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VIDEO - DUwHF #898 - Orest Komarnyckyj
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AUDIO - DUwHF #898 - Orest Komarnyckyj
Dr Komarnyckyj or as many call him Dr K has been a dentist for 36 years and a periodontist for 32 years in Phoenix Arizona. He has lectured to numerous organizations including the American Academy of Periodontology, Pacific Coast Society of Prosthodontists, I.T.I. World Symposium, Dentaltown among other groups.
Dr Komarnyckyj was one of the first surgeons in Arizona to place dental implants and has been at the forefront of many technical developments.
Dr Komarnyckyj has been providing to his patients non-surgical endoscopic periodontal therapy for over 15 years. He is the Chief Medical Officer for PerioEndoscopy.
Howard: It is just a huge honor to be sitting here at my house with my buddy at thirty years, Orest. How are you doing, Orest?
Orest: Good to see you.
Howard: My gosh. Orest Kom… I've never been able to pronounce this. I just called you Doctor K. Orest Komarnyckyj?
Orest: Perfect you got that.
Howard: Nice. Or as many call him, like me, Doctor K or Orest has been a dentist for thirty six years and a periodontist for thirty two years in Phoenix Arizona and I can attest to you, living in his backyard, he's legendary. He’s lectured to numerous organizations including the American Academy of Periodontology, Pacific Coast Society of Prosthodontics, ITI World Symposium, Dentaltown, among other groups. He's one of the first surgeons in Arizona to place dental implants and has been at the forefront of many technical developments. He has been providing to his patients non-surgical endoscopic periodontal therapy for over fifteen years. He's a chief medical officer for Peri Endoscopy and I've been trying to get him to have time to come over to my house for almost two years now wouldn’t you say? I've been…
Orest: Oh I’m not sure it’s been that long. It’s been a while.
Howard: Because true or false? I get out in 1987, in fact my thirty year anniversary in my dental office is September 21st, is next Thursday, but don't send flowers or anything… Just lots of chocolate… But of the nine specialties, I think periodontics actually changed the most in the last thirty years as opposed to… Like endo, pedo, oral surgery. I remember thirty years ago it was four quadrant surgery on and on and hemisection of molars roots and all that stuff and then the pendulum swung all the way to: “Hell, I'll just treat that with titanium. Pull that stuff and put in titanium, because those will never fail the brochure said they have a 98.999% success rate.” And now I see the pendulum coming back and now a lot of people are thinking: “Well I don't know if I'm going to give up all those periodontal surgeries from back in the day.” So, where are we at now on the pendulum?
Orest: I think we're looking at trying to save teeth that we might have taken out in the past and we're looking… The next evolution is something that I've been involved in, is a non-surgical therapy within the therapy in advanced cases… Of moderate type 2 type 3 and some type 4 cases. So, I think that saving teeth is coming back into vogue. We're looking at that and we have some therapies that are very valuable in that regard and you're right about the changes in perio. There's only one procedure that I learned in my residency that I still do every once in a while and that's a distal wedge. Everything else I don't… What I learned back in the in 1983, 1984 and applied, we just don't do it anymore.
Howard: You can’t name another specialty that says that?
Howard: There's not one. Yeah, that has really changed. It seems like, especially on Dentaltown, anything that’s got perio or whatever they’re just like, “I treated that with a cold seal and forceps, you know, I’ll show that you know you'll kill the perio if you exposed the roots to sunshine.” But now it looks like five years after the implant’s placed 20% have peri implantitis so extracting a periodontal involved tooth and replacing it with titanium is not cure for anything.
Orest: It's not and there's always risk in any procedure, especially when you’re involved in a surgery procedure so all…. Some of it may have been oversold I think, some of it may be due to technique and some of it may be actually due to the particular implants and I know that some people say implants are implants… I'm not particularly of that philosophy. I've tried several different kinds of implants and I've kind of settled on a few that I use in my practice and I very predictably we certainly have runs where we've tried different kinds of implants and I've seen not the results that we used to have and then we quickly rush back to what we know worked in our office and in my hands. Again it's also a very different thing. Some people… Different things work in different people's hands differently. That's very true, because that’s part of the art of dentistry.
Howard: Well you know podcasters are young, they’re millennials they are born after 1980 and you've been doing this for thirty six years so I know they're commuting to work. What brands did you end up sticking to?
Orest: There's two brands. I use Straumann quite a bit and also…
Howard: We just had the CEO of Straumann and…
Orest: I know, that was a very interesting interview that I had a chance to watch and see what they’re doing as a company. They're really expanding quite rapidly and by acquisition, which is kind of, as far as I understand, is kind of a new strategy for them.
Howard: And your wife's an attorney to their mergers and acquisitions.
Orest: Right, she's an investment banker.
Howard: But you said Straumann, What was the other brand?
Howard: BioHorizons out of Alabama. Wasn’t Carl Misch kind of involved with the beginning of that?
Orest: You know, I'm not sure, because I know he has his own brand but I'm not sure if it’s Buy Horizons.
Howard: Yeah. So, what do you think the Straumann and BioHorizons implants you went back to and why do you think others failed?
Orest: Problems with surfaces. There's one in particular which I will not name.
Howard: It's dentistry uncensored, throw them under a bus.
Orest: No, I’m not going to throw anyone under a bus. It's also called I don't want to get sued.
Howard: Your wife’s a lawyer…
Orest: No, litigation is expensive and she doesn't practice law. She's not licensed in the state of Arizona just in California. So, we had one that was promised to be the newest and the best surface etc... And it turned out not to be. It was just… It was… Quite frankly it was a nightmare to deal with and I couldn't get out of it fast enough.
Howard: Let’s talk about… You know, I keep asking my homies, email me, Howard@dentaltown.com, tell me your name, where you're from how old you are, all that kind of stuff. Where are you are on your journey, because you don't know who's listening to this on iTunes, but… There's bleeding edge and leading edge. I mean these kids jump on this hot new sexy thing but when you're fifty five and done it for thirty years you've already been burned. I remember when I got out of school the beautiful lady came in and did anterior crowns . Guess how many of those fractured and I had to replace for free?…. About 132% of them. Then art glass came out (unclear 06:52), Ivoclars Targis vectis failure. I declare targets vacuous failure. You just don't jump out. You sit back… And remember in the implant journey… I remember some of these HA -coded implants and it was “all new and improved”. No it wasn’t. It was a really bad idea and you don't see those anymore. The worst one was Member in LSU, where they were doing artificial joints… I mean this goes back, way back in the day. Do you remember that?
Orest: I think you’re talking about TMJ jointS.
Howard: Yeah, and what was it made out of?
Orest: Some sort of… It was… a Teflon type of material?
Howard: Yes, some new latest greatest and it was replaced the TMJ joint. Yeah they were finding macrophages eating it in the knee caps. Six months later that lawsuit was horrendous. There is a difference between bleeding edge and leading edge isn’t there?
Orest: There is. You know, my philosophy to a certain extent has been to look at a new technique, to a certain extent, assess who is promoting it, because I have people that I follow in terms of the quality of research and quality of that clinician, and then see whether it works in your office.
Howard: You don’t mind dropping the names of who you follow?
Howard: OK. Another thing that you have to think of, I know we have listeners in Kathmandu and China and India, but in the United States we have one million…
Orest: Actually I will. I do have one person that I always call up because he's probably one of the smartest periodontists I know. His name is Bob London. He used to be head of grad perio at USC at Nova and now he's on faculty at the University of Washington in grad perio.
Howard: London like the city?
Orest: Yeah like the city... And I called… If I have a question I call Bob and he kind of tells me what the skinny is on the stuff .
Howard: Bob London, the periodontist at where?
Orest: He's at the University of Washington, the Department of Periodontology.
Howard: But you just don't want to be jumping on the latest greatest bandwagon and when you're our age we actually laugh at the kids, because we’re like, “let the new graduates play around with that stuff for five years and see if it works”, because in a practice like mine where I've been in one place for thirty years, and you’ve been in your place for thirty six years, we're going out to eat that stuff for free. I can't do a Targis Vectris crown on you and have it delaminate in a year and a half and say, “well it’s not my fault.” Well actually it's absolutely my fault.
Orest: Well that's my philosophy also on computer software upgrades. I usually wait until the patch comes out before I use the upgrade.
Howard: Yeah, and you know we have programmers since we have Dentaltown and Orthotown and oh my god… My programmers… Especially if it's Microsoft. They’re just like… That company is just. I mean it’s really criminal of how… I feel like when I was little and bought my first Intel 286 you'd buy a piece of Microsoft's offer of like $300 and then you’d end up spending a thousand dollars on I.T. guys coming out and fixing that and the whole time, for the first ten, twenty years the I.T. guy is using profanity about Microsoft. They know it's riddled with bugs, because that was Microsoft's deal, let's just release it and then you guys find all the bugs and report it to Bill Gates and it'll sa… I mean he's screwed his own customers for twenty five years and earlier this year
Orest: I actually you know that's kind of interesting that now…
Howard: Whereas Apple was completely the opposite. Steve Jobs wouldn't release it till it was perfect and Bill Gates released a turd every single time. I see Bill Gates I mean I don't want to hear him talk. I want him to refund all my I.T. bills for twenty five years.
Orest: That, I was listening to podcasts. I don’t know if you were listening to Tim Ferriss?
Orest: OK. I was stunned when, he was somebody in the software industry, and he said, “Oh yeah, we release stuff before it's all ready to go so that we get feedback from our customers and then we fix it.” I was like, “Wow I don't know like…”
Howard: Well dental companies do that too. So dental companies are just like Bill Gates. They're going to say, “I wonder if this works should we do a five year study? I mean we got sixty dental schools in the United States, we pay five dental schools to do a five year study. Oh hell no. Let's take all that money for studies, sell it to you today and then see if it works and if it doesn't work will kill that product, right, and we’ll come out with something next year.”
Orest: Absolutely. That's exactly what happened with this particular dental implant. They’ve released it without studies and…
Howard: Would you say that's the norm in dentistry or the outlier? I mean there's four hundred dental implant (unclear 11:35). Do you think there's been four hundred studies?
Orest: No, and that's why I think you're wise to stay with some of the top tier people.
Howard: And back to what I was saying, not for my international listeners, but for the United States. There's one million attorneys. So you charge a gazillion dollars for this case and you use this low price implant you bought from Russia and where's the research published on that? So why was she paying retail and getting some implant with no research? Why did you not use these implants five or six companies that have thousands of studies going back ten, twenty years? Agree or disagree?
Orest: No I agree. I think people… There's an assumption that all things are equal and that's not true and there’s a reason why I can purchase an implant for a fraction of what I paid for an implant. My math is not so good. You can buy an implant for $40-$50 versus paying $400-$500 dollars, but they don't have the same backing. They don't have the same testing. They don't have the same quality control. If you have the opportunity ever to go visit let's say a company like Straumann or Buy Horizons and you go into their facility and see the quality control. It's absolutely amazing. I mean each of them, I don't know if this is the case still, but like Straumann, each implant is individually examined underneath a microscope. I was just stunned.
Howard: Yeah, and also it's called price segmentation. So like GM owns a Chevy a little more money. A Pontiac a little more money. (unclear 13:26) little more. Cadillac... And so it's very disturbing to a lawyer and a journey and when you charged for the Cadillac but you bought an implant that was somewhere between a Chevy and a used car and they're saying, well if you bought, if everybody your neighbor was buying an implant for five hundred and you use one for fifty. How can we charge the same going rate? And Mrs. Jones needs... And the other problem with failures is implant case failures are probably the most expensive failure
Orest: They’re huge, especially if you're getting a large prosthesis on them. Retrofitting a prosthesis is very challenging.
Howard: So in implant perio prosthetics what case would have to fail out of how many before your other ones were just for free, because you got overhead. The average dental office has 65% overhead or anything I'd say. It's basically like, if every fifth case failed and you had to redo it for free then that was the profits from the other four.
Orest: Correct. And then you got (unclear 14:29) quite often actually, because we get a number of patients from the Internet and there are times where there are significant issues and it's not as new, it has to do maybe more with angulation and other issues and the fix is actually quite a big financial investment, just getting back to ground zero, because you go (unclear 14:59) them out, you’ve got to graft them… There's just a lot of work just to get back to the starting line.
Howard: Yeah, so you talk about… We’re at the beginning of a seismic shift in how and where definitive periodontal therapy is completed. Improvements in technology engineered by perio endoscopy. What does that mean?
Orest: I've been using a endoscope to treat periodontal disease in my office for about fifteen years and my protocol has evolved over time. Actually there are some times where I'm sure we've all had that experience where you buy a piece of equipment and it becomes a very expensive coat rack in the corner. So we had that issue. What has happened is that, because of some changes that we've had in our protocol, initially I used to use it with… we used to do the traditional scaling and (unclear 15:55) in my office, basically the non-visual scaling and (unclear 15:59), then come back and re-evaluate and then treat the areas that did not respond with using the endoscope.
Howard: That's this Website here? Perio endoscopy?
Orest: Yes, perio endoscopy, yes… And then over a period time my protocol changed, where we said okay, we are just going to go ahead start with the perio endoscope and we started to do that, where the endoscope… That really started doing, where I actually, a lot of the perio surgeries, both for receptive and regenerative were not showing up in my office anymore, because we were having very good definitive results with the endoscopic therapy. About three years ago I started to add some things to… Some adjunctive therapy, including systemic antibiotics, short term course, based on using… Basically some tests that turned out what the pathogens are and so…
Howard: Whoa, what company did you use?
Orest: …for DNA.
Howard: So you would take a swab or a sample of oral DNA and then they would tell you what antibiotics to use?
Orest: Correct. Yes, for usually about an eight day course.
Howard: Eight day course? Is there one antibiotic used more than the rest?
Orest: You end up mostly with a Metronidazole combination with Amoxicillin or something like that. There might also be some other things that… And every once in a while there’ll be…
Howard: Metronidazole and Pen Vk?
Howard: Or Amoxicillin?
Orest: Amoxicillin. And most the time that would be the course within the… They would vary every once in a while, depending on what the pathogens were there… And what happened, Howard, and then we also use the in some new cases with (unclear 17:53) defects, we used emdogain…
Orest: Emdogain, which is a…
Howard: Endogain? How do you spell that?
Howard: Can you send me a link to that?
Orest: It's an … The fancy term is an enamelled matrix protein. The protein only shows up when your teeth are forming the roots and the deep periodontal attachment, when you're young, or in utero. So basically this is a porcine product and it basically helps re-establish some attachment that area. Howard, really at this point I have done almost… With that protocol, I do almost zero periodontal surgeries resective or regenerative.
Howard: Wow. By the way you just made me almost nauseous whenever you say Metronidazole you just... You know why?
Howard: I took all four of my boys to go to scuba diving at Cosmouth back in the day and I came back. We just had black diarrhea runs and I had this “we ate something or whatever”… It just wouldn’t go. It's like four days later my boys are just all black water. So I finally call my doctor and he says you know you got to call this place… Anyway, you go to the grocery store and buy five tubs of whipped cream for the bowl and dump it all out, clean it all out and everything (unclear 19:17) put the name in and then you’ve got to mail it to this company to culture and find out what it was. We all had picked up a parasite and they put us on Pen Vk and Metronidazole and it was gone in like two or three days, but he said when he got on that it could be there a long, long time.
Orest: I've heard people, like, are never able to get parasites. Especially…
Howard: Yeah. So, Perio Endoscopy, that's right here in Scottsdale. Who owns that?
Orest: Michael Austin and Chad Kennedy, he's the CEO and Chad is…
Howard: Do you know those guys?
Orest: Yeah, no, I work… I’m chief medical officer for the company.
Howard: Oh wow.
Orest: So the three of us… They've been working on it for quite a while. I came to the…
Howard: So they manufacture it here?
Orest: We're still pre production stage right now.
Howard: So what you're talking about is not released yet?
Orest: It's not released. We’re expecting to have a production by the end of 2017 early 2018. So while we're just finalizing some poignant things before we're ready to go. We have… There are several prototypes out there. One of them is in my office. I've been using it for several months.
Howard: So it’s just a little bitty camera attached to a scaler?
Orest: Well, it's… what it is and let me just kind of show you… This is a… There's a fiber optic cable with a light and a camera at the end and there's a handle we call the Explorer that the cable goes into that slip between, into the periodontal pocket, between the gum and the tooth and with that the hygienist, usually it’s the hygienist is visualizing the subgingival deposits underneath, while removing them with a ultrasonic instrument.
Howard: So you can put the ultrasonic down there, the ultrasonic thing with water coming out and see it in a camera?
Orest: At the same time, yeah.
Howard: I would think like the windshield of a car you would need a windshield wiper…
Orest: No. Actual water helps with the… Waterflow actually helps with the focusing there. Prior to our device being here the learning curve to learn how to do this was monster. It was actually because the technology was old. The screens rolled. The image was not particularly good…
Howard: And in all fairness it didn't really take off. There’s two hundred and eleven thousand living Americans with a dental license. One hundred and fifty thousand GPs doing thirty hours a week or more. So when you talk about something like office computers with 90% market penetration, digital actuary is 80%, but then you look at… What as the market penetration of that?
Orest: Almost nonexistent…
Howard: So the reason I'm telling you that is because when you look at market data, what the average hillbilly buys, you would think that Mountain Dew is the most nutritious drink, but market data for you, you're a doctor, all of your peers have eight, ten, twelve years of college. How many years of college did you have altogether?
Orest: That’s four, four and two, so ten.
Howard: Ten. So market data is very important for you guys, because your data is coming from all extremely highly, top 1% education in the United States and always in the top 5% income and that holds true no matter what. Of the two hundred countries and territories around the world there are dentists or… So when he says it's improved over the last one, well how did last one… It didn't penetrate…
Orest: Well, you’re right.
Howard: And then you might say well, they've sold one thousand units. That's out of three years. You can get a thousand dentists to buy frikken anything. I don't even pop my head up and look until five to eight thousand bought it, but when twenty five thousand dentists have bought it and they got the same A’s in biochem and calculus as you do. When twenty five thousand dentists have bought it, now you’re on the witness stand saying, okay what do you know that twenty five thousand dentists don't know? So, it works both ways. There comes a point in time where… Like digital x rays, when twenty five thousand dentists had a digital x rays computer or an actual camera and you were still thinking about it. I don't know what the hell you're thinking about. You can't fool twenty five thousand doctors.
Orest: No, you can't. The challenge the previous company had was some ownership issues and health issues and then they kind of went downhill from that. The disposable item, there is a one-time use disposable item. It was very difficult to get for a while and there was a periodontist up in the Bay Area basically brought the company back to life to a certain extent, basically got it on life support, but there was never any really… Growth in terms of the number of users and this is where we come in and I've, just kind of giving you an idea of the image here… This is the little trademark symbol on that Spry gum that (unclear 24:26) you probably have that in your office and as you can see that’s about a millimeter, millimeter and the half. That's what that looks like on the screen.
Howard: Damn… Nice!
Orest: You can't even see those dots that are there.
Howard: We're in the middle of September. So you're thinking after Thanksgiving to…
Orest: Thanksgiving, early 2018.
Howard: And what do you think it will cost?
Orest: Oh look I can tell you that right now. The unit is about fifteen thousand and there's a $3000 training and set up fee. They come to your office and the trainer will work with your hygienist or whoever is going to be using that in your office. They come is and set it up. Do some cases. Hands on training, over the shoulder, to do that. One of the nice things that we also have is that we're not only just going into the dental community on the retailer and the retail side, but we're also actually going to be in the Department of Defense one of our… Basically we've partnered with a company called Global Med, which is telemedicine company here in Scottsdale and they basically provide telemedicine to the military and actually... So, we're very, very excited about that.
Howard: What percent of Global Med is dental?
Orest: Right now this is it. Mostly just basically medical stuff, it's in the field. It's actually on air force one. It’s actually in the White House medical dental office. So we are as (unclear 26:12) very exciting part for us, because that's not a market that would be accessible to us, especially at this early stage that we're in.
Howard: So, are you going to have course where other dentists and hygienists from other states can come here and do live, over the shoulder programs?
Orest: We're working on that. I think the value of the thing is that, if you have the device, is basically coming in and showing you how to implement that in your office.
Howard: But what if they’re in Florida or New York.
Orest: Then somebody flies to that area, brings a thing. The device is actually fairly transportable. It gets delivered to your office in a roll away suitcase that fits in the overhead compartment of an airplane. The previous company actually, their stuff shows up in a wooden pallet… So it's portable. It fits on a stand. It can be on a stand, freestanding, or we also have an attachment that if you have a pole in your hygiene room for the light and tray, that can attach to that. So this is a game changer in terms of being able to do definitive periodontal therapy
Howard: And what's the name of it going to be?
Orest: Perio endoscopy and the device is actually called the Dental Visual System 1. This is the Deva 1.
Howard: So Deva… Devas in dentistry. D-E-V-A one. In the ad you should be wearing a little dress with a foo-foo and say that you're a diva.
Orest: That will just drive sales…
Howard: It will be memorable.
Orest: That… It will be memorable. It will triple the sales.
Howard: Call it divas in periodontology… So, do you see this is being more used by the hygienists or the periodontist?
Orest: Oh, by the hygienists, it's meant to be. In my office it's actually the hygienist who uses this, she uses it day in and day out.
Howard: And this is designed to work with an ultrasonic?
Howard: And what ultrasonic do you..?
Orest: She uses a Dentist Fly.
Howard: Dentist Fly Ultrasonic? How many hygienists do you think are in the United States?
Orest: Well it seems like there’s just a shade under two hundred thousand.
Howard: So of two hundred thousand hygienists, what percent of them do you think endorse and routinely use ultrasonics?
Orest: I probably… I would mention the vast majority do. I mean some like to do the bulk removal of subgingival deposits with ultrasonic and then come back with a hand and strength, but a lot of them do rely on using...
Howard: Is it safe to say that back in the day you would flap the tissue just so you could visualize what you're removing?
Howard: And so if you can minimally invasive it, if you can visualize it without pulling the covers down off the mattress to find out where the remote control is you're better.
Orest: Right and depending on the amount of bleeding that one would have during surgery the visualization might not be as good. This is… You know you can go all the way around. Now I'm not going to say that… I will say that there are certain things that are very challenging like the distal furcation of a maxillary molar, that’s going to be a tough one to treat, but that's going to be tough one to treat even in surgery.
Howard: That’s the maxillary or second molar?
Orest: A maxillary or second molar, yeah. Those are going to be challenging.
Howard: And you know what I say that just pisses off people right and left, but it's so true? On those second molars, they're always like, “Oh, I don't know if I can do the root canal on this second molar, I’m going to send them to an endodontist with this and that” and a lot of the times they’re sending somebody to an endodontist to do a root canal on a second molar because they can’t do it and then they come back, get a crown on there… So you’re two thousand twenty five hundred into that one tooth. So then they’re maxed out the insurance or out of their money, but they have like eight other cavities and what I've noticed in thirty years that, when you remove a second molar, when you remove a third molar, no one's ever came back and he said “Well, I can't chew back there.” When you remove a second molar only one time per decade does someone come back and say, “I wish I had that tooth there and I miss it when I’m chewing”, because it's one sixth on the second molar, one third on the first, one third on the second bicuspid and one sixth on the first bicuspid and when you go to some European countries for ortho, instead of pulling the four bi’s they'll will pull four seconds. I think seconds are highly overrated and you know people… What do you think about second molars?
Orest: They're challenging to treat. I think that it's important to have them if you have any TMD issues. I think that that's probably a bigger factor, but we treat people to first molar occlusion all the time and you're right, people are very happy with first molar occlusion and they don't know…
Howard: And when they're totally dentureless and you rebuild their tooth what do you rebuild? Do you (unclear 31:09)?
Orest: No, usually that first molar occlusion.
Howard: I know and that's considered the top of the line… I mean Clear Choice would do that for 25000 arch, they wouldn't have a second molar right? So you go to Clear Choice you give them $ 50000 and they wouldn't give you the second molar, but explain to the kids why a second molar is important if they have TMD issues.
Orest: It just, it’s another place that can keep the joint from over seating and causing pressure in that area and causing, maybe, changes in the morphology of the condyle. So, I think those are the patients that say like… You know, I've had patients that say if they had TMD issues they say like, “Oh yeah it feels a lot better in my mouth if I have a tooth back there.”
Howard: So how much is, could we call it Deva 1?
Orest: Deva 1. $15000 plus training.
Howard: Plus training is $3000. Is that $3000 a la carte or is that plus your travel?
Orest: Plus your travel and housing.
Howard: Ok, then let's compare that to the alternative technology which everyone is on about, the LACC. What would the LACC cost?
Orest: Well, I'm not familiar with that…
Howard: I mean it's like $135000.
Orest: Is that what it is? OK.
Howard: Yeah. Are you into LACC?
Orest: No, I'm not.
Howard: Well, as a periodontist, why did you pass on LACC?
Orest: Endoscopic. The results are the results. I mean, there aren't decrease in periodontal therapy when you're, in periodontal surgical therapy, when you're providing endoscopic therapy. It works and if it works, not out there experimenting…
Howard: And you know that's what the surgeons are doing. When we were little and you had to get your gallbladder or anything they're flapping and now you see your uncle’s, they are like three little puncture points and one was a camera, one was a suction and was the deal, because they just have less complications.
Orest: Oh sure, everything's going endoscopic. I mean you think but your knees being redone, all sorts of things. That's really the wave of the future.
Howard: Talk about more periodontal… This dentistry and such I don't want to talk about anything that everyone agrees on. Some of the kids complain they work in these corporate centers and you know dentistry, a lot of it's insurance driven and, going all the way back, like… Roentgen had invented the X-rays a century ago and dentists came to look at it and when the first dental insurance came the Longshoremen's Union started and they gave their workers dental insurance and that was out in the Northeast Coast, Washington, Oregon, that later turned into Delta Dental, and they covered 100% for (unclear 33:57) and X-rays. Oh my god, like dominoes. Every dentist within just a few years had X-ray machines, because they were covered 100%. Well, now these kids are working at these big corporate chains and they have a six (unclear 34:12) in their pocket, you’ve got to put in a chip, because there's a billing code for it and they can buy these chips for X and bill them for 3X and some of them are asking on Dentaltown, is that legit or is that not legit? Is that just an insurance driven ideology or is that therapeutic?
Orest: I have not been a big fan of putting in chips in those type of things.
Howard: Name the chips on the market. PerioChip…
Orest: I think PerioChip is the only one I'm familiar with. Again, you know Howard, it just, I’ve kind of got my protocol about what works…
Howard: One was a orexin glutamate and one was like a minocycline…
Orest: So, I think I just haven't been a big fan. We see patients that come in and have had that, again because I have mentioned we have a large Internet base of patients that are coming in, and so we see patients that had lots of different kinds of therapy and they end up coming to our office for endoscopic periodontal therapy. So, a lot of this stuff has kind of, I think, a questionable value in terms of that. I think some of it’s, very frankly and unfortunately, it's driven by money or insurance companies and so, regardless of the end result. I mean I remember when I first graduated, I don't know if they were still around when you graduated from dental school, but I remember working for a large corp, I think it was called DentaHealth.
Howard: Oh yeah, in fact the dean of the dental school, he was director of that.
Orest: Was he?
Howard: Yeah he wasn’t the owner , but he was director. Jack Dentalberg was a director of DentaHealth. Yeah, that was here when I got here and that was… Wasn’t it Mort Copenhaver who lived on the big castle on the hill?
Orest: Right. Being on the inside of that was…
Howard: Yeah, I thought it was so funny when people talk about how corporate dentists is all new. When anybody says that you know they're under fifty, because when I got out of school Orthodox Centers of America was trading on the New York Stock Exchange as a billion evaluation, a dozen in NASDAQ, came to Phoenix or there’s DentaHealth and they had the dentist owner more (unclear 36:22) than ever had this house like a castle on the side of a mountain and they all famously imploded. Every last one of them, didn’t they?
Orest: Well, yeah and who is it..? He was a big immediate denture guy up on the East Valley. Doctor Peace and the interesting story about that it was he died and the dentist who bought it changed his name to Doctor legally.
Howard: He changed his name?!Oh my God.
Orest: That's a trip back in time, Howard.
Howard: Now is that still open?
Orest: I don't know.
Howard: I went down there and spent a couple of days, because I figured, that was back in 1987 I was making like a denture a month, and I had friends that were working there. They were making ten, fifteen dentures a day and I didn't learn one massive thing. You know, he had a lab in office, but like I totally, I've seen the pattern to this day that if you do… Whoever does the most of any procedure gets the best at it and I think, when dentists, if they don't do a procedure at least one time a week they never get good, fast and profitable at it. So if you get into place implants and you go invest $100000 in a CBCT, $50000 dollar in a system, $50000 dollars in training all the way around the world or whatever, and then you place an implant every three months your failure rate’s high and you never made any money and you didn't recoup your investment. So think about that before you get into anything, whether it be sleep apnea, TMJ, anything. There's a critical mass and furthermore, if you need to have your gallbladder removed, would you rather go to a doctor who did it every day, doctor every week or doctor did it every quarter?
Orest: Yeah. I think it's important that when you're deciding what you're going to do in your office there is always that financial condition, but make sure you enjoy it, because if you enjoy it there's a good chance you’re going to o more of it and do it well. If you do it just for the money, that's a miserable way. That's a miserable road to go down.
Howard: Yeah, I always say that what I'm most proud of is my four boys. What I'm second most proud of is I still haven't worked a day in my life. I mean I worked for my dad for ten years; he was my idol, role model. Hell, you’re a kid working at Sonic from ten to twenty with beautiful car (unclear 38:46), cheeseburgers, your dad who’s a big jokester and then when I came out of dental school I always worked for myself and if I didn't like doing something I quit doing it and I remember a dentist up the street for me one time said to me, I hope you’re listening man, it was Robert Sundberg, Bob Sundberg, he said, “Dude, I'd rather be beat with a stick than do molar endo.” I said, “Then you can't do molar endo, because it will take a smile off your face, you'll burn out and you’ll hate dentistry.” You either got to commit to it and take all the CE in training and immersion until you master it, then hopefully you’ll love it, but man if you ever get to the point where you hate something you can't afford to do it, because you can't burn out in this profession.
Orest: No, you're actually correct.
Howard: And I wouldn't want a doctor doing a bypass on me if he hated the procedure. I’d rather want one that just couldn't wait to fling me open.
Orest: True and is excited about what they’re doing inside, about being there and that’s…
Howard: You don't have to answer this, but I’m going to ask you the most controversial question. I'm convinced that your specialty hasn't even agreed on a definition of peri implantitis or a protocol to treat it. Do you see this as part of the… The research I'm seeing is that after five years, in just the United States, 20% of implants have peri implantitis at sixty months. Is this do you agree that there is not a consensus on the diagnosis and treatment plan of peri implantitis in 2017?
Orest: There does not seem to be. I think different people have different approaches and again it’s one of those things that work… Some things work in some people's hands and don't work in other people's hands and it depends on what tool you have. We have, fortunately (knock on wood), not a real issue in my practice though. We have had some cases and one particularly comes to mind, because it was someone that I did a six implant on maxilla and he was he was a guy that I'd known from my twenties and he was also a political hatchet man for the governor of our state and he was very, very nasty guy. It was pretty funny because I could yell at him and it wouldn't faze him, but I did some implants, he was not a particularly healthy guy and all of a sudden his implants… He comes back after the restored and the implants are basically draining puss and I'm like going, “Oh my god, this is not good. I don't want to deal with this guy because he's just nasty and I can be nasty back but I think his nasty factor might be better mine…” and so I was on the company… I was on the phone with Straumann and they were trying to be helpful on this and that. They put me, I can’t remember his name now, but he was a surgeon up at Harvard that they were trying to hook me up with and there were all sorts of things, and so, right about that time was the time that I'd gotten… Started using platelet-rich plasma and I was probably one of the first in town to use it, because this is before he actually had the machines. I had a old hospital perfusion machine that we used to, basically process the blood through there and get the players plasma and basically I flapped the area open, cleaned up the granulation tissue, put the platelet-rich plasma, closed it up and we stopped seeing him maybe about ten, twelve years later, but up until that time it seemed to have basically stabilized. There was some, obviously there's the agreement on whether there's attachment or new bone attached to the implants, but that's a theoretical discussion, but I was able to get some radiographic bone growing back, especially into the infrabony defects and the implants and no evidence of inflammation or continued breakdown. So this was 2000, Howard. There wasn't a lot out there. It was like you're just out there basically on your own.
Howard: So what percent of your implants would you say… OK, so the research is pretty clear, I’d say it's got 20% on five years. What would you say your percentage is after five years?
Orest: I would say as far as the failure rate. 1%.
Howard: Peri implantitis.
Howard: Yeah, you know Tatum? Remember Hill Tatum?
Howard: Who’s still practicing. He just did last…
Orest: I'm stunned he's still alive.
Howard: Yeah, and I think so is he. He’s in France and we podcast interviewed him and he had just done a lateral nerve repositioning grafts on his wife! The second side and placed an implant. He's convinced that peri implantitis is because when the implant’s placed they didn't handle the tissue properly and get a nice tissue seal and that that's the problem.
Orest: I think often that is a problem and there’s some theories about the number of times you take a healing button on and off and you click the buttons on and off. I think hygiene is an issue with patients in terms of peri implantitis and again, go back to the quality of the particular implant. That certainly is a factor.
Howard: I think dentists are overly hard on themselves, because when I (unclear 44:34) on my patients, every time they come in and they had an artificial knee or an artificial hip I would say, “Well who put it in, in town?” and I want to know who put it in, did you like the guy? Then I always say, “How long did he say it last?” I mean on all these artificials they're all being told that it'll last five to ten and then dentists are like, five years it starts, or if it fails. Five to ten years and they’re all upset, emotionally distraught, paid for the replacement… Man, the orthopedic surgeons. Where’s the difference in the oral surgeons, periodontists and general dentists and the orthopedic surgeons? There is not an orthopedic surgeon in town who’d tell you a hip and knee are going to last forever. There’s not one. So, why the big difference between..?
Orest: I don't know what it… It's a cultural thing in dentistry. It's a…
Howard: What are you hearing on knees and hips when they put them in patients, how long..?
Orest: I mean the same thing, about, five, ten years now. No one is promising you forever. Especially as we're living longer.
Howard: Yeah. So, these dentists, I mean there's a guy the other day on Dentaltown replacing a failed crown after twelve years. I'm like, dude I don't think my own refrigerator will last twelve years. My car's 2004 to 2017, but that was a Lexus. I mean it's got 140000 miles, I think a Lexus might go... I'm hoping I get 200 out of it, but gosh everything… My dishwashers, trash compactors, none of that should last ten years. The dishwasher that's, that thing that your wife pulls a door down and puts the dishes in… I noticed when I said dishwasher your eyes glazed over. It’s disgraceful.
Orest: No, I use the dishwasher a lot.
Howard: You use the dishwasher a lot?
Orest: I use the dishwasher a lot and I also use the washing machine and dryer.
Howard: When my boys were young I hired a chef and she would come in here once or twice a week and do a big old cooking lessons with the boys. By God if I don't have four you know (unclear 46:38) but my god. All four of my boys are (unclear 46:43)., because I thought man, why give them piano lessons when I'd rather… I mean they love… They all loved the cooking and it was all because of Anne… They were all boys. She was gorgeous, blond, lived up the street, she was a professional chef. She loved it. They loved it… And by God are they all the best cooks in the world and so I absolutely never cook, because all the boys do. More controversies. What do you think the next biggest periodontal controversy will be?
Orest: I think this is it. I think this is a disruptive technology, Howard, this is a major disruption. I mean we're talking about the ability for the hygienist, most of the time the hygienist, to perform definitive periodontal therapy in the hygiene department of a restorative office or in a parallel office. We're really, in a big way, minimizing the need for periodontal surgery
Howard: I’m going to ask just some more controversial questions. This is the big debate in dentistry. So, I'm seeing you every three months for periodontal therapy for ten years. I've never seen your lover. She finally shows up. She hadn’t been to a dentist for ten years. She’s got a bombed out wisdom tooth. She’s got six 9mm pockets and you guys are kissing and sharing utensils and trading saliva. Was that a factor in… You know I mean, below the belt… If I was treating you for chlamydia every three months for ten years and then your wife walked in with chlamydia I'd say well we should have treated her. Is it the same in the mouth as it is below the belt?
Orest: I think there is some factor to that. At the same time also your personal health and your immune system resistances is a factor, because you see that sometimes in couples, but it may not necessarily be because of the bacteria it may be actually similar lifestyle habits that the couple share. So they might be smoking, they might be a lot of drinking, they might be you know, poor oral hygiene that they share so that can be a factor.
Howard: And when you say smoking is that cigarettes?
Howard: So another thing that’s massively changed since you and I got here is: Across the street from me the dental office has been there for thirty years and Ahwatukee got its first medical marijuana dispensary and it's right underneath the (unclear 49:24). So, it's actually kind of confusing, it's like dental office, sunflower marijuana medical. It seems like a dental office owned medical dispensary, but some people are claiming that marijuana may be deleterious to oral health. How do you weigh in on that?
Orest: I think probably it is. I don’t really know any of the data on that, but I would assume that it would be a problem, just like any other kind of smoking in terms of, because it changes the O2 levels in the mouth. That’s what I think.
Howard: In your thirty six years, what percent of your referrals generated almost all the crown lengthening procedures? I mean some periodontals say I got 25… How many do you think general dentists routinely refer to the average periodontal? So there’s four thousand periodontists.
Orest: I don't know the statistics on that, Howard, but I do know that the referral patterns have changed dramatically in terms of, there's a lot less being referred to specialists and to periodontists in general, as more general dentists are doing services that used to be just in the scope of the periodontist, are doing them in their office. So, a lot of crown lengthenings. Pinhole is, again, a big technique that's out there and really has a lot of market penetration in the general dental community.
Howard: Dr. Chao.
Howard: What do you think of the pinhole technique?
Orest: I think it's applicable in some areas. I think there might be some areas...
Howard: Have you heard of, Delia Tuttle has kind of a similar deal. The gumdrop technique. Have you..?
Orest: No, I am not familiar with that.
Howard: You know Dr. Elizabeth Fleming? She's bringing her out to give a course on her gumdrop technique, which is not the same as the pinhole technique, but I'm sure…
Orest: They're similar right? What we do is a Pat Allen, he's a periodontist in Dallas, Texas. He does a course where you use alloderm, which is just freeze dried skin and it's similar in terms of… It's a highly technical procedure in terms of being able to elevate the flap without cutting into the pill. Basically you do a split dissection in a lot of the areas and you kind of bring it down like the (unclear 52:00) shape. So, a lot of these procedures are being done in a general dental practice. I will tell you that most of the cases that we get for crown lengthening, which is not that many of these days, but are cases that probably should not be crown lengthened, like I got one just the other day it was like the decay is on the distal of the root of the second molar. I don't care how much crown lengthening I do, that's not a case that needs to be restored traditionally, that’s an extraction and possibly a dental implant, maybe not.
Howard: Is there any questions or any subject that you think that I missed?
Orest: Well I do want to tell, we have a special offer for your listeners, for the first hundred to purchase a device we have 10% off the Deva 1 and you go to www.perioendoscopy\Howard\
Howard: They're going to think they're supposed to slap me twice.
Orest: I did. (unclear 53:20) backslash Howard with a capital H backslash and you'll get the deal. This…
Howard: By way these aren't commercials. I didn't know it was going to come. I didn't pay him to be on the show. That company’s not paying me to be on the show.
Orest: Whoa, you told me I was going to get honoraria.
Howard: But you did give me one hell of a gift a couple of years ago. You took me and my boys to the ballgame and my God. Greg… I got four boys great fun loving… I don't know if you ever... (unclear 54:03). Anyway, that was so damn much fun. I am too much of a workaholic and I would've never gone to that ballgame and… But I thought well I want to see you and so I went took my boys and you bought us all tickets. God dang, they had so much fun. We got to go to a ballgame. In fact Brian, we're going to go to a baseball game. There's no sense, because you don't have to be into… Just going to the event. The beautiful stadium. Do you know why I hate going to ballgames? Because every time you hear that bat crack I think I'm going to get smacked.
Orest: Oh yeah. You got to watch out.
Howard: It’s paranoia and I was fine with it until Real Sports did a whole issue on it of all these people whose lives were ruined by a ball hitting them at 90 miles an hour. And I watch this whole episode on Real Sports and I’m like, well I was afraid I was going to get hit, but now I'm like should… you could be killed. I mean there's people, their whole lives are ruined from this, but other than that. Do you ever sit behind the fence or do you ever sit up high so they won’t hit you or does it not matter where you’re at?
Orest: It doesn’t matter.
Howard: We had the best seats in the house. We were right behind the dugout. I could hear the bat crack. I’m like, “Oh my god.” Maybe I should wear a helmet with a side thing, but thank you for doing that. It's one thing when you go out and have a lot of fun with the dentist. It's another thing when that dentist really touches one of my boys.
Orest: Well, it was my pleasure to do that.
Howard: Great things. You were just amazing, because you're very knowledgeable in history and politics and I mean you’re a periodontist, but outside of periodontitis, man, I could call you a historian. I really could.
Orest: Well, thank you.
Howard: I mean do you agree or disagree?
Orest: I'll humbly agree.
Howard: Yeah, you’ll humbly agree. You know…
Orest You’re overrating me Howard.
Howard: No, because that's Greg's favorite subject. That's why you connect enough with Greg so well. He just loves history and you really, really understand history. Where did you get your passion for history?
Orest: I just have always liked reading about history and things like that. I think it's really fun, especially when you get down into the weeds of stuff happening. You know that's kind of special.
Howard: And speaking of history. I posted a historical deal. Did you know Robert Tanner Freeman, after being selected as one of the first six persons to enter at Harvard's dental program, shortly became the first African-American to graduate the dental degree in the United States on March 10th 1869. He was born in 1846, graduated in 1969 and then died in 1973. So he was the first African American dentist, but he practiced four years. I wonder what their, back then, what infectious diseases were at the top, but hey thank you so much.
Orest: Howard, thank you for having me. It was a pleasure to come into your home and visit with you.