do you ever use a tetracyclin port or a perio chip, an Arestin, do you ever use-

Speaker 2: I find the use of tetracycline very useful in patients with aggressive periodontal disease. [crosstalk 00:44:34].

Speaker 1: In the port, or-

Speaker 2: Many of the modern trends are slightly different, I feel [inaudible 00:44:40]. When I started in Boston in my post-grad training, we were using a lot of tetracycline in aggressive ... at that time, was juvenile periodontitis and rapidly progressive periodontitis, were treated quite well with the use of tetracycline. Especially in Europe, the tetracycline have not been used recently, they're quite effective because the bacteria don't know tetracycline, so it's still a really good antibiotic for me.

Speaker 1: Are you talking about systemically, like tetracycline, two hundred and fifty milligrams four times a day?

Speaker 2: Yes, yes.

Speaker 1: Do you also ever place it locally, in chips or ports?

Speaker 2: No, I just take the tetracycline capsule and I just mix it with the bone graft, for instance. I [enhance 00:45:29] the use of ... tetracycline has many good effects. Also, I use it a lot and new gingival surgery, for instance, because tetracycline is an antibiotic so it has an antibiotic localized effect on the root surface. We know that we can find the bacteria in the dental tubes so the tetracycline can benefit the dental tubes. It's also an asive, so it has an asivic effect on the root surface and also an etching effect on the root surface if you put connective tissue graft or whatever, you're going to put on top of the root surface. Many different effects.

Also, from the histocompatibility of the tissue after use of tetracycline, get better. We have many- [crosstalk 00:46:16]

Speaker 1: When this person's healing up, do you also recommend any mouthwashes? Do you think those, like Listerine or chlorhexidine-

Speaker 2: Mostly we use chlorhexidine, point two or point twelve percent, depending on the necessity.

Speaker 1: You still like chlorhexidine gluconate, point one two percent.

Speaker 2: We have no alternative to chlorhexidine yet. 

Speaker 1: That would be the gold standard?

Speaker 2: Yes.

Speaker 1: Is it called Peridex over in Italy? 

Speaker 2: We have different names it can be called, it can be called [Sodilc 00:46:48], can be-

Speaker 1: I want to ask you kind of a strange question, but we're doctors, it's got to be true. If this person's healing up from periodontal disease and you've cleaned her up, you pulled teeth, you're doing all this stuff, but she's going home an night, she's sleeping with her husband, and he's got a full mouth of perio, and he hasn't seen a dentist in ten years, if she's kissing him, is she, is that giving her more bacterial load and making the problem harder?

Speaker 2: That could be, because there is always a bacterial transmision. We've seen periodontal patients that have localized periodontitis, sometimes it starts on the lower molar and you will see the same effect on the upper molar because there is a bacterial exchange through chewing the food. It could be, it's not necessarily happening because it should be a long-lasting, unless they kiss for three hours [crosstalk 00:47:46].

Speaker 1: Look at the other end of the body. Humans transmit STDs so quick and fast and efficient. They're saying Hepatitis B, you only need one virus, one virus, for a successful infection, whereas like the number one cause of death on the planet is drinking dirty water. Cholera, which kills four million people a year, and you need to drink a hundred thousand in cholera bacteria because the stomach's got enough acid, and it takes a hundred thousand for one to survive, but I don't know. It seems like we're going to know a lot more about this in five, ten, twenty years. A lot more.

Speaker 2: We should actually do a study on that. That would be very interesting [crosstalk 00:48:31].

Speaker 1: I think that the STD that no one ever talks about is the kissing. Everybody talks about below the waist, and I think that comes from, you know, that's the most important thing of a species, to reproduce, have offspring, so they're always talking about STDs but people are putting on a condom below their belt and then they're sticking their tongue in someone's mouth, and we see an increase of oral cancer and HPV virus, and so now, I think one of the biggest studies no one's talking about is there's an STD going around called HPV, and people are killing each other by kissing.

Speaker 2: Right.

Speaker 1: No one's talking about this.

Speaker 2: The dental association has [inaudible 00:49:17] cancer day, in the past two or three years, and they do free screening in the streets, in the main cities because they are aware of this, these problems.

Speaker 1: I want to ask you another controversial question. This is one of the biggest controversies about implantology on Dentaltown. We had to separate, under implantology, regular root form implants and everything else from [minis 00:49:37] because it seems like people like yourself, periodontists or oral surgeons in America, you send in someone and they only have one solution and it's the big Ferrari. It's the fifty thousand. It's six implants, upper, lower, sinus lift, it's always a big deal

In our country of America, with three hundred and thirty million people, eighty percent of the population can't afford anything close to that. Then if a dentist goes in there and uses a mini-implant, like 3M has an [M-tak 00:50:11], and they put four minis in front of the metal frame, and we're just talking about fully dentures, there's thirty-one million Americans, we're not talking about just one tooth. They put four minis in front of the metal frame and six minis on the upper in front of the sinuses, and really help stabilize seventy-year-old poor old Grandma's denture, Grandma really likes it but man, you just can't get any respect from your dental colleagues. All the periodontists, all the oral surgeons are beating their chest, saying that's not it. It's almost like you're not a real doctor if you place mini-implants.

My question to you is, if a poor Italian grandmother came into your office, clutching her rosary, and she said, I can't afford the deluxe Ferrari, do you offer a low-cost mini-implant solution, do you do those or do you not?

Speaker 2: Why not?

Speaker 1: You place minis?

Speaker 2: Of course. I have done many in the past, less now but with good results. The only problem with mini-implants is that they're not coded, because anything that's below three millimeter is not considered an implant. All the implants that were smaller than three millimeter diameter, I think the FDA didn't categorize them like implants. Then the mini-implant came back. Even in Europe, is the same thing. I remember that until 1995, 1996, we had two point nine millimeter implants on the market, that they were then eliminated, and then they were brought back with the point one millimeter became three millimeter implants.

Speaker 1: You're saying in the Italian dental association an implant has to be three millimeters, or you're saying it's not coded that.

Speaker 2: We can see also some nails, some dentists in Italy they put the nails, needles ... there is a school in Genoa, one of oldest Italian implantologists used to use nails that would solder in the mouth, then join them with titanium bars and then place the denture on top of that. We have examples that have been in the mouth for maybe forty, fifty years so actually, everything works. 

For me, it's a different concept. I wouldn't do to my patients something that I wouldn't do on myself. If I had the necessity to put one lower incisor and I have a narrow space, and the only solution is to put a three millimeter implant, I will do it.

Speaker 1: I want to ask you, one of the most famous dentists in the world, Gordon Christian, saying that he thinks a lot of perio implantitis could be an allergy to the metal, a metal allergy, and he's talking about, we've all seen the phenomena where if you put on a solid, noble metal, gold, silver, palladium ring, there's no tattoing, but if you use a base metal ring you can see how the acid in the skin leaches out the metal and you get a greenish tattoing around there, and he's thinking, and there are some websites on this, do you think metal allergy is an issue with titanium implants?

Speaker 2: It could be. It could be because we did some studies and was done, maybe, ten years ago, and we were evaluating the soft tissue reaction to different metals on the implants, and of course titanium, and titanium was the gold standard, that titanium and gold was also pretty good, but titanium and certain kinds of metals was a mess. We would find inflammation in the soft tissue just because of the biochemical connection of two different metals. That's absolutely an issue. I would say I cannot say for sure that it is issue, but we have to look into that, for sure.

Speaker 1: I've only got you for five more minutes and so I feel like I'm not smart enough to be asking you the questions, you're so much more gifted on all things periodontal, implantoloy, than myself, what can you tell my elitist friends? To the periodontists or oral surgeons or people who are our age, at fifty-two, tell them something they don't know.

Speaker 2: I think at our age is very different to tell something you don't know. I mean, the thing that would motivate people our ages is to have fun working. To do it, enjoy what you're doing because I think that the most exciting thing for me is to go to the office in the morning. I enjoy doing that, because when I see my patient smiling, that's already paying off besides what I find in the box at the end of the day. Enjoy what you do, being happy, making people smile, I think is the issue. If you do something you enjoy, going to work is not hard at all.

Speaker 1: Oh, my gosh, well said. I feel like I have never traded time for money in my life. My dad had a restaurant, so I worked with my dad, who was my idol and hero, from ten to twenty, and then I worked for myself, and I've just been playing my entire career. I just don't do anything I don't like. When a dentist tells me he hates endo, they're called endodontists, just do what you love and have fun. If you love it, you'll do a lot of it, which then you'll get good at it, and then you'll make money at it.

Speaker 2: Right. Exactly. Because you become good if you do it over and over and over and over, then you see how you can change the thing to make it get better and better from time to time, and I mean it's the ten thousand hours rule, you know? To become a superstar you need ten thousand hours of practice, and then to do it for a long period of time, and to see it over and over again.

Speaker 1: I've been to your country several times and it has got to be the most gorgeous country in the world. Italy is just amaz- ... and I'm not saying that just because I was raised Irish-Catholic and my oldest sister's a nun, I just truly love Italy, the most amazing food. But since eighty percent of my listeners are from the United States and a lot of them have never, or if they've gone to Italy, they've gone to Rome, they've gone to all the tourist places, they didn't go visit a dental office and understand the systems. 

Tell us what differences do you think American dentists don't realize with doing dentistry in Italy. Like, do you guys use insurance, is it paid for by the federal government, or is it private insurance, are you allowed to advertise like we do in the States, or, tell us those types issues. [crosstalk 00:57:17]

Speaker 2: Until about seven, eight years ago you could not do any kind of advertisement, it was very severely checked by the dental association and basically dentistry in Italy is private practices because the hospitals provide the dental system that is very weak, very few dentists work for the hospital, and the insurance company very rarely pays for dentistry. Only people working for big companies, they may have a small insurance company that covers part of the cost. People going to the dentist, they have to pay with their own savings.

Speaker 1: Do you think that makes Italians use the dentist more or less than America, where fifty percent of the people have some form of insurance? Do you think it's a factor, or just not really.

Speaker 2: No, no no. The people before the bad economy, they loved to come to the dentist because they want to eat well, the food is good in Italy so people like eating, and they enjoy chewing the food so they need to have good teeth to enjoy what they eating. One of the issues with the patient is very often, I want to have the denture away because I cannot feel and cannot taste the flavor of the food. That's one of common complaints. I understand that. If I had the piece of plastic in my mouth and chewed it, it tastes different than if I have my natural dentation and something that can handle the chewing in a different way.

We have a lot of low-cost dental clinics popping up in Italy, because the multi-national discovered that dentistry is a business, and we have ow-cost dental clinics coming out of nowhere, everywhere. In every city in Italy there are now five, six, ten, and they're bringing down the level of dentistry that I think in Italy is very, very high. We have excellent dentistry in Italy, even if the dental schools are not all fantastic, but the level and preparation of the Italian dentist I think is pretty high.

Speaker 1: You're a member of the EU, Italy is. Are you able, Roberto, to take your Italian dental license and go practice in any other EU country, or are-

Speaker 2: Yes.

Speaker 1: You can. You can all move around.

Speaker 2: Absolutely. If I want to work in France, in Germany, no problem. I have to notify the local organization that I'm going to open a clinic there.

Speaker 1: You're saying that because of Italy's joining the EU, it's allowed an influx of licensed dentists from other countries into Italy, so now there's more dentists on every corner? Did I hear that right?

Speaker 2: Not really that. We have only some, well, some Germans and some French, neighboring countries can ... like we go to Germany, they come to Italy and they practice here now. It's a different phenomenon, the low-cost dental clinic appeared in Italy, something that never happened before. Before, the dentist was a dentist. Now, the dental clinic that offers the cleaning for twenty Euro and the free consultation, free X-rays, is something very new that is entering the Italian system and is bothering a lot of people.

Speaker 1: We're exactly at one hour, and it's over, so I'm going to ask you a question I shouldn't have the right to ask you, and if you don't like the question I can chop this off at one hour, but I'm just curious. My oldest sister's a Catholic nun, I'm just curious, are you Catholic, and what do you think of the new Pope?

Speaker 2: I love him. The moment I saw him I fell in love with him.

Speaker 1: My god, he's a rock star, isn't he?

Speaker 2: He's a very nice guy. He's a very nice guy and he's cleaning house, so I know a lot of people in Rome don't like him, but he's the right person in the right place.

Speaker 1: I never saw that coming. I never thought that one day I would be cheering on the Pope. It's just a-

Speaker 2: The best Pope the world could have at this time in history.

Speaker 1: Can I put words in his mouth? The fact that he doesn't take a limousine and he drives his own small humble car, and he's just a humble guy, I think he would be telling dentists, I'm putting words in his mouth, I think he'd be telling dentists, hey, if they can't buy the big rich Italian Ferrari full-mouth, fifty thousand dollar/Euro implant case, check out those minis. Something's better than nothing, and I just don't know why dentists only sell Ferraris and Audis and Mercedes Benz, and I just know why-

Speaker 2: That is wrong. You should always find the right car for the person that you have in front of you. Not necessarily, not all our patients have the financial capability and the necessity to drive a Ferrari. Some people would be very happy with a cheaper Cinquecento. 

Speaker 1: What's your personal favorite Italian car?

Speaker 2: That's very hard to say, because I was just driving a [Vigor 01:02:33] Ferrari, because I took my [crosstalk 01:02:37] to see the Ferrari Museum, and we had a ride in the Ferrari California, but I would say, I like the new Cinquecento, it's very nice. It's the car that is selling very well all over the world, it's charming, it's small, it's-

Speaker 1: What's it called?

Speaker 2: The five hundred. The small, the tiny, the Cinquecento. It's called Cinquecento. 

Speaker 1: Spell it.

Speaker 2: It's five hundred. Five zero zero. 

Speaker 1: Oh, I got it. And I just want to say one thing for all the Americans who haven't traveled around the world because they're too young, or they have too many student loans, but you know, when you eat Mexican food in America, tastes nothing like, you can't even find those dishes in Mexico, when you to China, you can't find a single Chinese restaurant dish in America in China. They don't even know what you mean when you say almond chicken or sweet and sour pork, or whatever, but I tell you what, I thought Italian food would be the same in Italy as it is in the finest Italian restaurants, and my god, it was so much better. 

I'll never forget in Venice, eating ... oh, my gosh. Your food is at a different level, and you tell any of those Italian restaurant owners in Italy that they could make bank moving a real Italian restaurant to any major city in America. You go to the nicest Italian restaurant in America, and you just get a nicer delivery of what Americans think Italian food is. Americans don't know ... maybe, I mean, have you ever eaten Italian food in America? New York, or ... have you ever found authentic Italian food in America that's as good as back home?

Speaker 2: Yes. When I lived in Boston I used to go to the north end, which was the Italian section of the city, and there were food Italian restaurants there.

Speaker 1: That's true, but Boston is the oldest city in America. That's a four hundred year old city, and it's the closest major city to Italy, but when you get out here to Phoenix, Arizona, I'm on the other side of America. I'm on the side closer to China, and it's literally almost comical.

Speaker 2: Probably San Francisco, because there is a big community of Genovese that left Genoa for San Francisco, and there are good Italian restaurants in northeast, too.

Speaker 1: Then I w ant to ask you one last question. We're in triple overtime. We're four minutes over, and like I say, I can cut this .... but Greece is in the news twenty-four/seven, a lot of dentists over here, they don't really understand the issues, you're living there, we dentists, it's just one six hundred word story every day, what is the Greece situation and what is your prediction? Will Greece be in the Euro ten years from now? Is this going to work, or do you think it's not going to work, or ... what would you say to American dentists?

Speaker 2: For Europe, I hope that it will work out. On the other hand, the depth of Greece towards Europe is quite big for the capability of Greece, so it will take a big turnaround from the politicians to fix everything. But it's the interest of Europe to keep Greece where it is.

Speaker 1: I have an MBA from Arizona State University. I love business. You know what my take-away is on the Greece issue, is that the Euro still doesn't see themselves as the Euro, and Americans see themselves as American. We always are transferring extra money from rich states like California and Connecticut to poor states like Mississippi, Alabama, Kentucky, and we've done it all year, every year, since the Civil War. We always do this. 

Americans would never say to Mississippi, oh, you got to pay us back. We just see this as distributing wealth, we're all in this together, and the bottom line is, and I'm not over there and I don't know half as much of this as you do, but the bottom line is, Greece is poor, ten million people, and you're going to have to give them debt relief, and the richest countries over there are going to have to be always giving money to some of the poor countries until they get their act together.

Speaker 2: Right. I agree. I agree with you, so I hope that the richer state, Germany, Italy, France, will find a way to help Greece, because Greek people are also nice people. I have many friends there and I feel bad for them that they are going through-

Speaker 1: The last word's going to come from me, there's not one authentic Greek restaurant in all of Arizona. You should go to Greece. You should drive over there and tell them, pick up your restaurant and move to Phoenix because you know a fat dentist in Phoenix that will eat there at least once a week and take his four boys.

Speaker 2: If you want, someday I'll bring you some tzatziki instead of some pesto.

Speaker 1: Truly, seriously, you're a rock star, I mean I follow you on Facebook, you have a course coming up on Dentaltown, I can't wait to see it, and thank you so much for, nine hours ahead of me, spending an hour with me, and I just think the world of you and thank you so much for your time.

Speaker 2: It was a very fun times spending some time with you, and it was a privilege. I can only say thank you very much.

Speaker 1: And I love your haircut. You must be a model. Bye bye.

Speaker 2: Thank you.

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