Revolutionizing Bone Grafting Techniques

Hi everybody, I'm Dr. Sanda Moldovan, periodontist and nutritionist. Welcome to the Holistic Dentistry Podcast, the show that gives you the tips and tools to detoxify your mouth for a healthier body as we explore together the root cause of disease. Remember, you're not healthy until your mouth is healthy, so take care of it in the most natural way. Today's show, I'm very excited today to talk about Bone Vitality Beyond the Normal. That's basically, um, having a conversation with Dr. Steiner, who is also a fellow periodontist. Um, and today we're really diving into what's the problem with certain bone grafts that are on the market, uh, and what should you be using as a dentist or as a consumer? Perhaps what are the questions you should be asking if you're going in and you're being told that you need a bone graft? So, Dr. Steiner, welcome to the show.

Well, it's a pleasure to be here and it's a pleasure to speak to another periodontist because we're definitely on the same wavelength and with similar training.

Yes. So I always read your articles and you know what you have to say about bone biology because you have such a different perspective on things. And to me, it is, you know, the right perspective. I've noticed myself, you know, finished my residency. And of course, everybody in their residency is taught to do bone grafts at this point and basically like throw everything in there and, you know, be fine. And what I noticed from my practice and, you know, I stopped using a lot of like the xenografts, synthetic grafts and the cadaver grafting, especially in patients that are immunocompromised, because I was seeing a lot of problems of non-healing. So I really want to dive into this topic with you to kind of make, make sense for everybody listening. What is really the truth about, you know, bone vitality when it comes to bone grafting? But how did you— I want to start with how you got started into Steiner Bio. How did you develop this company?

Well, uh, goes a long way back. I was, uh, trained as a periodontist, and I love periodontics. In my residency when I was at UCLA, which is, uh, your alma mater, as a dental student, I took my first periodontal class, and that was it. I wasn't going to do anything else the rest of my life. So I went from dental school to periodontal residency. I loved every bit of it. I couldn't get enough, and I was trying to be the best periodontist I could ever be, keeping up with all the research after I got out. And a few years after I got out, I just noticed that, hey, there's nothing's changing. And so I sort of thought to myself, well, maybe nothing's changing because I was so well trained. I was up on all the latest things, right? A few more years go by, nothing's changing. 10 years go by and I said, nothing is ever going to change and I'm simply not going to do this for the rest of my life. Telling my patients the same thing, telling my patients that I'm gonna do the same thing to them. All the treatments are gonna be the same for the rest of my career. 'Cause I know that was what would happen. And so I quit completely. I left.

Wow.

Moved to Hawaii, didn't practice for 5 years, 6 years, and, uh, was never gonna go back to periodontics 'cause I knew I just couldn't do the same thing on and on for the rest of my life. And, um, uh, then, uh, a colleague called and he had a disability. He needed to be selling his practice, but he needed somebody to keep it alive until he could get it sold. So I says, okay, I'll come back. And so, uh, in that process of coming back and helping him out, I read everything published over those last 6 years to make sure I was current with my knowledge. And I was current with my knowledge because there was nothing new, which I already knew. But I had to confirm myself. And so when I came back, I had a completely different perspective, and, uh, I wasn't bound by my training any longer because I had cast all that off. And, uh, I just thought about it, and I looked at it, says, these grafts aren't working, uh, the surgeries I'm doing are not working. So as long as I'm going to be doing this, I'm going to make new bone grafts, and I'm going to make new surgeries, and I'm going to figure something out that works better. And that's why I'm sitting in front of you today.

Amazing. So how did you, you know, the process of getting something started? And I know because I've started a lot of different things and it's always difficult to get that idea of getting a new type of bone graft. So how did that idea spark for you?

Well, what I knew about the bone grafts at that time was that I know none of them actually stimulated bone formation. The best you could hope for is that the bone graft you put in there would hopefully go away and leave you with bone. But none of them stimulated bone, none of them made much difference. And so I set out to find a bone graft that actually stimulated bone formation and resulted in normal bone as a result. And that's what led me to actually find a key to what forms normal bone. And what stimulates bone to form. And also I put that into a biologically compatible carrier, and that's what we have today as our— the basis for our bone grafts.

For those people listening that maybe you've had a bone graft, you went to a periodontist and you did a bone graft, you know, what exactly— we're going to start with the basics. What is a bone graft? A bone graft typically is something that, you know, it's needed when we're trying to regenerate a structure around the tooth. Periodontics— peri means around, dontics means the tooth— so any structure around the tooth or maybe around an implant where bone was lost due to disease or trauma. We're trying to bring it back. Do you have any other definition of bone grafts, Dr. Steiner, that you wanna—

Yes, because you used a term that all dentists and periodontists use that's inaccurate, regeneration. In order to consider something regenerated or a regenerative process, it must wind up with normal, healthy bone exactly the way it was before. So that's what regeneration means. And virtually none of the bone grafts on the market produce normal, healthy, vital bone, either because it's scar tissue or because there's residual graft particles in it that never go away. So basically there's, um, there's extremely few bone graft products on the market that actually regenerate a site. That's where we're different.

Absolutely right. Because we know, like, so the different kinds of bone material that we have today are cadaver, meaning donation from another human. We have, uh, sperm whale source, we call them xenografts, either cow, uh, could be horse, it could be pig origin. Uh, it could be synthetic. And there's all kinds of— I mean, I've seen glass particles being used. It could be like calcium sulfate, or we can have somebody's own bone that is being just transplanted either from the back of the jaw, moving it forward, or whatever it is that we need it. Now, how did you discover this bone induction? That comes along with your material.

Well, the process came down to that's all I was searching for. I was searching for something that I wanted to be able to put in a patient that would stimulate their bone to grow. And everybody at the time was looking at what was already there. Everybody looked at bone healing and they looked at bone healing in the most minute manner, studying the various molecules and the molecular reactions. And PhD scientists at our best university spending all their time focused on what was in the site that they could manipulate to make the bone heal better. And I thought to myself, that's not the problem. 'Cause bone heals very poorly, very on its own. And so the problem must be, it's not what's there. The problem must be what's not there. And I was able to find out what's not there. And introduce that into our bone grafts. And that's why our bone grafts actually stimulate bone regeneration.

Are your bone grafts, for those people listening, any like human origin or cow origin? What is the basis of your bone?

No, those are heretical words in our building here. No, nothing, anything that comes from an animal or human is gonna cause inflammation in your body. You, you deal with holistic therapies. And so, you know that any protein that comes from another, uh, animal or human into a patient is not matched. And in fact, in dentistry, it's pretty amazing. We do trans— a cadaver bone graft is a transplant, right?

It's not, yes.

Not a science-based material. It's simply taken from one person, put into another. Uh, and in dentistry we do these transplants not having any clue and any understand— understanding about transplant medicine. Okay. If you're gonna have something transplanted in a medical situation, they're gonna test it with phenomenal amount of testing to figure out if this actually matches our patients. And because if it doesn't match, it's a disaster. But in dentistry, ah, we got a bottle of something here. We don't need to match anything. We're just gonna put it on our patient, hope for the best. Well, oftentimes when you're dealing with animal or human transplants, which are cadaver bone grafts, they don't match up at all. In fact, they never match up. And what you get is a variation of the amount of rejection that you get. So when you take, uh, a cadaver tissue and you put it into your patient, the best you can hope for is scarring. The worst that's gonna happen is it's gonna be total rejection and failure of any of your grafting, but you're never gonna get regeneration because the process is completely inflammatory. The process of mineralization using a foreign protein like a cadaver protein, that process of mineralization happens through the inflammatory process because of all the inflammation that's created. And that type of inflammation results in what's termed as sclerotic bone. Sclerotic bone is just another name for scar tissue.

And a lot of them, you know, one of the big topics on my podcast is cavitation areas. And, you know, some of these bone grafts, we actually see bacterial components, especially if the socket is left open at the time of grafting. And there's no circulation. Oftentimes I've gone into these sites that have been bone grafted with, you know, cadaver or animal, and there's really no circulation.

Well, you're absolutely correct on that part, and that's a critical part because that's one of the pathonomic features of sclerotic bone. Let's take, let's take a scar on your skin. If you have a wound on your skin, sometimes it heals without a scar. That's great. But if you have a wound on your skin that is slow to heal, in other words, the healing becomes chronic, That leaves a scar, and a scar is basically a bunch of dense collagen that is nonfunctional. It doesn't move, it doesn't bend, it doesn't flex. It will never change for the rest of your life. That is the same thing that happens when you put a cadaver bone graft in somebody's jaw. It's just that the scar tissue in bone mineralizes. That's the only difference. It's just like the scar on your skin. It will never be functional. It'll never change. It will never adapt. Never go away, and that's what you're putting your implant in.

Uh-huh. And actually, we do know that in grafted bone, we have more implant failures and more peri-implantitis. And probably it has to do with the fact that, you know, there's no circulation. It's really a scar. It's not completely healthy bone.

Uh, you got that right. Absolutely. And we spent quite a bit of time I set out to create regenerative bone graft products, but of course, I'm involved in dentistry and I'm also treating patients. And I took over a practice in Sacramento from two previous periodontists. One was a guy that was trained in the military, never did a bone graft in his life and never did, but he put in some implants. I never saw a failure from him. Somebody came in for two years before me, was a recent graduate out of UCSF. And, um, he was putting in implants and doing bone grafts. And here I am seeing failures and I'm looking at 'em being a bone guy. I'm gonna look at the bone and it just, all of the failures I was seeing were implants put in cadaver bone graft by this young, very knowledgeable periodontist that was there just before me. And that's how it dawned on me, it's the graft and that's the problem. And so I've done a lot of histology and we've actually gotten to the point where we understand the process of how sclerotic bone fails. And yes, lack of blood supply is a factor, but really it's— the problem is this, like a scar, like I said, any structure in the human body that can't adapt is going to fail. And you can liken that to just a bridge on the road. You have to maintain them, you have to check them out, you have to do maintenance, or ultimately it's gonna fall over even though it's strong. In the body, if you put an implant in sclerotic bone that can't repair itself, ultimately it's gonna build up enough damage that that implant's simply gonna fall out because the bone breaks up and the implant falls out. Yeah, there's very little blood supply, that's a factor, but it's the whole concept that the bone that you're creating cannot repair itself. And when you have that situation, it's only a matter of time before the implant's gonna fail.

So the bone graft that, You are offering, and that's actually inducing bone formation or stimulating bone formation. Is that a resorbable product then?

You should never put anything in a person's bone that isn't completely resorbed. Every one of our products are resorbed. In fact, almost all of our— well, all of our products are cleared by the FDA for putting an implant in them. And we're virtually the only bone grafts that are cleared for the FDA to put an implant in them. The reason is we are fully resorbed in the time period needed, and our putties, like our SocketGraft, it's resorbed fast enough that the FDA allows you to put an implant in it in 2 months. Our Osteoconduct granules are resorbed in a period of 6 months, and that's what the FDA has allowed us to actually state in our set of indications, that you can put an implant in our site grafted with our material. You look at almost any other— in fact, you go into any— dentists never do this. Physicians do this a lot because indications are very important in medicine. Dentists never read the indications. But if you look at the indications on your bone graft box, it'll tell you what you can do with it according to what the FDA has allowed. And I can almost guarantee you, if you're using almost any other bone graft, it will not say that you can put an implant in the site grafted with that material. Because they don't have proof that it will last and it doesn't have a success rate associated with it that's acceptable to the FDA. And most dentists, dentists don't hear that because almost all dentists lecturing use cadaver bone grafts and they don't wanna, they don't wanna deal with that.

It's so true. I, I think probably like most of the bone grafts used today are cadaver grafts.

Yes, by far.

Yeah, by far. Um, and actually can recall a patient of mine who, uh, had a cadaver graft done and she developed autoimmune issues. And what I actually had to do is go in the jawbone, clean out the entire graft, and she actually reverted back to normal.

Well, that's phenomenal. There's a lot more of that going on, but it's very rarely linked. Uh, a good study was done in Germany where they actually studied grafting with an allograft in patients and looked at the systemic inflammatory response, looked at what the immune system did in response to that graft. Now, some of the grafts only had a localized inflammatory response, but other grafts had systemic inflammatory responses that were persistent. And those grafts did very poorly and actually failed because the body rejected it completely. And so, uh, but all amazing, you, a cadaver bone graft, if you take a core sample of any cadaver bone graft such as an allograft or Bio-Oss, um, they will be chronically inflamed and it will never be anything other than chronically inflamed. And that's what the pathologists tell us. Now you have very few studies published. There's only been 2 studies published where the pathologist looked at the histology. Most all studies are done by periodontists or oral surgeons. They get, they do a, sample, they look at it and they say, oh, this, this looks fine. They don't know what they're looking at. I don't know about you, but in my periodontal training as a specialist, and I think today, uh, we aren't trained to look at histology to determine what's healthy bone, what's unhealthy bone. We don't get that training. And so periodontists simply don't know it.

Really, we have to let the histologist interpret this for sure. Um, So I wanna talk about this, 'cause you mentioned systemically inflamed and chronic inflammation. The healing happens via acute inflammation. So I think we've gotta, I would like to establish what is acute inflammation, what is normal, and then what is chronic, when does inflammation go chronic?

Okay, that's a good question because all surgeries cause acute inflammation. No matter what you're doing, how you're doing it, you're causing acute inflammation. Because what happens when you do a surgery, you make an incision or you drill on the bone, there's damage to the tissue and the acute inflammatory process is absolutely vitally important. It must happen because the acute inflammation comes in and removes that damaged tissue as a result of your surgery. And then what you need to do is transition immediately from that acute inflammation once the damaged tissue removed into regeneration. But if you transition from acute inflammation to chronic inflammation, such as a cadaver bone graft, then you get scar tissue. So the chronic inflammation is something that you have to avoid in order to have normal tissue. You will never get bone regeneration if you have chronic inflammation.

Exactly. So definitely, you know, some acute inflammation is actually also needed to kind of stimulate that initial bone formation.

Exactly.

Now, your technique is different because you actually go back to place implants, I think sometimes even 1 month after extraction, after grafting. Is that correct?

That's my go-to procedure. Yes, that's my favorite. And it's a favorite at my office too, because all my staff members know that they get a coffee break every time we do one because it takes so little time. So because the concept is this, We graft the site when we take the tooth out, of course. One month later, we go to put the implant in. There's a number of advantages. Not only is it very short period of time, but we don't have to, uh, make any incisions, lay any flaps, expose any bone, because once we take that membrane off after a month, then there's nothing but immature bone underneath that membrane. It's not covered by gingiva at that point. So we just drill a hole and screw the implant in. And the concept is this. What you're doing is you're putting your implant in as the socket is healing, rather than waiting for the bone to completely heal, let it go to sleep, because after bone heals, it basically goes to sleep, then drilling a hole into it, and then hoping it gets kicked into gear and starts to heal around your implant. So the whole idea is put the implant in when there's a massive amount of millions of regenerative cells present, which is what's happening when a socket is healing.

Makes total sense to use that growth factor power during the healing process so that the implants, you know, are already set in a bed where all this healing is taking place.

Yes, it's very— and there's a number of technical things that you have to be very concerned about, but once— it's very simple to do. Once you got those technical things worked out, we do any bicuspid or incisor that has a complete socket. Meaning that the extraction left a nice alveolar process. We graft it and then incisors and bicuspids, we go in in 4 weeks. Molars, we go in 6 weeks because it's a larger area and takes a little longer to mature. So we go in molars in 6 weeks.

Now, is your product indicated for times where we can— we want to do an immediate implant and put the graft around it, or you need that healing time?

Nope.

It—

in fact, we— I do quite a few immediate implants. In fact, we— what I do now is I have a product called biodensification, comes in a very small amount, 0.3 cc. And so I take out or I remove the tooth, prepare my osteotomy for my implant, I fill it with biodensification, which is a putty type of material, and then I just screw the implant in and it's grafted and it's done. And our products are the only products that have been proven to actually integrate to the implant surface in an immediate implant situation. No other bone graft does that. You put your implant in, you do an immediate implant, you put your packed cadaver bone graft in it, you fill the hole, it looks great on a radiograph, but it's not attached to the implant.

Yeah, that— I've definitely seen that happen. And for those of you listening, the reason why we're talking about, you know, especially in the front area, The reason why it's important to fill the gap, you know, once you take out a tooth and place an implant, we need to fill that gap somehow so we don't get that collapse, especially in an aesthetic zone. You know, like if somebody like with like me, I have a gummy smile and then now, you know, if I have a collapse of the front bone, it's not going to look aesthetic. So we need some material there in that gap in order to preserve the smile line. Do you ever see any adverse reactions to your material or any contraindications?

To be perfectly honest with you, I'm a little hesitant to answer that because it's not possible with our graft material. You cannot have an adverse reaction to our graft material because there's nothing in our graft material that's not already in your body in its precise form. And so you can't have an allergic reaction to yourself, and therefore our graft materials exactly mimic what's in your body. And so you can't have an allergic reaction. We've done all types of testing for the FDA, and it's completely biocompatible.

Okay. But I mean, something like infection, obviously, have you seen that? Or do you still put patients on antibiotics, or you don't?

Yes, I do. I do put patients on antibiotics, but it's not so much for the graft material. It's pretty much for the surgery that I perform. The graft material, let's put it this way, bacteria need places to grow, right?

They need—

they just don't grow out in soft tissue very well. And so when you put in a bone graft, if there's no place for the bacteria to hide in order to, you know, multiply that is away and protected from the immune system, then they can't grow. And so our graft materials, which is our granular graft materials and our putties, don't allow bacteria accumulation. Our beta-tricalcium phosphate granules have a microporous structure, and that structure is below the dimensions that are required for a bacterial colony to form. So you can't, you can't form bacteria in our granules, our beta-tricalcium phosphate granules. In fact, when you put our beta-tricalcium phosphate granules they immediately get coated with macrophages. 'Cause the macrophages are first line of defense. They don't cause inflammation, but they recognize it as foreign. And so now you've got a granule in there that has no room for bacteria to accumulate in, that's covered with macrophages. That's not gonna get infected. And our putties are designed in such a way that the only— you have to be, uh, mobile to be able to get into our putties. Our putties are designed in such a way that the only thing that can get in there is something that crawls. And very few bacteria crawl. And so almost any bacteria you have, you know, it doesn't have legs, it doesn't have pseudopods, it doesn't have any motility to it. So the only thing that can get in our putties are, you know, our osteoblast regenerative cells that actually are mobile and crawl around. They crawl in, but nothing else can crawl in. So the problem with infections, we don't feel our grafts get infected, but the surgical site can get infected. So I always use, if there's no Current infection, I use low-dose antibiotics usually.

Now, now you've described, you know, bone as one of the most complex organs in the body. And why do you think there's such a gap in education about bone physiology in dental training?

That's easy, because when I was trained, we didn't do anything with bone. We didn't have dental implants when I was trained, right? And so, uh, when did dental implants really become popular? Maybe 20 years ago, right? Yes. It started to become popular. So before then, we didn't need to know anything. We, we didn't deal with bone. And so still to this day, I talk to recent graduates outta dental school, they get no training in bone whatsoever. Still today.

True.

Specialists, they get trained on how to use bone grafts, but I don't hear anybody that's getting trained on bone, what bone is. And what happens inside the bone. What do the various bone grafts do to your body when you put them in? I don't hear any specialists even getting trained. And so the problem is this. The problem is, is that all of our professors today have never had any training in bone because they're older, right? And so when they got their degrees and they graduated, they never had much of a need to be trained. So they were never trained, and they're the one that's training us today. So there's nothing out there.

So, no, I mean, I did residency 20 years ago and I've got to say, I can't say that we— I remember actually distinctly learning about bone healing, maybe just the basics. You know, there's 4 stages to bone healing, but you're right about what the actual graft and how that incorporates in the bone. I don't think we went to that depth. We just looked at clinical studies mostly to see what works and what doesn't.

You're exactly right. And it hasn't changed.

Mm-hmm. That's true. It hasn't changed.

And you know, you go to meetings and, I don't go to a lot of dental meetings anyway, but you go to meetings and nobody's talking about bone physiology. Nobody's talking about what's happening to the various bone grafts that are put in a person's body because I hate to say it, you know, there's only two people that know about bone. Okay. The only people that really know about bone are PhDs in bone biology. They know, they, they're the people that know about bone. You're never gonna hear a lecture from one of those guys, right?

And I would be good.

Yes, it would be wonderful. The only problem with bone is it's, it's, it's good to have any type of training you can get with bone, but it is such a complicated subject. It is the, in my opinion, it's the most complicated organ of the body by far. Without question, a brain, it's just a bunch of neurons, right? A liver, that's complicated. You know, different parts of the body, muscles, not that kind. It's just muscle cells. But you take bone, not only is it allowing you to walk, stand, run around, it's got joints that move. Then inside of it is what creates all of our blood cells, all of our immune cells. I mean, bone, in my personal opinion, is the most complicated structure in the body. Course, I feel that way because it's my subject.

So I know for sure, you know, I was always fascinated about how you have this whole cascade that needs to happen. You know, you have the osteoblasts and osteoclasts, basically cells that are forming bone and resorbing bone. And that process is so complex that if one of those steps is like cut off, for example, like the use of bisphosphonates, you know, cuts off that, that basically completely stops bone metabolism and bone from forming. Any words of wisdom when it comes to patients with bisphosphonates and bone grafting?

Yeah, I don't really worry about them at all. There's been a big scare and I lived through it. It was really sort of funny because I go to bone lectures, I belong to bone societies. One of the main ones is the American Society of Bone and Mineral Research. I've been going to them forever. And way back when I was sitting in their lectures and they were telling us that this whole new idea about bisphosphonates causing ulcers in the mouth is just ridiculous. They said, "Nah, that doesn't happen." And I'm sitting there saying, "I'm a dentist and it happens." And so they really tried to, downplay it and act like it didn't work. Well, why is that? Because bone scientists were relegated to the back hall closet because they didn't have anything that was of much monetary value, right? They didn't sell anything, they didn't make anything. But when the bisphosphonate came on, they became wealthy. I mean, the money poured into the bone society like you can't believe. So they were a little bit biased and very protective. And so the whole bisphosphonate thing was an interesting story when you were looking at from a bone perspective. But now the thing is about the bisphosphonates, the problem with the bisphosphonates is not your implant integrating because the bisphosphonates only block resorption now. And thankfully it doesn't completely block it because if it completely blocked all resorption, then you would not get integration because as we talked about, the acute inflammation needs to remove any damaged tissue. You drill a hole in the bone, you put your implant in, and you just crushed all the bone adjacent to that implant. It's crushed. It's got to be remodeled. So there has to be some resorption, but the resorption is adequate for removing the damaged tissue. But the cells that grow bone aren't affected by the bisphosphonates at all. They function perfectly well. So, uh, I don't worry about bisphosphonate patients, um, at all.

That's good. Good to know. Now, I know, you know, your, your beliefs on bone grafting, because, you know, you spoke so much against the things that don't work, like, you know, the cadaver grafting and the xenografts. You face quite a bit of resistance from the dental community because you're challenging these, like, mainstream beliefs. And that's usually what happens when you're challenging mainstream beliefs. How are you navigating or how have you navigated those challenges and Have you seen like a shift in acceptance? Like, are we accepting this more?

Oh yes, absolutely. Well, my attitude is I never go looking for a fight. I'm smart enough for that. But if somebody wants to fight, I love to fight. So, uh, but so as I was telling you, I came into this practice and I was noticing this problem with cadaver bone graft failure in implants, and it seemed like that's what they all were. Uh, I started looking at the histology of cadaver bone grafts. I started studying the medical literature. Because, uh, cadaver bone grafts create sclerotic bone. And, uh, when you have osteoarthritis, the bone in your joint is sclerotic. So it's the same tissue and the same function. And so I was able to go into the medical literature to understand why these implants are failing in sclerotic bone. And, uh, because of that, that allowed me to take that information and start talking to dentists about it. And I started talking to dentists about, you know what, You think your cadaver bone graft stimulates bone formation? You think it's resorbed? You think it goes away? You think it produces normal bone? And I could go into the dental literature and pull out all articles that disprove that. And there was never one article that said it was true, not one. And so I confront dentists with it and they don't like it. And so 10 years ago I confronted them with this information, um, you know, in a professional, hopefully pleasant way. Oh, and I would just— they would cuss at me. They would yell at me. They would condemn me. How can you criticize this wonderful graft material? That was 10 years ago. 5 years ago, that went on and it's quieted down. Today, crickets, because everybody I think that uses cadaver bone grafts today knows there's some problems. They're just not willing to deal with it yet. So there is a— and plus our our company's growing. We're, we're getting new customers every day that are looking at their graphs in a different manner, a more critical way. And they're looking— they're not liking what they see because I'm pointing it out to them. And when they see that, they're interested in making a change. So there is— there has been a sea change in how this is accepted. Now, I don't know if the journals will still accept this information because they're Uh, they're run by professors that still teach cadaver bone grafts and they don't really wanna see publish the things that, uh, I have, um, that I've come up with. Uh, oh, maybe 4 or 5 years ago I came up with a few papers that explain the process. All the journals rejected it. Uh, so I got it on preprints, but I'm thinking of resubmitting it because, and I'm thinking of resubmitting those papers to Jay Perio just to see what their reaction will be.

Yeah, well, I think they're definitely more open to it because I know there's a product called, I think, Gen 21 that I was actually using Beta TCP together with. So I think people are just— I find it very interesting that they ended up using that carrier for Gen 21.

The Beta TCP is by far, without question, the best granular out there on the market. There's nothing that compares to it scientifically, statistically. His performance is the best there is.

Yeah. So I think that just because I see other companies doing that, you were onto something early on. So I think there's definitely going to be, as we're seeing more autoimmune issues in patients, and you're right, maybe we're not associating them to the oral bone grafts, not for everybody anyway. But I think the more knowledge we have out there, you know, that, and that this could make better choices in their grafts.

It's a real shame because as dentists continue simply, well, you know, you go through your residency, you believe your professors, right?

Sure.

And they're smart, they know what they're talking about. And you can't imagine that they're misleading you. They're not doing it intentionally, they just don't understand. And so every periodontal program in the United States still packs cadaver bone grafts in their patients and, uh, they don't know how to use anything else. And periodontists are the worst cuz they'll go through 3 years of training using nothing but cadaver bone grafts. And so they come out and they say, Doc, I've never used anything else. I don't know how to use it. And so there's, there's some resistance there. And the resistance is primarily coming from the professors. But the professors, they, they all know, because if you know all the things that you've received from us as Steiner Bio, that goes through the professional ranks and all the professors read the same thing. So they're aware of what's going on.

Yeah, I care. Your graft is easy to use, which is nice, the Beta-TCB. But you mentioned earlier on that you're actually putting a membrane. You're talking about a non-resorbable membrane for the guided wound healing, or is it a resorbable membrane?

Well, let me explain membranes. Membranes basically, as I said, the regenerative process, it cannot have any inflammation whatsoever associated with it. If there's inflammation, you're never going to get regeneration. And any type of membrane that you put over a bone graft has to be completely biocompatible. If it's resorbable, resorption is the opposite of regeneration. So you have to have breakdown of that material some, some, some way. And almost always the breakdown of that material, if it's any type of resorbable product, is usually an inflammatory reaction that actually the inflammatory cells get into the membrane and start attacking the membrane, and that's how it's removed because it's a foreign protein. And so you— we tell our patients or our customers, you can't put anything other than a biocompatible bone graft membrane over our bone graft or it won't work. It'll stop the production of bone. And so no resorbable membranes are advised.

Yeah. And in terms of non-dissolvable membrane, Yeah. Is it basically just one type of membrane that exists or there's different types out there?

The only one that I've ever used is Teflon, which is dense polyfluoro whatever, you know. Originally, I was quite skeptical of all membranes and I was actually thinking about developing my own membrane. I actually hired a PhD chemist to develop a membrane, but then I realized actually that that's probably never going to be able to develop something that, that's resorbable. And doesn't compromise the healing process. So I use the, the Teflon membrane. It really works beautiful. I like it, but that's not my preferred membrane and I never use it for periosurgery. I'll use it for covering sockets because it's a good barrier, but I always use the periosteum for perio or most of my bone grafts. I use the periosteum instead of other bone graft, other membranes.

Other membranes. Yeah, that's very good. I mean, that's definitely a more biological way to go for sure. But I've used also the non-resorbable membrane, the PTFE, and they do work well for sure. What advice would you give to patients who want to be proactive in understanding and advocating for the dental bone grafts? Like, what kind of questions should they be asking? Maybe 2 questions if they do need a bone graft.

Well, here's the problem you're going to run into as a patient. Uh, the doctor's gonna offer you a bone graft and he says, I'm gonna do a bone graft here, but he's not gonna tell you what's in it. He's not. Cuz he knows if you say cadaver, the ears go up and you're, you're repulsed. Okay. So he's not gonna tell you what's in it. You're gonna get it in your body and you're not even gonna know what is in it unless you ask. And I get this question a lot, even though I do what I do. Doctor, what's in it? And that's the best question a patient can ask. Don't accept anything in your body unless you know what it is that he's putting in there. And if you ask him, then he's going to tell you, oh, well, it's a cadaver bone graft, but it's totally safe. You can't catch anything from it. Uh, it works really well. It's gonna grow your own bone back. It's gonna stimulate healing and it's gonna be fine. And everything he's just told you is false. So yeah, that's the problem. And so if I had a patient that was listening, just don't accept anything that's out of another human being because there's nowhere you can ensure that you're not going to catch something from it, have an inflammatory reaction to it, or if it's going to work. And so you should be using something science-based that an FDA— that the FDA said, yes, this will work for your needs. And that's what—

yeah, I like that advice. I think that's great advice. If you are in need of a bone graft, definitely always be curious about what's going on in you, inside your body, of what somebody's about to put into it. And I know you have a great 1-hour course online about, you know, bone healing and bone biology. We are going to put that link down below in the show notes for any dentists that are listening, or hygienists, or anybody in the dental field, or patients who want to learn about bone. And also we're going to put your website for those dentists interested in finding out more about your bone graft, do you offer like some courses or is it pretty much easy to use for somebody that, let's say, has done other bone grafts?

Well, we have continuing education courses. We have our short course, which is about a 2.5-hour course for professionals. It goes through bone biology. It goes through how the different bone grafts work, and then it goes through how some of our bone grafts work. And then that is a short course for a 6-hour a CE course that goes through everything in detail. If you wanna— if a dentist wants to understand, and believe it or not, we've had some of the most preeminent professors take this course, uh, and it's 6 hours, and basically it goes into a lot of detail on bone biology. It goes into a lot of detail on the different types of bone grafts and how they work in your patient, and then it goes into our products and how they work. And so that's out there, but, uh, I'm just finalizing this week after a year, we're putting out a course on why implants fail. And that's turning out to be about a 2.5 to 3-hour course. And, uh, it goes into basically all the reasons why implants fail. Uh, and one of the reasons we felt it was necessary, because, you know, if you have 10 dentists sitting around and they're looking at a radiograph and you see a failing implant, there's gonna be 10 different reasons why that implant failed, right?

Absolutely.

No one can agree on why that implant failed. Well, there's only one reason that implant failed. And the only one reason that implant failed is because the bone failed that holds the implant in, because implants never fail. Only bone fails. And so if you're not, if you don't understand bone and you don't look at the bone, then you're never gonna figure out what the problem is. And so it's really simple— only bone fails, implants never fail.

Yeah, so true. And, you know, exactly, a lot of dentists don't even recognize bone starting to fail when it just begins. We see it sometimes, you know, I get referrals like the implant— that bone is 80% gone already.

So way too late at that point.

Exactly. Yes. Yeah, so, you know, excellent that you're having these courses for everybody to understand and really, you know, help make the right choices for patients, the biologically correct choice. That's it.

I see your sign in back, the holistic, holistic dentistry. Now, I'm sure you've got some grief being a periodontist that's holistic because, you know, when I started out a long time ago, the holistic group of dentists Well, let's, let's say they took a lot of heat for a lot of things they were involved in. And, but there's such a wide range of the concept of holistic. I mean, you know that also, but basically we have a lot of holistic practitioners simply because I can assure them that our product does no harm and will not have any negative symptoms. So we have a lot of holistic dentists that have transferred over to our our products. And so the idea— the one thing I like about the holistic group is because they are holistic, because they're open-minded. You have to be open-minded to become holistic because you're never taught any of this in your training at all. And so it's like a dirty word in the academic circles, right? You know, but we find that my experience is change only comes from the group that's not mainstream. Mainstream is only interested in maintaining their position and their reputation. It's the outside groups that are not in the mainstream that actually affect change. And a lot of holistic people are doing things that are very interesting and I think are going to become mainstream in the future. And so I like working with them and, and they're a good group to work with. But I do imagine When I, I heard your name, I, I didn't know of you until you contacted me, until— and then I saw you were a periodontist. So this is amazing, we have a holistic periodontist. That's awesome. I do know an oral surgeon, I know that. So there's, there's some out there.

Yeah, this is from my own challenges with healing, and I became a nutritionist. And I, I want to put here above an actual W in front of holistic, because that's really how I think about holistic, just really treating the whole and really being mindful of the things that we do in mouth affect the body. And, and it's still unfortunately a disconnect in the dental community that that even happens. So, um, I was recently at the IAOMT meeting, and I was so happy I, I actually met a handful of periodontists that were actually there learning about the, the whole integrative approach. So, but I agree with you, for a lot of people, holistic with an H is kind of like, oh my God, are you doing some woo stuff? No, We're really— we want to be based on science. We want to do the right thing. We want to be biocompatible. I think that's really the meaning of the word.

Yeah, I think that, but that's, that's the most important part. And, uh, everything we should— we put in our body has got to be biocompatible. If it's not, it shouldn't be in the body. And that's our philosophy at our company. And, uh, we didn't start out that way. We wound up that way because we, we studied all of our efforts into making us understand what works. And guess what? The only thing that works in the human body to get it to heal is something that's biocompatible. And so we didn't start out this way, we wound up this way by constantly studying constantly what works in the human body.

Yeah, and following what makes sense, what makes sense for healing, which, uh, instead of just following the recipe that you were given in school. That wasn't the right—

anyway. Now, with your communication, you're in the AAP. I've had some run-ins with the AAP, shall we say. Do you have much communication with other periodontists out there, and are their minds being opened up to anything other than cadaver bone grafts?

Yeah, I'm actually— I was just at the meeting over at the AAP meeting in November, and I have to say there's more and more people being open to, okay, let's look at how everything is affecting the body. So I want to say yes, there's definitely more, uh, openness to doing things more biological and getting away from the, from the grass that come in a bottle. Definitely.

Well, that's good to hear. We've been pushing it for a long time. We used to go to the conventions, we used to go do advertisements, but what we've come, what we've come down to is that The only way we can promote our company is through education. Nothing else works for us.

Absolutely.

If, if I can get a person an hour or two of a dentist's time, I can make him understand what we're doing and why. But an ad or a booth in a convention is of no value for a company like ours.

Yeah, definitely. And one of the things that I'm going to be launching in the next year is ceramic dental implant courses. So, um, I would love to talk to you more about that. And, you know, to just hopefully you wanna join me in this effort in changing dentistry and really making it more compatible.

Well, that's all good. I've had experience with ceramic implants for many, many years because many of our customers use 'em a lot. And I think here's something that's I think a little different with ceramics than titanium. Titanium is what it is. You're never gonna change it. It's never gonna improve. It's not gonna ever get better. But with the ceramics, it's scientifically constructed. It's put together by scientists that are really smart people, and they will constantly endeavor to make it better. And that's the same way with science-based bone grafts that we do. We're science-based. We can always improve our bone grafts. You can always improve a science-based implant, but a titanium implant is going to be a titanium implant forever. Uh, I've seen ceramic implants greatly improve over the years that I've been involved in, in bone and implants, and I think they're getting to the point now where many people are feeling very comfortable with their use and longevity and that type of thing. But I, I like to tell dentists, I don't know anything about implants. Only thing I know about is what holds them in. So I don't know that much about.

But that's an important part. Well, Dr. Steiner, this has been so informational. I think everybody listening found it hugely helpful. You really have been enlightening in your comments and conversation. Any last minute words that you want to leave us with?

Well, the— what I would leave you with is the biggest problem we have, I think, in dentistry today is falling into a routine of what we've been taught and thinking that's the best thing to do. Because unfortunately, what we're taught is something that is historical, not so much science-based, not so much something that's forward-looking. And I would think that any, any health professional out there needs to question everything they're doing and actually try to find out is what they were taught the right thing to do to their patients. Because the problem we have is everybody that's out there saying, let's say cadaver bone graft's a perfect example. All the universities teach cadaver bone graft. If you're a, if you're a periodontist and you want to get into the academic environment and you want to work in a clinic, well, you're not gonna get there with our products cuz everybody uses cadaver bone grafts. And so it's a closed loop that just feeds on itself. And to break that cycle is the only way we're gonna start improving the educational process for our dentists that are coming outta dental school. And so, uh, if anything needs to happen, it's our educational system needs to update itself about 30 years.

So, yes. Yes. I'm determined to help out with that movement.

Well, that's great. You're going in the right direction then. That's very— well, it's been a pleasure talking to you. I love talking about bone. And, uh, as I said, I'm honest when I say it's the only thing I know about. But I spent full-time studying bone for about 25 years now, and I love studying. I love talking about it, and I'm happy to talk about it anytime you've got a question. Please shoot it to me, and if I can be of any help, I'd be glad to.

Thank you so much. I'm definitely going to take the 6-hour bone course. I'm super interested in that.

Okay. Okay. Well, I hope you can make it because it's long and it's science-based, but if you can get through it, I think you'll realize it's of some benefit.

Awesome. Well, everyone, thank you so much for joining us today. You can go to my Instagram page @DrSandaMoldovan and leave us any questions or comments about today's podcast with Dr. Steiner, all about bone grafts, and leave me any notes about future shows that you're interested in. With that, everyone stay healthy. Thank you so much for joining me this week. Please make sure you check out the show notes for any links mentioned in the show. If you like today's show, please invite your friends to listen as well. That would mean a lot to me. Do you have a question you'd like me to answer? Message me on Instagram @drsandamoldovanova. This is Dr. Sanda Moldovanova, and remember, your mouth is the gateway to your health, so take care of it in the most natural and best way possible.