Committing Your Practice to Ultimate Patient Care

Course Author(s): Jennifer Hirsch Doobrow, DMD, FACD, FICD


Thank you, Jen. Thank you so much, Sarah, for this wonderful introduction. Thank you [Seezdom] and most importantly, thanking each and every one of you for being here with us today. Crest Oral B, for what you're doing for our dental community, for providing free CE for all of us in need of just something to take a break is just wonderful. And so today is about each and every one of you. I know these are really challenging times with you, but I want you to know we are going to get through this together. We will prevail. If those of you like myself have been on so many of these Facebook threads and posts, our dental community is so strong and absolutely we are here. We are going to come out and we are going to be incredibly, incredibly strong after this.

I can tell you this from personal experience. Again, thank you so much Sarah for the introduction, but one thing that I want to share with you, that's not in my introduction and bio, is why I do what I do each and every day and what brought me to dentistry and in my life. The gentleman that you see on this screen was my father, Dr. Dr. Harold Z. Hirsch and you see, yes, I was a cheerleader for the University of Georgia. But that goes so far beyond cheering for university. It was about not being a cheerleader for life and being about a cheerleader for what we do each and every day.

I want to share with you my story. My father, Dr. Harold Z. Hirsch, was a practicing periodontist, for 30 plus years and had practices in two areas in rural Alabama. Between my first and second year of my residency, my periodontal residency, which is three years for those of you that aren't familiar with it, he passed away suddenly. Talk about losing your mentor, your cheerleader, your teacher, your best friend, that stopped us in our tracks.

When my dad passed away, not only did he have the two periodontal practices for over 30 years, he also had eight... What's called Krystal Hamburgers, which is like for those of you that may be in an area where they have white tacos, the square hamburger restaurant. So when he passed away suddenly, we knew we were facing adversity firsthand, and we knew that we were going to have to do whatever we could to pick up those pieces and in that very moment, do what we had to do.

So from what we're talking about today, this comes from so deep inside my heart to tell you that we will get through this. Each and every one of us we'll get through this together. And again, we will prevail and we will be stronger. What my dad instilled in me from day one is that we need to make the most of every moment. Unfortunately, so many of us, all of us that are on this webinar today, understand how important that is.

Again, I want to thank you all for being here, because right now is the time to embrace what we have to look at our families, to look at our lives and to realize how fortunate that we are. Thank you for being here and I'm excited that each and every one of you are on this webinar because we are just taking a moment out of the craziness that's taking place right now and we're going to be in control of the moment. The reason that you guys are here, the reason that you're on this is because you love what you do.

I know we have so many individuals on this call. I know we have doctors and we have hygienists and we have assistants and so each and every one of us adds so much to our patients' lives. And so with that, I want to share a quote with you as we start our time together. I want to share with you those of you that may be familiar with Dr. Grace Yum who's the founder of a Mommy Business in Dentist. She shared a quote the other day, and it was so powerful. It stuck with me and I want to share it with you. "When you can't control what's happening, challenge yourself to control the way you respond to what's happening. That's where your power is."

So I ask each of you right now. You don't have to say it out loud. You don't have to write it down. You can do all that if you want to, but I want to ask each and every one of you, who are you? Why are you here? I shared with you that my dad instilled in me that we need to make the most of every moment. If you didn't believe that before we were on this webinar, and you didn't believe that maybe two and a half weeks ago was before the calm before the storm, then I want you at the end of our time together to really understand why you are here and why you do what you do.

I want to share with you a thought, I want you after we get off today, I want you to think about how we say things and maybe just think about how you can say it just a little differently. Instead of those times, when we get back to our practices and we will get back sooner rather than later, I know we will. But I want you to think about starting to tell your patients not what you do or how you do it, but I want you to start with the why.

If you're taking notes, I want to really employ upon you after we get off today. If you're not familiar with this gentleman on the screen, his name is Simon Sinek. He has an incredible book. As you see here, Start With Why. He has many podcasts and Ted talks and he explains the importance of starting with the why. So I want to go back for a second and I want to share with you again, when we all get back to work, and we're thinking about why we really do what we do and how passionate we are and how excited we are and how this is reaching the bar flame, to get back, to help our patients.

Again, I want you to start by telling your patients not what or how you do what you do, but I want you to start with your why. I will share with you, Tony Robbins. Many of us have heard many of his incredible motivational speeches and it's having a powerful enough reason, will absolutely provide you with the necessary how. As I was preparing for this presentation and so, again, that shows us this... I look back every day that I've been reviewing this about how quickly time can change and things can change in our lives.

I put this in prior to the news that was released over the past day or so about how the Olympics have been postponed. The reason I did this is not to talk about the Olympics, but it's to talk about the three things that our patients are most concerned about. So again, just think, say it out loud to everybody in the room as you're social distancing, if you want, what are the three things that our patients are most concerned about?

I'll tell you what I think our patients are most concerned about. It's time, pain and money. And so I mentioned to you, let's start with our why. I want to share with each and every one of you, this has been a game changer for our practice as a whole, for our patients, for our community. I've had the good fortune of going out and lecturing all over the country and it's been a game changer for so many individuals that I have spoken to. The reason is our why now is we want to get you healthy in the shortest amount of time possible, because what did I tell you our patients are concerned about? They're concerned about time, pain and money.

If we know, our patients equate time to money and they equate pain to a lot of other things. So if you can, in the moment and the few moments that you have, and I'm going to stop for just a second and just kind of digress, because many of us have heard about tele-dentistry and now more than ever, we're going to be learning more and more and more about tele-dentistry. So this may be even something that you can start with that initial conversation when you're introducing yourself to those patients, when maybe you're... What used to be our new patient consultation in our office, happens to be over what we're doing right now. Overseas Zoom or a Zoom call.

So we want to get you healthy and the shortest amount of time possible. What happens so often is our patients' expectations don't meet the reality. I'm seeing tons of comments coming in because you guys know this is true. It is so true. So often these patients go to Dr. Google and they go to PubMed and they know so much more about what we're going to do for them before they even come into our office. Right? You guys all know that this is the case. Because of that, so often now our patient's expectations don't meet reality. What happens is a lot of this is all on us.

A lot of this happens to be on us, because what happens is we way, way too often and this is not just with our patients. This is in life. We so often minimize disease. We minimize disease. What we're doing is helping our patients not own their disease. We're not helping them get healthy. We're minimizing it. Because look at what you see here, how often... I did it all the time until I thought about it this way, how often do we say, "It's a little bleeding, Ms. Smith. You got a little cavity. You kind of have a problem. I think there may be an issue. You have gum disease." What we see, all right. So when we get off of this webinar today, I cannot charge you with enough to say, think about things differently. When you go back to work... And we will go back to work, you guys all know this and we'll go back to work soon. God willing. I want you to think differently, so you can act differently. Because, what happens is you've got to get your patients to 0-W-N. Own their disease.

Can you tell them that cheerleader of life, not just the cheerleader of University of Georgia, not just the cheerleader of dentistry, but the cheerleader of life and each and every one of us have the power within us and our entire team. And I say, team, you guys heard me say team, I'm going to say team so many times today because you're a team. When you get back together to be a team in your office, or whether you're doing Zoom meetings, like we're going to do with our team. So we can stay a float together. Team is a team, team gets it done. Staff, S-T-A-F-F is actually S-T-A-P-H. Many of you heard this before. Staff is an infection. So it's all about how not only we talk to our patients, how we talk to our family, but it's how we talk amongst ourselves with our team as well.

So get your patients to own their disease. Get your team to own being part of that team. I'm going to stop and I'm going to pause. Because when I'm in a room and right now I'm pretending I'm in a room, because we have over 1100, 1200 now attendees, excuse me. I just pause. I want to introduce you to Calvin. Calvin, well, before I even say it, I want you to think about it to yourself. How old do you think Calvin is? Okay. You think he's 15? Do you think he's 40? Do you think he's 75? How does this present to you when you walk, when this patient walks, when Calvin walks into your office, is this one of those patients hygienists out there? I know you're like, "I want to get my hands on Calvin. We can help Calvin." I know that you see this and you know what we can do.

I see a lot of guesstimates and somebody hit the nail on the head. Calvin is 25 years old. God bless them. 25 years old. And if you can imagine, has never had the opportunity to see a dentist. When Calvin came in, I asked him a bunch of questions and guess what? He didn't answer a single one of them. But guess who was in the room that did? And many of you know what's about to come, mom. What mom told me was this, "Calvin doesn't really speak. Calvin's 25. He's really never spoken. The reason is he's got selective mutism." Selective mutism. Now I happen to be a double major in college. I was the psychology and a biology double major. I can tell you, when you look under selective mutism, if you go back after this, read up and really understand what potentially that can mean.

So when I share with you about Calvin, Calvin is why we in our practice, do what we do each and every day as a periodontist, as periodontal practice. I hope Calvin after this will be the reason you do what you do. So I want to share with each and every one of you, and you may know this, but I want you to believe it. I want you to really dig deep inside your heart and understand. Calvin and everybody else that we see each and every day shows us, proves to us that we have the ability to do what? To save people from dying of dirty teeth. Now, as a periodontist, I know I'm a nerd. Okay. I was sharing with you right now, the video.

Thanks Jeff for doing that. But what I want to share with you about Calvin is this. Again, we have the ability to save people each and every one of you, from dying from dirty teeth. And don't we understand that, we know, again, I was saying, I'm a nerd. I read all the research in the literature. But we know how strongly correlated and associated don't ever say causative. But we know how strongly associated the mouth is to the body, right? We all know that the mouth is the window to the body. So if we can take somebody like Calvin and just wait, this is how he presented. And those hygienists in the room that I know wanted to get up that neutron and that ultrasonic that you just saw and probably were jumping for joy and at one week post up... Now, I want each of you to understand, okay, again, those of you that may have not caught on until now, this is a 25 year old gentleman that has been diagnosed with selective mutism that came to my office and wouldn't say a word, but mom said every word for him. Okay.

I see somebody that said, "That looks gratifying to see those chunks come off." Absolutely, hallelujah. It's gratifying, but wait, what's even more gratifying. At a one week re-evaluation from just across debridement. Now you can appreciate, unfortunately, you won't be able to see my point, but in the top left screen, how inflamed the gingiva is. And this gentleman has never been to a dentist. This is how he presented at one week. Now, I can tell you that when I see this, this brings every tear that I have and every emotion that I have to the forefront. This is the one week post off. Now on the bottom right picture, you'll appreciate that yes, there is still build up on their teeth. But that was only because we got to the point that we said, "Calvin, we are done for the day." We could tell at that point he was finally getting a little antsy. But what I want to share with you is because of that, we had a believer.

Let me tell you, this is when I get so emotional, because he came to us at one week and he was brushing his teeth and he came in. If you all can imagine this, he came in initially with his greasy hair, probably hadn't washed his body for I don't even know, days, weeks, months, we made a believer out of him. And so what we decided to do, and this was hugely profound. These are those cases that each and every one of you need to really think about when they come in, we went ahead and we gave them every tool in the toolbox that we could. As you can imagine, these are these pro bono cases. These are not cases that you are going to be... They didn't have anything. He didn't have anything. So we gave him toothpaste. We gave him an electric toothbrush and don't you know that when he came back, what you see on the right side of the screen looks better and better and better each time.

That is something that each and every one of us had the ability to do. We have the ability, absolutely to change lives one mouth at a time. Now we're getting a lot of questions and as we get to the end, we'll answer a lot. I'll tell you how we do things. So please know that I'm going to answer these, but I did have an important question to understand that this was one gross debridement appointment, which took about, I would say about an hour and 45 minutes. Because those of you that are hygienists, that love getting into the mouth like this, you know that this stuff just starts to come off, as somebody mentioned, just in quotes. Really, high volume, suction, all of that. Okay?

I want you to understand, I want each and every one of you to understand that people do not care how much you know, they really, really don't especially now when they can go to PubMed and all these doctor MDs and all these, right? They don't care how much you know, until they know how much you care. That is absolutely true. John Maxwell, thank you for quoting that. So let's get into what maybe each and every one of you see today. Okay. So it may not be the Calvin that you see, but quite frankly, you may see this. Okay.

A lot of buildup, a lot of inflammation, erythema and edema. Those of you again, that are hygienists that are on the webinar. I know you guys are getting excited seeing this, because you're like, "Oh yes, I got this. We can help these people." But what about when in our periodontal practice, when we turn the lights on and roll the window shades up, this is what we see. This is what we see. Okay. And my question to you is why are we seeing these one and two, all these facts? How do these patients get like this? What if I told you that the patient on the right is a mother of four, works three to four jobs on any given time.

Again, these are these pro bono cases that we are doing because you have to do that for some of these cases. This woman could not work on the right side that has the lower central incisor completely fully exposed. Remember when we talked about making sure that the patient's expectations meet reality, these are where these serious conversations come in. What if you were presented with this and a patient wants an implant? You've got to have these conversations with these patients and you got to be real with them. How about these cases? Sometimes I want to ask my referring doctors, that send me these ailing teeth that are ailing implants, are failing implants, are failing teeth, did I upset you? What did I do? But that's not the case, right? The majority of these cases, these patients didn't even know that they didn't know that they had a problem.

Because each and every one of you on this webinar and what you do for your patients and how you empower them and change their lives, you guys hopefully are recognizing these cases before they get to this. How about this? In the upper middle picture, you can identify not just ailing implants. How about BRONJ, Bisphosphonate-related osteonecrosis of the jaw. These are cases that when we turn those lights on and roll the window shades up, we are seeing each and every day in our practice. What I want to share with you is periodontal disease is not just a disease, as we mentioned before, it's not just a disease of the gums, right?

Our patients remember it years ago, they call Ed pyorrhea. It's not just a gum disease. It's a bone disease as well. And so what I want to share with you is remember this, when you're looking at cases and you're looking at these patients, I shouldn't say cases. I don't even like the word patients. When we're looking at the individuals that trust us each and every day, those of you that are hygienists on the call, they come back to you five years, 10 years, 20 years, 30 years to spend an hour, twice a year with you, maybe three to four times because they trust you.

So when you see this, when you see what you see on the screen, I want you to identify it, not just as a gum issue. When you see it, I want you to understand that it's an underlying bone, right? There's a bone issue and a gum issue. This is why it's called periodontal recession. So I tell you that because when you see something, you need to say something, right? Because, we have the ability to change what's happening in our patient's lives. Changing lives one mouth at a time.

I want to share with you a secret. It's not really a secret anymore. My dear friend that I speak with her name is Tracy Anderson Butler. Many of you may know her, she's a hygienist. I've had the good fortune of lecturing with her around the country on this specific topic. I want you to know all of those cases that you just saw we treated, because here's what's new for you maybe or maybe you knew this, but in dental school and hygiene school and assisting school, we used to think that once it's gone, it's gone. Guess what, y'all. I threw in that y'all from Alabama. I got to give you a little bit of humor. Once it's gone, it's gone. It's actually a myth.

We have the ability each and every one of us on this webinar today to turn this around. So maybe before you weren't identifying those patients with the recession, maybe you thought it was a little bit of recession, but then what you're going to see in a little bit, that little bit can turn into a whole lot. Okay? Once it's gone, it's not gone. What if they knew that there's an option to reverse disease?

All of the patients that you're going to see today or patients that we've treated in our practice and so I can share this with you, not just from a literature standpoint, not just from an academic standpoint. Okay. But I can share with you because we are experienced each and every day. I'm seeing a lot of people who may or may not want to do this when they speak, but I am absolutely here for each and every one of you. So you're going to have my email address. So please feel free to hit me up with all of these questions. That's what I'm here for. I want to be a resource for you and for your team. So what if we knew that there was an option to reverse disease?

What I want to share with each and every one of you, and this is of the utmost importance. I'm hoping that I can share with you at least three facts, three items that you can take back that are going to be your pearl. At the end, we're going to circle back around and I'm going to share that message with you, again. What I want to employ upon you is early detection is key. Those cases that you saw that walk into our practice each and every day, believe it or not, they're walking into your practice as well. So get them, treat them, help maintain them, before they get to the point, put me out of business, go for it, I don't mind. Actually, I really do. I shouldn't say that. So there's going to be plenty of disease out there and we know that, but in your practices, early detection is absolutely key.

We've seen this. Now, this has been out since 2012. But back in 2012, according to the CDC, over half Americans in the United States, over the age of 30, had some form of periodontal disease. Now we just talked about it. Periodontal disease comes in all shapes and sizes, right? Maybe before we go on this webinar, you may have just thought about periodontal disease as five, six, seven, eight millimeter pockets, erythema and edema around your teeth. But in reality, we now just said that periodontal recession is a recession or loss of gum and bone. So therefore that is as well periodontal disease. Right? All right.

So let's put things into perspective. This is so important. We know that diabetes affects so many Americans in the United States. Now this number, this was 2013. So I guarantee each and every one of you that 29.1 million Americans back in 2013, had a diagnosis of diabetes. Okay. But let's really put it into perspective. Two and a half times more people in the United States have periodontal disease and diabetes. You all were talking about COVID-19 every single day, right? That is at the forefront of our phones on our TV, on our smart devices.

So we right now are facing, I'm not going to call it a pandemic. I'm not going to call it an epidemic, excuse me. But we right now within our own practices are facing so much disease. 2.5 times more people in the United States have periodontal disease. Half of the American population over the age of 30, have some form of periodontal disease. This is walking in each and every day to your practice. When we get back to work, I challenge each and every one of you to make sure you're helping to change your patient's lives one mouth at a time.

So let's talk a little bit about what repair versus regeneration means. I mentioned to you, yes. I've had a few notes about this. Once it's gone, it's not gone. That's a myth. What I mean by that, that is soft and hard tissue regeneration and we're going to see case after case as we move through the next 30 minutes together to make you and help you understand this. So repair what you see on the left. I want you to liken that to a bandaid. Okay. A bandaid on a problem. Regeneration. I want you to think about a starfish. A starfish can regrow its arm and what does this mean to each and every one of us?

Okay. We now know that over the age of 30, half of the American population have periodontal disease. We know that there are certainly other populations that are younger than that, that are affected as well. We know that repair is something that each and every one of us may perform in our practices. What repair is, is the down growth of a long junctional epithelium. I circled this for you. Why do I say that each and every one of you are doing this? If you, as hygienists or dentists are performing scaling and root planing, you are actually forming a scar. You're putting a bandaid on there. That doesn't mean that you are not reducing the pockets.

Now, I want you to think about that. Those of you that are like me, that may be kind of a nerd as I like to call myself, to think about the histology of what we do, what we're actually doing is reducing the inflammation, right? We're forming a long junctional epithelium. We're technically forming a scar within the pocket. What we are not doing by the strict scaling and root planing is we are not regenerating bone or soft tissue. If that doesn't make sense, or we need to go in more detail, we can do that certainly as we do a Q and A. But what does that mean? What does repair mean? It means that there's no bone fill. There's no new ligament formation. There's no new cementum formation. And certainly there is a long junctional epithelium.

Now, what do we really want? When I mentioned to you, once it's gone, it's not gone. How do we get there? What does that mean? Those of you that may have not been familiar or that may be familiar and just need a revision or some updates. We now have the ability and it's been out there for 15, 25 plus years, depending on the literature that you read. There is something called periodontal regeneration. What periodontal regeneration is, is the regeneration of bone fill, new ligaments, new cementum and new PDL attachment.

I told you, I'm a nerd. So of course, I've got to show you some histology. What it means is the reconstruction of functional attachments through regeneration of the new, hard and soft tissue. Now, those of you that are not in periodontal practices or those of you that may be in a practice that performed periodontal surgery, or that are not in a practice of performed periodontal surgery. Hopefully your periodontist in the area will have the capabilities and will be performing these procedures. If you have any questions about this, please feel free to reach out to me at the end.

I have had the great fortune of being involved in leadership throughout the country, especially in the periodontal sector. And so I can hopefully let you know who may be a periodontist in your area that may be performing periodontal regeneration or give you some names. So again, true periodontal regeneration is the reconstruction of functional attachments through generation of new and hard and soft tissues. What does this mean for each and every one of you on this call, on this webinar? You may not be performing these techniques.

You may be referring God-willing after this webinar to somebody that does. But what periodontal regeneration means is it means saving teeth. You're going to meet Lenny in just a moment, and we're going to talk and walk through Lenny and what that shows you, but what that could look like for you, look at the difference between the left as an initial probing depths, 15 plus millimeters in three years, post-op Lenny still has his teeth in the mouth. And now three years later, he is presenting with three to four millimeter [inaudible]. What does that really mean to you each and every one of you that does perform restorative dentistry?

That means, periodontal regeneration means that your dentistry can look greater longer. Your dentistry can look great or longer. What does that mean? Why do I say that? Because, together we have the ability. If you're performing these procedures in your practice, awesome. If not, please refer them to a periodontal practice that does. What that means is that we have the ability to build a foundation or rebuild a foundation. So you can build that housing on top of it, that building on top of it, that bridge on top of it.

So you can perform your dentistry that will last longer and impact so many of your patient's lives. So for the next short period of time, what I'm going to talk about with you, I want each and every one of you to understand there is no panacea and not in one single case, do we necessarily use the same thing. Certainly we have a protocol, but depending on taste specific, and please understand every individual that walks into your office is going to be a different scenario.

You have to understand, you've got to use the best clinical techniques, but more importantly, you've got to understand your patient and what they're presenting to the table. So what I'm going to discuss with you are the armamentarium and the procedures and the techniques that we do in our practice. This may not be what you do, but the ultimate goal is building back that foundation, whether it's with something like a laser, I get a lot of questions about lasers, with different growth factors. But what we have the ability to do is maintain and rebuild that foundation, so you yourself will have dentistry to do work on longer and greater.

So with that being said, what I'm going to introduce you to is a whole host of different types of growth factors. What growth factors are, you may have heard of bioactive modifiers, okay. There are many of them out there. The specific ones that we're going to be talking about today are not the ones that you see here, the BMPs. They are the ones that you see on this screen here. PDGF, EMDm PRF, and I'll highlight a little bit closer for you. Okay?

The first one that we're going to discuss is EMD. What I want everybody to understand is there's different sources of these growth factors and I'll explain where these sources are from. In certain manners, they're indicated for certain things. I'm also going to explain to you in what manner we use these growth factors mainly. But again, that doesn't mean that may be what you do in your practice or what your referring doctors do. The whole global picture that I want you, each and every one of you to understand is what bioactive modifiers and what growth factors can do for you and for your patients.

They're like a magnet to recruit healthy cells. They're like a magnet to bring cells into the mouth, into the area. So it can jump start that process of new growth, that new cementum PDL, alveolar bone, as we discussed the periodontal regeneration. Again, it all depends on your host. You've got to understand that and it all depends on the techniques that you're using. So I mentioned to you several different products or techniques that we use. The first one that we're going to touch on is called enamel matrix derivative. It's core sign in origin, if you saw from that chart, it's from Hertwig epithelial root sheath or the tooth buds of the poor sign teeth. Okay? And so what it is, is it's basically a viscous. You can see in the upper left corner. It's a viscous amount of protein that will adhere to the tooth, as you can see in the lower left corner.

In just a moment, you'll see actually how we perform these procedures. Okay? So this is actually Lenny, that you saw, this is what you call a one-wall defect. So for those of you that want to go back into our history books from our periodontal training, we know about one-wall, two-wall, three-wall. The one-wall defects are the hardest cases to treat. And so these are the cases that I wanted to introduce you to, to really see the abilities that we have within our own power and within our practices.

Now, again, I pause and I want each and every one of you to understand. Okay, this is very, very important. Again, we talked about those of you that are just joining us, or may have been on the entire time. Expectations for your patients have to meet the reality of what we can provide for them. So it's very, very important. If you're referring these patients for these procedures out, or if you are providing these services in your practice for your patients, you have to let your patients understand we are limited in what we do. So let's talk about how limited we are with Lenny.

Lenny is a 62-year-old gentleman that smokes one to one-half pack of cigarettes a day. That should put up red flags for you guys immediately. If you can see on the screen, his probes range from anywhere between three to 15 millimeter pockets and a patch to a pack and a half a day smoker. So what do we do? We obviously have informed consent about smoking. We have very, very, very in-depth conversations about listening, man, we're going to try to do what we can. I tell all of these patients that we firmly believe that God gave us our teeth for a reason, but I can never guarantee you I can help you hold onto them. Because what's going to matter is what you do at home after we do what we do, right?

Each and every one of you knows that, that's why you were so integral in that. Okay? What's going to matter is a year, a year and a half down the road when Lenny is doing is alternating recalls between our office and your office, every three months. What's going to matter is the team approach, what we all do together to help the Lennys and the Lesters, as you'll see in just a few minutes to help control this disease and maintain his disease. Okay? So as I highlighted, even closer, you can see number eight has a 14 plus millimeter pockets. Okay. And his remaining teeth again, have anywhere between four to 15 millimeter pockets.

What I want to share with each and every one of you as this I employee upon you, that you're taking appropriate radiographs in your practice. I can tell you almost each and every one of our patients get a CBCT. Okay. That doesn't mean that's going to be the case in your practice. But in order to accurately diagnose periodontal disease on a two dimensional radiograph, you have to use vertical bitewings. You have to use vertical bitewings or a PA, obviously. Okay. So those of you that may only be taking those horizontal bitewings, you know what you're seeing and what you're capturing or what you're not capturing. So understand it's all about going back to that foundation. It starts with what we're doing in our practice before we can even attempt to rebuild this foundation for our patients.

So this is what it looks like on a two dimensional radiograph, but this is what it looks like when I turn those lights on, like we talked about earlier, roll those windows shades up and wait a second. What if I show you that this is throughout Lenny's entire mouth. Okay? With the pack to a pack and a half a day smoker, you've got to talk about expectations versus reality. Lenny's got to understand that there may be no way for us to save not just one, but any of his teeth. But what I can share with you is using biomimetics, bioactive modifiers, growth factors, all kind of the same terminology, that we have the ability to take Lenny with 15 millimeter pockets originally, as you see here, and three years later, because of his care that he's receiving from his general dental practice, the care that he's receiving and providing for himself at home, you can see here what we're able to achieve and most importantly, what this accomplishes for you.

If you went back to the original pictures, Lenny did not have a full mouth of crowns. And as you see here, my referring doctor was able to restore Lenny. Yes, he's got recession, but he's not picking up his lips anytime. What is he so excited about? He's got teeth. But we didn't over promise because we didn't want to under-deliver. So it's all about having that discussion with our patients. This is so important for you guys, because remember what I said, the key is early detection. So get the Lennys to your periodontal practice or get the Lennys treated in your practice before it gets to this point. Because let me tell you, these surgeries are very long surgeries.

I'm going to stop for just a moment to ask. I got a question about, did he quit smoking? That was a journey. Yeah. That was a huge journey. But what I can tell you, he eventually did quit smoking. He started on vaping and that's a whole different conversation that we can have for a whole different day. But now he's not doing anything. I will stop and digress for just a moment to let you guys know, great time to say, please understand how we ask the questions to our patients. When you go back to your office and you will go back to your office soon enough, I'm going to keep saying that so we can keep reminding each other. Stay in the game. We're going to get there together. We will prevail. But when you go back to the office, I want each and every one of you to understand how we're speaking to our patients, because stop asking the yes or no questions.

What happens if I ask Lenny now a yes or no question about smoking or brushing, of course, he's going to minimize what he does. Sure, he brushes, right? All patients tell you they brush when they come to the dentist. It may have been that they brushed three days prior and that was it. And maybe that they're rushing with the other side of the toothbrush. I want you to stop asking the yes or no questions.

I want you to go back and I want you to say, "How much do you smoke Lenny? How often do you brush your teeth? What are you using to brush your teeth?" So again, I told you, you may not learn anything new about treatment here, but even if after our time together, our short time together, that you can go back and think differently, that hopefully we've helped you gain some pearl. I want everybody to understand the information that I'm showing you. These are day to day and a half long programs that I'm doing. So I'm really bringing a lot home for you guys in a short period of time. So you can understand what you have the ability to do within your practice, whether it's referring them or treating them.

So let's talk about the cases that we're presented with. This is Lester. Well, not only an ailing implant, but it's severe bone loss around a tooth as well. Lester came to me because his new hygienist, he went to a dentist, a new dental office, and his hygienist took the appropriate radiograph. That patient Lenny, excuse me, Lester. I got a lot of L patients. Lester got to us because of his hygienist. So way to go, hygienists, you guys are the forefront of this. You all are the gatekeepers. All right? I know you all can do God bless each and every one of you because you all make it happen.

You have those 40 to 60 minutes of a captive audience because they trust each and every one of you. So Lester presented with an alien plan, as you said, ailing tooth 15 plus millimeter pockets around the tooth and the implant. What I want you to understand is this, if you can appreciate it, and you will in just a moment that Lester doesn't just have that implant there, that implant is a part of an implant bridge, right? It's got to be hooked to something.

So the distal abutment is also an implant. So if he loses the implant, he's going to lose the implant bridge and he's going to lose this tooth. So for those of you that perform surgery or that you're just interested, hopefully you've already eaten and your food is settled because you're going to be seeing a lot of pictures as we finish up our time together here. What we see here is Lester presented with a huge, huge defect. Now, this is very, very hard to try to treat. This is not a patient that I want you to try to do peri-implantitis treatment initially. Because if you can appreciate, he does have a buccal and palatal wall.

Now that's great for a couple of reasons, those of us that do present surgery. Because then we have containment of what we're going to put in there, our graph, and we have recruitment for our blood supply here, right? Because blood supply is key for the success of our bioactive modifiers, for the success of our growth factors, for the success of our patients and their implants and their teeth. But what I want you to understand is when you have these walls, that makes it even harder to clean.

So can you imagine how long it took to just debride this area? Without loops or magnification or microscope, how do you really know that you are able to get down to the threads or to the surface of the teeth. But what I can share with you, and it's not magic, it's thorough discussion prior to, its proper treatment planning, it's impeccable technique. Then it's maintenance on the part of your practice and ours and the patients to be able to help maintain the Lesters and help maintain the Lennys. I want to share with you, I'm thrilled to be able to share with you that four and a half years, post-op he presented, Lester presenting not just with this tooth, not just with his implant, but his implant bridge, but let's take it a step further. Let's look at the CBCT. I told you we take CBCTs and so you can appreciate on the CBTC snippets, not just on two dimensional, but three, that we're able to appreciate the bone.

Most importantly, what I want to share with you about Lester is what this did for him. All right. He felt like his mouth and he knew his mouth was his health. That is how our patients feel. They trust you. They believe in you. If Lester had lost his bridge, his teeth, his implant teeth, told me that it would have been like losing a limb, like losing an arm or leg. And that's what our patients believe. The very sad thing about Lester is Lester disappeared. Unfortunately he disappeared. He had life alteration, life changes. And unfortunately we got a phone call a couple of years later from Lester. As I mentioned to you, those, those pictures were four and a half years out, a phone call from Lester. Unfortunately he started on some habits that were not right for him, became a [inaudible] one day, fell down the steps and contacted us because this is what Lester presented as, when we took the CBCT.

He has lost many of his teeth. The others had to be removed and in a very emergent situation. So what you see here is Lester came back to us because number one, he wanted to see what we can do for his missing [inaudible], but it also gave us the ability and he wanted to come in and thank us because even though he lost his teeth because of this injury seven years, post-op, he still has his implant. He has his implant bridge and he has his tooth.

I'm going to show you in a different view that even though he lost all the rest again, he came to me with tears in his eyes and said, "You know what, thank you for all that you and your team did, because you still are a glimmer of hope." This is what it looks like on a CBCT seven years later, where he was able to maintain his teeth and his implants. And we're going to go through the next few cases pretty quickly, just so you can see additional cases. Again, this is a cliff who had peri-implantitis adjacent to natural teeth. Again, you can see and appreciate the CBCT. That again, this is an older case. So if you can appreciate on the left side, you can see that this is bridge to a natural tooth.

So if he loses his implant again, he's going to noddle and lose the implant bridge. He's potentially going to lose that too. Because, we don't know what kind of support that natural tooth has. So again, without over-estimating and without giving our patients false hope and expectations, we need to have these very serious conversations about what can or cannot be done. So don't overestimate because you don't want to... Don't over-promise because you certainly don't want to under-deliver all right.

So again, these are cases that show you just how these defects present. Again, this is a case that takes an hour and a half, two hours, three hours with... I call it [inaudible] everything in your armamentarium. This is the kitchen sink. Okay. All this is everything. So that's why I told you, there's no panacea. And this situation we use the enamel matrix derivatives and a cortical cancellous allograft lin, specifically minerals, and what we have the ability to do again in these patients without over-promising and under-delivering 15 plus millimeters around his seat and his implant three years later, Cliff still has his implant bridge connected to natural teeth. This is not magic. This is not giving them the power of something that they can't have performed.

This is being real with your patients and knowing what's out there and the capabilities. Again, please early detection is key. Don't get the lectures and the clips to us, get them to us earlier. So let's talk a little bit about again, that was hard tissue mainly. Let me just show you very briefly about... We're talking about now, soft tissue defects, okay. Treatment of periodontal recession and other mucogingival defects. So this is what these cases look like prior to treatment and this is what it looks like post-treatment again, prior to treatment and post-treatment.

I want to introduce you, Jennifer. Okay. As you can appreciate, I want to show you some very, very challenging cases. Jennifer's not just a straightforward 20 year old. She's a 20 year old white female, Caucasian female, excuse me, with Type 1 diabetes. I want to show you how initially she presented with a lot of erythema, pain, swelling. Can you imagine what this has done to her sugar control and post-frenectomy post nonsurgical scaling and root planing five years later, because of your help as the hygienist and helping maintain as the dental practice and from the patient's maintenance at home and from what we were able to tilter off is five years later and a Type 1 diabetic, her sugar is more controlled. She's not in pain and she's a believer in what we have the ability to do.

So let's look at what this looks like. This is six weeks post-frenectomy. We also did nonsurgical periodontal therapy, which means that this patient will always be on a periodontal maintenance. Remember once a periodontal patient, always a periodontal patient. This is harvesting what's called a connective tissue graft, is subepithelial connective tissue graft. What I'm going to show you real quick is just the difference. Many of us have heard of free gingival graft and our practice when we use free gingival graft, we're doing this just to increase the keratinized gingiva, the thickness of the keratinized gingiva.

We use subepithelial connective tissue graft in order to perform root covers and increase the keratinized gingiva. So what does that mean? The best analogy you could use for your patients? It is a little disturbing. Hopefully you guys have already eaten. I use the analogy to you, not our patients, but it's like looking at a sandwich. The bread is a free gingival graft. It's a top layer to your palette. Okay? You put your tongue up there, it's that hot layer. The inside is going to be the connected tissue or the meat or the cheese. Okay.

So this is a connective tissue graft. What you've seen here is we've done root treatment with prep gel, which is 24% ethylene tranexamic acid. You can use different root surface conditioning. Some say, you don't even need it. And then the end, the game that we discussed. Okay? This is showing you how we tunneled. I do not do releasing incisions except tunneling in the majority of these cases. This is the immediate post-op. We use what's called a 6-0 Polypropylene. This is a non-resorbable feature. A vestibular release, so we stopped that full. Okay. This is six weeks post frenectomy post scaling and root planing.

As you can see here because of minimal, being minimally invasive as possible and invasive as possible, that's a one week post-op using growth factors and connective tissue graft. This is a five-year post-op. So initial five-year post-op and a type 1 diabetic. Now, 25 year old individuals, who's maintaining this to the best of her ability and doing a great job. I show you this only so you can understand what a free digital graft is. This is when they have that interproximal bone loss pass, mucogingival junction.

This may be what you call a Miller class three, even a class four defects. This patient does not have good oral hygiene. Unfortunately we have to have those conversations all the time about how successful this may or may not be. This is what a free gingival graft looks like. Remember, that top layer, the breath, top layer when you run your tongue up there, okay. These are what we used to call the tire patches. Again, this patient, this is three weeks post surgery. I show you this just to see where we took the grass from. We're going to talk about LPRs in just a few minutes.

For those of you that came on essentially late, we had to start about seven minutes late because we had technical difficulties. So, if everybody wants to say in there that it's okay. If we go over just about a few moments so we can make sure you get all that information, I hope that's alright with you. Again, if you need to get off, we totally understand. But this is three weeks, just three weeks post-op from the free gingival graft and this is what it looked also three weeks post-op from a free gingival graft.

That's using what we're going to talk about in just a moment, a patient's own growth box that they provide for us. So again, I want you all to understand that there's no panacea. This is the treatment that we performed in our practice. There are other graphing techniques that we use when we have multiple teeth. Usually in our situation, it's about three to four or more, to say four or more. We use something called an acellular dermal matrix. In this case, this is something called Alloderm. Okay?

This is donor grafting material. What that looks like, this is a patient, again, another mother that could not get off the couch because she was in so much discomfort, worked multiple jobs and came to us not because she was pulling down her lip and showing everybody what her gums looked like, she was in so much pain and discomfort. So what we have the ability to do, these are older cases, our technique is a little bit different. We'll talk about that in just a moment. What you see in the upper left corner is what's called an acellular dermal matrix. In this case, Alloderm. A donor tissue, not from the patient, a donor.

What you see here, again, a patient that initially had so much discomfort, she couldn't take care of her kids. She couldn't go to work and two years post-op is healthy, happy and comfortable. That is with Alloderm. Again, this is another case. This was a patient that had been treated twice already before getting to us, because those of you that can see it. Yes, we got great results and we're so happy. It's not perfect. None of our cases are perfect, but what wasn't addressed was the occlusal disease. I know many of you saw that, signs of bruxism and wear. And so what did we do with this patient? We talked to the general dentist, the referring doctor, and we made sure the occlusal disease was addressed, had an occlusal guard and certainly monitored the occlusal disease carefully.

So this is how important the team is. You're all getting the patients to us and then co-maintaining these patients and helping their... What we said before O-W-N own their disease, right? You all, that's what's important. Very briefly, another one that we talked about was Gem-21. Gem-21 is called rh platelet derived growth factor. What the rh stands for, again, that is from a donor. So this is from a donor, recombinant human growth factor. What we use this for, these specific cases, it is indicated for periodontal regeneration. The majority of cases that we use this on, as you see, is for something called guided bone regeneration, or more of you may know that as ridge augmentations.

So for the sake of clarification, for those of you that are familiar with a lot of the terminology, there's something called guided tissue regeneration, which we just talked about with [inaudible] which means periodontal regeneration, performing regeneration around teeth. There's also guided bone regeneration, which we're talking about here, or ridge augmentation or site augmentation. This is prior to implant placement, or also the terminology to be used when you're treating peri-implantitis.

So basically what it is, is as we mentioned before, it recruits all these cells and gets that new healthy cell party going. So in these cases, we can recreate, regrow the bone. Okay. LPRF, we're going to spend the last few minutes talking about that. What that is that leukocytes platelet-rich fibrin. This actually comes from the patient's own blood. Okay. What you guys may be familiar with are different generations, PRP, PRGF. The newest generations out there are called PRF.

In our practice. We use something called leukocyte platelet-rich fibrin LPRF. LPRS is used in a system, which is the only FDA-approved systems centrifuge, just call it interlock. What it's shown to do is enhance wound healing in both hard and soft tissue. What I want you to understand this indirectly can create a better environment for bone growth, as you see on here on the screen. Okay? What does that mean? Why is that important? I'm not telling you that it's going to induce periodontal regeneration. What we know is because it enhances wound healing, soft tissue healing that essentially has the effects on enhancing the environment for bone growth.

This is what it looks like when we harvest in our practice, we go ahead and harvest in our practice, the patient's platelets. We spin it down and we use it in multiple indications. Okay? Soft tissue, hard tissue. This is called the leukocyte platelet rich fibrin. Okay. Some people may know that sticky bone. This is that ridge augmentation procedure that I was telling you about where we're increasing the width prior to implanting.

So this is a CBCT axial view that you can actually appreciate on the left when there's the concavity and on the right where we now regrown that bone. This is called guided bone regeneration. Or as you may know it, ridge augmentation procedure. This is the patient's own blood. So now we've talked about growth factors from a pig as a source, we've talked about growth factors from a human. Now we've talked about growth factors from the patients themselves.

This is what it looks like for those of you that want to have implants to place crowns on, guess what? This is your answer. You have the ability, these patients may have not thought that they had a chance to have their bone regrown or have the ability to have implants. Together. We can do that. And you then will have dentistry to do, on longer, whether it's on implants or teeth. So I share with you as we close. I want each and every one of you to be the reason that someone smiled today or when we go back to our practice, there are other situations that we are dealing with each and every day. Periodontal classic surgical procedures. This is a friend of ours. Those of you that don't mind staying on, if you want to watch her video and her response, she's an amazing young woman that only for her senior portraits smiled. Up until that point, she would refuse to smile at any picture. So [Jed] go ahead. If we want to share our sweet friend's response when in an immediate moment she saw how her life had changed.

t's so different. Thank you.

Been a long time coming, girl.

I love it. I really do.

These are tears of joy or tears of being upset?

It's really hard at that moment to see if she is actually happy, but I can't even begin to tell you all how many texts, how many emails I've received from the young woman when she had the ability to finally smile for her first pictures? Not because she was forced for a senior portrait. And how about the young man? Same situation. With always, always, always embarrassed smiles. And the only time again that he did, was when he was forced for his senior portrait, and then he told his mom, "You can't send it out to anybody."

So what do we have the ability to do when you see these patients and identify them now that you know that there's opportunity for change and for help? This young man within moments, as you just saw from this young lady, his life was changed. He went from initially having this gummy smile, not understanding how to properly take care of it. And now he's motivated. He's happy. And you all know how hard it is to motivate a young man or woman. They have many other things they're concerned with. This is life-changing and each and every one of us have the ability to do this, whether you're referring or doing these procedures in your practice.

I want to leave you with a few messages as we close today, those of you that came on, thank you for your patience. Sweet. Since we had to get started a few minutes late. Take home messages, please, please, please, I charge you, I employ upon you, do what is right for the patient. Realize if you don't, someone else will. Know your limitations. Early detection is key. Most importantly know your why. The time is going to pass. It will pass in and gosh knows, we have a gift of time right now each and every one of you, we have to get the time.

You can either spend it creating the life you want or spending it living the life you don't want. The choice is yours. Take a moment to be with your family. Be with your friends, talk to your team, motivate your team, motivate your patients. When you come back, you need them. We need them. We need each other. Simon Sinek, we all started with him, we're going to close with them. Working hard for something we don't care about. It's called stress. Working hard for something we love is called passion.

I want to thank each and every one of you for your time, for your patients, for being here, you guys are all amazing. Stay positive, be safe, be well, be healthy. We will weather the storm together. We have the ability to change lives, one mouth at a time. I thank each and every one of you and God bless. Thank you.