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This week, Dr. Sam Low joins me on Practicing with the Masters<\/em>. Dr. Low is a professor emeritus at the University of Florida College of Dentistry. He is an associate faculty member of the Pankey Institute with 30 years of private practice experience in periodontics, lasers, and implant placement. Dr. Low is a diplomat of the American Board of Periodontology, past president of the American Academy of Periodontology and the board director of the Academy of Laser Dentistry.<\/p>\n Dr. Low provides dentists and dental hygienists with the tools for successfully managing periodontal patients and general and periodontal practices. He is affiliated with the Florida Probe Corporation, a proliferate consultant and presenter. Dr. Low was selected Dentist of the Year by the Florida Dental Association, Distinguished Alumni by the University of Texas Dental School and recipient of the Gordon Christensen Lecturer Recognition Award.<\/p>\n On this episode, Dr. Low shares his incredible knowledge of niche development and periodontal management. He reveals how he has grown his business by using patient referrals and incredible care practices. Listen in to discover how you can adapt his model and mission into your practice to provide the care that will have your patients raving about you and your staff for years to come.<\/p>\n Welcome to Practicing with the Masters<\/em> for dentists with your host, Dr. Allison Watts. Allison believes that there are four pillars for a successful, fulfilling dental practice: clear leadership, sound business principles, well-developed communication skills, and clinical excellence. Allison enjoys helping dentists and teams excel in all of these areas. Each episode she brings you an inspiring conversation with another leading expert. If you desire to learn and grow and in the process take your practice to the next level, then this is the show for you. Now, here\u2019s your host, Dr. Allison Watts.<\/p>\n Allison: Welcome to Practicing with the Masters podcast. I\u2019m your host, Allison Watts, and I\u2019m dedicated to bringing you masters in the field of dentistry, leadership, and practice management to help you have a more fulfilling and successful practice and life. Thanks for listening to Practicing with the Masters<\/em> for dentists, with your host, Dr. Allison Watts. For more about how Allison Watts and Transformational Practices can help you create a successful and fulfilling practice and life, visit transformationalpractices.com<\/a>.<\/p>\n <\/div> <\/p>\n <\/p>\n <\/p>\n <\/p>\n <\/p>\n <\/p>\n <\/p>\n <\/p>\n","protected":false},"excerpt":{"rendered":" This week, Dr. Sam Low joins me on Practicing with the Masters. Dr. Low is a professor emeritus at the University of Florida College of Dentistry. He is an associate faculty member of the Pankey Institute with 30 years of private practice experience in periodontics, lasers, and implant placement. Dr. Low is a diplomat of […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_et_pb_use_builder":"","_et_pb_old_content":"","_et_gb_content_width":"","_cloudinary_featured_overwrite":false,"footnotes":""},"categories":[303],"tags":[309,305,304,307],"yoast_head":"\nWhat You’ll Learn From This Episode:<\/h3>\n
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Listen To The Full Interview:<\/h3>\n\n
Featured On The Show:<\/h3>\n
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Full Episode Transcript:<\/h3>\n
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<\/a><\/p>\nDeveloping Your Niche with Dr. Sam Low<\/h3>\n
CLICK HERE TO READ THE TRANSCRIPT (7,768 WORDS )<\/span><\/a><\/div>\n
\nAll right, Sam, I\u2019m going to officially introduce you. For those of you who don\u2019t know him, you guys are in for a treat tonight. I know several of you guys already know Sam. Really, welcome, and thank you so much for doing this. I\u2019m excited to have you here tonight.
\nSam Low, D.D.S., M.S., M.Ed., Professor Emeritus at the University of Florida, College of Dentistry. He\u2019s an associate faculty member of the Pankey Institute with 30 years of private practice experience in periodontics, lasers, and implant placement. He is also a Diplomat of the American Board of Periodontology and past President of the American Academy of Periodontology. He is a current Board of Director of the Academy of Laser Dentistry.
\nDr. Low provides dentists and dental hygienists with the tools for successfully managing the periodontal patient in general and periodontal practices and is affiliated with the Florida Probe Corporation. He was selected Dentist of the Year by the Florida Dental Association, Distinguished Alumnus by the University of Texas Dental School, past president of the Florida Dental Association and past ADA Trustee.
\nWow. I\u2019m honored to have you here. I\u2019ve got a couple hygienists on the line and the dentist that works with me and several people are just excited to hear you tonight. So, welcome.
\nSam: Thank you, Allison. We just saw each other not too long ago and we had an excellent conversation then and I have made a decision a couple of years ago to reinvent myself and move in a couple of other different directions and attempt to really codify some of the areas that I had been emphasizing before.
\nAnytime I have an opportunity to be able to have a dialogue\u2014notice I didn\u2019t say speak to\u2014but have a conversation with my fellow colleagues in how we make this dental profession better for our patients, I always do.
\nI\u2019m somewhat warmed up since I got up at 5:00 this morning and actually did a 6:00 a.m. webinar on lasers for the international community, from Turkey to Japan to China to Australia to Romania, and who knows where else. So this has been my webinar day.
\nAllison: Wow.
\nSam: I took a nap by the way, so I\u2019m ready for you.
\nAllison: You’re refreshed for us. That\u2019s great. Well, do you have anything to add before\u2026? I was going to start us off with a question. Is there anything with the bio that you wanted to add or anything else you wanted to share before I begin the questions?
\nSam: I think it\u2019s critical that one always gives their conflict of interest before we start because there may be, somehow the conversation may lead to some brand names or products and I think in all fairness with insuring that we have ethics in our profession that we all know that.
\nI am a part owner of Florida Probe Corporation. I helped develop Florida Probe and our new product that\u2019s out there now which is a voice actuated system called VoiceWorks. I am a consultant to a startup company, actually it\u2019s not a startup company any longer since we have 2,400 dentist accounts. That is PerioSciences, which is an antioxidant gel toothpaste and rinse. I also do consulting with Biolase in which I do advanced training for them, especially in the area of periodontics, closed flap, laser with Waterlase lasers. Then lastly, I do some work with Philips Sonicare. I\u2019m on their advisory board plus I help them with development of products.
\nI would add a fifth, recently, I am I would say probably more now that it\u2019s formal, a consultant with Hu-Friedy looking at their present and their future products. So my career runs around three different things right now: consulting, speaking, and I still see patients every Wednesday at the College of Dentistry where I primarily do laser with periodontists, prosthodontists, and orthodontists.
\nAllison: I can’t wait. I do want to talk a little bit about the lasers but I did have a few things. First, I want to say to everybody, Sam is great with questions. I\u2019m going to be asking questions for any of you who haven’t been here before. This will be more like a conversation but he would welcome you raising your hand if you have any questions or comments. Just push *2 and I\u2019ll see your hand raised and I\u2019ll call on you as soon as I get a chance to create a little break in the conversation.
\nI wanted to start if it\u2019s okay, Sam, with some of the things you talked about at Pankey that I thought were really exciting. You talked some about creating a niche, the way that I heard you say it was that I want to be\u2014I took it in as, wow, that\u2019s exciting, I want to do that. I want to be the person that people think of and that people come to for oral health, total oral healthcare. And that periodontics is actually a pretty untapped niche. I wanted you to say a little bit about that and just as much as you want to say about it.
\nSam: Sure. Well just about the time, sometimes I think periodontics is old hat then it raises its angry head again and becomes important. Maybe it\u2019s the fact it never really went away. One of the areas that I truly emphasize in the practice of dentistry, and throughout this, yes, I\u2019m a periodontist but I’ve always considered myself to be a dentist first. I practiced general dentistry before perio school. I\u2019m a vibrant member of AGD. I do a lot of continuing education programs for them. In fact, I just finished a laser program for them at our national AGD meeting in San Francisco.
\nThere was an area that I also am involved in now, I never intended to go into it, and that is in-office consulting. Where I literally go in and spend a very little time with a dental office and get them oriented into periodontics, especially with the hygienist.
\nFrom that, I created a concept that is called \u201cdeveloping a niche.\u201d We are in a way in competition. That competition is not only with our fellow practitioners, but it\u2019s also in a competition with actually getting patients to see us. We have data that clearly demonstrates that patients do not come to see us like they did even 12 to 14, 15 years ago. There are reasons for that.
\nI will always mention that I\u2019m a huge Malcolm Gladwell fan and sometimes I believe that when we look at ourselves, we\u2019re wondering, is there something I\u2019m doing wrong? What\u2019s going on? I used to have 25 new patients, 30 new patients a month. Now I have 15 patients a month. Some of my patients are not staying with me. They seem to be titrating over to a corporate practice or to an insurance practice. What am I doing wrong?
\nWell let me assure you that none of us are doing anything wrong, it\u2019s just that we\u2019re doing the same as we\u2019ve always done and the world is changing around us. So we have to create somewhat of a uniqueness of a niche. This doesn\u2019t mean that you put on false airs. You don\u2019t represent something that you’re not, but practicing comprehensive care and presenting it in a way that is value based, I truly believe will attract patients.
\nOne of the areas that, Allison, that you mentioned that I think is a sleeping dog out there\u2014a good dog\u2014that is periodontics. To give you some numbers, periodontitis and when I say periodontitis, I mean tooth-loss periodontitis, I don\u2019t mean this elementary gingivitis stuff. I mean truly bone loss, attachment loss. We know as a fact, CDC numbers is now 46 percent of everyone over the age of 30.
\nWhen you look at baby boomers and hopefully we\u2019ll have that conversation a little bit later in the program, which is a predominant component of our present and future practice. That number can go up to 60, 65 percent. There is no doubt that 10 to 15 percent of our patient base has severe periodontitis. In other words, if we don\u2019t intervene, they will be edentulous. So this population is sitting out there.
\nUsually folks that get on a webinar at night are, I\u2019m somewhat preaching to the choir. So then I will say to you, how many times have you done a periodontal exam, picked up a periodontal probe, explained what you were about ready to do and the patient looks at you quizzically and says, \u201cI\u2019ve never had that before. What are you doing?\u201d
\nThat\u2019s most unfortunate but let\u2019s turn that into lemonade in that everything we do in our practice, we do it to market and to attract new patients through the referrals of others. So primarily that\u2019s what I mean by a niche. A niche is actually practicing, interesting enough, Allison, the standard of care in periodontics.
\nAllison: So you’re just like making the patient aware of what you’re doing. You’re educating them that you are doing something that they may or may not have had done before but they weren’t aware of and what it means. Then how do you see that stimulating referrals? Is that something that you’re specifically asking or\u2026?
\nSam: I guess one could and practices do that. I still believe that the most empowering symbol, icon, of a practice is when one of your patients\u2014and I will just go through the scenario. Your patient, Jane, who saw you at 8:00 this morning sees her friend Sally in the grocery store. Sally says to Jane, \u201cWell what did you do this morning?\u201d
\nJane says, \u201cI saw Dr. Low. He\u2019s my dentist.\u201d Sally says, \u201cOh, I hate dentists, but you look so good after being at a dental office.\u201d Jane says, \u201cI love them. They are fantastic.\u201d Notice she didn\u2019t say Dr. Low is fantastic. \u201cThey are fantastic. They explain everything that they do. They are gentle. And you know something? They give good shots,\u201d which I still believe, partially because I teach local anesthesia, I still believe is a lost art. That we take that so much far into for granted.
\nBut then what happens to Sally? Sally then does what? She makes an appointment with Dr. Low. That, in my mind, is how we interact. I appreciate social networking, but there\u2019s still something called word of mouth that builds practices that are sustainable practices.
\nAllison: Yeah, I agree. I mean, if you’re differentiating yourself, you stand out. If patients see the value for what you’re doing and it\u2019s different from what they can get somewhere else, I believe they will be loyal and tell their friends. I totally agree with that. Okay, well that makes sense.
\nSam: We are approaching approximately one third of the population see a dentist in the last twelve months. That is down from almost the 45 to 50 percent that saw a dentist in the last twelve months 15 years ago. Now a part of that, in fact the primary part of that, is dental insurance. That has decreased.
\nThe reimbursements have decreased and has suggested then that patients are not seeing us because of that. Whatever it is, and I could continue on the variables that creates that environment, I think also part of it is the number of dental practitioners that we have in the United States, especially in dense areas. We never expected dentists to not retire. We thought everyone would retire like they did in the past at the age of 55, 60. Dentists don\u2019t retire.
\nWe never expected to have 10 or 15 new dental schools in the last decade. Fortunately, we don\u2019t have any new ones coming up because they figured out that dental students aren\u2019t going to pay those kinds of tuitions. But we\u2019re in a squeeze right now in which I will flat out say to us that we have just too many practitioners and we\u2019re all doing marketing to try to acquire those patients. Therefore, I still believe, it\u2019s a slightly slower process, but doing Groupons and whitening and discounting our fees, will only attract those patients that expect that kind of service.
\nAllison: Yeah. So can you speak to the piece about\u2014maybe this isn’t really different from what you already talked about but patients come to us for everything related to their oral health. So maybe that also links into their overall health some, some systemic stuff.
\nSam: Absolutely.
\nAllison: Okay.
\nSam: In fact, there\u2019s been a running blog lately on the Public Health Dental blog on what would have happened if in 1900, 1905, we had not become a separate profession from medicine? What would have happened if dentistry had become a subspecialty of medicine? Now, I must tell you that I\u2019m very fortunate, we\u2019re all very fortunate that that didn\u2019t happen, especially with ACA and especially with the Supreme Court ruling which I think will not end there.
\nHowever, forget about the political throes of that for just a moment. I see a dentist being a stomatologist. I see a dentist being an individual who truly manages the oral health of a patient and that a patient seeks out a dentist for anything related to their oral health, that includes anything from oral pathology.
\nNow let me preface something. I still believe in doing restorative dentistry and that it is a serious component of our revenue. I\u2019m not taking anything away from that. I\u2019m just suggesting that now it\u2019s time to balance out in effect that we are the center of managing one\u2019s oral health. Allison, I know you recall that I really emphasize not ever to use the word \u201ctreat\u201d in a dental practice ever, ever, ever again and to substitute the word treat for manage. Because when we start to get into periodontal disease, it\u2019s not an infection. Sorry. That is mythology.
\nPeriodontal disease is a chronic inflammatory disease, very similar to rheumatoid arthritis, diabetes, cardiovascular disease. None of those diseases are \u201ctreated.\u201d They are managed. So it will take to a certain degree an old term, but let\u2019s resurrect it, a paradigm shift, to appreciate that we are not what we were in dental school and what they taught us to be in countless numbers of hours in preclinical labs working on Ivorine teeth. We are that and more.
\nSo in reference to your question, it is not just about the oral health but it\u2019s also about the overall health because all of these chronic inflammatory diseases, and it\u2019s actually almost scary, it\u2019s uncanny how all of them have almost identical scenarios relative to how you get these diseases. They all follow the same inflammatory cascade from the neutrophil plasma cell lymphocyte to the cytokines, all of these purines. The prostaglandins, tissue necrosis factor, all of that is very common in all of these scenarios.
\nSo if our number one patient in both\u2014and I\u2019ll speak to the dollar part of this in a moment\u2014but if our number one patient in quantity is a patient over 60 for the next 20 years, these patients are incredibly well versed in chronic inflammatory diseases. I mean, we have four million Sj\u00f6gren’s patients in this country, so therefore we have xerostomia coming through the roof in this country.
\nSo to sit down with a patient and not have a conversation about oral systemic link would be myopic because no matter what hype we have had in the past, every evidence-based study demonstrates that there is a direct link between cardiovascular disease and periodontitis. Meaning that if you’re susceptible to cardiovascular disease and you have moderate to severe periodontitis, that that periodontitis will have an adverse effect on cardiovascular disease and therefore puts us in the center of being able to manage not only oral health but also overall health.
\nAllison: Then there\u2019s a few things that you mentioned are not directly correlated but associated with perio as well.
\nSam: There are. They are not as strong but naturally, an uncontrolled diabetic will follow the same patterns with periodontal disease. The preterm low birthweight baby scenario is slightly weaker, it\u2019s an independent association, not a direct relationship like cardiovascular disease. Then there has been some studies, slightly weak, but studies out there that rheumatoid arthritis and with Alzheimer\u2019s.
\nI\u2019m going to jump one little area on risk factors just for a moment because I don\u2019t want to forget it, that is when one has a chronic inflammatory disease, it\u2019s the result of a stimulus. In periodontal disease, one could say that the biofilm, and to a certain degree calculus, is that stimulus that initiates the chronic inflammatory reaction.
\nGingivitis and early periodontitis are the initiators of a self-perpetuation of periodontitis. So when once these biofilm initially and the repeated insult of biofilm, then we get this reaction which we call periodontitis. In the future, if one sees any biofilm, I\u2019m not talking about substantial biofilm, I\u2019m saying any biofilm, then there is an exaggerated response to that biofilm because the body has gotten smart and just said, \u201cThe next time I see the stimulus, I am going to overreact. I\u2019m not going to be in that position again.\u201d Very similar to anaphylaxis, very similar to spraining our ankle.
\nSo having said that, from that standpoint, it behooves us to appreciate that when one sees these exaggerated responses, then it can be almost subclinical to us. Many of us have seen a periodontitis in a scenario where we saw very little biofilm. That is somewhat due to the genetic predisposition of the patient but moreover due to this environmental effect.
\nSo when I say stimulus, I’ve mentioned biofilm, to a certain degree I’ve mentioned some risk factors, but there is one that I want to bring out of the closet when it comes to periodontists. That is occlusion. For whatever reason, we have put occlusion for the most part, we periodontists, on a shelf. Part of that is our training. Our training has always been with 15C blades and bone grafting and now implants, but occlusion is a major stimulus that perpetuates periodontitis.
\nNow, that does not mean that you don\u2019t need biofilm in the mix and to get the thing started. But to ignore occlusion and not do an occlusal assessment, potentially an adjustment, and possibly some type of appliance, I think would be very myopic in managing today\u2019s periodontal disease.
\nAllison: I\u2019m really happy you said that. I know some of the people on here totally agree. I know everybody is probably going, \u201cWoo hoo.\u201d Yeah.
\nSam: See we went through a stage, and again, those of you on this call, if you haven’t read Malcolm Gladwell, please pick up at least Tipping Point as your first. If anything, don\u2019t really have to buy the book, just buy the CD and listen to it. Then you will begin to develop the fascination with trending as I have. I think in the 60s and early 70s coming out of the University of Pennsylvania, Boston University, and University of Washington, those are the icons of periodontal centers of learning. All three of those centers were permeated with occlusion and periodontics.
\nIn the mid to late 70s, moving into the 80s, the Scandinavians began to dominate our impression of what periodontics was. Many of these studies were done with Beagle dogs and squirrel and rhesus monkeys and we began to lose the emphasis of occlusion. In its place became the predominance of what? Oral hygiene. That if you do scaling and root planing and oral hygiene, everything will work. Well some of us, even in our infancy in periodontics began to appreciate, I don\u2019t think that\u2019s true because there is a genetic susceptibility, there is an environmental susceptibility.
\nThose of us who stayed in the same practice, as you know, I always say, \u201cHow to be successful in periodontics? Move every three to five years.\u201d Those of us who stay with the same patients, when we observe these mobility patterns to the point that I rate prognosis on a particular tooth, I highly rate it depending upon what? Its mobility.
\nAllison: Yep.
\nSam: Think of all the teeth we extracted, sometimes even with quality partial dentures where the major connectors were around slightly mobile teeth. So to disavow occlusion I think again would be missing the boat. Naturally, as a dental educator, and this is not my age speaking, but I\u2019m extremely concerned about the dumbing down of dental education at this point in which many of our schools are approaching producing more of an apprentice type scenario instead of a scholarly type individual.
\nHaving said that, sorry for venting, but having said that, I also am quite concerned that many of our dental students do not undergo the dental laboratory experiences that we did. I know that I\u2019m sure many of you remember the midnight oil, actually melting wax, as we did waxups over and over and over again. But our dental students aren\u2019t experienced with that, so therefore, they’re very susceptible when they leave dental school to any corporate\u2014when I say corporate I mean manufacturer\u2014influence on where their practice may go. So, Allison, sorry for venting, but I am very concerned about where we are with dental education at this point.
\nAllison: Do hygienists learn anything about occlusion as a factor?
\nSam: Very, very little. You probably are not as aware of this as some others but as I begin to speak, I become extremely candid, which you’re probably going to ask yourself, \u201cMaybe we ought to end the call now.\u201d
\nAllison: [Laughs] I\u2019ll just change the subject.
\nSam: But let me be candid: Unfortunately, those who educate hygienists are generally who? Other hygienists.
\nAllison: Yes.
\nSam: Therefore, we begin to perpetuate a continuation of the same subject matter. If I thought they would attend, I would love to give CE courses on occlusion to dental hygienists. I just don\u2019t know, when I\u2019m speaking to a large group and I speak about occlusion, hygienists are like sponges. They should be because they are the ones that are seeing our patients actually more than we are when you look at the life of a patient. I don\u2019t mean initially, I don\u2019t mean the initial therapy. But on the life of the patient, it\u2019s the hygienist that truly needs to know a significant amount of what we\u2019re dealing with and unfortunately, I think they want to know, I just don\u2019t think they’re exposed to occlusion.
\nAllison: Yeah, I think that\u2019s true. I\u2019ve got a couple hygienists on here. I do have a question about something you just spoke about before we go on to the next subject. You were talking about biofilm. I have a pretty good sense that I know what biofilm is but you talked about seeing biofilm. When you said seeing biofilm, my brain goes to, \u201cOkay, maybe I don\u2019t know what biofilm is.\u201d
\nI know we can see plaque, I know we can see calculus, I don\u2019t think of biofilm as something that we see. So can you just\u2014and maybe this is a dumb question but I\u2019m curious about when you say\u2014you were talking about the exaggerated response and that we can see just a little biofilm and see an exaggerated response. Are you talking about in a microscope or are you talking about in the mouth?
\nSam: No, I\u2019m not talking about necessarily visualizing it. What I am suggesting is quantity of biofilm in that we now know that biofilm initiates a periodontal reaction. But the same magnitude of biofilm is not necessary to perpetuate the reaction.
\nAllison: Okay.
\nSam: As an example, if you are stung by a bee the first time, you get a reaction. If you’re stung by a bee the second time, you get an exaggerated reaction. It\u2019s the same venom, it\u2019s the same quantity, but now your body reacts differently. That\u2019s what I mean by when I say seeing, I mean appreciating a small amount of biofilm can create a very exaggerated response. We know this by something called hyperactive neutrophils.
\nIn other words, a neutrophil is not hyperactive until it\u2019s been under the consistent influence of biofilm and then those neutrophils, eventually plasma cell lymphocyte, begin to overreact to protect the body. Unfortunately, that overreaction is literally what destroys the tissue through an enzymatic process. Therefore, why we believe periodontitis to a certain degree is an autoimmune response, just as we get in Sj\u00f6gren’s.
\nI guess what we would suggest if all of our patients had excellent early care, including oral hygiene, and excellent chairside care with periodontal debridements, then one would never get to the exaggerated response that produces such a bone loss of periodontitis. So my point is that periodontitis is linear in the gingivitis to early periodontitis stage. It\u2019s exponential from the early to moderate to severe stage.
\nAllison: Interesting. You did talk a little bit about something I thought was pretty neat that you do for your perio patients. I don\u2019t have it in front of me, my notes, but I remember you talking about putting them on some supplements, anti-inflammatory supplements. I can’t remember what you put them on, fish oil?
\nSam: Right. When we look at these reactions, basically what we are trying to do, I don\u2019t want to confuse our audience, but we\u2019re trying to suppress actually something called bad inflammation. That\u2019s when we get this overreaction. What we\u2019re trying to support is something called good inflammation in which it naturally takes care of the stimulus.
\nWhat we\u2019re finding out in medicine right now is that there are certain supplements that enhance these naturally occurring substances that deal with supporting good inflammation. This really deals with primarily oxidation and free radicals. I know I\u2019m starting to sound like an infomercial and every time I go through this, I begin to think that I\u2019m going through some type of infomercial and I\u2019m suggesting all of us to visit our nearest health food store and forget about seeing a dentist. Then start just brushing with some herbal toothpaste. I am not suggesting that.
\nI am suggesting, however, that wouldn\u2019t it be nice if the West started at least listening to a little bit of the East? Likewise, I’d like the East to listen to a little\u2026 I\u2019ve traveled to Asia extensively this last year with lasers. I must tell you, that I wish the East would listen to a little bit of the West.
\nHaving said that, omega-3s are really not some homeopathic, holistic scenario by which there is a level of voodoo. Omega-3s truly satisfy these free radicals or assist in it. 81 mg of aspirin is not about coagulation but about supporting positive inflammatory response and likewise, the resveratrol that we see enhances something called resolvins, the resveratrol, in particular peelings of grapes. Why we drink so much Cabernet.
\nThose kinds of things supplement chronic inflammatory diseases by attempting to reduce bad inflammation and enhance good inflammation. This goes with the whole area of enhancing our\u2014trying to suppress certain cytokines and lymphokines that we know that exaggerate the inflammatory response.
\nThere is a couple of just incredible animal studies. Now, let me suggest they’re animal studies, but where they\u2019ve been able to either take simulated fatty acids, including something like olive oil\u2014I\u2019m not speaking about coconut oil here\u2014but literally make them into supplements and use them on periodontitis in the rabbit model and also in the dog model. In the rabbit model, they were able to extract naturally occurring resolvins from rabbits, make it into a gel and literally place it topically on periodontitis and get bone to grow back. It\u2019s a while before but now the resolvin idea is actually approaching human FDA trials through Boston University.
\nThe point is, I think we need to continue to ask ourselves why do we do periodontal debridement? That\u2019s the next space I would like to go into, if that\u2019s okay, Allison. That\u2019s what we do at the chair.
\nAllison: Oh yes, that would be great.
\nSam: The scaling and root planing works but not for the reasons that we\u2019ve always thought. Actually, I really do not like the verbiage scaling and root planing because that\u2019s not what we do. We don\u2019t scale teeth. There\u2019s no scales on teeth. We don\u2019t root plane teeth. They’re not a board like would be in a carpenter\u2019s shop. We\u2019re actually disrupting the biofilms. As we disrupt the mature biofilms, then they don\u2019t have the properties of being a stimulus and thus then the body can\u2019t react. I disrupt the biofilms and I cause a decrease in an overreaction by using omega-3s and etc.
\nThen I can literally balance the system out to where I do not see a net loss in attachment or a net loss in bone loss. So in my mind, I would rather us use something called periodontal debridement. Now here\u2019s where the controversy comes in. I don\u2019t care what the state laws say, there is not a hygienist alive that does not do curettage every single day of their practice. You want to call them inadvertent curettage, so be it, but all of that stuff coming out of there, including a significant amount of hemorrhage, is the result of actually degranulating the wound, whether you want to or not. Whether you use an ultrasonic or not.
\nWhen you degranulate that wound, you literally are removing many of these negative post inflammatory cells and that is why you’re seeing such a response. If it was only removing the bacteria, wouldn\u2019t you think that the bacteria would come back? And they do. And why we do not use as many local delivery antimicrobials as we used to. It is why we do not use systemic antibiotics like we used to. Why? Because you didn\u2019t change the environment. The bugs came back.
\nYou can’t make a mouth sterile. It\u2019s impossible. But you can create an environment by which there is a decreased inflammatory response by removing these hyperactive negative inflammatory cell mediators and you do that through our old friend called curettage. I\u2019m not suggesting purposeful curettage. I\u2019m suggesting continuing to do what we\u2019re doing.
\nHowever, there are some of us who now have been able to functionally use a laser\u2014and think about this, and I don\u2019t mean heat, I mean vaporization\u2014to literally go down with a tip the size of a periodontal probe and de-epithelialize, degranulate, and while at the same time on particular settings, if you desire, do something called laser bacterial reduction. I\u2019m not advocating that laser must be used in nonsurgical perio. However, I am suggesting that it truly facilitates a nonsurgical periodontal care.
\nSo I would strongly advise that we do not scrape on roots like we used to. As I always say, what are we trying to do with root planing? Find the pulp before the patient dies? That\u2019s not our objective. Our objective is to do what? Remove the stimulus. Remove the stimulus. That is why a quality occlusal assessment is as important in the phase one therapy as all the other things that we do in removing the inflammatory reaction.
\nAllison: Wonderful. I have a question here, somebody has raised their hand. Is that you, Ryan?
\nRyan: That is. I\u2019ve got lots of new laser questions now that he\u2019s dug into that but\u2026
\nSam: Ryan, I should have stayed off that subject, sorry.
\nRyan: No, you’re good. Sam, I was wondering, when we look at the traditional ways we diagnose periodontal disease, we\u2019re looking at factors like bleeding and bone loss and pocket depths. This all represents damage that\u2019s already occurred. Can you talk a little bit about salivary testing or other advanced diagnostic techniques that are available? Because it sounds like to me it\u2019s important to catch this stuff before it gets to that point.
\nSam: Absolutely. No, you hit it right on the head, Ryan. Thank you. The train has left the station when you see radiographic bone loss. My goodness, we have looked for the last 20 years especially trying to find that crystal ball to be able to determine host susceptibility before it occurs.
\nI\u2019m not a big fan of bacterial testing because my emphasis right now is primarily more on the host but I do think we\u2019re getting closer and closer and closer to determining by looking at the level of the cytokine\/lymphokine scenario, the overproduction of that. That\u2019s really what these tests do that are looking at salivary diagnostics from the standpoint of inflammation, they’re looking at primarily the lymphokine reaction to a stimulus. I don\u2019t think we\u2019re there yet but I absolutely believe we\u2019re on the right track.
\nHaving said that, I\u2019m a big fan of something called PreVisor. PreVisor is actually a survey of the patient\u2019s condition meaning that you ask them about smoking, about diabetes, you actually put into the computer algorithm the amount of bone loss they have for each sextant. The amount of pocket that they have for each sextant. Then there is a computer algorithm that gives you in two or three minutes their susceptibility to periodontal disease, on a score from one to five. That test is widely available. You can do it from a computer. It gives you a score. It\u2019s extremely valid and reliable. And you know, it\u2019s only like $10.
\nThank you because you opened up the door for a conversation on risk assessment. That\u2019s really what this is about. And Ryan, you hit it on the head. Diagnosis is a clinician\u2019s assessment after the damage. Risk assessment is a clinician\u2019s determination before it occurs. I just don\u2019t think we are at where we are as an example, with salivary testing for breast cancer, that is out there.
\nWe\u2019re honing in on it but there are so many variables that contribute to periodontitis that just doing one of these\u2014now some folks would disagree, especially the Delta study that was done up in Michigan where now they’re beginning to determine reimbursement based on a salivary diagnostic which I think is premature, but that\u2019s just me. You’re right. Bleeding on probing, I always say about bleeding on probing, you can get anything to bleed if you work at it.
\n[Laughter]
\nI mean, you’re having a slow day, you can get 9mm pockets. You’re having a day to where you just want to get them out of the chair for whatever reason, you can angle that probe and get 3mm pockets. I\u2019m kidding, but our diagnostic prowess in periodontal disease is actually with a lot of issues with reliability and validity.
\nRyan: Awesome. Thank you for that.
\nAllison: Yeah, that was my question. If you had more.
\nRyan: No, that hit it, completely.
\nAllison: Ok, awesome. If anybody else has a question, push *2. Sam, do you want to speak to the\u2014oh gosh, you just said it, I can’t even remember what you just said\u2014it felt like a natural lead-in to the something you and I had talked about talking about and I can’t even remember what it is now.
\nSam: I do want to mention there are three primary risk factors in periodontal disease which Ryan raised as far as the assessment goes. The three primary risk factors that augment a genetic predisposition, and this is extremely clear to us with our research. The number one risk factor for periodontitis is genetics. We can’t ignore it. We’ve done identical twin studies, and you know, those are good groups to study.
\nYou study identical twins versus familial twins, if you\u2019ve ever gone to a twins convention, believe me, there must be 2,000 companies ready to pounce on them because they’re such a great group to study because then you can change the environment between the two because the genetics are basically the same. So the number one risk factor is genetics. So we always ask our patients, \u201cAnyone in your family, parents, sisters, brother, anybody in your family, do they have a history of periodontal disease?\u201d
\nThe second most significant risk factor is nicotine. I did not say smoking, I said nicotine. So if you’re in a nicotine smoking cessation program, you still have nicotine. Nicotine is a major factor in creating, sorry, hyperactive neutrophils. A major factor in tissue necrosis factor. A major factor in slowing down phagocytosis which is if you recall back in dental school which is what we wanted, slowing down chemotaxis which causes inflammatory cells to aggregate.
\nThe next risk factor\u2014by the way, the odds ratio on nicotine is five times greater. So if someone smokes or takes nicotine and they already are genetically predisposed, they have five times greater chance of having attachment loss than if they didn\u2019t.
\nOur next in the cascade is diabetes, especially uncontrolled diabetes, and especially Type I. You know, Allison, if you give me a patient that is 22, that has Type I diabetes, that is a smoker, that is a clencher, with para-functional habits, you have a patient that will be edentulous by the time they’re 40. I’ve seen it too many times because our last risk factor is occlusion.
\nSo we\u2019ve got genetics, we\u2019ve got nicotine, followed by diabetes, and ending with occlusion. Those are the primary risk factors in our business. Not that we\u2019re going to try to get these folks to change but we will change our management systems based on those habits that they may have.
\nAs I move into that, we do a lot of motivational interviewing in our practice and I know you\u2019ve had, I believe a podcast on motivational interviewing. Motivational interviewing is a critical aspect in this business. Unfortunately, I decided to be a periodontist. Let me tell you why that\u2019s unfortunate, because no patient knows they have periodontal disease. It\u2019s a silent disease.
\nEvery now and then, we have to pull out the \u201cc\u201d word to get a patient\u2019s attention. We ask them, \u201cDid you ever know anyone that all of a sudden got a diagnosis of cancer? Didn\u2019t know they had it and then passed away within weeks?\u201d Then everyone says, \u201cAbsolutely.\u201d We say, \u201cPeriodontal disease is not cancer but there\u2019s so many ailments in the body that patients just don\u2019t find on their own. That that\u2019s why we have practitioners and that is why you’re here. That is why we\u2019re going to use these radiographs. That is why we\u2019re going to use this little device to go in and determine if you have any bone loss, we hope you don\u2019t.\u201d By the way, you notice, Allison, that I\u2019m doing scripting through all of this. I\u2019m a strong believer in scripting.
\nFrom there, we do our periodontal charting. That\u2019s why the VoiceWorks came into play because we wanted a system by which a dentist or especially a hygienist could speak into a microphone and chart, completely do a periodontal charting without ever touching a keyboard or writing something down. We have developed a system, nonsurgical, periodontal protocol systems for the practice of general dentistry.
\nWe\u2019ve developed systems for collecting data, all of these are definitely related to timeliness, in other words, not spending 20 minutes to do a periodontal exam. We have developed flow charts, flow systems by which patients move through the practice of dentistry: who sees them first, who sees them second, who sees them third.
\nWe have developed systems for our brothers and sisters out there who take third party and developed systems for the appropriate ways of coding and trying not to allow a third party to dictate a patient\u2019s care. With all of that, we\u2019ve actually developed oral hygiene systems for our patients. I know, Allison, I think I saw the last time that we were in a group when I said that flossing in periodontitis is definitely mythology.
\nFlossing is just such a poor, poor way of managing periodontitis at home. No study shows it\u2019s effective. We\u2019re much more effective with Sulcabrushes and interproximal brushes and using the right medicaments in those particular sites in hopes of getting quality compliance.
\nYou may be aware in the last seven days, the AAP has released a lot of press statements. They\u2019ve been on DrBicuspid, they\u2019ve been on the Today Show about how patients lie about flossing. As if that was news to any of us. I never believe patients in the first place. I guess it just took a survey for us to find out that they were all lying.
\nWe do know that only 7 percent of our patients floss every day. I try to find the most simplest ways to manage their oral hygiene at home to get compliance. We do not have any manual toothbrushes in our practice. Everything is electric. We have moved almost exclusively to the Airfloss by Philips and putting a medicament in the Airfloss.
\nWe\u2019ve also moved over and that\u2019s why I became a consultant, to utilizing these antioxidant gels that supply electrons to these free radicals that are called PerioSciences. One can go on PerioSciences.com and get that information.
\nAllison: It\u2019s a fantastic product for many things, not just periodontitis. I know there\u2019s some people on here that use it.
\nSam: Yes, a few weeks ago after some intensive research, we have released an FDA-supported product just for dry mouth. The original gel works quite well on xerostomia but we enhanced the formulation, including adding glycerin to make the dry mouth product even more significant. Actually, I think it\u2019s called Dry Mouth Gel.
\nAllison: Is it a single thing? Not the kit?
\nSam: It\u2019s still a kit but the only thing that we changed in the kit was the gel. We enhanced the amount of the antioxidants and we added glycerin so that we would be able to get FDA approval. So that now we can put on the side of the package that it is effective for xerostomia. You can still get it separately, Allison, or you can get it as the kit with the three, but the toothpaste and the rinse are still, I believe, the same. It\u2019s the gel that has been changed.
\nAllison: Okay.
\nSam: As you know for lichen planus, for oral mucositis, patients undergoing chemo or radiation therapy, I mean, it\u2019s a godsend for them. Aphthous ulcers, herpetic lesions, anything. Also for individuals who are doing restorative dentistry, to try to decrease all the gingivitis before we do anything esthetic as far as doing any esthetic preparations. It\u2019s excellent for that because it not only has the antioxidants in it, it also has menthol thymol, which is in Listerine, which is our essential oils. Then it has greater than 2 percent xylitol which as we know is critical for the caries around our restorations.
\nAllison: Yeah, we use it, I’d say daily we use that for something. It\u2019s fantastic. We even had an assistant use it for\u2014she had a curling iron burn. That was worked best for her curling iron burn on her arm.
\nSam: Well, you know, it\u2019s a little out of our scope, but I must tell you, many of us have taken that gel and put it on a wound site outside of the mouth and have found that it did enhance the healing. It would because it is truly an anti-inflammatory supporting by providing these electrons and freeing up these free radicals.
\nAllison: We are almost out of time and we didn\u2019t get to the baby boomer thing. Is there something you want to say about that quickly?
\nSam: Well, I alluded to it and in fact, it\u2019s great. Let\u2019s do a 360, going right back to the niche which started our conversation. I believe that the practice who parlays itself towards the needs of the baby boomer is the practice that\u2019s going to win. Those three conditions are periodontitis, xerostomia, and the caries that is the result of that xerostomia.
\nIf I were you, I would take as many courses as I can about how baby boomers think, about how baby boomers interact, about the medical conditions of baby boomers. Actually, I have now on the CE circuit, I am actually doing courses which are called Dental Conditions of Baby Boomers and How to Manage Them. It\u2019s become quite a hit and many of our groups like Yankee and others are picking up on that plus I\u2019m just doing it as a standalone CE course.
\nAllison: Awesome, great. That\u2019s exactly what I was wondering. You did speak about the thing that I forgot which was the calibration and the quality of data so you actually got to that, that was what I was trying to get you to say after Ryan asked his question. Do you have a way for people to get in touch with you? I know I\u2019ve got your contact information, do you want them to contact you through me?
\nSam: I truly believe in open source culture. We have a website. I only created a website so that folks would know where we\u2019re speaking. That website is very simple. It\u2019s www.drsamlow.com. My email is simply Sam at that site. It\u2019s sam@drsamlow.com. If you\u2019ve got a paper and pencil, I would be more than happy, my cell number is (352) 538-9654. When I\u2019m actually not involved doing something else, I try to be responsive to all emails within 24 hours. If I don\u2019t answer the phone, leave a message and I\u2019ll call you back.
\nMy mission is to truly enhance the quality of patient care. As I end all presentations with a quote from Dr. Pankey, the mission of my practice is simply to \u201chelp you keep your teeth all of your life if possible in comfort, esthetics, and function.\u201d I think that\u2019s what we\u2019re dedicated to do as practitioners. So thank you, Allison, for giving me this opportunity. I really appreciate it.
\nAllison: I really appreciate you being here. I appreciate your contribution to dentistry and your willingness to say yes and to spend time with us tonight and away from other things you could be doing. That goes for all of you as well. Thank you, I do believe and that\u2019s why I\u2019m doing this too, that it will make the profession better and it will allow us to better care for our patients.<\/p>\n
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