So, now we what the health program is in Health Canada.  They go around to see if they see any horns, moose horns, deer horns, goat horns, bull horns, cow horns, and not having found any horns growing on Canadian citizen, they have declared the fluoridation is safe and effective.  This is the total, as far as I can see, of the health studies in Canada.

Now, instead of health studies, what they do is reviews of the literature.  So, Health Canada did a review of the literature, and they selected six experts to review the literature.  Four of the six were dentists who were known to be pro-fluoridation, and they reviewed the literature on safety.  Incredible.  Four pro-fluoridation dentists out of six people reviewed the safety of fluoridation, and when it came to IQ studies, they said, “The weight of evidence indicates there’s no significant effect of fluoride on IQ.”  Where is the weight of evidence?  They didn’t cite a single study that had not found this relationship.

This is very bad science, and very bad science has been the name of the game since 1950 as far as fluoridation’s concerned.  In 1950, the US government endorsed fluoridation.  Not one single trial had been completed, and no health studies of any significance had been published.  So, it was political then, and it’s political today.  One of the reasons they don’t do the studies is because they don’t want to find harm, because they don’t want to threaten this policy.  Something that is driving this policy has nothing to do with teeth and certainly nothing to do with protecting our health.

Now, what it is?  I’m not sure, but one that we’re sure is that dentists have controlled this debate for far too long.  That’s how they see us.  We’re a very big mouth with little legs on it.  The only tissue that they’re concerned about are teeth, teeth, teeth, and teeth, and we get study after study after study after study on teeth.  Where are the studies on the bottom?  Where are the studies on the brain, and so on?

This is what Philippe Grandjean said about this study.  By the way Philippe Grandjean is a world famous epidemiologist, particularly famous for his work on mercury.  “Fluoride seems to fit in with lead, mercury, and other poisons that cause chemical brain drain.  The effect of each toxicant may seem small, but the combined damage on a population scale can be serious, especially because the brain power of the next generation is crucial to all of us.”  So, I want to illustrate what he’s saying now with these simple diagrams.

This is what we call the bell-shaped curve.  Every human trait is normally distributed. It goes through this shape, which means the average person has the average height, the average weight, the average IQ, but you’re going to get extremes at both tails.  In terms of IQ, the two tails, the extremes, are children above an IQ of 130 are very bright or geniuses.  The area-under-the-curve, the green area, represents the total people in a population which is in that category, very bright or genius.

The people in that mauve area, unfortunately, are the mentally handicapped, their IQ is less than 70.  Now, see what happens when we shift the curve over by five points.  The average person goes from 100 to 95.  That’s not noticeable.  You’re not going to notice that walking down the street.  A parent’s not going to notice the difference between two siblings, 100 and 95, nor is a school teacher, but what I want you to look at carefully now is what that shift, that small shift in IQ does to the two tails.  It halves the number of geniuses in your society, and it doubles the number of the mentally handicapped.

This has huge social and economic ramifications for any society, any population, especially in the world coming up where having an intelligent population is going to be crucial.  Any public health official who is presented with these IQ studies and does not do anything in his power to avoid exposure of our babies to neurotoxins should not be in that job.  When you got something as simple to decide as being able to solve the massive exposure to a neurotoxin simply by turning off a tap.  When you know that communities that have done this have no difference in tooth decay, the very reason that we’re doing it, and also the more rational application of fluoride via fluoridated toothpaste is readily and universally available, it takes something which is stupid to something which borders on criminal.  Really.  Yeah, I’m going to answer your question at the end.

The meta-analysis done by Harvard mentions this study, but it doesn’t fit into their meta-analysis because they did a different type of study.  They didn’t compare low fluoride and high fluoride village.  They simply found out, looked at the IQ of children drinking water between about 0.3 and 3 parts per million.  That overlaps the range in New Zealand, 0.7-1 ppm, 0.3-3ppm.  Now, what the three concluded was that, “Overall, our study suggested that low levels of fluoride exposure in drinking water had negative effects on children’s intelligence…”  This is what they did.  They found that the higher the level of fluoride in the urine.

They measured the fluoride levels in the urine, and that measure is an indirect measure of how much the kids were getting on a daily basis.  The higher the fluoride intake, the higher the fluoride in the urine.  There’s about a two to one ratio because we get rid of about 50% of the fluoride.  The 50% goes into the bones, and the 50% that we measure is what does not go into the bone.  They found the higher the level of the fluoride in the urine, meaning the higher the exposure to fluoride in that range, the lower the IQ.  You’ve got that very strong correlation there.  The bottom, actually, is the level of fluoride in the urine.  The higher the level of fluoride in the urine, the lower the IQ, a very important study in my view.

I don’t have time to go through all the other health issues, but go through them in a series of chapters in this book.

So, the tricky question of why the Ministry of Health and the local DHBs continue to promote fluoridation.  We have to look at this at this at the three levels of bureaucracies, at the bottom, in the middle, and at the top of the bureaucracies, or, if you like, you can rephrase it another way, the chain of command.   The chain of command that stretches from the Ministry of Health down to local doctors or the New Zealand Dental Association all the way down to your dentists.

At the bottom of the chain of command, we have thousands of dentists who truly believe that fluoridation works, and, by the way, before we go any further, I do appreciate your coming here today.  It took a lot of guts and courage for you to speak out in an audience that’s obviously not on your side.  So, hats off to you.  This is good for democracy.

So, this is all that dentists were taught in dental school, and now, they’ve already got one dental school in New Zealand, in Dunedin.  They’re so busy treating patients that they don’t have time to read the literature.  The three of us, retired professors, we had a lot of time to read the literature that we could possibly get our hands on.  So, they’re very vulnerable.  They’re very vulnerable then to taking shortcuts, believing what their professional bodies tell them, believing them what consultants organized by the government tell them.

There’s a problem here, and the problem is associated from the American Dental Association which wouldn’t know the difference between a bicycle and science.  Here’s white they say in a white paper in 1979, “Individual dentists must be convinced that they need not be familiar with scientific reports of laboratory-filled investigations on fluoridation to be effective participants in the promotion program and that nonparticipation is overt neglect of professional responsibility.

Can you imagine any other profession saying that to its membership? Could you imagine engineers saying, “You don’t really have to be an expert on the safety of bridges to support this bridge over here, and if you don’t support it, you’re neglecting your professional responsibility.”  So, obviously, this is a pretty sick state of affairs in this profession.

Now, in the middle of the chain of command, bureaucrats are taught very early on not to challenge policy.  Policy is established out there somewhere.  The policy is established in the center.  In the case of health, policy is determined by the Ministry of Health in Wellington, and if you’re working for the District Health Board, your job is to promote that policy.

I would venture to say that if a member of the District Health Board went to any community in New Zealand, and said that fluoridation was a bad idea, they would be fired tomorrow.  I haven’t seen anybody disagree with me on that.  They are simply obeying orders.  It’s a frightening thing, and hats off to any bureaucrat that breaks out of this system.  When they do so, they usually threaten their pension, their jobs, and everything else, and we have examples of that, by the way.

So, what we have to be concerned about then, because the middle isn’t going to do much, the bottom is not going to do much.  What about the people on the top?  What’s their spin on this?  Their concern is about fluoridation is losing credibility.  For them, to lose fluoridation is to lose credibility.  They’ve been promoting this for years and years and years.  They told us, it’s the best thing they’ve done.  They’ve told us that the people opposed to this are a bunch of Looney Tunes, and so on.

So, if they turn around and say, “We were wrong,” they will lose their credibility, and they feel, I believe, that if they lose their credibility, this is going to threaten other public health policies.  This is important because fluoridation as a practice isn’t worth a hill of beans.  It’s pathetic.  It does not reduce tooth decay.  It doesn’t work.  Tooth decay does not go up when you stop fluoridation.  There are other ways of doing it.

So, why are they expending so much political capital on trying to keep this foolish practice going? I think the answer is they’re protecting something else.

They are protecting other public health practices, and when you get into those other public health practices, they are worth billions.  They are worth billions.  So, fluoridation is like a skirmish out there to delay the day when they have to defend some of these other public health practices.

Another thing to bear in mind that public health practices require the public’s trust.  You have to have the trust of the public.  That’s why they’re very reluctant to say it may work.  Everything is completely definite.  It’s definitely safe and effective.  People opposed to it are crazy.  It’s definite.  They cannot express any doubt if they want the whole public to accept what they’re doing.

It’s a different kind of medicine.  Public health medicine is very different from individual medicine when a doctor has a chance to discuss this with the patient.  He or she can you give the nuances, can talk honestly about the side effects, and then eventually, you can make the decision, but that’s not the case with public health policies.

So, now, then, we have to see the other side of the court.  Well, first of all, if it’s not doing any good, if swallowing fluoride doesn’t reduce tooth decay, that should be the end of the story.  If it doesn’t work, why do it?  Well, that’s not a scientific explanation.

So, no, we move on to the other issue which is, let me make this clear, there is no argument that fluoride damages health.  Fluoride has wrecked the lives or literally millions of people in India and China, parts of Africa, and other countries which have high natural levels of fluoride in their drinking water, who cook with coal, who drink a lot of brick tea, and so on.  We know that fluoride wrecks bones and causes harm to other tissues.  That argument should not be going on at this moment.

The real argument is will people be exposed to doses of fluoride in fluoridated communities from water and from other sources where the combination puts them closer to doses which cause harm.  Is there an adequate margin of safety between the doses which cause harm and the doses that people get sufficient to protect everybody?  Not the average person because if you do something as stupid as putting a toxic substance to the drinking water of every man, woman, and child in your community, it’s beholden on you to be certain you’re protecting everyone.  That becomes tough because now you have to protect people with poor kidney function, poor diet, who are sick.  You need actually a large margin of safety to make sure that you’ve taken into account all the genetic variations, all the variations in lifestyle, health, and diet of a whole population.

So, let’s look at this now.  First of all, the harmful effects of fluoride have been carefully documented in a 507-page report by the United States National Research Council published in 2006.  This took them three and a half years.  It’s the most comprehensive document, and it is revealing that the promoting health agencies in the fluorinated countries have largely ignored this report.  That goes for New Zealand.  It goes for Australia, and it goes for the United States.  It goes for Canada.

The harmful effects of fluoride include dental fluorosis, brain damage, lowered thyroid function, accumulation in the pineal gland, bone damage, osteosarcoma (mixed studies there), and some people are very sensitive to very low levels of fluoride.  They examined that as well.  They examined other issues, but there are a lot of big health issues that they examined.

Dental fluorosis.  This is the easy one.  This is the one they don’t even bother to deny.  They thought at one part per million that they could limit dental fluorosis to 10% of children in its very mild form.  Remember, that’s up to 25% of the tooth enamel.  In 2010, the CDC reported that 41% of American children aged 12 to 15 had dental fluorosis; 28.5% had very mild; 8.6% had mild; 3.6% had moderate or severe.  Black and Hispanic children have higher rates of dental fluorosis.

New Zealand dental fluorosis rates, there’s very little data that’s been published in New Zealand, but from what we can see it’s about 30%.  It’s about 30% in fluorinated communities, and about 15% in non-fluoridated communities.  Thirty percent is three times higher than the original pioneers of fluoridation anticipated.

Now, the real issue is this:  When fluoride is damaging the growing tooth cells in the baby, causing this condition, what is it doing to the other tissues?  This is what Arvid Carlsson, again, said in 1978, “One wonders what… an increased in the exposure to fluoride, such as occurs in bottle-fed infants… may mean for the development of the brain .“  He’s a neuropharmacologist so he’s interested in the brain, but that statement was made in 1978.  The first animal study didn’t come along until about 1995, and the first IQ study didn’t come along until about 1991. So, it was pretty prophetic, his concerns.

So, let’s look at evidence that fluoride damages the brain.  According to National Research Council, “It is apparent that fluorides have the ability to interfere with the functions of the brain.”  Many more studies on the brain have been published since 2006.  The review itself only looked at five IQ studies.

There have now been, as of last month, 36 published studies, courtesy of my son Michael whose translated many of Chinese studies into English.  The one I particularly follow, it’s a study by Xiang because I had the opportunity to go to China and visit these villages where the study was done.  One village had less than 0.7 parts per million in their well water.  The other village had between 2.5 to 4.5 parts per million.  Those were the two villages.

Now, going to these villages.  This is an area of China which has been stable for literally centuries, practically no movement, no migration.  The people all had the same occupation.  They are all rural farmers.  They all have the same diet.  They all have the same lifestyle.  All had the same schooling.  Everything looks the same except for the fluoride levels in the well water.  They were even controlled for lead exposure and iodine intake, both of which would be serious confounding variables, but they were the same.

He found a drop of about 5 to 10 IQ points across the whole age range, and the whole IQ curve was shifted over for both males and females.  Here’s the males.  The black line is the low fluoride village.  The dotted mauve line is the high fluoride village.  Xiang estimated that the IQ was lowered 1.9 parts per million.  By putting all the data, he extrapolated and found the point at which the lowering just occurred was 1.9 parts per million.

This is why I say that there is no adequate margin of safety to protect against known harmful effects because 1.9 parts per million does not offer an adequate margin of safety to protect all of New Zealand’s children from two things, one, the range of doses that you’re going to get, and, two, the range of sensitivity that you can expect to cross the whole population.  In this case, the study group was pretty homogeneous, fairly uniform genetic stock so quite tight, but in New Zealand, you’ve got so many different ethnic groups, many different lifestyles, etc.

Let’s see, does it protect against a range of doses?  Of course, it doesn’t.  A child drinking 2 Liters of water, 1 part per million, would get a dose of 2 mg per day.  One part per million is 1 mg per Liter.  So, if you drink 2 Liters, you’re going to get 2 mg per day dose.  A child in the Chinese study that drank 1 Liter of water at 1.9 ppm, where the IQ is lowered, would get 1.9 mg per day, a lower dose.

So, you can see that if you had two populations, one drinking 0.85 ppm, the average for New Zealand, and another community, a study group, average 1.9 ppm, you’re going to get an overlap of the doses.  So, there’s no protection against the range of doses here.  We have to protect the most sensitive person in a large population.  We normally divide the dose that causes harm, the lowest dose that causes her, by 10, to get a dose that we think would protect everybody.

It may not be enough.  If there’s any argument, it may not be enough, the 10.  This may be rather crude, but I don’t want to mess around trying to work out how much water the Chinese children drink, how much water the New Zealand children drink.  So, I’m going to assume that both populations drink about the same amount of water each day in which case we can deal with the concentration.

So, if I take the 1.9 parts per million and divide by 10, I get to 0.19 parts per million.  Your average is 0.85 ppm.  That means you are exposing your children at four times the level that is safe for the most sensitive child in New Zealand.  That should be the end of fluoridation right there if regulatory agencies did the standard risk assessment for toxic substances.

Now, since that data was published, since I’ve been here, Harvard University has done a meta-analysis of 27 of the studies.  The methodology in all 27 studies was the same as the Xiang study.  They compared the IQ of children in a low fluoride village with a high fluoride village, and the study was published in the Environmental Health Perspectives. That’s important because the Environmental Health Perspectives is probably the best journal on environmental health in the world.  Number two, it’s published by the National Institute for Environmental Health Sciences which is part of the National Institutes of Health in the United States which, in turn, is part of the Department of Health and Human Services which has a policy of promoting fluoridation.  So, those who are promoting fluoridation at the highest levels in the United States have, under their noses, proof the fluoride can lower IQ.

Now, out of the 27 studies they looked at, 26 had lowering of IQ in the high fluoride village.  That’s a remarkable consistency, considering that these studies came from all over China.  They weren’t located in one specific place.  They weren’t all done by the same authors.  They were done by different authors in different places, a remarkable consistency.

The people that promote fluoridation say these studies are not relevant because they looked at very high concentrations.  Again, they cherry pick.  They cherry pick the highest concentrations in two of the villages, which was 11 ppm, but they forget something.  If you’re a regulator, it’s not the highest the concentration or the highest dose that you are concerned about; it’s the lowest dose that causes harm.  So, to refer to two studies where the concentration went up to 11 ppm is totally irrelevant.  It’s the lowest dose that you are concerned about.  Anyway nine of the 27 studies had, the high fluoride villages had levels of fluoride less than three parts per million.

Now, they found the average drop was 7 IQ points, and they felt this deserved high research priority, but fluoridated countries like New Zealand are not doing these or any other health studies.  There’s no indication that they’re going to change, that they’re going to suddenly start doing the health studies they should have done 50 or 60 years ago.  So, there’s been no IQ study done in New Zealand, in Australia, in Israel, in Ireland, in Canada and the United States, or England.  There’s none.

Now, the Master Research Council said the same thing in 2006.  This needs to be studied.  We need to study the IQ in fluoridated communities, no studies done in the seven years.  What they do is assume that the absence of study is the same as the absence of harm.  How many people have you heard this, “Well, we’ve been doing this for 50 years, if there’s any problem with fluoridation, we’d see it by now.” Oh no, you wouldn’t unless you did careful study.

How do you know that the arthritis in this country is related to fluoride if you’re not studying it?  How do you if hypothyroidism that’s increasing in this country is not related to fluoridation if you’re not studying it?  How do you know there’s no effect on IQ if you’re not studying it?  We could go on and on and on.  If you don’t look, you don’t find.

Here’s  a somewhat humorous example.  This is from Canada.  You get an idea of how good the research is in Canada.  Dr. Peter Cooney, the Chief Dental Officer of Canada, told an audience in Dryden, Ontario.  I was there.  I challenged him to a debate, but he wouldn’t debate.  They snuck him in the day before to poison the water, literally.  They would have a referendum a few weeks later, and he told them, “I walked down your High Street today, and I didn’t see anyone growing horns, and you have been fluoridated for 40 years!”

This is a quote from a review by David Locker from the University of Toronto.  He did it with the Ontario government.  He wrote, “ The magnitude of [fluoridation’s] effect (he means benefit) is not large in absolute terms, is often not statistically significant, and may not be of clinical significance.”

Now, I want to talk about the Queensland Scam.  You’ve seen the data, now I’m going to look at the scam, the politics.  In 2006, the current premier of Queensland resigned, and a new premier was appointed, Anna Bligh.  One of the things that she did when she came to office was to instigate mandatory fluoridation for the whole of Queensland even though communities in Queensland had fought and fought to keep fluoridation out of their communities, particularly Brisbane.  With one stroke with a built-in majority in the Parliament, she got mandatory fluoridation in.

This is what the Queenslanders, the citizens, were told by their government.  Queenslanders were told that fluoridated Townsville had 65% less tooth decay than non-fluoridated Brisbane.  You might be wondering what they mean by 65% less tooth decay.  Sounds big doesn’t it, 65% less tooth decay?  Alright, let’s have look at the table from which this was taken.  By the way, they ran full page ads:  This glass of water could protect your smile; in Townsville, water has been fluoridated since 1964, resulting in 65% less tooth decay in children than those in Brisbane.

Here’s the paper.  Here are the statistics. You notice that they’ve selected one year only, seven-year olds.  Decayed, missing, and filled surfaces in Townsville, fluoridated, 0.09 DMFS.  Tooth decay in Brisbane, 0.26 DMFS.  This is just for seven-year olds.  That is a 65% difference, but notice that the absolute saving here 0.17 of a tooth surface.

Now, imagine they were running full page ads in Queensland saying if we fluoridate Queensland, we’re going to save 0.17 of a tooth surface.  Do you think people would have been impressed with that? I don’t think so, but the arithmetic is correct.  This is how they do it.  You subtract 0.09 from 0.26.  That’s o.17 DMFS.  You divide by the tooth decay in Brisbane which is 0.26 and multiple by 100.  That’s 65% fewer tooth surface decayed, but again, the absolute saving is 0.17 DMFS.  It’s worse than that, this is an absolutely outrageous example of cherry picking the data.

Supposing they had looked at nine-year olds.  Look over here for nine-year olds.  Its 0.41 DMFS in Townsville.  It’s 0.51 DMFS in Brisbane. The difference is 0.1 of a tooth surface, and now the percentage difference is 20%.  So, it’s the vagueries of comparing these small numbers arbitrarily selected.

Yes?  [Inaudible 34:40] Do you think it’s fair then to pull out just the numbers for seven-year olds?  [Inaudible 35:00] Well, I think that you would be obliged if you’re going to pull out 65% to make it very clear that you’re talking about only seven-year olds, not give the impression that this is all your kids having that reduction.

Now, even more blatant.  This is what our teeth look like if they’re exposed to fluoridated.  This is what teeth apparently look like if they’re exposed to non-fluoridated water.  Now, this is so incredibly crude.  It’s Aurelian [35:53].  It really is. Do you think that the difference between those two sets of teeth is 0.17 of a tooth surface?  No, this is blatant propaganda, absolute blatant propaganda, and this not coming from industry.  This is coming from tax-paid civil servants, and let’s get one thing clear.

Civil servants should not be spinning the literature.  Civil servants should be presenting to decision makers objective analysis, a careful balance of the science of both sides.  It’s a decision maker. If there’s going to be any spin, it’s going to be from politicians because everybody knows the politicians spin everything, but we’re paying civil servants for something different.  They get large salaries, and I think it’s time that we created a fuss.

All the attention is on politicians.  Politicians are corrupt.  Politicians are lying, but underneath these politicians are these slimes, these faceless people who are, for whatever reasons, manipulating science to serve a political agenda.  That’s not their job.

Now, let’s look at the New Zealand Scam.  I will take your question later.   Let’s look at the New Zealand scam because we’re going to see that the launching of fluoridation in New Zealand was a fraud.  Was Rap Mann [37:33] here today?  No, he was here last time.  The Hastings-Napier Trial which launched fluoridation in New Zealand started in 1954 and ended in 1964.  Now, here’s a letter written by the director of the Division of Dental Health.  I’m assuming that this is the federal government here, but I stand to be corrected.  His name is Leslie.

Okay, starting from the second paragraph:

No one is more conscious that I am for the need for proof of the value of fluoridation in terms of reduced treatment.  It is something which has been concerning us for a long time.  It is only a matter of time before I will be asked questions, and I must have an answer with meaning to a layman or I am going to be embarrassed and as is everyone else connected with fluoridation.  But it is not easy to get.  On the contrary, it is proving extremely difficult.  Mr. Espie is conferring with Mr. Beck and Mr. Ludwig and I am hopeful that in due course, they will be able to make a practical suggestion.

I will certainly not rest easily until a simple method has been devised to prove the equation fluoridation equals less fillings.

Now, notice the date.  This is 1962, October of 1962.  This is eight years into this famous trial.  It’s been going on for eight years in 1962.  It’s due to end in two years, and they’re still looking for evidence that fluoridation actually reduces tooth decay according to this letter.

So, how did they pull it off?  John Colquhoun from Auckland found out.  He said:

Before the experiment they had filled his decayed teeth with any small catch on the surface, before it had penetrated the outer enamel layer.  (In other words, they were filling indentations, essentially.)  After the experiment began, they filled and classified as decayed, only teeth with cavities which penetrated the outer enamel layer.    It is easy to see why a sudden drop in the numbers of decayed and filled teeth occurred. This change in method of diagnosis was not reported in any of the published accounts of the experiment.”

In other words, the 60% drop in tooth decay reflected an artifact that they changed the method of diagnosing.  They had already dropped the control city.  They dropped Napier within one or two years of the start of the trial.  So, what they were left with was comparing tooth decay in the beginning and at the end, and they changed the diagnosis in the middle.  That is the study that launched fluoridation in New Zealand.  Incredible.  Based on fraud.

Now, studies in New Zealand.  Dr. John Colquhoun published many papers.  Bill Wilson is a colleague of his, sitting in the front row, and I’ve never been impressed with a scientist my whole than John Colquhoun.  He had been had been a principle officer of Auckland.  He had been a councilor of Auckland, and in both positions, he avidly promoted fluoridation and very successfully.  So successful, in fact, that in 1980, his bosses sent him on a world tour to collect more evidence that fluoridation worked.

He went to Australia.  He went to Asia.  He went to North America.  He went to Europe.  Behind the scenes, to his utter dismay, the researchers were telling him, “John, we can’t find a difference between the tooth decay in fluoridated and non-fluoridated communities.”

He came back crestfallen to New Zealand, and waiting for him, on his desk, was a report marked confidential.  That report was survey of tooth decay for the whole of New Zealand, and John went carefully through it.  It essentially found the same thing that there was little difference in tooth decay between the fluoridated cities and the non-fluoridated cities in New Zealand.  If anything, the tooth decay was a little bit better in the non-fluoridated communities than the fluoridated ones.

So, this man had the courage from being an avid promoter of fluoridation to becoming, for the rest of his life, trying to undo the damage that he had done.  Just like Robert Oppenheimer, he found that when he was presenting evidence that supported what his masters wanted, he was a hero, but the moment that he started presenting information that did not support what his masters wanted, he became the villain.   He steadfastly stuck to this effort.

In fact, he was part of the task force that went to Lord Mayor of Brisbane.  He was on that task force, and John was able to persuade even the pro-fluoridation people on that task force to oppose fluoridation.  So, run the clock forward, Betty De Liefde, in 1998, described the difference tooth decay in the permanent teeth between fluoridated and non-fluoridated communities in New Zealand as “clinically meaningless”.

Now, there’s been a very important study from Iowa.  This is the famous Iowa study where a huge amount of US government money is going to studying children’s teeth from the moment they’re born through.  This was a study of children from zero to nine years.

What they did in this study no one has done hitherto.  They actually measured the amount of fluoride the kids were ingesting, not whether they lived in a fluoridated community or non-fluoridated community, but actually how much fluoride they were ingesting.  They found no relation between tooth decay and the amount of fluoride swallowed, ingested.   This is what they actually said:  “These findings suggest that achieving a caries-free status may have relatively little to do with fluoride intake, while fluorosis is clearly more dependent on fluoride intake”.

One of the things they set out to do was to define the optimal level of fluoride that you needed to fight tooth decay.  They couldn’t do it.  They could not define what an optimal level of fluoride was from this experiment.

Now, I presented this paper last time I was here in April of 2011, and after I left, Dr. Robin Whyman who’s the chief spokesman for the pro-fluoridation movement in New Zealand prepared a response to my presentation for the National Fluoridation Information Service.  This is the propaganda machinery set up by the Ministry of Health to push fluoridation throughout New Zealand, a dependent from a tax like mine.   This is what he said, “Professor Connett’s highlighting of the conclusion from Warren et al 2009 that there was no relationship between fluoride ingested and tooth decay levels is unsurprising.  It is generally accepted that the principal caries protective effect from fluoride is topical.”  Precisely, Dr. Whyman, precisely.

Swallowing fluoride doesn’t do any good.  Fluoride works on the surface of the teeth.  I’m glad you recognize that Dr. Whyman, but shouldn’t that be the reason why you stop putting fluoride in the drinking water and focus on topical applications?

Even the promoters of fluoridation, not just Robyn Whyman but the Center of Disease Control in the United States, have admitted that the dominant beneficial action of fluoride is topical not systemic .  In other words, it works on the outside of the tooth enamel, not from inside the body.  So, why swallow fluoride and expose every tissue in the body to a known toxic substance when you can brush it on and spit it out?   Can we leave the question on until the end because I’m going to use up too much time.  Why put it in the drinking water and force it on people who don’t want it?

By using universally available fluorinated toothpaste, you avoid the medical issues and the ethical problems of not forcing it on people.  When the CDC admitted in 1999 that the predominant benefit of fluoride was topical, it should have ended fluoridation there and then.  At this point, you could see the difference between science and politics.  The science says it’s stupid to continue, but the politics says keep going, keep crossing the Big Muddy, the big fool says push on, according to Pete Seeger’s song’s about Vietnam.

This is what Arvid Carlsson said about the revelation that the benefits are topical.  Arvid Carlsson is the scientist who led the successful campaign against fluoridation in Sweden in the 1970s.  He said, “In pharmacology, if the effect is local (i.e.topical), it’s awkward to use it in any other way that as a local treatment (as a topic treatment).  I mean this is obvious.  You have the teeth there, they’re available for you, why drink the stuff?”

Now, the proponents claim that they’re merely adjusting the levels of a naturally occurring element.  Well, is anybody talking about adjusting the levels of naturally occurring arsenic?  Just because something occurs naturally does not make it safe.  Arsenic is not safe.  Fluoride is not safe.

As far as nature is concerned, we have a very good indicator of what nature thinks is safe, safe for a newborn baby.  The level in mother’s milk is extremely small.  It’s 0.004 parts per million.  Now, the average level that you fluoridate in New Zealand is 0.85 ppm.

If you bottle feed your baby and you use tap water, you’re giving your baby 200 times more fluoride than a breastfed baby, or put it another way, 200 times more fluoride than nature intended for the baby.  Now, who knows more about what the baby needs:  Nature, after experimenting for thousands or millions of years with evolution or a bunch of dentists in Chicago?  I put my money on mother nature.

In New Zealand, you fluoridate between 0.7 and 1 part per million fluoride.  The average is 0.85ppm.  That’s 200 times the level in mother’s milk.  To put that another way, it’s 20,000% higher than a breast fed baby.  In my view, that’s irresponsible and reckless.  Once you know that, it’s irresponsible and reckless for a pediatrician to stand by and let this happen.

The proponents claim that water fluoridation is not medication, but the definition of a medicine is a substance used to treat a disease, and we are using this substance to treat or prevent dental decay.  Clearly, fluoride is a medicine, and fluoridation is mass medication.

It’s a poor medical practice.  In the United States, the US Food and Drug Administration, after 68 years, has never regulated fluoride for ingestion.  It’s neither regulated fluoride pills nor fluoride in water, and the official classification of fluoride, it took us some time to get this in writing, is that it’s an unapproved drug.  Think of that:  The most prescribed medication in US history going to more people, over 200 million people every day in their drinking water, and it’s never been regulated by the FDA, never been approved by the FDA.

As a result, there has never been randomized clinical trials to demonstrate either the effectiveness or safety of fluoridation.  None, no, as what would happen with any other drug regulated by the FDA.  What do they do if a drug goes on the market?  They collect all the side effects.  They collect reports from patients and from doctors about what this drug is doing to them, and they don’t dismiss that as anectodal information.  They collect all this data.

Nothing.  The FDA is collecting no data.  Our doctors are blind to the health effects.  Our regulatory agencies have no idea.  Bruce Spittle in New Zealand has written a book called Fluoride Fatigue, and that documents the fact that one or two percent of the population is very sensitive to fluoride, experiences symptoms which can be reversed when you remove the fluoride and come back when you get re-introduced to the fluoride.

Many people are probably walking around with many symptoms, common symptoms, skin rashes, gastrointestinal problems, neurological problems, chronic fatigue, have no idea, having been treated with umpteenth medicines from doctors uselessly, that this is caused by something as simple as the fluoride in their drinking water.

Fluoridation is not ethical.  No government has the right to force medication on its people.  It deprives individuals of their right to informed consent to medication.  A local government, your Auckland government, is doing to everyone what no single doctor in Auckland can do to anyone.  Let me say that again.  The city of Auckland is doing to everyone what an individual doctor can do to no one in Auckland.

An individual doctor, if he went up to you and said, “I put something in this glass of water which is going to be good for you.  Drink it.”  You say, “I don’t want to drink it.” “Drink it.” “No, I don’t want to drink it.” “Drink it.” “No, I don’t want to drink it.” “Well, if you don’t drink it, don’t come back to my office.”  If he was to use pressure to force you to take your medication like that, he or she could lose their license.  This play has been written by Kafka.  We’re doing this to everybody.

In my view, doctors should be ashamed to allow water fluoridation to take place.  This room should be full of doctors here, full of doctors, because doctors are taught about informed consent of medication.  If you go to the webpage of the American Medical Association, it very clearly spells out what informed consent to medication is, and I’m sure New Zealand doctors also get this training.  How can they stand by and see this violated?  Probably because they’ve got friends in the Rotary Club or the golf club, dental friends, and they think they’re doing their dental colleagues a favor.  After all, this is about teeth.  Right, this is about teeth.  So, we’ll let the dentists get on with it.  No, this is more.  We have more tissues in our body than teeth.  We have brains.  We have bones.  We have kidneys.  We have endocrine systems.

So, these doctors should help us get dentistry out of the public water supply and back to the dental office.  You want to practice dentistry?  Practice it in your dental office.  Don’t practice it with my water.  Thank you very much.  I don’t want my dentist in my water.  Leave it alone.  Excuse me.  I’m glad you’re here.

The evidence of benefit is very, very weak.  This is one of the shocks for us. This is one of the shocks.  When we wrote this book, we had assumed, like most people, that the big arguments would be, is this dangerous?  We know it’s good.  We know it’s good for us because the dentist will tell us it’s wonderful, but the shock was when looked at the literature on the effectiveness of swallowing fluoride, whether or not swallowing fluoride reduces tooth decay, we were amazed how weak the evidence was.

By the way, this is not evidence from anti-fluoridation scientists.  The evidence that I’m about to cite comes from their side, pro-fluoridation dentists and pro-fluoridation agencies.  This is what’s so funny.  If only dentists had time to read the literature, they would realize that their own literature destroys the validity of this practice, but I’ll share that with you now.  You can make up your own mind whether I’m exaggerating here or not.

First of all, 97%, as you heard from the first presenter, of Western Europe drinks non-fluoridated water.  Some started but stopped.  So, all those countries don’t fluoridate.  Four of them fluoridate their salt, but the vast majority neither fluoridate their salt nor their water.

If you look at the tooth decay in 12-year olds, which is collected by the World Health Organization and published online, you’ll see it’s coming down as fast in the non-fluoridated countries of the top 12 on the right, as the fluoridated countries.  In fact, you can’t tell the difference.  That’s tooth decay in 12-year olds coming down from the 1960s to the present.   If you look at the figures for the present, it’s awash.  There is little difference in tooth decay in children who’ve grown up from fluoridated countries or non-fluoridated countries.  So, there’s no evidence there to support the benefits of water fluoridation.

If we compare US communities, this was the largest study done in the United States.  They looked at 39,000 children in 84 communities, and this was sponsored by The National Institute of Dental Research, which is pro-fluoridation.  What did they find?  All they looked at was decayed, missing, and filled surfaces.

So, that you’ll know what we’re going to be talking about, the top six cutting teeth, the bottom six cutting teeth have four surfaces because they don’t count the cutting edge as a surface.  So, four surfaces, the top six, bottom six, and then the chewing surfaces, the rest of teeth, they have surfaces.  All together, by the time that all the permanent teeth have come out, there’s 128 tooth surfaces.  If you look at the average tooth decay for 5 to 17-year olds, for children that have always lives in a fluoridated community in the United States, the average is 2.8 decayed, missing, and filled surfaces.  If you look at the same for non-fluoridated children who’ve always lived in a non-fluoridated area, it was 3.4.  If you subtract one from the other, you’re looking at the average saving in tooth decay of 0.6, of one tooth surface out of about 100 tooth surfaces.  By the time they’ve all come out it may be up to just above one tooth surface, but this is what all the risks are for.  We’ll talk about the health effects in a moment, but apparently we’re doing it for this 0.6.  Wait a moment.  There’s something strange about this paper.

Even though it was a government-supported research at the highest level, they didn’t report the statistical significance.  They didn’t demonstrate that this 0.6 saving of one surface was statistically significant, and when Kathleen Thiesen, a member of the National Research Council Panel that reviewed this subject, looked at the statistics, it was not statistically significant.

Now, if we try to say, stop fluoridation because of this amazing result and we produce a finding that was comparable to this and say that it was not statistically significant, they would just laugh us out of court.  In fact, they have.

There’s a Chinese study on hip fractures in which there’s a doubling of hip fractures at 1.5 parts per million, but all the pro-fluoridation people ignore that point because it’s not statistically significant.  That’s about a serious thing like a hip fracture.  Alright, let’s go on.

Studies in Australia have found an even less saving the 0.6 DMFS.  Spencer and co-workers reported a saving between 0.12 and 0.3 DMFS.  Spencer is one of the leading proponents of fluoridation in the world.  He’s funded by Colgate and is from the Adelaide University, but they could only find between 0.12 and 0.3 DMFS.  Spencer, again, doing a study in South Australia with about 10,000 kids, found  no statistically significant difference in the permanent teeth between children who’d drank fluoridated water all their lives or bottled water or tank water.  Yet, these two went on to recommend a fluoridated bottled water.

The story of two relationships.  The first relationship is fluoridated water and a condition called dental fluorosis.  Dental fluorosis is a mottling of the teeth.  It’s a well-known biomarker of overexposure to fluoride before your permanent teeth have come out.  It’s a systemic effect.  It’s fluoride interfering with the growing tooth cells, interfering with the enamel.

So, very mild dental fluorosis has little white specs on the cusps of the teeth at one end of the spectrum, and then this is at the other end of the spectrum where up to 25% of the tooth surface has this patchy, chalky appearance.  With time, that can get discolored, go yellow, orange, brown, and so on.  Now, mild dental fluorosis, notice the terminology, is up to 50% of the tooth surface impacted.  Moderate or severe is 100% of the tooth surface impacted with indentations and with the severe, crumbling, brittleness, as well.

Now, we’re going to look at that same database from the National Institute of Dental Research that I’ve already talked about, and over here is the level of fluoride in the water, that left column, less than 0.3 g/mL, 0.3-0.7g/mL, 0.7-1.2g/mL, and greater than 1.2 g/mL.   Look at the prevalence of dental fluorosis.  This is for thousands of children in the United States, 39,000 children.  See how the prevalence of dental fluorosis goes up with the increased concentration of fluoride in the water, 14.6%, 19.6%, 25.2%, 40.5%.  There is a very clear relationship between the amount of fluoride in the water and this condition called dental fluorosis.

Now, let’s look at the same concentrations in the water and look at the children, this is fluoridated water, with dental caries.  The central column in green.  Less than 0.3 g/mL, 55.5%.  This is children with caries; 0.3-0.7 g/mL, 54.6%; 0.7-1.2g/mL, that’s artificial fluoridation, 54.4%; greater than 11.2 g/mL, 56.4%.  There is not a clear relationship between fluoride in the water and dental caries.  There’s a strong relationship with dental fluorosis.

Do you agree that it should be your choice whether or not you take a medication?  If you do, then 97% of Europe agrees with you.  They have eliminated fluoride from their public water systems because they’ve realized one critical point:  Compulsive systematic medication violates basic human rights.  In Auckland, we still have no choice.  Whether we like it or not, we are currently medicated with a highly controversial substance every day we live here.

Tonight, we are privileged to have Dr. Paul Connett with us to update us on the latest research about fluoride and how it’s affecting us.   Dr. Connett is the executive director of the Fluoride Action Network as well as the executive director of its parent body The American Environmental Health Studies Project.  He’s given more than 2,000 presentations in 49 states and 52 countries on the issue of waste management.  He holds a PhD in Chemistry and is a retired professor of environmental chemistry and toxicology.  He’s also the author of the book The Case Against Fluoride and is on our advisory board in the Awareness Party.

Get ready to be woken up, shaken up, and empowered.  Please welcome Dr. Paul Connett.

Dr. Paul Connett:

Let me start by saying this:  Fluoridation is one of the easiest health problems that we have to end.  It’s the easiest one that we can end.  We can end it by turning off a tap.  All we need is a strong wrist, a strong wrist.  We can turn off this unnecessary evil at the waterworks, but to turn that tap, we need political will.  To get that political will, we need masses of people informed and organized.

I didn’t say entertained.  I hope that you will enjoy my presentation this evening, but if you go away here entertained but not ready to take action, then it’s a waste of time.  So, hopefully, you’re going to be informed, and you’re going to want to be organized.  I will be telling you one step that you could take which could begin the ball rolling.

Monday is the deadline for submissions of this to your Council to get it into the annual plan or whatever the bureaucratic rubric is to get this issue before the Council.  You could sign this document.  You could make this submission.  You could add your own words at the bottom as we heard some eloquent words right now.  They will be excellent to add to this, and when you’ve filled out this form give it to Marina over here.  She’s our representative from New Zealand.  Now, I’m going to break off my talk very close to the end to get these forms out, get them signed, get them to Marina, and we will know that this meeting has had an impact right away.

Okay.  I have spent the last 17 years researching the fluoridation issue, first as a professor of chemistry specializing in environmental chemistry and toxicology, and then the director of FAN.  I’m happy to tell you that the person that got me into this 17 years ago, who twisted my arm with a cup of tea in the afternoon, my wife, is here with me, Ellen, Ellen Connett.

Amongst other things, the other major contribution that she’s made to this movement is having our son Michael.  For seven or eight years, Michael made a website, and then he took the time off to become a lawyer.  Now, he’s clocking for a federal law judge in Philadelphia, but he’s got involved again with the Fluoride Action Network.  He revamped the website, and if you’ve never to our website, the FlourideAlert.org, that’s Michael.  That’s my son.

One of the things he’s done is to make this huge health database, and one of the buttons you can click on is “researches”.  Anybody that’s researching this issue, click on “researches”, and you’ll get to the health database.  There are about 14 tissues examined separately, fluoride in the kidney, fluoride in the brain, fluoride in the bone, and so on.  All the literature reviewed is linked.  Full articles are there, and in addition to that, he had the idea of getting of these papers that had been written in China translated to English so that they would become available for Western researchers.  That has proved very significant.

How many of you heard me before?  Just to get an idea.  Okay, it’s quite a few.  This is more or less what you heard last time, but it’s been updated, particularly with the whole issue of fluoride and the brain.  So, there is new information here.

After 14 years of this, I got together with two other scientists.  We wrote this book, and one of the best decisions I think I made in 17 years was to ask James Beck, MD, PhD, a physicist from Calgary, Alberta, and Spedding, a biologist trained in Oxford and teaching at Edinburgh University.  So, we have three retired professors, one in biology, one in chemistry, one in physics, and we wrote this book.

I cannot tell you what a wonderful contribution these other two made.  They got the term right; this book is understated, not overstated.  Everything is documented, and they don’t go into attacking.  They certainly acknowledged some of the arguments, the other side, and every single argument is documented in the scientific literatures, eighty pages of references there.  Believe me, this is your protection.

One of the things about citizens is they don’t want to be embarrassed.  They don’t want to go out into the public and say something and be embarrassed, and the other side makes a special art of embarrassing people.  If you only knew as much as they do, you’d realize that you were stupid.  That’s the message that comes from these experts, but believe me, after two years, they have no answer to this book.

There’s been no scientific response critique of this book.  So, if you get attacked in public, if you’re made to feel that you are a member of the flat earth society or you put on a tin foil hat or whatever they do to put you down, just wave this book and say, “Have you got a response to this book?  Have you produced a written response to this?  By the way, are you prepared to debate Professor Connett because he will come back to New Zealand?  So, if you could pluck a courage and defend your position in public, he will debate you.  Are you ready to debate him?  Yes or no? Put up or shut up.”

I’m very, very tired of being insulted by people who have not read the literature, who think it’s good enough to quote a movie made in 1964 to counteract all the signs we’ve put on the table.  The movie, of course, is Doctor Strangelove.

So, the outline of my talk.  I will explain that fluoridation is a poor medical practice, that it’s unethical.  The evidence of any benefit is very weak.  There’s no adequate margin of safety to protect from known health effects.  Why does the New Zealand Ministry of Health continue to push fluoridation?  We have to conjecture them, and better alternatives.  Then, certainly, how can you help to end fluoridation in Auckland.  That’s where we’re going to break off before I talk about that to deal with these submissions.

Okay.  It’s a poor medical practice.  Fluoridation is the only example in New Zealand of using the public water supply to deliver medicine, and why not?  Well, for obvious reasons, once you put a medicine into the water, you can’t control who it goes to.  It goes to babies.  It goes to infants.  It goes to children.  It goes to the elderly.  It goes to the sick.  It goes to people with poor nutrition.  It goes to people with poor kidney function who, in the case of fluoride, can’t get rid of fluoride.  It goes to people with borderline iodine deficiency, and they’re particularly vulnerable to fluoride toxicity.

Ask a pharmacist if there’s any medicine in his store that he can give to anybody, everybody.  Of course, not.  You can’t.  Then ask him if there’s any medicine that you don’t have to control the dose.  Take as much as you want.  Drink as much water as you want.  It’s ridiculous.  You can’t control who it goes to.  You can’t control the dose.

In New Zealand, it’s worse.  No doctor has prescribed this medication.  Nobody’s tracking individual response.  Doctors in medical schools are not trained to recognize the side effects of fluoride.  No New Zealand health agency is monitoring its exposure.  There’s no monitoring in New Zealand of the level of fluoride in people’s urine, in their blood, and, most particularly, in their bones.

By now, you should have thousands and thousands of data points.  You should know how much fluoride you can expect to have in your bones as a function of how many years you’ve been drinking fluoridated water.  How many data points do you have?  Zero.  None.  How many health studies have you got in New Zealand?  Zero.  First of all, it’s a lousy experiment, but it’s the lousiest experiment because you’re not even collecting the data.

Fluoride is not a nutrient.  To demonstrate that a substance is a nutrient, you have to starve an animal of this substance in its diet.  Take it away, and then demonstrate that some disease accrues.  If no disease accrues, then it’s not a nutrient.  Nobody’s ever demonstrated a fluoride deficiency disease, a disease caused by fluoride deficiency.  Dental disease is not caused by lack of fluoride.  Dental disease is caused by too much sugar.  There’s not one single biochemical process, any biological molecule, any biological reaction, any process in the body that needs fluoride.  Forcing people to drink it is stupid since they cannot identify one single thing going on in the body that needs fluoride.

Fluoride is a known toxic substance.  So, in the contrast of the fact that they cannot identify anything that fluoride’s good for, we have identified what harm it can cause.  It could interfere with enzymes, inhibit enzymes, and now we know it could do much more than that.  It could interfere with G-proteins, the signaling mechanisms across membranes.  It could cause oxidative stress.  It could interfere with hydrogen bonds.  It could complex with metal ions that we need and metal ions that we don’t need.  It could get those metal ions into places that they, otherwise, wouldn’t go.

The first opponents of fluoridation in the United States were biochemists, biochemists that had used fluoride in their experiments to poison enzymes.  They realized that this substance should not go anywhere near the body’s systems.  Two Nobel prizes in enzyme chemistry opposed fluoridation, one from Sweden and one from the United States.

The chemicals used are not pharmaceutical grade, as used in dental products.  They come from the wet scrubbers, a spray of water, of the phosphate fertilizer industry, and these are designed to capture two toxic gases, hydrogen fluoride and silicon tetrafluoride, which, for a hundred years, decimated the vegetation in the area of phosphate processing plants.  Crippled cattle, damaged the citrus groves in Florida.

Once you captured this scrubbing liquor, which is a solution is hexafluorosalicylic acid, what can they do with that scrubbing liquor?  What can’t they do with it?  They can’t dump it into the sea by international law.  They can’t dump it locally because it’s far too concentrated.  It would cost an arm and a leg to get rid of it as a hazardous waste, but we have this vaguery in hazardous waste regulations that if someone buys a hazardous waste or from the chemical industry, it becomes, then, a product.  On that basis, they can put it into the drinking water.

These industrial grade chemicals contain many pollutants, and one of them, usually present in the batches tested, is arsenic.

Arsenic is a known human carcinogen, and, at least from the point-of-view of the US EPA, there is no safe level for a human carcinogen.  That means that inevitably by using these industrial grade chemicals to fluoridate the water, you are increasing the cancer rates in New Zealand.  We can argue about how much or how big or how small this increase is, but what they cannot deny is there will be an increase because arsenic is a known human carcinogen with no safe level.  That’s over-and-above the possibility that fluoride itself causes cancer.

Question back there, sir.

Okay.  So, two separate questions.  First one is what is titanium?  Titanium is in the periodic table.  It’s an element.  It’s not an alloy.  It’s found as titanium.  Tons of it.  It’s found all over the place.  It’s not a very expensive metal.  Just getting titanium in a pure form is what’s difficult.  Titanium has different grades.  So, there’s medical-grade titanium, also referred to as commercially pure 99.9%.  That’s what’s making it expensive because you’re taking it and processing into that.

The stem cell part of research is interesting.  There were people talking about trying to take roots and put oxide layer of titanium on it to see if anything would happen.  The other side of stem cell research is not so much on the titanium part but where I showed you the upper jawbone or these cancer patients who had no bone at all, and we’ve actually taken a bone from their leg or their hip, transfer it using stem cells to grow the bone first.  Then, putting the implant there.

Next week on Wednesday, I have a meeting with the MediCare folks because with MediCare, we’re having trouble for them covering implants for our cancer patients who didn’t lose teeth because of not taking care of their teeth.  They’ve lost those teeth from cancer, and if they can pay for breast cancer reconstruction, why can’t they pay for oral reconstruction which is not for cosmetics?  It’s for function and chewing.

So, we do have means, but the basic reason is it’s expensive.  It’s just outrageously expensive, and the insurance companies can’t just see.  Most dental insurance companies have limits of $1500 a year or something like that.

Okay, very good question.  So, if you have a piece of titanium in your jawbone, like all my cancer patients I showed you, you can do an MRI with the screw in the bone because the density of titanium is so low that it’s non-magnetic.  It doesn’t even interfere, but the teeth that are made on top, I have to remove those every time a patient has to go for an MRI. Those are so dense that they would interfere.

An MRI, it’s not magnetic, but because it creates a field that you don’t see exactly adjacent to it what’s going on, you get an artifact area.  So, we always remove those before we do a scan. The screw that’s in the bone, it does it not interfere MRI.  If somebody’s had cancer, you had implants in your jaw, and you ended up needing radiation for treating cancer.  That titanium doesn’t even interfere with the delivery of radiation because it’s not dense enough to interfere with the path of radiation.

So, the question is, do heat and cold affect, like you eat ice cream and you get a cold sensation on your tooth.  If you have titanium are you going to suddenly jump up?  I don’t think so.  I’m not so sure I’ve heard anybody say that.

Correct, so the question is, if you don’t have enough bone available for us to put an implant in, is grafting the only alternative?  Yes, and if you start going further on that question, the grafts are varied.  You could have autogenous bone graft.  This bone is going to come from your body.  You could have bone graft from another animal.  You could have bone taken from a cadaver.  It all depends how much bone is needed and what procedure the surgeon is going to use to grow a bone in that area.

The latest in that area is actually to take a liquid of what is called growth factors or bone morphogenic protein in TGF-beta which are proteins that help stimulate your cells to grow a bone.  Basically, if you took those and put it in a muscle somewhere in your body, it would still grow a bone.  Rather than all the other processes, you’re taking bone cells and having bone come there.  That’s where working on the latest because you don’t have to compromise any other site.

Pretty much, if you don’t have bone, we can’t put an implant there.  It’s not going to work.  You need to have enough bone to put an implant in.  Typically, for a single implant in the upper jaw, you need an implant that’s at least 13mm long.  So, if you want a 13mm-long implant, you’re going to need about 15mm of bone.  In the lower jaw, the minimum that we would work with is 10mm because the bone is denser so it’s got more stability to it.

So, if you are a grinder of your teeth or a bruxer, is that detrimental to implants?  That’s an interesting thing to your ligament question before because if you are a grinder, you’re putting more stress on the implant, and if you had a natural tooth with a ligament, the ligament allows the tooth to move a little bit.  So, you’re not fatiguing the system as much.  You’re fatiguing the ligament, and you could get gum disease after that, but you’re not going to have the tooth crack, so to say.

With an implant, you run the risk, not so much of a failing implant, but maybe breaking the porcelain or breaking the screw that’s holding it in there.  So, for patients who have a history of grinding their teeth, our recommendation is to give them a night guard or a mouth piece that they wear at night to protect that from happening.  The night guards are made out of plastic, so it’s like have that shock absorber now over the teeth so the teeth are not hitting each other.

Titanium was accidentally discovered in this process, and because of all the other implants that I showed you before, they used all sorts of metals including gold.  None of them worked.  There are some people that say that the magic is not the titanium.  The magic is really the process of doing it in two stages rather than putting a tooth on it right away, but nobody wants to try that.  It works with titanium so why are we going to try some other alloy?

Titanium is standard. In fact, orthopedic surgery (all the knees and hips) are now almost all titanium because they used to be stainless steel.  When they were stainless steel hips, when they were put in, in order to hold the stainless steel there, they used what was called bone cement, and that bone cement was really plastic resin.  After 15, 20 years, you had instances where those actually separated.  So, a lot of orthopedic devices are made with the same idea that the bone is actually going to grow on the surface of that.

Just by how much bone you have below it.  If your maxillary sinus is coming way down, how much bone do you have between your mouth and the maxillary sinus?  If you don’t have 13mm, it’s not going to work.  So, one of the things, if you have to graft that area, you actually graft into the sinus.  It’s called a sinus lift procedure where you take the membrane the sinus, and you lift it up.  You’re creating a bone graft on that end.

Okay, the question is if that medical student who was playing basketball had the tooth knocked out, if he came to me right away, could be put the tooth right back like we do on little children?  That only works in kids.  In adults it doesn’t work so well, and most of these accidents that happen in adults, the tooth is also fractured.  It’s not like a young child.  They fall, and the tooth comes out.  They say, put it in milk and get it to your doctor as fast as you can so they can put it back in because their cells are healthy and more capable of regenerating.

Actually, that young girl that I showed you who had the resorption process, that happened to her.  Her tooth was a lost, knocked out when she was a little girl and put back in, and they’ll take for a while.  Eventually, that nerve still dies on the inside.  So the nerves die but the tooth is sticking, and they end up cracking, fracturing.  She’ll get 15, 20 years out of it, and then they’re eventually going to be lost.  In an adult, that doesn’t work very well.  So, if I was to fall, knock my tooth out, and put it back in, it’s probably not going to work.

Sir.

Correct.  So you have a screw, and you have a tooth that sits on top. The screw is in the bone, and a tooth is sitting on top of that screw.  To hold it there, you have to have a screw that’s going through the middle of that that’s tightening it down in place, and you just put a little filling.  If you don’t want the hole to show, if I was in Southern California, always make fun of South Orange, and didn’t want to show this hole, then I would make a metal post that would be screwed in.  Then, I would make a separate crown that would get cemented onto that post.  So, you cover it up, basically.

It would be like a thimble.  So, if you have that hole that I showed you, it would be beneficial in terms of retrievability.  That’s definitely an advantage, and most people, that’s what we would recommend.

Why would you want to retrieve it?

If there’s any problem.  If a screw or something chips, cracks, breaks, you don’t want to go through the whole process of having a crown made up all over again.  It’s expensive, and even the screw sometimes can just turn loose.  See, over years, right?  If you have a screw that’s holding the post inside and it turns loose, you’ve got crown cemented on top, you can’t get the darn thing off.

One of my mentors said, if you screw anything together, eventually it’s going to turn loose.  That’s why cars are welded together, not screwed to place.  So, we want the access.  If it’s loose, you just drill out that filling, put it back in and tighten it.

You have a question, sir.  We’ll take that, and that’s the last one.

Okay.  Very, very good question actually.  There’s some interesting research that’s coming out in Scandinavia that they’re looking at it and saying, “How many teeth do we actually need to have a normal masticatory efficiency, or how many teeth do we have to lose to get to a point where chewing is compromised?”

We all know of us having 32 teeth, but these wisdom teeth, they’re gone. Most people today have 28 or less.  If kids have braces, they pull for teeth out, so you’re like, “I’ve got 24 because I had four teeth pulled to have braces when I was a teenager.”  My wisdom teeth are either out or somewhere in there.  So, I’m left with 24 teeth.

They say, as long as I have 20 chewing surfaces, my masticatory efficiency should not be compromised.  So, if you’re missing just one molar at the back, you don’t need that replaced just to get you to chew normally.  Now, what people are talking about are if you have just one lower molar missing and the upper tooth is there, that tooth may come down.

Teeth want to be in contact.  So, if you have nothing opposing them, teeth are going to want to move.  If I have one molar missing in the middle, and there’s a molar at the back, that molar’s going to drift forward.  It’s going to tip in.  So, you want to be able to do something to keep that space.  You’re doing it for that reason more than making you chew better.

Alright, thank you all for coming.  We hope that you learned something tonight.

Another younger patient with what’s a sarcoma or a tumor of the bone end up with implants and a graft.  Removable, again, because in this case, you can see where these teeth are and how far down this bone is.  So, we needed to replace normally the teeth with the gum to make it look normal, and therefore, a larger prosthesis to make the gum functional again.

Lower jaw in the front, a large cancer that was removed.  Rebuilt with bone from the leg, and at the same time, implants placed in that jawbone.  After healing and radiation therapy and a bar, the denture that made this patient functional again.

This technology of osseointegration has moved on from teeth to other parts of the body.  Our application is to the head and face.  It’s very interesting when I see patients for making ears and noses and eyes.  They always wonder why they’re seeing a dentist, but it’s because the process of how it’s made is very similar to teeth.  We can use implants that are smaller in size that help hold the ear.

This patient had a melanoma.  Lost part of the ear.  We make him a traditional ear prosthesis out of silicone.  Has to be glued to place.  Not very stable.  Not very functional.  We can place some implants and have a bar, and then when we have an ear, there’s a magnet and a clip that actually helps hold that in place.  You can see what that restoration looks like from this patient.

This is a lady who had her nose removed from a cancer.  Implants were placed in the upper part of the jaw, implants and a bar that were made, and then a nasal prosthesis that restored this patient back to normal.

So, the technology and how it’s used in treating these patients is pretty amazing in what we are able to do for them.  An eye prosthesis for somebody.  Now, again, you got to remember, these prosthesis are not functional like teeth.  It’s for cosmesis, making them acceptable in society, making them comfortable, psychologically, to go out in public so they feel closer to normal.

I tell patients with the eye that all I’m doing is making you a custom eyepatch.  You don’t have a piece of white gauze and black patch that you’re wearing.  You’ve got something that looks more normal so when you’re walking down the street, people shouldn’t take a second look and try to figure out what’s going on with you.

This is the largest on that I’ve ever made.  This is a large facial cancer on a patient that we were able to place implants, and give him a prosthesis.  It made him halfway presentable, still not ideal but presentable.

Now, we got to talk about failures in the last three minutes or so here.  Failures can be broken down into multiple categories.  The first one is biological.  So we’ve got an implant here.  You can see the threads, and there’s blood on it because this was put in bone and it didn’t take.  For some reason, the bone did not grow into the surface of the titanium.  We call it a biologic failure because the biology didn’t work here.  Why did it not work? Well, it could be because the surface may have been contaminated.  It could be because the surgeon didn’t do the surgery in an atraumatic manner so the bone was drilled too fast.  Maybe the bone didn’t have the capacity to heal.  We do have scenarios where the bone has poor blood supply, poor vascularity, inability to heal normally.

We look at biological failure.  We break it down into two categories.  One is early that you put the implant in. You wait the three months.  You go back to put the second piece on, and you find that the implant is loose.  It never took.  That’s an early failure.  We call a late failure after loading.  That means it took.  I made a tooth that I put on there.  You started to chew on that tooth.  In a couple of months, it fell out.  So really, the bone grew into the surface of the implant.  That inferface between the bone and the implant was not strong enough to withstand the forces of chewing that you were putting on that tooth.  So, those are both biological failures.

We also have something that we call a mechanical failure, and we are starting to see more of these now because we’ve had these implants in our patients 15, 20 years.  Basically, mechanical failure is fatigue.  You take anything in metal, and you bend it.  You flex it. You flex it and flex it.  There’s going to a come a point in time when it can break.  It’s the paperclip right?  You bend it.  You bend it.  You bend it. You bend it, and boom it goes.  So, we are looking at this seriously.

It may be the dimension of that implant that we had made, and most of these kind of mechanical failures occur in the one tooth situation because when you saw multiple teeth, one of the things I didn’t point out was when you make multiple teeth, they’re all connected together.  The idea of connecting them together is that the force or the stress is shared between the multiple implants.  All the load is not just going to one implant.

People will say, “Well you’re putting so many implants, why are you connecting them?  I can’t really floss in here anymore”.  Well, it is a little bit more difficult for you to floss, but the biomechanical advantage is significant.  Therefore, we want to connect them together.  In the single tooth situation, we don’t have the ability to do that, and that’s where we see most of our failures.

So, we’re talking about maybe having a fatter screw that’s thicker, maybe talking about modifying the bites so there’s not a load placed on that, modifying the strength of the implant.  Most of the implants are made with what’s called commercially-pure titanium or 99.9% titanium.  Titanium is a pretty soft allow.  So, the idea is can you alloy this titanium to be able to make it stronger?  There are companies working on that to see can we mix something in there that will make it a stronger alloy but not interfere with the property of the bone growing out of the surface.

So, this is the one that’s fractured as you can see.   When it fractures, what do you do?  It’s actually a problem in a way because if it’s broken like this one here, it’s not easy to take out because the bone is still growing out of the surface of this thing.  The only way you can get this implant out is to core it out.  You’re going to have to get what we call a trephine or an apple core that’s going to go completely around this implant, and you run the risk of a lot of damage to adjacent structures.

In this particular patient that was broken, we opted to just leave it in there.  It was not going to do any harm.  It was buried and he ended up getting a traditional bridge because his tooth, the next one, already had a crown on it.

Biological failures are also related to the inability to clean.  So, this patient, as you see, he’s not doing a good job.  You see a lot of buildup of tartar and calculus.  They’re not doing a good job of cleaning them.  What’s that going to do?  It’s going to harbor bacteria.  The bacteria that’s going to be there is going to create inflammation.  You can see the irritation and swelling, and if that goes on long term, there’s going to be pus.  It’s going to cost a problem.  So, maintaining these implants is a critical part of it. You just can’t say, “I’m going to have the implants placed in my mouth, and then, I’m done.  I’m never going to see the dentist again.”  You are stuck, too.

I tell my patients almost-always that they’re married to me.  They can’t go any place.  They have to come back.  There’s going to be maintenance.  There’s going to be issues, and with that are costs associated with it.  So, you have to be prepared for that.

You can see how much tartar and calculus can build up because what happens for a lot of these patients, they’ve been wearing dentures for 10, 15 years.  They don’t own a toothbrush, and all of a sudden we tell them, “You have to start brushing your teeth again.”  They haven’t done it for so long.  It’s not easy.  Some of them are older.  Their vision is not so good.  The manual dexterity is not so good.

It’s a challenge for us which when we first started doing this, we didn’t pay enough attention to.  We didn’t really realize that.  We are very proactive now.  We don’t let these people get away or start off on a bad track.  If we feel someone can’t do good oral hygiene, we sometimes don’t make them bridges.  We make them the dentures that they could remove from their mouth and clean because they’re less complex, and they’re easier to clean outside the mouth than having something screwed into the mouth like you see here.

You see a lot of buildup of tissue or tartar and what the tissue’s doing to it.  In the single bar, it’s all tartar.  You have to see your hygienist to have your teeth cleaned every three to four months.   In fact, the way tartar sticks to this titanium, it’s very tenacious.  Hygienists have to work really hard to get it off.  It doesn’t come off as easily as it does with natural teeth.

We give our patients a whole box of tools that they’re going to need to keep this clean.  It’s not just about having a toothbrush anymore.  You spend a lot of time and a lot of money, a big investment, in it, and you’ve got to take care of it.  You have mirrors and things that allow you to floss and keep that clean.

These are all the stuff I give my patients when they finish an implant.  So, they walk away with a goodie bag.  It’s like going to a kid’s birthday party and going with a present and leaving with one.  So, they leave with all these stuff.

In the dental school, we actually think titanium is pretty incredible, and we’re hoping the Golden Gate Bridge will refurbish itself with titanium so it won’t rot.  Maybe our tolls won’t go up the way they’re going up right now.  The maintenance would be less of a problem.

So, open for questions.  Who wants to start?  Right over here, sir.

I’m not sure I get your question.  Your question is that because an implant doesn’t have the ligament, you have a natural tooth next to it that’s a ligament, is that going to fail?  Well, interestingly not because it doesn’t have a shock absorber.  It doesn’t have that path for bacteria to go down as easily.  Therefore, you don’t get the same kind of periodontal disease or the recession that you get in natural teeth.  You also don’t get cavities because titanium can’t get decay.

So, there are certain advantages.  We still don’t think that titanium’s that good that you should take out everybody’s teeth and put titanium in it, instead.  It’s not 100% successful yet, but, no. there isn’t a higher risk of failure.  The failure mechanism of titanium implants is not the same as it is for teeth.  The failures that occur in teeth are ligament-related which are not there.  We don’t have it.

The failures here typically are if an implant has been in a person’s mouth long term, biological failure is not going to occur.  Biological failure has two types:  failure that occurs because the bone didn’t grow into the surface or after you load it in the first few months, that interface is not strong enough to tolerate that loading, and it’s going to be lost.  If you go pass the one earmark, the failure of implants is very low.  It’s like 0.2%, 0.3%, but it’s only been 15, 17 years.  I can’t tell you what’s going to happen 50 years from now.  We haven’t followed them long enough.  There are probably going to be other failures like the mechanical failure that I showed you, potentially.

Our preference for predictability in the back of the mouth is to actually use gold.  Not everybody likes that, but in the back of the mouth, for most of us dentists, gold is the gold standard.  There’s nothing better than gold in terms of how it behaves and how it responds, but not all of us want gold in the back of our mouth.  We fall into that being wane issue and having something done.

So, what did I show you?  I’ve shown you people with no teeth.  I’ve shown you people missing just one tooth, and we move up from that to people missing more than one tooth, multiple teeth.  It was a gradual progression of how this technology of titanium and osseointegration progressed in our treatment of patients.

We didn’t want to just use it anywhere and everywhere unless we were sure that it was going to be predictable.  Another study, 87% in the upper jaw, 92% in the lower jaw.  Common theme that you would see, higher success rate in the lower jaw because of the denture bone that we talked about earlier.  Almost any study that you look at, you’re going to find that.

This is a young man who was in an accident, lost his three front teeth.  He had a temporary denture that he didn’t like.  We had three mini dental implants placed, second part of the surgery done.  A temporary bridge made first to make sure we liked the way it looked then converted to a permanent bridge, and what he looked like when he was done.  Uninvolved natural teeth.  Predictable.

This is a lady who showed up with two teeth that were periodontally hopeless.  Look at how bad these looked.  She was very unhappy with what was happening.  These teeth were loose.  We call them immobile, their mobility, because they’ve lost the bones.  When you bite down the tooth moves, and the dentist just put some bonding material to keep them there until she could decide what she wanted to do.

We took her through a significant amount of treatment and took her from here to this spot.  She’s got two implants that are holding up these two teeth.  You can’t tell that these are implants in there which is the key.  Very different from those teeth on stilts that I showed you, 1982.  Right, that Profession Branemark first started out with in patients who had no teeth whatsoever because that’s what we wanted.

In order to be able to use them for everyday tooth replacement, not only did we want them to be functional, which they were for those patients, but we wanted them to be aesthetically acceptable.  We needed aesthetics and cosmetics in this day and age.

I mean look at the People magazine.  I don’t know why we dentists even have the People magazine in our office.  I mean, it’s crazy because we set ourselves up for trouble because everybody wants teeth like the cover of the magazine, and we can’t always deliver that.  There are limitations to what’s going on, but we all look at that.  We see it every day, and that’s what people want.  They’re not going to want teeth that are not going to look that good.  So, you could have a great technology, but if you can’t make it look right, it’s not going to be very successful.

This is I think I showed you, this was 2003, and this was three years after still looking natural which is the key part to it.  I don’t know how many of you are local San Franciscans, I’m assuming, but when I trained at UCSF, there used to be a program at the Letterman Army Medical Center, and as residents, we would rotate.  We would go there, and the residents from Letterman would come over here.  One of our mentors here would always talk about the Letterman guys, and some of them would be doing this crazy treatment and they’re saying it’s 100% successful because either the patient moves or the dentist moves.  You never see each other again.

So, it’s very critical that we follow these patients over time and we know what’s going on.  So, this is a three-year follow-up on her not only to show the fact that the implants are still in place, but that the aesthetic outcome, the way that the gums look, they look natural.  They shouldn’t look artificial which is the key to success.  We cannot always do that though.  It’s important to understand.

This is a young patient who was in a car accident.  He was actually taken to San Francisco General for trauma.  He was missing teeth and a lot of the jawbone.  Well, we cannot make teeth look natural when somebody’s missing all that gum.  We can’t grow the gum back there, alright.  So, in his case, we’ve got three implants.  We’re going to modify a treatment.  We’re going to give him something moveable.

We’re going to make a bar that connects the thing together, and he’s going to have teeth that go in and out of his mouth like the upper denture I showed you on patients with implants because what did we need in him?  In him we need this gum portion to replace all that gum tissue that was lost in the accident as well, and only then can we give him teeth that are about the same size as the other teeth and give him gums that can go in between these other teeth so it starts to look natural.

So, not all patients are candidates.  This is a patient.  It’s actually my mother.  She’s 73 years old, a diabetic, had a congenitally missing tooth.  I made her a gold bridge moons ago, probably when I was still in dental school.  One of the teeth fractured.  We couldn’t do that anymore and gave her implants.  Three implants were placed and a bridge.  She didn’t want gold in the front of her mouth.  She wanted porcelain.  I told her it may chip and break, and she says, “No problem.  You’ll fix it.”  We had three implants with three teeth on there.

Typically in patients that are not my mom, we’re going to try to give them a metal [53:00] surface or a metal biting surface because of the fact that we have concerns if we put porcelain at the biting surface at the back, it’s at a high risk for fracture.  It’s okay for me or a dentist if you’re going to go back in.  You’re going to be charged again to fix it.  Do you want to go through that hassle?  So, we give you that choice.

You also notice that you can see the holes.  That’s because that’s the screw that’s going through that channel to hold it in.  Now, we have ways of covering that up and not making it look like a hole.  We would then have to take a crown and actually cement it, but if we cement it and something goes wrong, we can’t take it off.  We have to cut it off.  I don’t know how many people have experienced having crowns and bridges that are broken.  They have to be cut off.  If they have to be cut off, they have to be completely remade.  So, there’s a retrievability advantage of having a screw channel that we put a filling in.  Most people are willing to accept this aesthetically.  I guess if I was practicing in Beverly Hills, then that may not be acceptable, and everything will be cemented on.

On the upper jaw, same thing.  Three implants, metal occlusals, metal biting surfaces, and screw-access holes with the retrievability part built in.

Quickly going over to show you some of what we do to a cancer patient.  If there’s any group of patients that I believe has had the most benefit of implant, it’s been these patients because in these patients when they lose not only their teeth but a major part of their jaw, we have to be able to put something back in there that can help create separation between different parts of the face.

What you’re looking at here is a patient who had cancer of the sinus.  This is one-third of the upper jaw remaining.  You’re looking up at the sinus cavities.  There is no way, in this patient, that I could ever have a denture that would stay in place.  Upper dentures, I told you, stay in place by suction.  If you have a hole, you’re not going to get suction.  It’s going to drop.

Therefore, in order to be able to anchor and keep this in place, we needed implants because this patient needs implants not to be able to chew, just to be able to swallow and to be able to speak effectively because if the denture is moving up and down, the air’s going to be coming out of the nose.  They’re not going to sound right.  There’s a big difference in terms of quality of life in what we’ve been able to do for these patients.

Another patient like that lost the upper jaw on one side from a tumor, had two implants and a bar placed on there.  You see a denture with a plug that actually goes up into that sinus cavity, but this clip helps hold this plug in this spot because if this is not up there to hold the plug, the plug’s going to move around.  You’re going to have leakage, and it’s not going to be functional.

A patient who lost the front of the jaw.  We had implants there.  They’re going to help a lot, holding this bulb there and sealing the cavity so that they are presentable in society.  Much larger, half of one side and a quarter of the other side that has gone from a tumor.  Three implants and a bar, and if you look at the size of the denture that is to be made for this patient just to close off the hole.  This thing is never going to stay up if we didn’t have the benefit of these implants.

This is actually an older patient with a cleft.  They have a cleft of the soft palate.  I don’t know how many of you may have come across people like that.  In this day and age, fortunately, when we see these kids at a young age, the surgery is done to the palate that they don’t need prosthesis, but older patients who didn’t have that benefit are completely missing their soft palate.

In order for them to speak and swallow effectively, we have to have a prosthesis that has a bulb to it that goes all the way back.  This portion, that is part of the replacement for the soft palate, and in order for this to stay in that area without teeth, it would be impossible.  She had teeth before, but these old teeth of hers were failing now so we ended up using implants to help keep a large dimensional prosthesis like this.

This is a patient who ended up with not having any jawbone left to put implants in, and one of the innovations that have been made by the Swedish group is most of the implants that I showed you before were implants that were placed in the jawbone.  They’ve actually made implants that are about 40-50mm long, and these implants, they’re going up into your cheekbone or your zygomatic arch.  From the zygomatic arch, they come down into the mouth, and we connect them with a bar and have a prosthesis.

If you look at her without the prosthesis in her mouth, her lip has completely fallen back because there’s nothing there to hold the teeth.  She can’t swallow.  She can’t function, but when we have this, we’ve improved it significantly to allow her to be able to speak and go back out in public.

In the lower jaw, same thing.  Somebody who lost the front of the lower jaw.  In the old days, you would just place a bar of metal and leave them alone.  You couldn’t do anything.  Now, we can graft them with bone, place them with implants, and make them function 100%, 99.9% if not more.

Side of the jaw totally lost from cancer rebuilt with bone from the hip and implants and teeth that allow this patient to function.  Young patient who had a tumor that involved moving the entire front of the jaw rebuilt with some implants and some teeth.

Basically, what you see here is a patient who got only got two dental mini implants or two screws, and there’s a little gold bar that’s been made.  The inside of the denture has some clips, and these clips clamp onto that and allow this denture to be held in place very well.  So, it doesn’t move around very much which is really what most patients complain about.

This can be done with four implants, and basically, the more implants you use, the less support you’re getting from the gum.  If somebody’s got gum tissue that’s very delicate and very thin, very friable, can’t take the load or the pressure of having a denture sitting on the gum, then you have to try and place more implants to make them successful.

The patient with the two implants is typically somebody whose worn dentures successfully for 20, 30 years but now have lost so much gum that the denture’s sitting on a totally flat surface and just slides around too much, and we now want to have a little something to give it a better hold that doesn’t move around as much.

So, that’s just different overdenture ideas that have been done, and I’m showing you this here, somebody who’s got four implants that are spread out.   If you can look at the geometry of this, in this case, even though we have a denture that is completely sitting on this bar, there is no pressure actually being placed on the gum whatsoever.

So, for the patients with the gum that’s delicate, we can still provide this kind of treatment.  Upper jaw, same thing.  This is actually a patient who was born with no teeth that we were able to place implants in a young child and give him teeth.  Patient has eight implants in the upper jaw and some in the lower in back where they already have their own teeth and a bar that’s been made in the upper jaw and then a denture because most patients who have lost their teeth in the upper jaw have lost enough gum that we need this gum to support the lip because if you don’t have that gum to support the lip, the lip looks like it’s fallen in.  We didn’t want those spaces like I showed you.  So, typically, in the upper jaw, this is a treatment that we do, something that’s horseshoe-shaped anchors on and stays in place.  It’s very solid and very stable and allows the patient to function.  There’s all different designs that you can see here for different patients made with different materials.

Now, there’s some people who don’t want teeth than even can be removed.  They want to have their teeth that’s just screwed in.  They want to be as close to their natural teeth as they possibly can be, and there are a few patients that we can do this on.

The big problem with that in the upper jaw is the aesthetics.  Can we have the implants put in the exact right spot where a tooth needs to be, not in between two teeth, because then you’re going to see some of that metal, and it’s not going to be aesthetically acceptable?  So, those are the challenges that we have to face with, and typically when we do this, we’ll have the implants.  We’ll make a temporary bridge first before we make something that’s going to be solid and screwed in.

This patient doesn’t take her teeth out.  She can walk through security at the airport, and it doesn’t let the buzzer go off or anything like that because this metal is not as dense to let that happen but allows this patient to have teeth that are as close to their own teeth as possible.  Obviously, the more complex that you have the treatment, the more expensive it gets, the longer it takes to be done.

This is a patient who had no teeth of her own and wanted teeth that couldn’t be removed in both jaws.  So, there were six implants placed in the lower jaw, eight implants placed in the upper jaw, a lot metal that’s in there, and porcelain that’s placed on the top with the pink surface.  When she smiles, that’s what she looks like.  We have to give her room here to be able to get in and clean these things.

It’s very important, maintaining hygiene, and we’ll talk about that because most of these people ended up in this position because they didn’t do a good job cleaning their teeth.  They’re probably, in some ways, also susceptible to periodontal disease.  There’s lots of people we know who don’t clean their teeth but don’t lose their teeth as much as others.   It’s something more than just not cleaning your teeth, and we know the ones who are in this situation in early age are susceptible and haven’t done a good job.  We want to be able to provide and maintain them over a period of time.

When I started doing this in 1987, I would have to say that 80% of my implant patients were people who had no teeth, and out of that 80%, 80% were the lower jaw because that’s where most of the problems were.  As we got more predictable and most successful with this, there were young patients missing just one tooth, and our big challenge was if somebody was just missing one tooth, what do we do in 1987?   What do we do in 1992?

Well, we made a bridge.  We took the natural teeth.  We cut them down.  We capped them, and we cemented a bridge that was of three teeth, but in effect, in order to replace one tooth, we were working on two perfectly healthy teeth that didn’t need us to be doing that.  In fact, we were actually compromising these teeth.

Even and insurance company pays for a crown to be redone after five years.  What does that tell you?  That they think the life expectancy of a crown and a tooth is five years.  Something’s going to break down.  There could be decay. Something could happen to these teeth, and therefore, we were setting a young patient up like this that we did a bridge on in early age for repeated visits with the dentist over years of their lifetime and having replacements that needed to be made.

We were really interested in using treatment that didn’t allow us to treat the natural teeth.  Could we have a way avoiding touching these teeth and giving the patient an implant?   Studies were started, again.  We had success with patients missing all their teeth, but did that apply to a patient who’s missing only one tooth?  We didn’t know that.  We had to test it out.

People started to publish in 1996 and 1999 where we were doing single tooth implants where somebody was missing just one tooth and how we were going to place an implant.  This is an example of a patient like this that I treated many years ago.  She was actually congenitally missing this tooth.  It was not there when she was born.  It happens quite often, about 11% of the time.  We didn’t want to cut her beautiful teeth down at age 17.  So, we put one implant in, made a temporary tooth first, let the gums heal, and were then able to make a porcelain crown that was cemented in place.

If you look at this young girl smiling, you couldn’t tell that she’s got an artificial tooth in there. The biggest thing that we did for her was that we left her natural teeth intact.  We did nothing to compromise them.  All of this was done by putting one screw and having a tooth attached to it.

Predictable process are my practices from treating patients with no teeth and implants have really gone over to treating mostly patients who have teeth, are missing one, two, three, four teeth.  It’s an even mix now.  Bridgework that we used to do 15 or 17 years ago, we don’t do that much anymore, at least I don’t in my practice because of the type of patients that come to see me.

This is a young fellow who was actually a medical student here at UCSF who was playing basketball across the street and got elbowed and cracked a tooth, and it was lost.  He didn’t want to have a bridge made, and we placed an implant.  You can see, six months later, he’s got something in there that looks like a tooth and looks healthy.  You couldn’t look at this and say that it was something artificial.  Same thing, one screw, a tooth that’s attached to that.  Interesting part, the screw or the connection coming through the gum surviving without an infection.  What osseointegration did for us, allowing bone to grow onto the surface of the implant.

Another young patient.  This is a young lady who refused to have anything removal.  She had been in a bicycle accident when she was a teenager, another very common injury.  You fall down, and you get a hockey puck or something to your face.  You crack a tooth.  This tooth had got.  It was dead, and it turned gray.  A root canal was done to it. We know that these teeth, over time, break down.  She started to get what we call resorption or for some reason the tooth’s been eaten away on its own, and it had to be replaced.  That’s what the tooth looked like.

She would not tolerate walking around with no tooth in her mouth.  So, this was a case where we actually removed the root and put a tooth on it the same day, but we made a tooth that was a lot shorter than the other teeth.  We made it in such a way that she couldn’t bite or touch it.  So, we weren’t loading that.  Fortunate part for her was that she had a lot of good bone so we could put a long screw that was stabilized and was solid in there.

If you put a screw, and it’s moving and it’s not stable.  Then, we’re not going to be able to do what we call an immediate load in a situation like this.  This is what it looks like four months later.  This is still a temporary tooth.  You see a little grayness from where the screw hole is at the back through the plastic.  Once it’s healed, this is her permanent tooth that’s been put on there about eight months later.  If you look at her mouth right now, you couldn’t tell that she’s got an artificial tooth placed in her mouth.

This is another patient in the back of the mouth, congenitally missing or a tooth that was not formed.  An implant, tooth attached, porcelain.  Looks like a natural tooth.  A molar in this patient replacing the tooth at the back, not involving adjacent teeth.

So, I can show you slides of this on and on and on because it has become a pretty predictable procedure.  The only changes that have occurred are how many should be placed, where would we place them, what the size should be, how long should we wait, what type of material should we put on top.  Should we put porcelain?

I mentioned to you earlier that a natural tooth is attached to the bone with a ligament.  Well, that’s an advantage because when you have a ligament, it’s like a shock absorber.  When you bite down on something, it has the ability to give.  So, when you bite into something hard, there’s something to take off that shock.

When you have an implant that’s screwed into the bone, there’s not ligament.  There’s no shock absorbing effect.  When we put porcelain on the biting surface, we’re actually at risk for this porcelain fracturing.  We don’t like putting porcelain in the biting surfaces of back teeth because if you’re eating some food, and by accident you get something that’s a seed in there or stone or something harder, then you expect you can just bust that porcelain off.  Porcelain is glass, is brittle.

It’s really boring.  You’ve got to sit there, and you watch this thing slowly going in.  You know, great, next.  Let’s get going.  It’s just the nature of you, and we have to patience.  We want everything done right away, but it’s absolutely critical that you do that.

The drills that they use is very critical.  We use new drills for every patient because if they’re new drills, they’re sharp.  If they’re sharp, they’re going to cut efficiently.  They’re not going to generate heat.  So, you don’t want to get cheap and use recycled drill that’s been sterilized again because it may not be cutting as sharply as a new drill.

So, those are important parts in the atraumatic portion of the surgery and the period of healing without loading on it.

Before osseointegration became popular, which start in North America in 1984, 1985, the Swedes were very good about this.  They did not, in fact, let the rest of the world know about it until they had treated patients for almost 10 years, and had a long-term success before they published any data in their literature that everybody else could read.  Basically, they were being conservative.  They wanted to make sure that they had a process that worked because dental implants, as I told you before, were fraught with failure.

There was no dental implant system that was predictable.  Every dentist around had tried something.  You can see how crazy this person must have been.   This is like modern art.  We can hang it up in MOA downtown.  It’s job-owned.  They made a casting out of chrome cobalt metal which is now being placed under the gums and teeth put on it, and these things never worked.  Their 5-year success rate was less than 30%.

The people still went through and had these things done because they had no alternative, and there were about 20-30% of the patients that they worked for about 10 years but were really not successful.  The downside or the reason why these different implants did not work was primarily because (a) they were not made out of titanium, (b) the surgery was not done atraumatically (it was quick), and (c) the teeth were put on it right away.  It didn’t give it a chance to allow the bone to heal on the surface of the implant.

All of these failed, and if you go back historically, you can see all sorts of shapes and sizes and materials that we used.  They had different names to them but were really, really unpredictable.  When I started my residency in 1987, we actually spent more time treating patients where these had to be taken out than the osseointegrated implants that we were putting in there because of the problems that these created.

The other interesting thing that this group did with osseointegration was they standardize the whole process.  They made standard-diameter screws.  They made the system predictable.  You would just go and buy it.  If you look at it and say, it’s pretty crazy to have a screw fits all.  It’s really not predictable for patients with different dimensions of bone and different requirements, but that’s what they started out with.

They started out with that because the patients that they were treating initially for their first 10 years were patients with no teeth at all and had trouble with their lower dentures.  They almost could not wear the lower dentures, and so they said, “Let’s try and use a new technology to test it on people where we have no other option.”  If it works for that group of patients, which is what happened, then these systems were modified to adapt them to other clinical scenarios like we have today.

So, these screws were basically 3.75mm in diameter, and they came in different lengths.  In the early days, they were actually only in 7, 8.5, and 10.  That’s all they made because they were little old ladies whose jawbones were pretty small.  They resorbed a ton of weight.  They’ve worn dentures for 20, 30 years, and nothing remained.

This was the first screw that was put in the jawbone, and then the second step was to connect a cylinder of some sort to the implant that then came through the gums into the mouth.  The teeth were made and attached at this level.  It was a pillared system.  There was a screw that went into the bone. There was an intermediate component that attached this implant and brought it to the gum into the mouth, and then you made the tooth that got attached to that.  That was the system that was done originally.

Now, one of the changes that modified this from us using it in patients who had no teeth at all was what was still today, and it was done in 1990.  It’s called the UCLA abutment where the intermediate part was actually eliminated, and you could make a tooth by using this plastic part that you then waxed and made a tooth out of gold or porcelain that could be directly screwed to the implant like that one tooth X-ray that I showed you in the mouth.  That’s what it was like, and you’ll see more of these in a bit.

Talking about clinical applications.  We’re going to split this up into three categories:  the edentulous patient (that means somebody who was not teeth), partially edentulous (they’ve got a few teeth), and then we also use them in our cancer patients who are missing more than just teeth and major parts of their jaw structure.  This is what we’re talking about where somebody’s got a large facial tumor and has lost a lot of structure.  We’re trying to use these screws to help anchor some sort of prosthesis and make them presentable in society.

When we look at the patients who have no teeth, it’s important to know what the success rates are, and if you look at these success rates that was a 15-year follow-up that was published from the original group in 1981, they claim the success in the upper jaw was 89%.  The success in the lower jaw was 100%.  That doesn’t make sense does it?  Nothing in medicine and dentistry is 100%.  It can’t be.

They have these and other numbers in parenthesis.  What they were trying to tell you was that if somebody in the lower jaw was missing all their teeth and they put five screws in this person’s lower jawbone or five implants, that patient may have lost one implant, but if four remained, they were still allowed to give them the teeth which was the original objective of the treatment.  So, you could provide teeth on four implants instead of five, and therefore, it was considered a success.

Am I clear to everybody about what’s going on there with the success?  So, if you put 100 screws in somebody’s jawbone, only 91 of those screws really took.  Nine of the screws didn’t take in the lower jaw, but because they were spread out, they were not all nine in the same patient, there were enough in one patient to allow them to give the patient teeth which is what this patient came in for.

In the upper jaw, that was not the case because in the upper jaw, only 81% of every plant that was placed was successful.  So, 19 out of every 100 were lost.  You could end up with a patient who put four or five in, and all five were lost in that patient and they couldn’t get a prosthesis.  So, the success rate in the upper jaw was 89%.

Why does that happen?  Well, two reasons.  First of all, the upper jawbone is a much, much softer jawbone as compared to the lower jawbone.  The lower jawbone is much denser and harder, and therefore, it provides a greater chance for the implant to be stabilized and held in place, a critical part of it.

The second part is that in the upper jawbone, we have these sinus cavities that come down, and you have your nose in the middle.  When you’ve lost a lot of jawbone, there isn’t a lot of area remaining for us to put implants in.  You end up with shorter jaw implants and fewer numbers.  Therefore, they were not as successful.

In the lower jawbone, typically, if you were to go between where my two fingers are right now, there’s a nerve that comes right about here.  It’s called the mental nerve.  Between those two areas, there is no anatomical structure that’s going to limit you from putting the screw in there in majority of the patients.  Therefore, you can get enough numbers of implants that would allow you to have a successful result.

What are the type of the teeth that were made for these patients who are edentulous?  We break them down into three terms:  a hybrid bridge—this was what traditionally done. Teeth that look like this; teeth on stilts.  Titanium coming through the jawbone, and then teeth screwed on to that. A very primitive way, but that’s what was used in the early days and even today in some of the patients in the lower jaw.

This doesn’t work very well in the upper jaw because what happens when most people smile and laugh?  They show their teeth.  They show their upper gum.  You typically don’t show your lower teeth.  So, if you had a scenario like this in your upper jaw, you’d be blowing bubbles of saliva at your guest.  It wouldn’t be very friendly.  There would be spinach that would be stuck, and it would be showing and not so aesthetically.  Therefore, we really didn’t do these kinds of prosthesis in the upper jaw.

We’ll show you what we did in most of those patients so you can understand what the differences are in the type of the prosthesis.  Take you through some of the steps involved.  This is the lower jaw treated in the traditional manner where there’s five implants, so five screws, that are coming in to the mouth.  This is the second part already attached.  Remember that pillar system that I showed you coming through the gums.  We have to attach some metal pieces on there to actually make a mold so we can capture the position of these.  We need to be able to generate a model of some sort because we can’t make the teeth.  We can’t weld stuff in your mouth.  We got to do this outside.

So, things have to be made outside so we have to accurately replicate this position on a stone model or a plaster model that we can then go make teeth on.  Try them on, and then make sure that they’re successful.  We first try the teeth in the mouth to make sure that the bite is correct.  Based on that, we then have to make a metal structure that’s cast that fits the implants, and then, the teeth are actually bonded or attached to that metal structure.

So when you look in the mouth or an X-ray here, you see the implant part A, part B that comes through the gum into the mouth, and part C, the metal casting that which the teeth are attached.  It’s quite an elaborate process which takes a lot of time to do.  Typically, doing something like this is going to take seven appointments after the implants are ready to be used, and they’re about a couple of weeks apart and a lot of time and effort in the lab and expense that goes with it.  When it’s finished, this is what the patient ends up looking like, and most of these patients are actually very pleased with the outcome that they end up with.

Now, I said to you that these hybrid bridges wouldn’t work very well in the upper jaw, and I also showed to you that there were five implants that were placed.  What does that do?  Well, it’s a number of things.  Sometimes patients, medically, are not candidates for extensive surgery, or the costs of putting five implants in and making that superstructure may make that treatment something that is not realistic for them.

So, what other ways can we use the implants to provide this treatment to a larger group of patients?  This is what happened in North America.  We were very good, in those days, at saving one or two teeth on patients and using them to anchor a denture.  So, instead of having a denture sitting and floating around the gums, if we could keep two or three roots, we would hold on to them.  They were called overdentures because we were keeping some of the roots, and keeping the roots helped maintain the bones.  We felt, why can’t we use that concept with implants?