An interview with Dr. John Chao – Part 2
We were last talking to Dr. John Chao on his revolutionary Perio Gum Lift procedure, the Pinhole Surgical Technique. John Chao continues his discussion on how he developed the PST and how focusing on Periodontal needs of patients can be a great practice builder.
In this interview you’ll learn:
- How PST was developed
- How Perio can be a great Practice Builder
- How to prevent Furcation and tooth loss
This procedure sounds revolutionary. How did you come up with the Pinhole Technique? Did you have an “Aha!” lightbulb moment?
I have two answers, a short and long version.
Short Version: “I was sitting underneath a tree, and an apple fell down and hit my head.”
I’ve always been interest in periodontal surgery for a very long time for many different reasons. I believe general practitioners should build their practices upon Perio. You must treat perio as the fundamental first step. Then once you’ve treated it, you have a strong recall system to bring them back regularly every 3-6 months. The center of care should revolve around their periodontal health. We need to keep track of their perio health for the life of the patient.
I strongly feel that perio should be the first basic step in the building of a dental practice. Or to help an office convert from insurance based to a Fee for Service type of practice. Start with Perio. Then do everything else. There is so much to do with Perio.
In the 1994, after finishing Law School, I looked around and I realized that the practice of dentistry has changed quite a bit just within the 4 years I was in law school. So I decided to reanalyze my situation and pursued dentistry.
After graduating I realized the importance of building a dental practice upon Perio. Then I gained interest in perio grafting techniques because I was doing a lot of Class V fillings.
Then I took many courses from the very best in the country on perio grafting. The actual technique if very challenging clinically.
But I was most appalled by the results in terms of postoperative pain and bleeding.
I remember clearly the very last time I did the SGCT procedure:
I was working on a patient also named John. I painstakingly harvested a piece of epithelial tissue from the palatal donor site. I set it aside while I was doing a partial thickness flap around the surgical site. When I was ready, I grabbed my hemostat to suture the tissue. I looked around but couldn’t find the donor tissue. I heard a suction noise earlier and I then realized that my assistant Joy had suctioned up the graft.
Panicking, I actually contemplated on running to the amalgam trap to retrieve the donor tissue. But I quickly discarded the notion. After thinking long and hard, I was able to finally hunt and find some allow derm. We survived the situation by grafting the alloderm. But the patient never forgave me for causing him pain on his palate.
After that experience, I never did any more SGCT procedures, ever again. That was back in 2000 and I started to search and pursue a better way at treating gingival recession. Thought to myself, there has to be a better method that is less painful.
I studied the literature and investigated the whole thing. I saw that there were no methods that advocated getting to the recession area from the mucosa. I began to do root coverage from the mucosa, I realized that it would not work unless you make the opening very very small.
From that notion, I began to work from a very small incision and quickly realized that there needs to be a whole new set of instruments to work with from such a small pin hole. The instruments at the time would not allow me to work from a pinhole. So it took me 6 years to invent 2 different sets of instruments to allow me to do this procedure. After 6 years the exact protocol to go along with new instrumentation was finalized.
So that’s the long version of how I came up with the Pinhole method.
That is very outside the box thinking, as most flaps start from the gingival sulcus. Don’t think that anybody would have thought to start from the other end.
I think it’s beneficial for a General Practitioner to look at something like this. If you never start from a box to begin with, you are not trapped by the box.
In other words, I was never “boxed in” to begin with. I did not go through the training a formal specialist would go through. I was never indoctrinated. It was easy for me to break out of the box because I never had a true box to begin with. I didn’t have strict dogma ingrained on me. Was never constrained by the dogma because I was never steeped in the particular way of viewing Perio surgery.
In general, perio seems to be overlooked. Do you feel more general practitioners should start offering this treatment to correct gum recession in addition to routine SRP’s for comprehensive perio tx?
Receding areas often show signs of abrasion, abraction, and decay. Most of the time these areas are patched up with Class V resins, or with unsightly tall crowns on the buccal. Over time the class V’s just keeping getting larger and gums continue to recede.
Most of the time unless patients request treatment, many patients leave the office unaware of these perio procedures to help with recession.
It’s a shame, b/c when you treat perio, you’re not just limited to treating the early onset or moderate perio cases with just conventional root planing.
There are now 2 modalities that can allow you to do what periodontists do with osseous surgery.
1. Lasers: Lasers can take the place of osseous flap surgeries
2.Perioscopy: A tiny endoscope going underneath the pocket, showing images of the root on the screen. Then you can use the ultrasonic tip to then remove the calculus that shows exactly where on the monitor. You can virtually remove all the calculus on the root no matter how deep the pocket is without a flap.
It’s an easy skill to learn, my hygienists perform this procedure, I don’t even do it anymore.
It’s important for GP’s to know the crying need of treating periodontal health beyond just SRP. The technology today has advanced the modalities of treating Perio.
You can build a successful practice from just treating Perio. Then from perio you have your implants, bridge work, operative, restorative and cosmetic dentistry. Treat the foundation to frame the restorative work.
In addition, Perio usually has 80% insurance coverage vs 50% prosth. So there is so much more room for a GP to expand his work into Perio.
Since we’re discussing insurance, how exactly is the PST billed out as?
The basic code that I use is D4270 Pedicle Graft. According to the ADA code book, there are two kind of graft procedures. Free gingival graft, where you take a piece of tissue, relieving it of its blood supply, then you transplant it to a different site. Free from it’s blood supply.
Pedicle graft is when you move tissue from one area to another without cutting its blood supply completely off. So moving a tissue from a defective area to cover it’s root is called a pedicle graft, b/c there is still a pedicle of blood supply to give circulation to the tissue.
PST moves the tissue from mucosa to defect site, so it’s a Pedicle graft.
Guided Tissue Regeneration is also what PST is. Socket perseveration bone grafting is guided bone/tissue regeneration.
Instead of placing a membrane to cover the defect, PST brings the gums down over the exposed roots, instead of a sheet of membrane, we place collagen strips on the buccal of the root. This creates space for the bone to grow. Similar to guided bone regeneration.
We actually grow the bone around the root. So this is guided tissue regeneration. We guide the mesenchymal cells from the PDL, and from the periosteum and the fibrin clot to grow over the root, before the epithelial cells from the gingival tissues attaches to the root. Depending on which cells reach the root first, If the osteoblasts and the cementoblasts attach first we get bone and keratinized tissue. If the epithelial tissue attaches first, then we get scar tissue. We still get functional connection without a pseudo pocket, but no genuine true bone regeneration.
All the other methods, such as the SCTG, b/c the graft is epithelial in nature, if you put it up against the root, you will have long junctional epithelium. You won’t have a chance to get true bone regeneration.
So this is another advantage that the pinhole has. It allows for true Bone regeneration, b/c we are creating an environment for the osteoblasts and cementoblasts to grow back over the root.
It can be coded for the Guided Bone/Tissue regeneration. When we use collagen membrane as a separating medium between the root and epithelial tissue, we do get genuine bone regeneration. There are histological studies being done now to prove this. Again we are working on publishing these studies.
Any Limitations to PST?
Periodontitis is a contraindication. For this method to have the 80% predictability for root coverage, we must have a mouth completely free of Periodontal disease. Perio must be treated first.
Also systemic issues. One case a doc brought in a patient that developed tissue infection a week after PST, w/c is highly unusual for our procedure. We went over the patient’s Medical Health Hx again. Sometimes patients develop systemic issues after the procedure they’re unaware of or they don’t tell you the whole truth. In this case, the patient had an autoimmune disease she omitted from the health hx.
Case selection is critical. No compromised health and no patients that are non compliant with instructions.
There are no limitations to the sites that PST can be used on. It can be done in back on third molars, any teeth you want.
Can any GP easily learn and apply PST back at their practice?
Absolutely. About ⅔ of our docs are GP’s. Some are experienced at implants and others are not surgically experienced. We’ve even taken a new dental school graduate and taught him this technique. So it’s something that’s different but everybody is at the same starting gate. It’s as different to the Periodontist as it is for the GP. I personally teach them 1-1. We go through typodonts on the first day and then on very realistic, fresh cadaver heads, mounted to the headrest of dental chairs. They practice up to 6 hours on the cadaver heads. After the 2 days, they’re very confident and ready to go.
Once a dentist learns this technique, they start seeing a great demand in this area.
It’s like when you focus on the color blue, you start seeing all the blue objects around you, but you might miss the red objects, until you focus on the red ones. You start seeing things that you were previously missing before.
Any critical areas to avoid? Often paresthesia results from flap surgeries around the mental nerve, which often turn into big litigations cases.
For any lower bicuspids, the Pinhole is very safe. It is the least riskiest method for root coverage along lower bicuspids. The actual pinhole is placed right below the canine or the lateral. Then the instruments only point upwards from there, avoiding the mental nerve all together. Other methods are done from the sulcus done, involving flaps where they have to keep their finger over where they guess the mental nerve to be to try to avoid it.
Anything else you would like to add?
Yes, PST helps tremendously for preventative and longevity of teeth.
One of the areas often overlooked is molar recession.
With gingival recession around molars, we know over time a furcation will develop. We don’t do anything about it. We watch and wait until the furcation develops. Then after there is a furcation we refer the patient to the periodontist, when it’s often too late to treat.
GP’s need to be on the alert whenever they see any recession around molars. You must jump on it and do something before it becomes a furcation problem.
The easiest thing to do would be a Pinhole procedure there, to help regenerate bone and tissue.
You would be doing the patient a big favor.
The choices are:
- You wait for the furcation to develop
- You do the pinhole now
If we can see the danger and urgency in molar recession, we can catch and stop the furcation and tooth loss early on. There are many many first molars that badly need the PST done for them.
Finally, how can dentists contact you and learn more about your Pinhole Technique?
They can go to my site to watch many videos on the pinhole technique and find class information, and financial interest free payment plans with the lending club. Classes get filled very fast so doctors need to book in advance.
(If you would like a deduction, mention “Auxo” for a 10% discount off the tuition)
Watch a brief introduction on PST
Dr. John Chao Bio
Dr. John Chao is the inventor and patent holder of the Pinhole Surgical Technique. He currently teaches this scalpel-free, suture-free technique for correcting gum recession to Dentists from North America and from around the world. This method has been featured on over 240 TV stations, numerous blogs and newspapers. It is estimated that viewers reached by TV stations number about 25 million. Dentists trained in the Pinhole Surgical Technique are in great demand in the US and around the world.
Dr. John Chao graduated from the USC School of Dentistry and currently practices general dentistry in Alhambra. He received professional degrees from both USC School of Dentistry and Southwestern University School of Law. Dr. Chao has served as a reviewer for the Journal of Periodontology and he also teaches ethics at the USC School of Dentistry. Dr. Chao also holds the following professional titles: Master of the Academy of General Dentistry, Fellow for the Institute for Advanced Laser Dentistry, and Member of the Academy of Microscope Enhanced Dentistry. In 2012, Dr. Chao was recognized as the teacher of the year at the USC School of Dentistry for outstanding service over 10 years.
In his spare time he enjoys Lecturing and presenting at many dental societies and study clubs, attending and Hosting TV talk shows, and being a columnist. He also has a Doctor of Divinity, in Theological Seminary.