Dr. Kotikian on “The Medical Show with Dr. Kipper”

Peter: Talk Radio 790 KABC, The Medical Show with Dr. David Kipper and Peter Tilden. And there was a big story in the news this week, a bizarre medical story again. It’s another patient that got a face transplant. Yeah.

Dr. David: A facial transplant. This story in Boston this week, Peter, I thought was fascinating. So we contacted our friends at Glendale Adventist, and we got Dr. Armond Kotikian, who’s an excellent maxillofacial surgeon. And I wanted to know from his point of view what this was and what it involved as far as the specifics. And he’s an expert in dental implants.

Peter: Okay, all right.

Dr. David: I thought we could ask a few questions about that.

Peter: Dr. Kotikian, how are you?

Dr. Armond: Wonderful. Thanks for having me on the show.

Peter: By the way, what is maxillofacial? I know facial. What does “maxillo” mean?

Dr. Armond: Maxillo is the upper jaw and facial is the face. So what — I’m an oral and maxillofacial surgeon.

Peter: Oh, all right. So talk to us about this face transplant, because that seems so dramatic.

Dr. Armond: Right. This poor patient, who had injuries from, what my understanding was, an electrical line that had come down —

Peter: Right …

Dr. Armond: — and had a face transplant done at Brigham andWomen’s in Boston because of cosmetic reasons. He was quite deformed, and it was a — there’s only been a few of these done in the world. Cleveland Clinic being another one, and there was one done in France several years ago, which I believe was the first one, if I’m not mistaken.

Peter: How did they — by the way, how do they do it? I mean, do they — so his face, he had no nose, no lips, no nothing, basically, correct?

Dr. Armond: Right. That’s correct.

Peter: And then do they really — is it Mission: Impossible, like we’ve seen with Tom Cruise? They actually peel somebody’s face off, keep it on ice, and then are able to place it on and have it all live?

Dr. Armond: You know, this is — I’ve never done one. And these surgeries were done by a plastic surgery team.

Peter: Right.

Dr. Armond: But what my understanding is, from what I’ve read and heard in the news, it is another patient’s face, and they actually reconnect the muscles, the vessels, and the nerves actually —

Peter: Wow.

Dr. Armond: — and try to bring the patient back, you know, as functional as possible.

Peter: And this poor guy is blind. He can’t even see it. 

Dr. Armond: Right. 

Peter: It’s for his family, for his daughter —

Dr. David: I know.

Peter: — so he can go out without shocking people. What a severe, extreme surgery.

Dr. Armond: I know. My understanding is that, you know, they’re doing it for his family.

Peter: Yep, yep, yep. 

Dr. David: Dr. Kotikian, can you talk to us a little bit and explain to the listeners about the dental implants? 

Dr. Armond: Sure. 

Dr. David: I know this is a common thing now, but this also had to be part of his surgery. But I would love to know a little bit more about that.

Dr. Armond: Sure. Dental implants became very popular approximately about — you know, they were around several years ago, and they’ve been becoming more and more popular recently. It’s standard of care. Basically, they replace missing teeth. So when patients come to me for a consultation, I explain to them, you know, it is surgery. So what the dental implant does, the portion that I do, it’s actually the root portion, so everything below the gum line, everything that goes into the bone.

Peter: All right. When do I — by the way, I had a tooth in the front that was replaced years ago. It just — it’s fallen down to a sliver.

Dr. Armond: Right.

Peter: And I’ve got a cap over it, and it came off the other week, and they put a permanent on. But if that sliver had broken off and there’s nothing there, I probably would’ve needed an implant, correct?

Dr. Armond: Most likely, yes. If they couldn’t salvage the tooth, then most likely you would end up losing the tooth, getting a bone graft, followed by —

Peter: Okay. All right. So, okay. That’s where you lose — that’s where I start going, “Ugh.” Bone graft sounds big pain and big job. Is it?

Dr. Armond: Not at all. Actually, a lot of times when we take out a tooth, we can actually do the bone graft right there into the extraction site to preserve the ridge so we’ll have enough width and height to be able — 

Peter: And what does a bone graft involve?

Dr. Armond: Bone graft, basically, after the — there’s several ways of doing them. If it’s at the time of extraction, we just pack it into the extraction site and let it heal for about four months, followed by an implant placement four months later. Sometimes, if it’s a back upper tooth, if it’s very close to the sinus, you know, there’s not enough bone, so the patient will end up getting a bone graft in through the sinus to augment the ridge, meaning —

Peter: Through my sinus? You’re going in through my nose?

Dr. Armond: Not through the nose. Everything is done inside the mouth.

Peter: Okay. Thank God for that. And then you put what? A titanium implant in? A titanium-like pole? Post?

Dr. Armond: It is. It’s a titanium implant. It’s an alloy. It has a couple of other metals in it. And overall, the success rate in the entire mouth is 95% five years out, 85% 15 years out.

Dr. David: Where is the bone taken from?

Dr. Armond: The bone, most patients, I would give them the option. A lot of it is cadaveric bone, meaning bone that’s been donated to science. But if the patient prefers their own bone, I’m able to harvest it from inside the mouth if needed.

Peter: Which is better? Okay, if I’m okay with a cadaver bone, is that less aggravating?

Dr. Armond: Yeah, exactly. It avoids opening up another area of the mouth. 

Peter: Yeah, yeah, yeah. Okay. So I’m going with that already. That’s my A choice if I come to you.

Dr. Armond: Definitely.

Peter: And then B, when does somebody get a — I don’t know. When does somebody need an implant? At what point does a patient need a dental implant?

Dr. Armond: You know, anyone who’s missing a tooth in an area which is, you know, an aesthetic area, meaning —

Peter: Right, right.

Dr. Armond: — you know, up in the front teeth or in the back where they do most of their chewing. 

Peter: And it’s not that — and how long does it take? Do you put me out for this?

Dr. Armond: That is an option. I do my own sedations in the office —

Peter: Okay.

Dr. Armond: — because we do — as an oral and maxillofacial surgeon, we do our anesthesia training, so we’re fully equipped. If the patient prefers, yes, we can offer that to them if they like.

Peter: So can I be out until it heals?

Dr. Armond: I’m sorry, can you repeat that?

Peter: Can you knock me out till it heals, like for a week?

Dr. Armond: No. No, just during the procedure.

Peter: And by the way, you talk to me off the air because I’m a pain guy. You know what I mean? I can take all kinds of pain. Dental pain is not my favorite.

Dr. Armond: You know, it’s — I know. It’s a very sensitive area, but I can tell you nine out of 10 times when I tell patients just to follow my instructions, they do just fine by taking the medication.

Peter: And you said — I was starting to say off the air because I asked you about the pain, and you said the extraction is usually worse than the implant, and that’s because the extraction involves a patient who’s coming to you with an infected tooth already, so there’s already a problem.

Dr. Armond: Exactly. When I ask patients nine out of 10 times which one was worse, the extraction or the implant, they will say the extraction because, you know, usually a tooth is broken down, there’s free nerves exposed, or it’s infected.

Peter: And you try — well, in that case, can you give them all kinds of anesthetic?

Dr. Armond: Definitely.

Peter: Or Novocaine and stuff to try and take any of that away? 

Dr. Armond: Definitely. There’s a variety of stuff we can use. The most common one is lidocaine that we use, which is our local anesthetic of choice, and that usually takes care of the pain.

Peter: So you’re all about the pain control when you’re doing this stuff?

Dr. Armond: Definitely. Always. 

Dr. David: Dr. Kotikian, are there things that people need to be aware of as far as prevention from losing these teeth? Are there specific risk factors that people have?

Dr. Armond: Sure. As far as prevention, the biggest things we tell patients obviously is, you know, make sure they see their general dentist every four to six months, see their primary care physician at least once or twice a year, to stop smoking. That’s a big one because, you know, as we know, smoking increases the chance of oral cancer up to seven times.

Peter: Do you see that a lot? Have you seen a lot of oral cancers?

Dr. Armond: I see some in — I do, in certain areas. I definitely do because of the demographics in certain areas.

Peter: What do they look like? What does an oral cancer look like? Is it real obvious?

Dr. Armond: Not always. Sometimes it’s just a white plaque, just a white lesion, or it can be red and white or just be red.

Peter: On the gum?

Dr. Armond: On the gums or on the tongue. The tongue and the floor of the mouth are the most common areas in the mouth, and the lower lip being the most common because of the sun exposure.

Peter: Wow. And then do you have to take out a big portion to get rid of it?

Dr. Armond: Usually, we have to take a little bit of normal tissue around it as well.

Peter: Because I know — yeah, I’m thinking of Eddie Van Halen, who had the tip of his tongue removed.

Dr. Armond: I’m sorry?

Peter: Eddie Van Halen had to have, I think, the tip of his tongue removed. 

Dr. Armond: And Michael Douglas.

Peter: Michael Douglas had part of his tongue removed?

Dr. Armond: No, not tongue. He had throat cancer.

Peter: Oh, right. No, that I know. That I know. 

Dr. Armond: Yeah, that’s another type of oral cancer. Yeah.

Peter: Oof.

Dr. Armond: Van Halen, that’s correct.

Peter: All right. Well, so you — this guy deals with — anything else we didn’t touch on as far as dental implants or the area that you do? Of expertise? How big do — how deep do you go?

Dr. Armond: How deep do I go? Well, in the office, a lot of what I do is mostly wisdom teeth, dental implants. I do my own twilight sleep, IV sedations.

Peter: I’m right there. 

Dr. Armond: [Unintelligible] tumors and treat TMJ patients.

Peter: Right.

Dr. Armond: But in the —

Peter: Oh, oh, oh, let me ask you this. My son — yeah, there’s a — my son has a jaw problem. 

Dr. Armond: Yeah.

Peter: It hurts. It clicks horribly bad.

Dr. Armond: Yeah.

Peter: And we went and saw a — and the dentist is a family friend. And he said, “Go to the orthodontist. Go to the oral surgeon,” whatever. The orthodontist right away was with braces, and let’s do this. We went to an oral surgeon who said, “You know what? If he sleeps with a retainer and just cuts himself a break, and for a couple months doesn’t stress it, doesn’t try and click it out to make it feel better, just leaves it alone, I think he’ll be okay.” And sure enough, when he does that, when he doesn’t eat foods that are really taxing, you know?

Dr. Armond: Right.

Peter: And when he does with the retainer, and he just watches it and doesn’t — I guess he gets relief from clicking his jaw. It’s 100% better.

Dr. Armond: Wonderful.

Peter: Is that — do you find that a lot with TMJ, that you can get that kind of relief with a retainer?

Dr. Armond: I do. But what I usually do before I go to the retainer is I try to put them on a conservative therapy, meaning, you know, have them avoid, you know, chewing gum, biting their nails, stay on a soft diet.

Peter: So it is that. No, it’s like an arm break or muscle pull. Just stay off it. 

Dr. Armond: Definitely. Majority, it’s muscle, just muscle fatigue. Just like going out for a run and you haven’t gone out in that sense for a while.

Peter: But do you find — because I found with him, as much as it’s painful and as much as it ruined a lot of his life because every day it was something, that it’s very hard for them to do that? That a lot of people don’t, because they will eat the sandwich or they’ll eat the –you know, they won’t do the soft food thing for six months or whatever.

Dr. Armond: Exactly. Exactly. That’s the biggest problem. But if the patient is disciplined, majority will be able to — it has up to an 80% success rate just by following our instructions.

Peter: Whoa. And so what kind of diet do you put him on?

Dr. Armond: Just put him on a soft pureed diet. Anything he can break with a fork is considered soft, but anything for which you have to use a knife is considered hard.

Peter: Wow. And how long?

Dr. Armond: Usually four weeks.

Peter: That’s — see that? TMJ, what’s the success rate? 80%?

Dr. Armond: 80%.

Peter: That’s stunning. 

Dr. Armond: Yeah.

Peter: And people are rushing to do braces and all kinds of other stuff.

Dr. Armond: Yeah. I always try to treat them conservatively. If not, then we can use certain medications, muscle relaxants or —

Peter: Wow.

Dr. Armond: — nonsteroidals.

Peter: If I bring him in to see you, can I get twilight sleep just while you’re seeing him?

Dr. Armond: Sure.

Peter: You sound like such a good guy. Well, thank you for this. Dr. Kipper, you got anything else you want to ask him? 

Dr. David: No, thank you so much, Dr. Kotikian. 

Dr. Armond: Thank you for having me. It was a pleasure talking to you.

Peter: Oh, it’s Dr. Armond Kotikian. And by the way, Glendale Adventist, they’re good friends of the show. And we will hook you up. We’ll link to his site and get you all his information on our site so that you can find him if you need him, if you got reconstructive issues or dental implant issues or TMJ. The TMJ thing, man, it was huge in my family. It becomes a major issue when you got a kid with that problem.

Dr. Armond: Right. 

Peter: So thanks for that. I’m going to make sure he’s eating pureed stuff for four weeks, and we’ll see what happens.

Dr. Armond: All right, wonderful. Nice talking to all of you.

Peter: Dr. Armond Kotikian. We’ll get you in touch if you need to reach out to him on our site. We’ll link up at Glendale Adventist. Thanks, man.

Dr. Armond: Thank you.

Peter: Yeah, take care.

Dr. Armond: You too. Bye-bye.

Peter: Bye-bye. Well, this is The Medical Show with Dr. David Kipper and Peter Tilden. I’m so excited about that, because you know Robert, my son.

Dr. David: Yes.

Peter: And that’s amazing, that 80% success rate, and other people are so apt to send you to dentists and orthodontists and surgeries. And one guy actually suggested a surgery, believe it or not, to cure, to correct Robert’s issue, which is not a major issue. Can you imagine?

Dr. David: No, it’s amazing how the behavioral therapies work and the other therapies, the surgeries where they cut out the uvula and they —

Peter: Whoa.

Dr. David: Forget it.

Peter: Not there. Not there. 

Dr. David: No. 

Peter: And also be nervous if they say they’re going in from the rear. Get out of that office right away. The Medical Show with Dr. David Kipper and Peter Tilden. And you, taking your calls at 800-222-KABC. That is 800-222-KABC. Be sure to give us a call. Dr. Kipper will be happy to answer any question. And if he can’t answer it, I will, non-medically. 800-222-KABC.