If you want to kill yourself, don't go from here. And the patient had chronic cocaine use and she had developed a very large oral nasal fistula. Mhm. And so anything she would drink would come out of her nose. He had a drug addict patient who used cocaine and nose collapse. And as you know in the Middle East and there's a lot of organ sales, kidney sales is very popular. Yeah. Working with kids, I always worry when I refer somebody to oral surgeon. So I recently had a patient went down there for implants and they all failed. I mean, look at my smile. It's beautiful. I said, "Yep, your teeth are moving." Dubai, Turkey, and then you hear horror stories. A lot of people go to Mexico to have veneers done or braces done. Sometimes it works out great. It's already the bone loss and everything. Failing implants is no joke that people look like the predator. Welcome to the Ask the Dentist podcast with Dr. Olga Dogear, where your smile meets your overall health. So today I'm extremely excited because finally I have an oral surgeon on my podcast. This is Dr. Wishi Ramen. He is owner and founder of Desert Reach Oral Surgery and he came today to answer all your questions. Oral surgery is a very unique specialty. Can you your resume is very impressive. I was reading about you. Your volunteer work was like amazing. The Haiti story, how you volunteer in Haiti after the earthquake. That was something um unbelievable. Uh tell me why did you start did you become oral surgery in G oral surgeon in general and what motivated you? Sure. Well, thank you for having me. Absolutely. Dr. This is a real pleasure and honor to be here. I was very excited when uh we spoke. So, I'm happy to be here. I'm I love u uh talking about oral surgery. It's my passion. For me, oral surgery isn't just a job. It's more of a way of life. Actually, uh years ago, uh you know, when I was growing up as a child, my father is a nephrologist, my brother's a nephrologist, my sister and my brother-in-law all went into nefrology. Now, I had an uncle who is now 99 years old. Oh, wow. And uh you know I spent about seven years of my life in Iran and the rest of uh you know my life I've been here in the United States. My parents moved here from Iran in the late60s moved back in the early 70s. So I spent the early years of my life here and then the between 10 to 17 there and uh then I came back here. So I've been here ever since then. But during the time I was there my uncle who was an oral surgeon, he trained during World War II. So he's 99. He trained during World War II and I was always very impressed with his pictures. It were always black and white but you had all these soldiers that were hurt um and they had to be you know fixed reconstructed completely back then obviously reconstruction was very different and the nature of warfare you know my specialty has been defined by facial trauma. Yes, you know years ago you know oral maxel facial surgery started out as an offshoot of dentistry then later on medicine came into it and even now you know we do lots of facial trauma. So I still pride myself in being a full scope oral maxel facial surgeon. I do lots of dental implants. I do lots of wisdom teeth but at the same time you know I still do lots of facial trauma and head and neck reconstruction. After my training, I spent um you know uh some time doing a fellowship in head and neck and tumor and reconstructive surgery and when I was at the University of Miami and that's always been my passion. That's wonderful. And so I try to I try to do everything and stay engaged in my specialty and at the same time teach um and lecture and that keeps me um um fresh in the game so for sure because everything is changing nowadays. Yeah. So many new things coming out every day almost. Every day. Every day I'm learning something new. Yes. And you're not just dentist, you're actually medical doctor as well. So for our listeners, oral surgeons, there's two types. There's just dentist who did oral surgery residences for four years. Right. Correct. And uh Dr. Visha actually did six years. So you graduated from medical school as well. So you're dual profession technically dual specialty right? That's correct. So as far as the like oral maxel facial surgeons a lot of oral surgeons decide to um you know pursue a medical degree as well and at the time when I was applying that was the norm and obviously I wanted to go on and do more of reconstructive surgery. So, as far as uh my privileges in the hospital and as far as exposure to my medical colleagues, getting the medical degree certainly helped me a lot, of course. Um, and as far as the oral surgery training goes, um, single degree and double degree oral surgeons have the same training as far as what we do in our residency, but of course, education can only open doors for you. It never closes doors for you. So um you know my advice to anyone going into oral max facial surgery is if you're young and you have the endurance and you have the energy um you know pursuing the medical degree is certainly not going to hurt you. It will only help you. Of course you spend the best years of your life in school. Yeah. Plus you can do hospital privileges, right? So I have hospital privileges. Uh I'm now on staff at uh the local Banner Hospitals, the local Honor Health, and uh just recently I was invited to be the oral surgeon on staff at the Mayo Clinic. Oh wow. In Phoenix. So uh I'm excited to do some uh great cases there with the Mayo Clinic, the plastic surgeons and ENTs. Okay. Uh so a lot of our trainings go hand inand we complement each other. But it's nice when we can work together because we can do great things for our patients. Amazing. Amazing. Yeah. So tell me about your volunteer experience. I read about Haiti. Do you want to talk about that and tell us how did you end up in that whole journey volunteering? Sure. It's it's a great story. I was actually telling u someone the story yesterday. They said, "How did you end up in Haiti?" Yeah. So years ago when I was u when I had finished medical school, some of my medical school classmates actually and I we did two years of general surgery together. So in my early years uh you know after dental school and in between finishing oral surgery I had to do oral surgery uh I mean general surgery. So my second year general surgery I uh I connected with some great guys and they did a lot of trauma and reconstruction. Uh in 2010 I was uh involved in a car accident where I wasn't paying attention and I hit a semi-truck from behind. Oh no. I'm lucky to be here. I was Yes. I was texting and driving. Oh, and that's something that I recommend against. It's never a good thing to do. I know. But I hit a semitruck from behind. I was probably going 90 and he was going 50. They didn't even feel me hit him. But in that car accident, I broke my my hand and my back and your back and my back. But I didn't have surgery. I just wore one of these turtle shells, a white ivory colored turtle shell. Um, but I didn't really miss work. I went to work the next day wearing the turtle shell. But on the weekends, I would always rest. I couldn't exercise anymore. I was training a lot. I was exercising a lot then, too. So, I think that's what kept me going. Of course, before the before the accident. So, your muscles strengthen. Yes. Otherwise, I probably may not have survived the accident. Oh, wow. But when I was um watching TV in 2010 when on wind, I realized some of my friends from general surgery that I had spent time with who are now general surgeons are in Haiti after the earthquake. and the University of Miami where I went to medical school and did my oral surgery and general surgery training had a set up a tent hospital there in Haiti. Oh wow. After the big earthquake. Yes. So when I was a medical student my actually funny enough my sister and I were classmates in medical school um at the University of Miami. Um you know everyone in my family became doctors doctors. Um and it wasn't because we wanted to follow in my father's footsteps. He kind of let us decide what we wanted to do ourselves and just my mom and dad. My mom was an air traffic controller back in, you know, in the early 60s when it was not a very popular job for women. Yeah. And so my dad and mom worked hard and they said just try to be the best at whatever you become. Of course. Yeah. And somehow we all followed in my dad's footsteps. He never they never forced us to become doctors. It just kind of happened. Nobody became air traffic controller. Yeah. Nobody became an air traffic controller. Yeah. So my sister, youngest sister became a dentist. My two other siblings became physicians. But my sister and I were classmates in medical school. Medical school. And uh so at the University of Miami when we were classmates, there was always an option to go to Haiti. Uhhuh. Uh for rotations in family medicine. I didn't go. Uh but I know a lot of my classmates went. The University of Miami always had a very strong presence in Porter Prince in Haiti. So, and when I saw the University of Miami had set up a huge tent hospital right outside the airport in Presidential Palace, I thought to myself, you know, that's where I want to be. Uhhuh. So, you know, it's a really interesting story. So, I contacted my partners at the time, there was five of us, and I said, I really want to go for a week, and one of them said, I want to go with you as well. Oh, wow. And uh great guy, John Acres. So, then he said, well, we need a plane cuz all the airports are closed. So he said, "Let me call around. I have some friends. I've been living here in Daytona Beach cuz I moved from Miami to Daytona Beach after my training and I joined a great practice." So we called around and he said, "I got a plane for us. One of my friends who has a furniture store is going to let us use this plane." So I contacted some of my other friends. There was another anesthesiologist, two orthopedic surgeons, two family medicine doctors, even an oncologist. Oh wow. We were all so eight doctors, three or four staff members and a couple of dentists. Uh we all packed the back of this plane with lots of supplies. I reached out to all the local hospitals. Uhhuh. And everyone donated the supplies. So we went down to Haiti. Of course, I had a broken back. I was wearing my turtle shell. So we landed in Porter, not in Porter Prince. I'm sorry. We couldn't fly to Porter Prince. The airport was closed. Yes. So we flew We flew to the Dominican Republic. public and we got in the back of a pickup truck and it was a very very bumpy ride. We had two trucks. It was it was an interesting time but it really makes you appreciate for sure in Dominican Republic as well as dental student and I remember that bumpy road for sure. But this was very bumpy for a few hundred miles going because you go up to the mountains and then you have to then you have to go back down. We were on the border with Haiti. It was interesting. So we got finally we got to Haiti and there was martial law um and uh it was awful because you know a few hundred thousand people had died in the rubble underneath and we got there about 4 days afterwards. So uh we set up a um a camp right inside the University of Miami uh tent hospital. Then a few days later we found the United Nations tent uh camp. It was really amazing because the United Nations, every country had set up a tent for their staff and their providers, healthcare providers. Some were doctors, some were first aid, some were EMTs. It was amazing. Everyone had come together to help the people of Haiti. And uh so we were doing surgeries and um you'd have to see these photos. It was um it was like um you know what's that show? U MASH where there was a MASH hospital. That's exactly what it was. So, I was washing my hands over a garbage can where they were pouring water and alcohol on my hands when we were doing surgeries. Uh, we had people that were stuck underneath the rubble and they had wounds that had maggots in them already. And, you know, as an oral surgeon, I delivered a baby there. We were doing amputations cuz it was such a shortage of doctors. But what's great was that every country in the world had come together to do this. Amazing. Yeah. But the the best part of the trip was at the end when we were getting ready to come back, um the plane that we had come with couldn't come back. Oh. So, uh NASCAR, um Joe Gibbs, um who's one of the he used to be the coach for the Washington Redskins, and he was one of the owners in NASCAR, he sent one of his own planes. Oh, nice. Yeah. It was the Gibbs the racing team. It was phenomenal. So, they sent one of their big planes. It was a 737, big one. the big one and took us all back. But while I was in the airport, um, a gentleman approached me and said, "I see your t-shirt says Florida Oral and Facial. Are you an oral surgeon?" I said, "Yeah, as a matter of fact, I am." And he said, "What's your name?" I said, "My name is Vishy." He goes, "Oh, do you have a brother named Vary?" I said, "Yeah, I do." He goes, "I work with your brother in Texas. We're both nefologists." Oh, wow. Small world. A small world. But he showed me a picture of a lady with a big tumor on her face. And he said, "Can you help her?" So when I I saw it, it was a massive tumor the size of a watermelon on her face. And that was still in in Haiti, right? It was in Haiti. And I and she said and he told me, he goes, "We tried to operate on her here and she almost bled to death." Oh, wow. Can you come back? And I said, "Let me see if I can go back to the US and get her a hardship medical visa." And this is during President Obama's uh term. Good. Good. So I came back and I contacted my hospital CEO and we took a lot of call. Now, when you serve the community in the hospitals, they do a lot of favors for you. And I said, "Would you let me bring this lady back? They don't have any funds." And he said, "If you can get her a visa, we will. We will." And you know, back then it was very hard. A lot of people were trying to flee Haiti, you know, after the quake. There was a lot of domestic turmoil. Yes. So, we wrote a letter to the State Department and sure enough, they offered her a visa. So, we brought her back and, uh, she stayed with us for a few months. Um, and we took out this massive tumor. It was a I think a 12-hour surgery me and my partners did and uh it was a great great um ending to that to that trip. So, I've I've tried to do a lot of mission trips, but that was the probably the best mission trip I've ever been on. Wow. It's pretty amazing. Was it one of like those cases you remember for the rest of your life? Oh, yes. We actually published it because the the tumor was so large they called it a gigantapiform familial cement. We actually published it. It was basically an oifying fibram which is you know a benign fibroius lesion of the mandible or you know it can happen in the facial bones but this thing had grown so much it basically devoured her face and her teeth were pushed out. She couldn't eat anymore. Um, so we had a big pizza party for her before she went back to Porter Prince and, uh, it was just an amazing thing. Uh, you know, I've been to Haiti several times. Gotcha. Gota after in Dominican Republic, but now I would imagine, you know, she's living a great life and I' I've been in contact with the church that sent us Okay. Um, some pictures from her and she's doing pretty well. She's doing good. No, we couldn't say anything. No, no recurrence at all. That's wonderful. Yeah, she's doing saving lives. Well, you know, it it actually we had a nonprofit foundation way back in the day. It was called um Changing Faces, Saving Lives and um you know, we were um we did a lot of great things. That's amazing. Yeah. A lot of great things. So, I still try to do as much as I can. I try to teach my kids that, too. Yeah. To get involved with mission trips. I've t I took my wife and kids on a mission trip to um the um the Dominican Republic through the dental school that I went to, University of Florida. And um you know obviously sometimes when you go on these mission trips you have to sleep on the floor because it's nice and cool. There's no air conditioning you know. So yeah I remember when we went to Dominican Republic one of the experiences we had like a giant spider and I was one of the like brave ones. So other girls from our room called me Olga go get the spider. And I'm like huh I can get in spiders. I'm not afraid of you. Sure. The spider was bigger than the size of my shoe. He was a huge one. Yeah. I remember they had lots of wild animals there, but it was it was a great trip. I I look forward to going back if I can one day. Mhm. We'll see. Yeah, me too. It's amazing to do to give you It's just such a rewarding experience. It's even more amazing. Lifeanging. Yeah. When you can give to people that you know that they can't repay you and you expect nothing in return and um it just makes you feel great. You know, there's no reward greater than giving to people that absolutely have no other means for help. Yeah. I remember we did a couple of kids with broken front teeth and they were always like hiding their smile and then we did the good giant beautiful feeling that's amazing and it was life-changing for that little child. They would hug us say oh thank you. We all have to set something up and go again. Yeah, I agree. I'm all open for it. And taking your children is so important because they don't know how good they have it here. Absolutely. There's no there's no luxury there. For sure. Yeah. There's a very raw kind of conditions but that's how life is. Absolutely. Yeah, we did some good things and I look forward to going again. Absolutely. So another question we have. So a lot of moms and dads like in pediatric dentist they ask about wisdom test like wisdom test is like as soon as they hit 14 15 even when they get 12 year old mers in they're like okay they're getting wisdom test. I'm like okay hold your horses not wisdom test yet. Sure. So tell us do we need to take out all wisdom tests is it case by case tell us when is a good timing sure when we should not miss certain things when it's not too late but it's more complicated on your side because me as a pediatric dentist I can screen them early and I can send them in a perfect timing when is that perfect timing for you to so that's a great question doctor so you know years ago, the AAL, our national organization, came out with a uh a white paper, basically guidelines as far as wisdom teeth go. And you know, there's a lot of benefits from from taking out wisdom teeth. Obviously, um full bony impactions um are certainly they lend themselves to coming out because they lead to pathology down the road. You know, a lot of times it's just simply bone loss on a distal second. Sometimes it's dangerous cysts, OKC's, amalb blastoomas all develop in the posterior mandible. And I see it all the time where patients come to me in their 30s and 40s and 50s and now they have a big cystic lesion in the mandible and they say, "Well, my my dentist told me I don't need to take it out unless it bothered me and it was fully impacted." Now once in a while I do see patients that have fully erupted wisdom teeth and they're in occlusion. It doesn't bother them. There's really no reason to get them out. But I see a fair amount of uh facial trauma. Um athletes, you know, as you know, I both are both involved with professional teams. I work with uh you know, all the local uh professional teams and I see a lot of athletes with mandible fractures and it usually happens right at the angle of the mandible where there's an impacted wisdom tooth. And so it does like a weak spot. Yeah, it's a weak spot. It weakens a mandible because you have this massive tooth occupying space. Generally when I see teenagers um you know I see 12 13 year olds that come in sometimes and I tell them listen there's no root formation at all let's wait there's no reason to get this wisdom tooth out first of all it might come in perfectclusion yes and it's more difficult for me to take out teeth that have no roots cuz they roll around they roll around I heard about that tricky I try to avoid them now once in a while the 12year-old patient has a impacted second mer so 12 year mer or even six year mers impacted then we have to address the third mer to create space but you know years ago when I was u you know in training a lot of you know there was a lot of controversy some orthodontists thought wisdom teeth moved their their other teeth after treatment some didn't believe it I think it was proven that it's not right correct so there was different schools of thought but we know that the wisdom teeth don't you know create crowding in the front still a common belief because that's number one question it's Oh, I need to come out because they're going to make the teeth crooked. But as you and I both know, you know, the mandible maxilla change shape throughout life. So, you know, we go through changes. But, you know, a lot of times when I see patients with crowding prior to orthodontic treatment, it's a good idea to get the wisdom teeth removed because you're trying to create space. Um, you know, so much has changed. Years ago, we did a lot of bicuspit extractions to create space for orthodontics, but that's a that's kind of a taboo now. We don't like to do that because it creates a lot of facial changes the long term. So, as far as wisdom teeth go, I would say most people need them removed, but I like to take them out. Obviously, when they're not completely symptomatic, you know, sometimes patients will come to me and they're in pain. Yeah. Because they have paricornitis. You know, we try to clean the area out, irrigate it out, put them on antibiotics, and have them come back a week later. That way they're not working on an infected site unless it's has no option. If they have tismas, they have a lot of pain and swelling, then we have to address it. But as you and I both hear about it sometimes in the news where people die from their wisdom teeth that were not removed. There's last year there was a um a story about a truck diver that was in his 30s driving all the way from Atlanta to Arizona. I heard about that. and he had paricronitis for a week and ended up becoming a big Lwig's angi and he didn't survive that. So you know impacted wisdom teeth can lead to infections and those infections can be avoided. So overall I would my recommendation is to at least have the wisdom teeth evaluated to see if they need to come out. So it's more of a case by case basis. I don't like to remove every single set of wisdom teeth because sometimes they're imperfect function because you know I'll see adults and their wisdom teeth are in perfect occlusion because they had bicuspid extractions at a young age and now their wisdom teeth have moved forward. So uh like like you know I were mentioning I think it's a case by case basis but always have them evaluated mid- teens. I'd rather see someone at 15, 15, 14, 15, 16 rather than 25 or 26. You know, I had my wisdom teeth out in my late 20s and you know, interestingly enough, I have right paristhesia of my inferior alvolar region due to oral surgery. So you still do? Yes. 20 years. So um paristhesia guys has not been able to feel numbness. Yeah. Yeah. So I've I've been numb. So every time I get work on in the right lower quadrant, my lower right mand, you know, the mandible, I have to get um even though it's numb, but it's painfully numb. So when I shave, it tingles. And it's funny when I get a cleaning. Wow. The ultrasonic sends me through the roof. So that, you know, it's better to take out those teeth when the roots are a third of the way formed, not when they're fully formed and have room to get around the nerve. So when I had my wisdom teeth out, we didn't have a CT scan in dental office, right? Yeah, that's right. Now, every oral surgeon should have a CT scan just like every orthodontist and pediatric dentist does. That way, you can evaluate the position of the nerve. So, you know, at 16, there's virtually very little chance of damaging that nerve taking out wisdom teeth, but at 25 and 26, there's a higher chance. And that keeps on increasing as we get older and older. So when I see someone in their 50s and 60s, I tell them there's a good chance you could be numb for the rest of but now the wisdom tooth has caused a big cyst or it's fractured. So we have no choice but getting out. So I always tell them I'm like make sure you bring your children in and if they've already had it done, make sure your grandchildren have it done as well because you never know what's going to happen. What's going to happen? Yeah. And tell us how you guys handle now after surgery. So I remember back in the days dry socket. Sure. Was like the biggest uh complication. Absolutely. And it it still is, I believe, in certain cases. But now I hear about those new um medications you place also in the plasma and so on. So tell us more stem cells, right? Absolutely. So what's has changed since? You know, a lot of things have changed. You know, when I was um first out of practice, I joined a group practice in Daytona Beach and my two older partners, they never sutured any sockets. They said that way stuff can get in, can get out. But then I would have some patients, I would see them come back with infections. I sutured every single socket, top and bottom, and I still do. And I would see less dry sockets. But of course, one of the things that um I like to to point out is if your surgeon is skilled and has been doing this for quite some time, they can get through the procedure a lot faster and um there's less trauma to the area and that becomes less paintop and less complications. So if a procedure takes an hour and a half to two hours to take out wisdom teeth, then that doesn't sound good. It's well, but it happens all the time. Really? Of course. I mean, not in most oral surgeons practices, but sometimes I'll see a patient that was referred to me from an outside office, either an oral surgeon or general dentist or perodonist was doing the procedure under local anesthesia in some office because as you and I know there's a lot of traveling doctors now. I call them itinerant surgeons. Mh. And uh you know if you're traveling from office to office, you don't have all your tools, the right assistance and uh you know you see the patient for the first time day surgery, you're doing a procedure and it takes forever. I you know I do a lot of nerve repair as well and we'll get to that in a little while. But you know there's higher complications when procedures take longer longer. But for all my lower sockets I always take PRF. So years ago when I was at the University of Miami we developed uh my mentor Dr. Robert Marx. uh he did a lot of stem cell and bioengineering and we started using uh PRF and PRP. Can you tell our listeners what is sure PRF? So plateletri fibbrin and plateletri plasma they're pretty much very similar very similar. It's just we use them for different purposes. So we basically draw 10 to 20 cc's of blood when we start an IV. So almost 99% of patients that I work on are sedated and uh I have a full-time medical anesthesiologist that works in my office with me. As an oral surgeon, we have the training to do our own sedation. But over the last few years, there's been some instances where complications have arised in different offices. So we're most oral surgeons are now um you know hearing about you know from different boards and different societies where the two provider model might be safer and I think that's something that's we're gradually moving towards over the years. So um I kind of uh jumped ahead of the curve and hired a full-time anesthesiologist. Wonderful. And so he does all my sedations unless he's on vacation then I do my own sedation myself and just didn't remember and I remember how to do it. But a lot of oral surgeons still do their own sedation and we have the training to do it. Um I just like to concentrate on surgery alone. Yeah. Instead of doing surgery and anesthesia. Yeah. Working with kids, I always worry when I refer somebody to oral surgeon. Kids and adults, you know. So yeah, especially adults medical history and children when airway is very unpredictable. Yeah. So I it's nice because I don't have to worry about it at all. Yeah, but years ago when I was at the University of Miami, uh we did a lot of uh research with PRP plateletri plasma and where we were growing bone in areas of defects in a mandible and maxilla using cadaavver bone to mix it with because you know when you're trying to do a bone graft or create bone in a sinus or in any area where you've extracted a tooth, you can take autotogenous bone from the leg but nobody wants you to harvest bone from their leg anymore. So or from the back of the men or you take cadaavver bone and which is all just a matrix you know there's no live cells and you're adding live cells by you know drawing some peripheral blood spinning it down and taking all the platelet derived growth factors there's platelet derived growth factors there's um stem cells there's a lot of good um material that help grow bone help soft tissue heal so uh we could mix the PRP with cadaavver bone and grow bone. Then later on a lot of our colleagues started using the plate edge fibbrin and so we basically spin it down and create a plug with lots of growth factors in it and I lay it in the lower third mer sockets and I suture it close. I honestly can't remember the last time I had a dry socket. Wow. It's been quite some time. So some oral surgeons are now gravitating towards using the PRF and we just include it with our with almost every single case. Wonderful. And uh I see far less complications, you know, by using PRF in the lower sockets. We don't use it in the maxilla at all because I don't want to float away into the sinus. And often times you're not drilling at all in the maxilla, so you don't really need to worry about that. Gotcha. Gotcha. But yeah, the the the shorter the procedures are, the less complications I see. And now that we use PRF, it's even better. in dry sockets kind of getting less and less and less you know the less I have to pick up a hand piece or the shorter the cases the less uh the incidence of any complications especially dry socket as well dry socket we usually don't worry about dry socket in children but if we do adult tooth extraction what do you think for example completely like broken six-year-old mer sure would it be beneficial for a child or do you think they have enough like blood flow Well, you know, children have a lot more circulating stem cells. Obviously, that's why children heal so much better from nerve injuries or any kind of injury or even their facial trauma. Um, I think unless there's a large defect, uh, a large like bony defect. I don't really use the the PRF in children a whole lot unless I'm dealing with a big cyst. Like I'll see a child come in with um a large cyst in a mandible that I've removed and I just basically put PRF in the defect then that makes sense to kind of but on a daily basis he would say like for adult extraction doesn't need it. That's what I thought. Not on a regular basis. I don't use it in kids. Mhm. So talking about technology you mentioned CT scans. How common is that? You've been practicing so many years. Sure. So when CTER, how much does it help you? And we still have people who don't use CT scan. Sure. We have oral surgeon who use CT scan. How did make a big change in your practice? I mean, what's the difference? It's a tremendous difference because, you know, I know practices here locally in Arizona, oral surgery practices that didn't have a CT scan until just a couple of years ago. Wow. And uh so like 2023. So I first got a CT scan in my practice in 2004. Wow. When it first came out because it's it's a game changer. Imagine, you know, when we look at a panorex, remember it was in in our training, they would put panorex up and it's a two-dimensional picture. Plus, it's kind of squished up. Yeah. It's all squished and it's a three-dimensional object. You really don't see anything. No. And it hides a lot of information. The CT scan gives you so much information. And you just have to know what to look for. Exactly. And uh you know I uh I pride myself in having a CT scan in my practice and I've had it for you know 20 years now because every case um that you do and you compare a panorexia CT scan there's so much information that you could have missed from a panor special pathology probably. Oh absolutely pathology 3D inclination of teeth. You know, patients come to me and for an orthonathic surgery consultation and their teeth are perfectly straight and, you know, they just finished their ortho. Then I look on the CT scan, there's no facial bone at all. Right? So, the case was finished orthodontically to mask their their skeletal deficiency with dental compensation. And I tell them, hey, you know, we're going to have to do some decompensation here to get you ready. And um you know there's a lot of things that we see like with impacted canines you know I'm sure you see it a lot in your practice where patients come in young kids with impacted canines um sometimes all four of them are impacted which is quite unfortunate usually I see it more in the maxilla maxilia but you know impacted second mers canines and like you said pathology and you know remember back when we were training where we did it with a plane film you had the slob rule same label opposite buckle nowadays I I I would imagine the younger dentists wouldn't even know what a slob rule is. Yes. I mean, they read about it, those peas, but uh you know, the the the days of just taking out teeth with periapicals and and doing implants with a parapical is is over. And you know, in in some states, it's still not below standard of care to do an implant with just a plain film, but uh you know, and I'll see once in a while because I have lots of colleagues overseas and they've done um X-rays on a implant afterwards and they've just used a PA or a Panorex, but I just can't imagine it because I'm only seeing Imagine if you can only read one page of a book and they ask you, "How was the book?" Exactly. You have no idea. Yeah. So I think it's very important to to have all the information. I can't imagine not having a CT scan in my practice. Talking about overseas, a lot of patient nowadays trying to do like a budget surgery. Oh, for sure. So they're flying to I mean common destination is Dubai for example, Turkey. Sometimes even on your Instagram some kind of feed pops up with all of a sudden everywhere everywhere like they're flying to Mexico and it's a trip it's a vacations/oral surgery. Do you see a lot of people coming back with complications? Oh, I'm absolutely. So, it's interesting. That's a great question. Um, you know, I see a lot of patients that go down to Mexico or South and Central America for work. And I have amazing colleagues, friends that are oral surgeons or general dentists or perodonists in all over the world. All over the all over the world in Brazil, Argentina, Mexico, and even on in Europe and the Middle East like Dubai, you just mentioned that. Yes. Yes. Yes. It's um it's not usually these guys that are seeing the people going there for medical tourism. A lot of times it's these clinics that they set up. It's very similar to the the groups we see here. We see a lot of um practices now. You know, dentistry is been engulfed by private equity and big DSOs. DSOs for sure. And I can tell you with absolute certainty, the quality of care that you and I provide as private practitioners in a boutique style practice is superior to any kind of private equity or DSO or a chain practice. For sure. You know, I I when I first got out of residency, I went and worked for one of those DSOs. They promised me the world Me too. Lots of money. And after 6 months, I couldn't take it anymore. Yeah, I didn't care how much money I was making. I resigned. I said, I can't do this anymore. And uh for me, that's the best competition. So, here in town, there's a there's a Nuvia Dental Implant Center and a Clear Choice right next to me, and there's so many of these chains, you know, Affordable Dentures, Aspen Dentl, and that's fine. Um, you know, they're they're great for some people. Yeah. But, you know, and they're very similar to those medical tourism clinics that you see in Mexico or Turkey and all those places. For some people, it worked great, but when things go wrong, um, they're not equipped to deal with some of those complications. Complications. You know, I just recently had a patient that I had seen for consult. I do a lot of allon fours. My practice is completely digital. We have five 3D printers. We do photoggramometry. We don't take impressions for implants anymore. It's all scanning. So, I had a patient that I had seen for a consult, several of them, and they said, "Well, I can get it done for half the price in Mexico." Mexico. Yes. Yes. We get this question. So, I tell them, I mean, a lot of people go to Mexico to have veneers done or braces done. Yes. And so, you know, sometimes it works out great, some great, but when it doesn't work out great, you're in big trouble. So, I recently had a patient went down there for implants and they all failed. All of them all of them failed and and I said, "You know, we gave you a quote back then and and it was something like $40,000 and you went to Mexico and had it all done for $15,000. Now you've wasted all your money there. You went and stayed there for in a week for a hotel. They didn't give you anesthesia. He was awake for the whole procedure." Oh, wow. It was awful. And so now he's got to pay to have it all redone. Another more complicated now because it's already bone loss and everything. Failing implants is no joke. I had another patient who wanted full mouth veneers. And I referred him to one of our mutual friends. Okay. And uh he's like, "Oh, it's too expensive. I can get it done for a third of that price in Mexico." Okay. I was like, "Okay." So he went to Mexico and they did all these veneers and some of the teeth got overheated. They had to get root canals. When they did the root canals, the sealant material went into the um mandible and the inferior alvular nerve. Then the patient became completely numb. So as a result Yeah. and painful paristhesia. So then the patient needed to get nerve repair done and that is not Oh that's so sad. And and a cheap procedure so he had to be hospitalized and he regrets having to do that. I had another patient who went and had a nerve repair done elsewhere. Uh another ones are the patients that have orthodontics. They go down there for orthodontics. U they don't treat the second mers at all. it's not a an area of interest to their orthodontist. But now um you know they they come back and their mouth is a complete mess because they move the teeth so rapidly the roots on the anterior teeth are completely gone. Yeah, we see that. And they tell me, "Look at my smile. It's beautiful." I said, "Yep, your teeth are moving." Moving. So I tell patients now, "Yes, you can always go south to get the work back done, but then you have to come back up north to fix it if it goes wrong. Work." Oh gosh. But I, you know, like I said, I have great friends. I have a few friends that are working, they in clinics in Dubai, and Abu Dhabi. We almost did that ourselves years ago. Oh, wow. We were approached by the um the royal the royal family in Qatar. Oh, wow. Because they said, you know, the World Cup is coming to Qatar and we want to open uh a a multi- um specialty clinic in Doha. Would you guys be interested? And uh you know it was me and four other doctors. It was a general dentist, an orthodontist, a plastic surgeon, a dermatologist. And we we went there and visited. Actually went there with my father to visit and it was beautiful country. But I thought to myself, well, who's going to do the follow-up on these patients? So that's another topic. Yeah. The followup. So imagine you go to Doha to get an all-on Ford done and you come back to another country. you go to your country and now I have a problem. So you know they said well we want you know either one of you is always living here and that's not really practical of course. So but even if there if one of you is living here if you go back home to Germany let's say or come to the US now you have a problem now who deals with that problem for you you're going to have to fly back. So the money you saved on getting the procedure done here and now you have to spend again to go there to get it done to get it done. The technology is great in a lot of these countries and medical tourism can be good, but it's not always good. It's not always good. So, as a general rule, I avoid it. I don't recommend it, you know. Um, and the craziest story I just came across not long ago, um, these two young ladies went to, uh, Turkey for a mommy makeover, a full body mommy makeover, right? And as you know in the Middle East and there's a lot of organ sales, kidney sales is very popular, right? No, I didn't know that. Oh, yes. So people pay a lot of money for a kidney. I kidney transplant is one of those things where here people get on the waiting list sometimes a year or two years. Yeah. So imagine if you you need money, you can sell your kidney. So it's unethical unethical practice um to do that. But in some of these countries if they can steal your kidney. So, let's say you go in there for a tummy tuck and you wake up, you don't know your kidney's gone. So, that's happened here where patients have come back to the States, they had an infection, they got a full body CT scan and their kidney is missing. Oh my god. So, you know, it's Yeah, it's it's not one of those things where you're going to expect to happen with oral surgery, but if you're having like you said, anything done, like if you have nerve damage now, you have to come back up here to get it fixed because they're not equipped to fix that. Yeah. And so, like I said, there's some that, you know, there's there's some place for everyone. So, when patients come to me, you know, I have I have a lot of referrals from Clear Choice and Nuvia and Aspen Dentl and Pacific Dental Services. Um, you know, I started out in one of those corporate places. I only lasted 6 months. Just couldn't I couldn't do it. But, um, you know, there's something there's a place for everyone. you know, everyone can go somewhere, you know, because a lot of those practices, they take lots of insurance. So, people want to use their insurance so they can benefit from going there. But I always caution people about going overseas. Yes. Because it's so foreign and there's no well to lose your kidney. Well, there's no recourse. Imagine. Um, so this gentleman that had nerve repair done after all his veneers, um, I told him I said, "Did you try to get your money back from the clinic in in Mexico?" And they they said all of a sudden they wouldn't take his phone calls anymore. Of course. And even Yeah. There's no refund. You can't you can't complain. Reversible. Yeah. It's not reversible. There's no lawsuit or anything like that. There's no board complaint. Yeah. So here is more control environments. If something goes wrong, we all first of all know. But we have to answer. We have to answer to somebody. There is a wild there. There's no recourse like that in some of these countries. Some of these countries especially especially I don't know this new beautiful cleaning in Dubai because I know some friends from Eastern Europe. Oh yeah. They go all Dubai, Turkey and then you hear horror stories about the complications. I'm sure I'm actually lecturing um in uh Dubai in January. Um I'm lecturing in Abu Dhabi in February and then in Turkey in May. Uh-huh. So they have lots of great doctors that are, you know, there's great destinations. It's beautiful place to go. It's a great place for medical medical meetings. So when I go lecture at these places, there's doctors from all over the world coming there for the meetings. But I I wonder how many of them are local doctors. You know, it'll be interesting to find out. But they're great places to visit. But like you said it, if you go anywhere, it could be the best clinic. like you know we you and I can have a patient come from uh Germany for for dental work but if they have a problem when they go back home now what there's nobody yeah now there's nobody to see them so I always try to tell people try to get the work done uh somewhere local but if if it's so ultra specialized that you have to go somewhere make sure they have some way of helping you out when something and follow-up care yeah you mentioned the technology sure so AI now everybody's talking about AI What do you think about like how do you guys do you implement that in your practice in particular and what do you think in the future would it be like all robotic surgery and dentistry is going to just disappear? What is your opinion on that? No, I don't think so. I I actually that's a great question. You and I will never go away. U you know I have a robot the the it's something called you know it's called the XNAV Yomi and Navi dance. They all I heard about those. Yeah. So, I have one of those in my practice and there are limitations. First of all, it's big and bulky and you still need to operate it. You have to tell it where you want the implant to be and then it'll stop you from placing the implant somewhere else. So, you can't go wrong, but you still need to provide information to it. Information. So even in u you know even in uh general surgery they do robotic surgery with the da Vinci but you still need a person to operate it. So what where AI really comes into place in my practice now, you know, we use facial scanners to when I want to recreate someone's smile. Let's say a lot of my patients come to me, they're older, they've lost their teeth 30, 40 years ago, their faces collapse, their vertical dimensions collapse, and we want to basically create something that looks natural and youthful for them. So before when we did these kind of fullmouth rehab cases, we were placing the implants, taking a denture, hollowing it out and attaching into the implants and like hey that's a lot better than what you started with. But there was nothing natural and beautiful about that. Now with the virtual surgical planning, I recently wrote um a few books. So I'm the editor for the uh clinics of oral maxelo facial surgery of North America. and the Atlas of Oral Surgery of North America and uh you know through my years of lecturing I got to connect with some of the best um surgeons and and procedonists and general dentists in the world. So I invited all of them to write chapters. So we just recently came up with these books about uh digital dentistry and uh and graftless solutions. We have one more coming out solutions with grafting but I have friends from all over the world from Russia from Germany from Spain from Brazil. Yeah. That have all contributed to this and and almost everyone now is using AI to their advantage. Oh wow. Yeah. All of us are. I mean the good places are. So when I do a case, let's say if someone comes in there and like I just had a a patient come in from Florida last week who her dentist had seen me lecture somewhere and and he said that he didn't feel comfortable sending his patient to anyone in Florida to do this. literally was a very difficult case. And um obviously if there's a problem, I have lots of friends in Florida who can see her for followup. Yeah. But she came to me and she had been without teeth for 30 years. Oh wow. And we did a smile design. So we take photos. Nowadays we do 3D intraoral scans, 3D facial scans and a CT scan. And we send all this data to a software. It's called ExoCAD and ExoPace. And we use a lot of artificial intelligence to create a smile so we can show it to the patients. Wow. The same thing with jaw surgery. You know, we we use dolphin imaging. It's a software. But I I you I use um some companies products called MedCad. And um um so where we do is a lot of these companies when I want to do orthonathic surgery, we recreate what we're going to deliver to the patient so they know ahead of time what they're going to look like. Mhm. Back when I first started doing this, we would draw on wax paper. We're position moving the jaw like this and like that. This is how we think you're going to look. I remember looking at the pictures from before when we did dentures. Like yeah, that's how you used to look. You want to look similar to that. So when I So now it's all like now it's all virtual more inclusive than virtual and you can actually there's a lot of virtual surgeries

that get a little bit older they're like wow man this technology is really crazy but some some surgeons stay up to date they go to continuous continuing education you almost have to you can't you have to because you get absolute so otherwise you fall behind the curve So behind you. So when I did jaw surgery back when I was in training, we would buy wax paper. I had my blue pencil, my red pencil, and all these colors. We drew angles at a, you know, vernacular angles. Nowadays, it's all done click of a button digital. That's amazing. So obviously if technology ever fails, then you're in trouble, but generally it doesn't, you know. So um it AI is tremendous. it and it shows our patients what can be done ahead of time. And we can make changes ahead of time, not after the fact. After that's why it's so powerful, but I imagine that it's going to get even better. Wow. But I don't think it'll ever replace us 100%. Yeah. Hopefully not. Hopefully, we'll have our jobs. My behavior management techniques would I don't know what AI can do that. Like you know that movie I robot where the robots replace people. I don't know if we'll ever have an ident, but you know, we never know. Well, I can see like dosos, for example, placing those like robots everywhere and one dentist is just like supervising everything. I mean, sure, but but you and I probably wouldn't go to them. I mean, we wouldn't, but some people insurance issues or saving money back to score one. And absolutely, who knows what the robot does. Yeah, I I don't that's kind of I don't know futuristic but possible, right? But I know in our lifetimes it probably won't happen yet. Hopefully. Yeah, hopefully it won't happen where we get replaced. But our children absolutely could be. I mean the young children going to dental school now, you know, two of my dental assistants that had worked with me for several years started dental school this year. Oh, congrats. Yes, they're fantastic. Yeah, they were great and uh you know, we miss them a lot. But I'm really interested to see how their education compares to mine from 20ome years ago. Yeah. Yeah. Cuz it's that would be interesting to see. Yeah. If the dental school keeping up with all the new technologies and everything else. I wonder if they're teaching the old stuff. Because the old stuff is important, too. Sure. Absolutely. I think it's important to know how to mount a cast to learn about articulations. They may not teach that anymore because of the scanners. What do you think? And everything has changed. I mean, who wants to to mix material on inlays? We had to do like I remember when I was a child, I hated going to the orthodontist because they were going to fill up this tray and stick it in my mouth and take an impression. Now it's completely that's all gone. So going to the orthodontist, going to the endodonist, going to anyone is more fun. Absolutely. Absolutely. So yeah, all the problems completely different now. So we don't know. You better believe it. We better believe it. Another question I have for you. What about like medications? Now we hear about antibioticical resistance. Sure. And are we I remember in dental school penicellin was still like a golden standard in u in dentistry in general. So if we have what what is there any changes from uh different medications? Sure. So I mean that's a great question. So penicellin um and amoxicylone are great for oral flora and they give you the best coverage against the the aerobes some of the anorobes but you know most of the big uh infections in the oral cavity and head and neck region have some anorobes so then you have to take penicellin or moxicylin and add clovenate to it or add something else to give you a broader spectrum but you know I don't routinely give every patient antibiotics after an extraction but now if there is infection, my antibiotic choice is the penicellin family. Still penicellin. So we still don't have that antibiotic resistance medical doctors worry about. Yeah. Well, some of them do worry about it. So they recommend clintomy. But we have to be very cautious with clintomy because at the lower doses it's bacterioatic. It's not bacteriaidal. And then clintomy has been shown you know that leads to more dental implant failures. Yeah. leads to more non-healing bony sockets. So, uh, as a general rule, uh, we see, and there's studies that have come out that show higher dental implant failures in some patients that are on hormone replacement therapy or especially with the clintomy. Oh, interesting. So, I don't really use clinomy in my practice. Mhm. Um and unless it's absolutely in pediatrics guideline come out with no clin as well. So and one of the reasons is the higher incidence of um it inhibits certain bony healing like with the osteoblast and osteo class. So what happens is with these patients they have delayed healing but we certainly see a higher dental implant failure rates. So if someone's allergic to penicellin and they can't take penicellin after a bone graft and after a dental implant placement I would rather not give them anything. If they can't take penicellin then give them clentomy. Would you do Zpack? Sure. Absolutely. So I I would give them Zpack or I give them a fluoricquin alone like levocquin. Yeah. uh even though the coverage is not as great but with Zpack I I'm often care careful because with the macrolyte antibiotics with you know zithramax or chloriththramy some people get bad GI upset. Yeah, I personally I can't take Zerithax myself, but some people take it for for sinus infections and allergies. So, you know, there's always options. You can give them Kefllex even though it doesn't have great coverage in the mouth, you know, like the sephilosporins like Kefla, they give you great coverage on the skin, not in the mouth, not in the mouth as much, but it's still better than nothing because it only has good some gram positive coverage, but no gram negative or anorobic coverage. But I almost think that anything is better than clintomy clinomy in the mouth. Plus clintomy destroys your gene. Oh, absolutely. It certainly can. Yeah. So I have patients complaining of that as well. But more is the non-healing and the higher implant failure rate. And those studies just came out in the last few years. I didn't know that. That's very interesting. Yeah. Good to know. So I rarely use it. Mhm. What about tell me about like your favorite cases that you did. I know that that one volunteer one is probably one of the but I I rem I talked to one oral surgeon and long time ago and he was he had a drug addict patient who used cocaine and nose collapsed and the the cartilage was completely destroyed. Sure. Have you seen cases like that? It was for me it was like shocking. Absolutely. I just recently had a patient who um I saw as a referral from one of my other uh providers and the patient had chronic cocaine use and she had developed a very large oral nasal fistula and so anything she would drink would come out of her nose. Oh gosh. And over time her nose completely collapsed. Collapsed. Completely collapsed. So what's interesting is I closed the pallet and closed her oral nasal fistula with rotational flaps in the mouth. It worked very well. Now her nose was beyond my skills or anyone here that I know. So I sent her to Dr. Paul Nasif who's from the show botched. Oh okay. Yeah. So I had talked to him. I said, "Is this a case that you would take on?" And he said, "Yeah, it's very unique, but I mean her nose was completely gone, collapsed." I I can't wait to show you the pictures of it. Uhhuh. That would be interesting. Her nose completely collapsed and I think she just went there a few weeks ago for reconstruction. Uhhuh. And I haven't seen her post-operatively yet, but I would imagine they probably took some rib and reconstructed her nose because sometimes they take cartilage from behind the ear, but it's not enough in some of those cases. Yeah. Because um but as far as the the uniqueness of cases that I'm doing now, I just started in the last few years doing a procedure called jaw in a day. Okay. I already do lots of all on four, lots of zygomatic implants for people without teeth. We give them teeth the same day. Nobody goes home without teeth. And then I develop my own patient specific implants because not everyone's a candidate for zygomatic implants or on force. Can you tell us what are zatic implants because our audience might not know what is all fors because they don't know this terminology that is available even. So years ago, you know, what we did for patients without teeth is we would do big bone grafts from the hip, reconstruct them or do these sandwich osteotoies, do a le for down fractured backbone in there. It works sometimes, but people have to go without teeth for a long time. So then uh in the early 2000s, Dr. Paulo Malo, who I've become friends with now, he's from Poland and he's a very prominent oral surgeon. He actually wrote a chapter in my most recent book. Nice. He developed this technique called the allon four. And everyone thought this can't be this too good to be true. I actually myself thought to myself I sat in his lecture in 2004 in uh Austria and I thought I was like this is crazy. This doesn't make sense. But now 20 years later the success rate is I mean we've had hundreds of thousands of cases done worldwide every year. And uh the allon four is a concept where you place four implants you replace a full arch of teeth by screwing at the floor right away. Right away. Oh wow. Now in some cases there's not enough bone to do an all on four. So then we have to do zygomatic implants where the long implants that are five or six mill centimeters that go into your cheekbone cuz your alvololis is non-existent. Then we started adding on terragoid implants going into the terragoid region um to give you more teeth. You know some people don't want just first mers they want second mers. So okay that's something know especially if they have their full complement of teeth on the lower jaw. And it's a denture, right? It's well, it's a printed denture that screws in. It no longer comes out. Okay. So, I like to call it a bridge. Sometimes we don't have fake gingivo on it. So, it's like a real bridge. So, that's one of those things that has we're light years ahead of where we were 20 years ago. Um, you know, like I said, I have some friends that still do lots of over dentures, the snap in dentures and dentures. uh because like sometimes patients will go to a clinic like uh like affordable dentures and they want a denture they can't afford it right but a lot of the patients come to me they said we don't want a denture anymore first of all we've been burning a denture for 30 years and it floats around like a fish out of water and it won't stay the bone yeah they put tons of adhesive the jaw is so resorbed so some people their zygomomas are so thin we can't even do zygomatic implants and they have no option so on them um you know a few uh companies develop what we call patient specific implants. It's basically very similar to a subparostio implant. You know, years ago we did subostio implants but they were made out of chromium cobalt and u some of them were done great but it required multiple surgeries. You have to take an impression of the bone, close it up, go back. Now everything's done virtually. So I just wrote a few chapters on that too. And I think in the last two years I've done 15 of those patient specific implants. I've done more than anyone in the country now. Oh, wow. And I designed my own now. And I'm working with a company out of uh Europe, Germany. Um to to make these. There are other companies that make them as well. They're just very expensive. Some of the companies charge 25 to $26,000 just for the implant, which becomes very prohibitive for for patients. So what's the difference between that custom implant to to the regular implant? So basically, it's like a framework. It sits and screws into the jawbone and then it has ab buttons that the teeth screw into. Oh wow. But you know that's been around for a little while. But my favorite surgery now that I do is called jaw in a day. Jaw in a day. Where basically let's say if someone has cancer if they're they're abandable or maxilla or they had radiation necrosis or benign tumor. Years ago what we did is we resected the the lesion. You put a plate on there and then at the weight and then they came back and we did a bone graft from either the fibula or the hip to reconstruct them. Let that heal. Then we put teeth on. It took two or three years. Oh wow. Now uh I think I'm the only person doing it in the southwest here. There's a few of my friends doing it in Texas and the guys who trained me are in Texas and San Diego. A couple of great uh they're ex-military guys. They're uh but they're in the Navy now and phenomenal surgeons. Uh but they actually also wrote a chapter in my book and amazing guys. What's the name of your book? Uh it's called the clinics of oral and maxul facial surgery and the atlas of oral and maxel facial surgery. I'm the editor for it. Yeah, you guys are going to have link if you're interested. Yeah, it's it's it's great for anyone doing oral surgery for all the colleagues of ours would be amazing. Yeah. And it's it's great. We got solutions with grafting graphless solutions and digital workflows. I talk about all the various workflows. It's just not not just my workflow, but I've gotten some of the best in the world to each write their their special the way they do it because there's different ways to do things. So, what we do now with these patients is my colleagues here. They're doing the resection of the mandible. Um it's a ENT and a plastic surgeon working together. I do these at Banner and now we're going to do them at Mayo. And then I am placing dental implants in the fibula while it's still attached to the leg. Oh wow. So I place six or eight implants. Usually six. Okay. And we've already done this virtually. We planned the case ahead of time. The teeth are ready. So we take the fibula from the leg. We bring it up to the mandible. We section it in the right spot. We put it in place. We screw in the teeth. So the patient went to sleep with teeth and with a tumor in the jaw and they wake up with teeth in place and no more tumor. One and no more tumor. That's and it's called jaw futuristic. Yeah, it it really is. So it's called jaw in a day, you know. Jaw in a day. Yeah. When Dr. Mal developed teeth in a day or you know teeth in an hour, it was you know replacing your own missing teeth with dental implants. This is replacing the jawbone and teeth. I'm so glad you're talking about it. I'm sure nobody I mean there's very few people who know about not many people doing it. Uh this year I've done three cases here in Arizona. You know one was for a benign tumor. Two of them were for patients that had osteorium necrosis and one had cancer. So people have options now. You no longer have to go through numerous surgeries. And really you think about it that is available to me because of the technology the AI. Yes. AI. So what I do is I sit down virtually plan the case with the plastic surgeon and ENT all three of us together. Sometimes they're oral surgeons. So my friends that do that train me on this are all surgeons. They do everything themselves. So we sit there, we look at the fibula, I look at what part is better for dental implant placement and we section the fibula. So basically we take a straight bone and make it look like a mandible by sectioning and putting screws and plates on it. So patients wake up with teeth with teeth. Wow. and their own bone technically. There is no they got there's no plastic. There's no rejection. There's no amazing there's nothing. That's amazing technology. The fibula is really not necessary for for gate or ambulation. So they're fine. They're not missing it. Wow. So I've done a lot of fibula reconstructions where people had the fibula done a year ago and they come to me afterwards to get their teeth done. So I have to get implants then wait then get the teeth. Now it's all done. Now it's all done in one swift surgery. It's impressive. Yeah, I'm glad there is options out there for people who struggling with like absolutely big problems like completely missing jaw. Absolutely. Bite or anything. Tell me about the new implants. They have those ceramic implants. Sure. Versus titanium, right? Sure. Traditional ones. Absolutely. So it sounds like there's a new movement of this biotechnology organic and naturopathic and in that spectrum it looks like people more leaning towards ceramic implants. So I what's the difference? So obviously you know traditionally we've always placed titanium dental implants right and the surface coating has come a long way the technologies come a long way. There was a lot of studies that showed that dental implant failures often were because of micro fragmentation. Um there's a lot of studies that came out of different various groups. Some at NYU some periodon I said they looked at under electron microscope they found that sometimes dental implant failures happened due to sheer fracturing of titanium particles. So um there was development of zirconia or ceramic implants. Obviously, if you look on the periodic table elements, it's still metal, but you know, it's become kind of a misnomer where people call them ceramic. Ceramic. Yeah. But but the zirconia, it's zirconia. It's still on the periodic table elements, but um it's, you know, supposedly better and kinder to the tissue. Um now, in my hands, I've been doing them for about seven or eight years. Uh Nobel Bioare was the first company to come out with it, but then Strawman came out with it. Neody and Zeramax. There's a lot of companies that make it. Um oftentime some of them pride themselves in not having any metal in it, like a metal screw in there, but at the end of the day, there's always a portion of metal in them. There has to be um for it to be radio opaque, you know. So, and so they're not truly zirconia. They they have something in it. Well, some of them have a a metal uh screw to connect the abutment, okay, to the implant, but that doesn't come in contact with the patient with the patient with the actual patient. Um, I've had good success with them. Um, I wouldn't say amazing success because you're limited um by what's available right now. The technology is getting better and better. Actually, most recently, there's been a big shortage of zirconia implants because there's not as many companies that make them, so you can't find them readily. The failure rate is a little bit higher and the fracture rate is a little bit higher. Um, so I have rarely do I see a patient with titanium implants come in two or three years after they've been restored to with a broken implant. I've had a couple of patients young strong bites that have actually broken a zirconia implant after it was restored. So you have to be very cautious when you select the size. Um you there's less room for error so to speak. But it's um you know it's kinder to the tissue. There's a lot of studies that show zirconia is better for your tissue and healing. But there is a learning curve to placing them to placing them. Interesting. Yeah. Yeah. I see in the noise of like root canals failing placing for example implants. So especially in patients that some patients want to take a holistic approach to their healthcare. They don't want to get root canals but you know and of course unfortunately there was a lot of shows like the root cause where they thought people thought that root canals cause cancer and we've proven that over and over that it doesn't. Yes. Root canals are perfectly safe. Mhm. Um but um it's hard to convince some patients otherwise. And um I I obviously allow my patients and and my referrals to make decisions. I basically I tell them what I think what I would want in my body, but at the end of the day, um I've never told a patient, no, you know, as long as it's medically sound um decision making, I don't tell them no, I'm not going to do it. I mean, sometimes we tell patients this is not I may not be the right doctor for you. Yeah, of course. If you're asking me to remove all your root canal teeth. Yes. Um but um you know, we I show them scientific knowledge. I'm curious since you're in this field, you would be the the best source for kind of talking about this. So if you see root canals, you don't see tumors of the jawbone later on as I mean it's you see tumors. you said associated with wisdom teeth right impacted wisdom teeth and so on. That's definite correlation but I never heard of correlation on the location of the root canal of any kind of tumor associating with this. What is your input on that? It's a it's a great it's it's it depends on how you look at it. If the chicken came first or the egg, right? Yes. So sometimes I'll see patients that have a cyst in their jawbone and I'll see all the teeth in the area were root canal. I here they said oh the the doctor took a x-ray. So they took a periapical and all they saw was a big radolucency. They didn't see there was a tumor or a big cyst in the jawbone. So they thought it was a lesion, an endodonic lesion, right? So they did three or four root canals and the lesion never went away. Mhm. And I I see that sometimes that's really the only time I see it. But I but it's not related like the root canals were done not properly because it was a tumor initially to begin with. But I don't see root canals causing that ever. Uh it's kind of like when patients also have trigeminal neuralgia and I see them someone's taking out all their teeth cuz they thought they had toothaches and it was really a a trigeminal nerve area. Oh wow. And someone took out cuz they were like this tooth is killing me. I need it needs to go. So when patients come to me, as a general rule, if they don't have a referral from a dentist, then I have to do a lot of due diligence to make sure the tooth is the offending cause. Yeah. I mean, we make our own decisions, but if they come from a referral says this tooth is not restoable because there's deep decay, I don't take off the crown to take a look because I don't have a periapical film. So sure, but our CT scan shows a lot. Mhm. But sometimes patients will come in with some nerve disorders and they think it's their teeth causing them to have problems and they want to remove. That's good to know. Yeah. Especially in older population. We see we see that sometimes even in younger patients with with neuralg you know trigeminal neuralgia is often treated with radiation cyber knife or gaba knife. But sometimes patients think that their tooth is the problem and they don't realize until after two or three teeth have been removed that it had nothing to do with the teeth. Wow. It was a trigeminal nerve. you know any kind of neuralgia. Yeah, good diagnosis probably the key for Yeah, being a good diagnostician is it hasn't changed. Even with AI and technology, we still have to arrive at the proper diagnosis. And that's why I think you and I will never be replaced by robots because we can make diagnosis. Yeah. Yeah. Yeah. Because Yeah. To put all this information in the computer, it still can come up as a wrong diagnos. What about TMJ? That's something I see on a daily basis. Usually young girls or teen girls. Sure. Sometimes guys, but that's becoming like a very very big prominent issue more and more and more I see in my practice. Absolutely. The clicking uh painful and me as a pediatric dentist I still have to assess the growth and development. So I cannot put some kind of permanent night guard because they're still growing. Absolutely. What how do you guys handle on the oral surgery side TMJ? I see a lot of patients that have had trauma. So a history of trauma often times I I look into their history to see what's causing it. Obviously certain patients develop TMJ issues because of systemic issues like if they have juvenile rheumatoid arthritis or any other systemic issue that the TMJ can be involved in then obviously we have to address those situations first. But often times I see patients that are going through puberty and you know years ago actually I did a lot of TMJ research and I published this where a lot of uh retroiscal pain receptors the noia receptors are estrogen mediated. Huh. So and and a lot of patients that have had TMJ issues at a young age once they're postmenopausal they don't have as many issues. That's very interesting. But um you know and these are all studies that are well documented and published. But as far as clinical trials, there's no clinical trials. We're not going to ever remove someone's ovary to see if the pain goes away. But um a lot of it's estrogen mediated. You know, just like autoimmune diseases is more common in females. I see more TMJ issues in in females. And I often tell the patients and parents that a click itself, we don't treat a click. Yeah. as long as it's not symptomatic, we don't want to treat it. And I always look to see if the disc is a problem or is the bony changes. You know, I often times I'll see people with cortical thinning, their cortex is thinned out, the the joint itself has remodeled due to a tumor or real trauma. At that point, we have to treat those patients. But depending on their age, we'll treat them with a night guard or we'll treat them with with, you know, physical therapy. Mhm. Um I don't like a lot of appliances um because I see um patients that have had sometimes anterior discluding appliances or they have sleep apnea appliances that pull their jaw forward, open their bite. So if anyone's doing mandibular repositioning devices or anterior disccluding devices for any cause the dentist they have to make sure the patient's occlusion isn't changing drastically because sometimes patients will come to me with a big open bite and the only thing they did was wear an appliance. Oh wow. But now the retroiscal tissues have come forward. the joint position has changed and they can no longer bite their mouth closed and they have joint pain and those patients unfortunately need surgery. So it's non-reversible just with appliance just with appliances. So wow the because those appliances are so popular now they are very prescribed like back and forth everywhere for and they just need to be used with caution. So if anyone's using appliances, they just need to make sure that they follow those patients very closely and as soon as they see any ch changes, signs of changes, they need to stop that or make um changes. So that's one of the things I mean certainly if someone has obstructive sleep apnnea, a mandibular repositioning device can help them helpful. Yeah. But for like obstructive sleep apnnea, sometimes patients wear a mask or they have jaw surgery. Uh but the most simple and benign thing to do is to wear a repositioning device. But you have to keep in mind if if you're wearing a repositioning device, it can certainly cause irreversible changes if it's not monitored. You need to see your dentist on a regular basis, whoever is making sure. Yeah. Yeah. There's a lot of sleep dentists and if you're being treated by one, you have to see them regularly. Yeah. I've seen a lot of like popularity getting also the expansion in adults. in adults too and supposed to be healed the um airway obstruction which a lot of controversy about that that's also controversial I have a few friends that do it and like I said as long as you're not so sometimes you're just tipping the mers right but if that's the biggest problem and that's the biggest problem but if you are truly getting expansion as seen on a radioraph in clinical improvement then that's something that is as as a positive sign but once again I think that needs to be done systematically ly and slowly. We can't make rapid changes in an adult with well-healed sutures. Yes. Um because sometimes things will go wrong because they put the tads and they put the plants which open up the suture slowly in adults like I see as the oldest like 35 year old but it has to be done slowly. It's very difficult. Yeah, it's very difficult. Yeah. I I you know I recently saw a patient for an impacted canine that had been treated elsewhere as an adult in her 40s. So they wanted to bring the tooth down. As a result of trying to bring the tooth down, she lost all her teeth on the left side. She came to me for zygomatic implants. And uh so I'm very cautious when I do any kind of bony surgery on adults because the healing is is very different. It's it's far different than working on a teenager where they heal. Mhm. But what about like you what is your input on TMJ surgeries? So So I do a lot of joint surgeries. I do joint surgeries when it's indicated. So let's say if someone comes to me and they were at the dental office for 2hour cleaning like this and all of a sudden they can't close their mouth. The disc probably went forward and they have a entally displaced disc which is acute that we can treat easily with either repositioning or if the disc was doesn't want to go back with arthrointesis and lavage. But if someone comes to me and they've they've had pain and symptoms for 3 to four years and I get a CT and there's already bony changes and then I get an MRI and the disc has been damaged. We know those patients aren't candidates for an arthosentesis that might help with their symptoms temporarily but they need joint surgery. You know, sometimes if their disc is intact, then you need to bring the disc back and put an anchor on it, do an arthroplasty. But if that's not an option, sometimes you have to do a total joint replacement. Oh, wow. Do we do joint replacements? I do. Yeah. Oh, wow. So, I'm actually doing a total joint replacement in a few weeks on a on a lady in her late 30s. Oh, wow. And she had a big um osteocondroma of the condal. So, her condol is the size of a golf ball. Oh, wow. and she has a lot of pain. She can't uh open her mouth. When she opens, she deviates a lot to one side and she's in constant pain. Oh wow. So that can't that can't be fixed with appliances. Um she went to dentist back at home in in New Mexico and they told her we can try to control it with an appliance, but that's not going to work. So appliances have their place for the appropriate situation, of course, but and surgeries have their place for appropriate situations. So you know and that's the thing is um you have to diagnose the patients properly before prescribing an appliance or surgery because joint surgery patients they tend to get better if the surgery is done for the appropriate reasons is done properly of course but if I do a total joint replacement on someone who's a young teenager u which I see unfortunately sometimes recommended oh wow um then think about it if they're only 20 years old oh no that might have to be replaced when they're 40 or when 50 and the pain and limitation because when you do joint replacement surgery, they lose the ability to move laterally. So, there's a lot of things that I like to um you know see as far as um my data that I collect before I arrive at a diagnosis because TMJ patients can be very complex. And I'll have patients come in and say, "Well, um the last guy I saw said he was just going to do Botox." And I say, "Well, do you have a muscle problem?" Because sometimes people have clenching and and then we give them Botox and it works very well for the massitors and temporalis. But if your problem is in the joint, the disc or bone, that's not a muscular. It's not much. I remember from dental school, it was one of the most complicated surgeries and kind of a questionable outcome. It's a very small little area. Yeah. So you have to make sure that you're treating the right symptom, the right diagnosis diagnosis with the right procedure or right appliance for sure. Or modality. Yeah. But it's a very very delicate area. Delicate area. Yeah. With a questionable sometimes outcomes. Yeah. Absolutely. So what um did we come we covered a lot of topics today. I think we covered um a lot. One of the things that we do also that I I we talked about stem cells a little bit stem cells is where we harvest stem cells from the hip. Wow. We harvest it with the needle from the tibia, the tibial plateau, we harvest stem cells cuz you know here in the blood when you harvest PRP or PRF, it's it's some circulating older cells. But if you want to get primitive stem cells where you get a bone marrow, it's called BMAC. You get bone marrow aspirative cells. Now those are the ones that have the best the best the osteoprogenerative stem cells. And we sometimes I get that. And you know, one of my surgeries that I do a lot of is gunshot wound reconstruction. Oh wow. So um unfortunately there are some patients that have self-inflicted or otherwise they get shot in the face and that's those are always very challenging cases. I I I remember funny story about that. Not funny but bad story about gunshot wounds. We had the oral surgery lecture when I was in dental school and our oral surgeon who was lecturing us told us if you want to kill yourself. Don't go from here. Oh, sure. Because you're not going to have a face. Correct. And you often live. Yeah. You often leave most of the time. Yeah. I I reconstruct a lot of those defects and now I get amazing results because a lot of it's with the patient specific implants, a lot of it's with reconstruction, but we can almost make people look as good as new. Oh wow. Almost. Not no one with trauma patients, I tell them, you're never going to look like you did before you this accident, but you'll look really close. And some of the the results are just amazing. I still remember that picture of like a split face after that gun shot wound that people look like the predator. It's so but but we can reconstruct them now and put this all together with a lot of it together using stem cells. So I use a lot of stem cells in those more complex cases where patients have had bad trauma or radiation. But there's there's a whole lot of tools in our arsenal at our disposal now that we can use. Um it doesn't replace good surgical skills and good diagnostic skills, but it helps get much better results. But with the stem cells, there is a controversy that they can turn into tumor cells or cancer cells. So tell me a little bit more because I I know some practitioners not in adult field but in medical field for example if you have shoulder injury right so there is a practice in some countries not necessarily in US when they do stem cells injection into the shoulder and they get amazing results but in US it's prohibited from use and that form I guess right so I use stem cells more in patients that haven't had a history of cancer. I do it with patients that are I'm going from trauma reconstruction or um you know a massive defect but there is some controversy like someone had a history of radiation for oral cancer and if you're introducing stem cells into the area or doing hyperbaric oxygen therapy that you can awaken the cancer cells and um cause cancer to come back. Obviously, it's controversial because there is some data on either side of that. I've only had two patients over the years um that developed a recurrent cancer after either hyperbaric oxygen therapy or stem cell therapy, but because they were both done, it's hard to tell which caused it, which caused that. But there's there's a very low incidence, but it is possible. Um and uh you know obviously medicine is always changing and now we have more and more data available to us but u I I'm cautious when I use it obviously not in children um but obviously in people with a history of cancer with a history of cancer but do we use stem cells for TMJ for example for to heal so what I do is sometimes when I'm doing an arthosentesis um I have a PRP machine and we can get clear PRP. We we do a double spin. We remove all the the red blood cells and it's clear and we can inject it into the joint. Initially it was off label use and even now in some places considered off label use but if you if your disc has eroded and it's bone on bone then you're injecting PRP in there and it's a protective measure. Doesn't last forever but it certainly does alleviate symptoms. Do we see the reconstruction of the cartilage? Cartel does not I don't think it reconstruct. No, not that. Not from stem cells. Not from stem cells. You'd have to replace it. But there are a lot of athletes who had shoulder injuries and knee injuries and they would get PRP injections into those joints. Not so much into the jaw joint, but I actually now I'm treating a couple baseball players who had bad bad joint injuries. And I I told him I said, "You know, they asked me about PRP because they have friends that get it in their knees and shoulder." I said, "We can do it, but it's not a one-time thing where it lasts forever. It's going to be repeated because multiple times because the PRP doesn't last there forever. It's going to disintegrate after a while." So they they know that. And with stem cells in US, I mean, we have some limitations, right? Because of the laws, right? certain research certain research more research has to be done in the field but we've come a long way a long way we've certainly come a long way are we doing the same thing what other countries do uh well obviously with the FDA approvals and certain measures we are limited like for example when I lecture at our national meeting I can't talk about stuff that's not FDA approved okay or off label it has to be FDA approved well if I'm but if I'm lecturing in some other countries The FDA is not not there. It's not an issue. I mean, they have regulatory measures in place, but it's not as strict as what we have here. Here. Mhm. Yeah. Very interesting. Yeah. There's a lot of new things developing, new techniques. Yeah. Even some of the technology that we've developed like the the patient specific implants, some of them are not FDA approved yet. So, we are actually um getting FDA approval on some of them for all of them. So yeah, you know, the FDA obviously is there to protect the patients because years ago, um there were some bad outcomes due to some, you know, like TMJ devices. Um Dr. Kent, who's a phenomenal oral surgeon, he developed a prostesis called the Kent Vitec prostthesis and uh you know, they had teflon proplast which unfortunately caused some erosion into the cranial fossa in some patients and major problems. But as a general rule, we don't use Teflon propos anywhere else in the body. Um, as far as I know now either. But, you know, 30 years ago, that was standard. So, the FDA was really put in place for good regulatory purposes. Gotcha. Gotcha. And, uh, as you know, some other countries don't have the same regulations. But I think that's why sometimes it takes longer for certain measures to be uh, implemented here. But I think it's a good it's a good thing. Yeah. Yeah. To have some breaks on certain things. For sure. For sure. Absolutely. Anything we didn't cover? Do you want to um you know, and I know I'm just trying to think that like I said, our specialty was built on facial trauma. We started out as that. And I think it's it's great that there's still a lot of colleagues or max facial surgeons that do cover that because the way I look at it is, you know, there's a lot of oral surgeons that are no longer full scope practice. They just take out teeth and do implants. M but you know I have young children just like you do and many other people do and uh the way I look at it is if I'm taking care of someone else's child someday who had a dog bite or an accident hopefully there's an orthopedic surgeon somewhere else thinking the same thing that if some kid needs who fell off something and broke their leg they'll do the same thing. Yeah. So, I always recommend oral surgeons to all young and older to try to stay full scope as long as you can because you're serving the community that you live in. And we that's the the ultimate thing. I we all have great lifestyles. Um we have great, you know, um specialties, great. It's a great career, but at the end of the day, we have to serve the community that we live in as well. So, that's always been my my goal is to try to do that as well. Yeah, for sure. Yeah. But no, I think I think we covered a lot. We did. Yeah, it was very informative. That was fantastic. Yeah. Thank you so much for coming over. Thank you for having me. Yes. And sharing all this amazing source of knowledge with our audience because I'm sure we're going to have tons of questions. I hope it's useful for a lot of people. It's very useful even for my profession. It's very useful because uh we know what we know and we don't probably know what we don't. Well, you know, we're always learning. You always learning. And in our lifetimes, you know, they always say that you're going to learn a lot, but you're going to forget more than you ever learn. For sure. Because we relearn and relearn and forget and relearn and so Yes. Yeah. We forget more than we ever learn. Yes. Thank you. Thank you. I appreciate it. Thanks for having me. Yeah. This was fantastic. That was my pleasure. And you guys, if you have any questions, please don't hesitate to share this video with all the other listeners who has any kind of oral surgery problems because I think we covered every single spectrum. I'm sure there is more and we might do another podcast in the future. I would that would be great. Thanks so much. Thank you. Thanks for having me. Welcome to the Ask the Dentist podcast with Dr. Olga dog ear where your smile meets your overall