Howard Farran: it is a huge, huge, huge honor to be interviewing my rock star idol and mentor Glenn van As in so many ways. You’re Canada’s finest. We both graduated from dental school in 1987, even though you look like you could be my oldest son. Glenn, you’re looking great. I’m a huge fan of yours. I mean your dentistry is rock star dentistry, no doubt about that. I would say your unique selling proposition is you seem to know a lot about lasers in dentistry, microscopes in dentistry so during this hour I want to kind of pin you down on that and I just want to start with this Glenn. Let me start the first question: I’ve been in 1000 dental offices, I’m 52 and my God, if that dentist in under 35 Glenn they never wear loupes. What age would you recommend that dentists start using magnification?
Glenn van As: You know Howard it’s a great question. One of the things that’s interesting is when I graduated in 1987 in British Columbia less than 50% of people had any magnification at all. Now probably in British Columbia you’re looking at 80-90% and it’s not just older doctors. The magnification helps anybody. So even a young graduate just out of school, I really think you should start with 2.5 power loupes right when you get in school or just shortly thereafter.
Howard Farran: Glenn my whole passion with Dentaltown and everything has been no dentists has to practice solo again. Use name brands on magnification on wearing them and microscopes or are they all pretty much the same?
Glenn van As: That’s a good question. Companies like Orascoptic or Designs For Vision or SurgiTel or SheerVision, these companies are all making loupes that are more and more powerful because they’re seeing more and more docs going from 2.5 to 3.5 and 4.5 and if you ask them they say yeah, I have one set of loupes that I use for my endo, I have one set of loupes I use for all my exams and they have three or four sets of loupes there because they bought the first one and every time they see the value as they bump up higher.
Howard Farran: Glenn I actually purchased those for all my assistants and all clinical. All my hygienists, all three of my hygienists and all four of my dental assistants, they have to wear loupes.
Glenn van As: And you know if you see some of the patients that come in afterwards you can tell the quality of the work and I think that’s one of the things that I did it for. I only went to the microscope and I have nine global microscopes in my practice, I have nine operatories, I have a microscope in each operatory, so I have them for hygiene, I have them for restorative, I do 100% of my clinical dentistry through the microscope. The reason I did it was not because I wanted to lecture on it, I just simply wanted to do better work. When I went to India and you wouldn’t think that you would see them there, I saw microscopes in India that were $6000 US. They maybe didn’t have quite the same quality as some of the other North American companies like Global and Zeiss and Seiler and Leica but they were nice microscopes that had basic variable features and would allow the dentists to work on a regular basis using a microscope. Zeiss is German but they are worldwide. Same with Global, Global is made in USA in St. Louis and Seiler is also a United States company. Leica is out of St. Louis as well.
Howard Farran: So Glenn, how prevalent is a microscope? Okay so America has about 4000 endodontists. I know there’s no hard figures but what would you guess of the 4000 US endodontists, what percent would you guess have a microscope?
Glenn van As: I would say it’s approaching 90% now in the US. In the US I would say it’s become the standard of care.
Howard Farran: And to the dentist practicing alone who doesn’t want to remake a decision, can you go through any market share numbers? Did most of them go? Who is number one, number two, number three? For endodontists using a scope.
Glenn van As: Yeah that’s an interesting question Howard. One of the things that I’ll tell you is that it matters where in the world you are and I’ll give you an example, for instance in Germany, Zeiss might be very powerful there, but in the US I would say that Global is very strong. I would say that Zeiss is always still very strong. In Canada when I first started there was nobody else but Global in my area in Vancouver so Global has a tremendous market share in this area. There’s not as many Zeiss users so it depends a little bit on the area. In the United States I would say that the three biggest ones are Global, Zeiss and Seiler and then Leica is a little bit behind that.
Howard Farran: Glenn, what do you say to me if I say I’m a general dentist and I don’t do molar endo and I refer it all to the endodontist? Is a microscope pretty much only for molar endo in your view or do you use it? What other things do you use it for? You mentioned earlier you put one in the hygiene ops? Why would you have a microscope in a hygiene op? I only have one microscope and that’s above the bathroom and I can’t really explain why I need a microscope but that’s a whole other story.
Glenn van As: Well I don’t have any magnification there Howard, I’ll just leave it at that.
Howard Farran: Why do you have one in the hygiene room?
Glenn van As: I have all my microscopes connected to the televisions up above so when I come into the room to do my hygiene exams, I do a live view and the patient is able to watch as I’m progressing through their mouth so it’s actually an intraoral video camera with real time video that the patients are watching. I like it for two reasons because patients become educated. They see if there’s a filling missing. They don’t say, they don’t question me and say are you sure there’s a filling.
Howard Farran: Glenn, please now explain the difference to dentists around the world in every continent, the difference between glass ionomer fillings and composite fillings.
Glenn van As: One of the nice things for adult patients when you worry about recurring caries is that very rarely do you find recurring caries under a glass ionomer because it’s releasing fluoride and so whether you use that in the base of your boxes on class two’s or whether you use it on a high caries rate patient for class fives, it’s really nice material to prevent recurring, so you had talked about amalgam and glass ionomer. I like glass ionomer for those patients where-
Howard Farran: Glenn are you really going to stick to those words? I mean you just said that you don’t- did you say never find or almost never find recurrent decay under a glass ionomer? If that’s true, why would anybody not use a glass ionomer? My problem isn’t the fillings wearing out, my problem is that they’re invaded by bacteria. Hundreds of millions of gram negative anaerobes eat this whole thing out. It’s a biology problem, not engineering problem so again, are you pretty much only doing glass ionomers then? Are you looking at the CAMBRA caries index?
Glenn van As: We don’t have that. I know in California it’s a big thing. We don’t have that here. I know Kim Kutsch and his group, the minimally invasive people, have looked at caries rates in different people and you know guys like Graeme Milicich from New Zealand etc. are great proponents of glass ionomer. If the patient has a high caries rate, you’re constantly redoing class fives and there’s caries going on and you know the patients who have medications that dry their mouth out, patients who aren’t brushing at the gingiva and they’re at a high risk. The glass ionomer materials are much more able to withstand caries. My dad used to use silicates. You never saw caries underneath the old silicates.
Howard Farran: Why is that?
Glenn van As: Because again, it’s releasing fluoride in there and when you see these materials, the patient is walking out of the office and their already staining. When you take those materials out, they wore quite fast but if you took them out there was very rarely caries underneath them like composites.
Howard Farran: Okay Glenn, there’s a dentist out there saying Glenn, be specific. Can you walk through real quick a class five? Walk through the technique with the brand of a class five on an 85 year old lady with Alzheimer’s that has root surface decay on eight.
Glenn van As: What I’ll do is I use primarily, I really use diode lasers a lot for tissue management and I think that’s one of the key things for me is in many of these patients the caries goes subgingival and I need some form of laser and as you know, that’s probably my primary area of lecturing now, is not so much microscopes and magnification but lasers. So for me the soft tissue laser is essential for removing the soft tissue during a gingivectomy, getting that out of the way so I can see the apical portion of my prep. All lasers are anti-bacterial. All lasers, so when you put a laser inside an endodontic tooth, it kills the bugs. When you put a laser inside a periodontal pocket, it kills bugs. So all lasers are anti-bacterial and so one of the nice things is, not only do you get a low level laser therapy with the laser on the soft tissue, you kill the bugs around there so it gives a nice environment for it and it keeps the class five lesion visible and without crevicular fluid or blood, which is even worse, creeping into the class five lesion so you can put your restoration in. I like Fuji products, that’s what we have in the office, Fuji IX. We like to use that in our class fives in the situations where composite resin on a nice looking lady who is in her thirties or forties, maybe you don’t want to do that.
Howard Farran: Okay again, so diode. Diode is for soft tissue, carbon dioxide is for hard tissue?
Glenn van As: It’s a good question. In dentistry there’s four different wavelengths and these are four different categories of lasers. Diodes have become very popular Howard because they’re small unit that are in many cases they’re portable and they allow you to use them as a soft tissue hand piece as opposed to electrosurge. A diode laser has one fifth of the lateral thermal damage that an electrosurge has.
Howard Farran: If you cut your ears off and don’t listen to anybody, electrosurge might be a great idea but it’s not a great idea. In fact would you declare that electrosurge is done in dentistry?
Glenn van As: Yeah I will go on and say electrosurge does two things well, it cuts gross amounts of tissue faster than a diode laser and secondly you don’t need safety glasses for it.
Howard Farran: And by the way that mouth tissue is the fastest growing tissue in the human body. You said originally four lasers, but then you talked about diode. So let’s go to two, three and four.
Glenn van As: Other lasers include a CO2 laser and those are either completely soft tissue or there is a new hard tissue laser from a company called Convergent that is a CO2 laser. I have not used it, it is a big unit but those lasers, the CO2 lasers, the soft tissue ones are fast cutting and oral surgeons like them because they’re fast. The next laser is a Nd:YAG laser and like the main laser that people know about that one is the PerioLase and it’s used for periodontal therapy, they’re big proponents on Dentaltown and they’ve got a large user group that are very fanatical about using their product and their protocol for LANAP- it’s laser assisted new attachment procedure and that LANAP protocol is with their laser only. And then the final laser which I’m using a lot is a hard tissue laser, it’s called the Erbium laser. One of the best known companies is BIOLASE and I’m using a BIOLASE iPlus and it’s a laser that can be used for cutting soft tissue, bone, tooth- it’s kind of an all tissue laser.
Howard Farran: Glenn, would you please talk about the difference between periodontal disease on a human natural tooth versus peri-implantitis and how they’re different and are they treated differently?
Glenn van As: It’s a great question Howard. One of the things that- I always joke Howard, you know what the difference between an ailing and a failing implant is?
Howard Farran: What?
Glenn van As: Well the ailing implant is one that you did and the failing implant is one the guy down the street did. The reality is when you look at the gingival fibers around an implant, those fibers typically are not horizontal like they are on Sharpey’s fibers on a tooth. They’re vertical so I always tell the patients if you get a popcorn kernel stuck in a natural tooth there’s a defense mechanism to prevent it from going down. Same with a crown, if you had a little bit of extra cement stuck in on a tooth, it won’t go down halfway down the root surface. You get a little bit of cement stuck on an implant and you can push it halfway down the tooth and get a lot of problems. So when you see implants, you see not only mucositis problems which are not a lot of bone loss but gingival inflammation, those can be cleaned up by simple methods. Non surgical methods. But when you look at failing implants right now with bone loss, once it gets beyond 50%, doesn’t matter what you do, you might as well extract the implant and start over again and there’s a lot of effort now looking into how do I get rid of the granulation tissue, how do I disinfect the site because it’s got so many threads and you need- the hard tissue lasers is able to disinfect the thread completely and allow you to graft material back on so there’s a lot of excitement over lasers like the BIOLASE, the erbium lasers for disinfecting implant surfaces in a surgical manner on implants. So it’s really something that’s I’m lecturing a lot about right now and it’s an exciting topic.
Howard Farran: Do you think that bacteria, the bugs around a failing implant are the same as the ones around a failing tooth? Do you think perio and peri-implantitis bugs are similar?
Glenn van As: I don’t think that they’re similar but I do think that when it happens around an implant the machine surfaces are rough to aid for osseous integration but what happens, those same rough surfaces are very difficult to keep clean once the bacteria get on them so they just start to travel down and I think the bacteria that you have for peri-implantitis, I don’t think they’re going to be the same bugs that you find for peri-implantitis but the mechanism is much more aggressive and you see a lot more of it than people want to admit and I always tell people if you’re not sure, press on your implant, on the buckle surface. You’ll be amazed how many times you get something coming out of the sulcus and the patient says I wasn’t even aware that was happening. The microscope, when I have that hooked up and they press on it and they see the puss coming out, I had one today, she was literally crying. I didn’t do the implant, she had this implant done and I pressed on the buckle and I said you see that white stuff coming out of the gum, she said yeah, she said I get a bad taste from it, I said that’s actually infection that’s draining out of your bone.
Howard Farran: I’m always listening to you trying to predict what 1000 dentists questions might be around the world. You said implants have different surfaces for osseous integration. There’s somebody out there thinking well which implant do you use? What surface did you go to? Did you get a HA coded implant? What name brand and what surface does the wise Glenn van As pick for himself.
Glenn van As: I’ll just say that the surfaces are different but all implants will osseous integrate to a greater extent. Now if you took Straumann, maybe their success rate is 97%, maybe one of these lower price companies the success rate is 96% or 95%, but it’s not 75% or 35% so the difference is less. The differences between these companies are in the restorative capability, their service and support, their education, their commitment towards education so those kind of questions are the questions on the differences between implants but they all work. Now some people have a real preference for one implant system over another. I like HIOSSEN’s system because it has a SLA surface and they are doing some pretty cool things with some of their surfaces like BMP2 they’re going to start coding them.
Howard Farran: Bone morphological protein.
Glenn van As: Yeah they’re going to start coding them with that so you might find in the next year that these products are coming out and they’re finding in Korea that the products they’re loading at four weeks, because patients are always saying how long before I get my crown and if you tell them it’s going to be three months before I can load that tooth, a lot of them are like can’t you do something earlier. Some of these implants companies are looking at methods to try and get loading earlier than 12 weeks.
Howard Farran: Well Glenn I can’t believe we’re out of time. That was probably the fastest hour I ever spent in dentistry. I just want to say that in all seriousness, I’m not blowing air, you are one of my biggest rock star mentor idols of all time. Thank you so much.
Glenn van As: Hey Howard let me conclude by saying one thing: I started on Dentaltown in about 2002 and I started because it was nice to have communication with other likeminded dentists about various topics. I want to thank you for that. I’m going to tell you that the most amazing thing that I never knew would happen is how many people I’ll meet on a lecture circuit and they will say one thing to me: they say I read your posts on Dentaltown.
Howard Farran: Well thank you. We should start the mutual admiration club because I love you like a brother. Thank you so much Glenn for an hour of your time.