June 22, 2020
Kirk Noraian, DDS, MS
Marty Klein: Welcome to Dentistry for the New Millennium. I’m Marty Klein, Training Manager at the Institute for Advanced Laser Dentistry. My guest today is Dr, Kirk Noraian, a periodontist in Bloomington, Illinois. Dr. Noraian earned his dental degree, certificate of periodontics, and Master of Science from Northwestern University. Among many other accomplishments, he is currently a certified instructor for the Institute for Advanced Laser Dentistry. Today, we’ll talk about how he got started with LANAP, his use of the PerioLase for other value-added procedures, and his involvement with organized dentistry outside his own practice. Dr. Noraian, thanks for being our guest today.
Dr. Kirk Noraian: Thanks for having me, Marty.
MK: Sure. So you’ve been LANAP trained since 2008. And I’d like you to first think back to that point in time and how you first heard of LANAP and the PerioLase, and what persuaded you to incorporate it into your practice?
KN: Well, it’s kind of a funny story. It really all started in 2008. It was kind of a big year in dentistry because that was the year that basically the bottom fell out of the economy. And so a lot of people were, you know, looking for other ways to enhance their practices and what they could do. A lot of people said, you know, “Don’t spend money, don’t do it. Don’t spend any money on your practice because it could be a real problem. Could create financial hardship for you if you spend money that you’re not gonna be generating or earning down the road.” So that year, in the beginning of the year, I bought a device called Piezosurgery, and at the beginning of summer, I decided to purchase my first cone beam CAT scanner. And I went to the perio meeting. You know, I thought, “Gosh, there’s all this stuff kind of coming up about lasers in dentistry. So maybe what I should do is go to this corporate forum.” And it turned out that it was the Millennium Corporate Forum with Dr. Yukna presenting the research that he had conducted up until that point in time, and he was showing his cases as well as other cases from Dr. Gregg and Dr. McCarthy. So I walked into this meeting and I’m going Wow, it was kind of interesting. On my way in, the sales rep for my territory just happened to be there. And she said, “Well have you thought about a laser, Whatever? You know, we were doing some great things with it.” I thought, like, “Oh, yeah, right.” You know, I had learned about lasers when I was perio school and, you know, they were great gingivectomy devices at the time, back in the late eighties/early nineties. So I said, “Well, let me just go in and kind of see what was going on.” So Dr. Yukna was bombarding the audience with these cases that were re-growing bone, case after case after case, and my practice was known for re-growing bone.
I would say that back in 2008 I was pretty much exclusively a regenerative periodontist, so I used to do bone grafting quite extensively. That’s what I was known for. So I thought, “Wow, how’s he growing bone with this laser thing?” And so that week my staff were being trained on our new CAT scanner, and you have that big outlay of cash at that time. The new CAT scanner was $180,000. I bought Piezosurgery, which was probably like another, I don’t know, $20 or $30,000 maybe at the time. So I’m like going, “Holy cow!” You know, I’ve got a lot invested in everything. And so, you know, as a typical dentist, I called my wife and I said, “Okay, I’m at the meeting, I see this device, I really have to have it for the practice.” And she goes, “Are you sure? Do you really need this?” And I said, “Yes. I’m absolutely sure that I need this.” So when people ask me how long it took me to make a decision, I really say that it was a 10-minute decision for me to make a decision to purchase the PerioLase.
MK: And you just you mentioned there at the beginning that in 2008 this was an economic hard time, and that reminded me of kind of where we are today in our COVID-19 world. But yet you made several equipment investments at that time. Was that a wise decision, looking back?
KN: Well, this is sort of how I’ve run my business over the years, when I see people that are kind of following trend. And when I heard that people were saying, you know, “Don’t spend money, don’t invest in your practice, don’t put money in or what have you,” for me, I was thinking, “Well, that doesn’t make sense to me.” If things are contracting and you’re not doing anything to make people want to come to your practice, you’re not doing procedures that are enhancing the norms… What can you do to help enhance the norms? And so for me, my philosophy was, I was gonna go against trend, and I was gonna put the money into my practice at a time when people didn’t. I wanted to see if there was going to make a big difference for me. What was the worst thing that was gonna happen? Yeah, maybe I could go bankrupt or something like that. But at the same token, if it worked, and I had reasons for people to come to my practice, that was gonna be pretty exciting.
So you can say like, well, like, “How do you know what it did?” Well, for the two years before 2008, I had done 150 quadrants of guided bone regeneration with bone grafting to help regenerate bone for patients with periodontal disease in my practice. For the two years after, so from 2008 to 2010, I actually did 700 quadrants of bone regeneration with the LANAP protocol. That sounds a bit crazy to some folks like, what contributed to that difference? Well, LANAP is a full-mouth protocol, so the advantage of it is that you can get the whole patient treated at one time or in a couple of visits. Whereas patients who are probably getting bone grafting done, were not really very likely to return because you would treat him usually a quadrant at a time.
So for me with LANAP, because I offered conscious sedation (which was a big benefit), I was able to do the typical 2 appointment visit, to get the 2 half-mouths done in one visit with conscious sedation. That made a huge difference for me in my practice, and really made patients who were very apprehensive have a very comfortable procedure post-operatively, and if they needed to be sedated, they could be. Now not all patients choose to be sedated, but a vast majority of my patients choose to get the LANAP protocol done with IV sedation. That’s not a requirement; it’s just something that works out well for my practice. So I get the job done and patients are very happy. They have very minimal postoperative discomfort issues. So it was really a very beneficial decision for my patients at the time.
MK: It sounds like it was a combination of the patient friendly aspects of it in addition to the economic “I need to try it; I need to show that I’m doing something different to set myself apart.”
KN: Yes and the thing was I embarked on this pretty much hook, line and sinker. People would say, “Well, you know, like I kind of pick and choose what cases I want to do with LANAP and what I do.” I said, “You know what?” I said, “If this is a good as everybody says it is, then I need to embark on this. I need to embrace it, and I need to move forward. And it was a very substantial paradigm shift. But when I came back from the perio meeting in 2008 and I told my team that I was gonna be introducing this new protocol, everybody was excited, because patients really didn’t care for traditional flap surgery that made them uncomfortable. Now LANAP was gonna help treat them and help regrow bone around their teeth and save teeth for them. So patients were really excited about it, and they didn’t have to be beaten up to have the procedure done.
MK: So I want to switch gears a little bit and then I’ll bring it back to the PerioLase in a moment. But I know that you’ve held positions for years now, with on the national stage in organized dentistry, either with ADA or now the AAP. What made you decide to get involved on that level versus just staying in your private practice? And how has that affected you professionally?
KN: Well, I feel that we’re all given many gifts in life, and if we have a chance to give back that we should try to do that, and everybody’s at a different point in their life. Some people feel like, “You know what? I have so many blessings; I don’t have the time to get involved.” But for me, I felt that, you know, I had a perspective, you can already tell from some of the things that I have told you that I didn’t necessarily have to be a person who followed all the trends. I was a person who thinks out of the box and moves against trend, and I felt that that was an important perspective to present to different folks in terms of the future of dentistry and where we need to be headed. I’m proud of the fact that I can think out of the box, and I have the ability to provide a perspective that maybe other folks haven’t necessarily considered or are necessarily willing to embrace just yet.
MK: Yeah, and speaking of trends over the years and certainly the farther back in time you go. There was certainly a reluctance by the national organizations to embrace lasers, and the PerioLase for LANAP. I believe at one point you even were, at least I would say, reluctant to get on board. Certainly you did, and it’s gone very well for you. Have you seen an evolution in those opinions among your colleagues in the last dozen years?
KN: Well, I think that there’s a difference in terms of how everybody looks to incorporate something into their practice. We talk about the evidence basis of dentistry, and there’s always a range on what that evidence is. So I have a tendency to be more of like a first mover or an earlier adopter when it comes to technologies. Whereas some folks are saying, “Well, you know, I have to really wait until everything is like tried and true.” I mean, I embarked on my PerioLase investment with the idea that if it didn’t work out, I was gonna be redoing a lot of surgery. I felt that because of my surgical skills that I was gonna be able to regrow bone in other ways if the laser, specifically the PerioLase, didn’t help me to do that.
And so I think anybody who believes that there are no re-treatments with any treatment solution that you provide to your patient, they’re kind of unrealistic. But I would say that the vast majority of my cases are successful and as good, if not more successful, than the cases that I treated with traditional guided bone regeneration. You also have to understand that at the time when I got involved with guided bone regeneration years ago, there were people who refuted that guided bone regeneration worked, and felt that osseous surgery was the only way to treat periodontal disease. Then, what was interesting was that I always felt that the LANAP protocol was regenerative, but it wasn’t really able to be called that until the FDA said that it’s equivalent in 2016 when they evaluated the protocol against parameters for assessing regeneration. So for me as a regenerative periodontist, it was very exciting to be able to regrow bone and not beat people up.
MK: Well, certainly. I do want to talk a little bit as well about re-opening in this COVID world. Most states at the point at which we’re recording this are allowing for dental practices to reopen for non-emergency patients. I understand you have reopened and of course, I’m sure put a lot of thought into how you would do that from a safety perspective for your yourself, your staff and, of course, your patients. Can you tell me a little bit about your decision making and the best way to do that and how you approached reopening in this COVID world?
KN: Well, I think that the first thing is to understand is that when it comes to managing your practice during this time period, the biggest decision factor is really what is your local areas exposure rate to the COVID-19 Pandemic, every place is different. I have friends who practice in New York City and where my practice is located it’s in a more rural area. Although, you know we’re in the metropolis of a corn field called Bloomington, Illinois. So I think that you really have to understand what’s going on. I think that a great piece that came out recently is from the American Dental Association is “Understanding What Your Local Risk Factors Are?” One of the things that I started to do because we were seeing all these numbers on a national level, and I was trying to understand the magnitude for me locally. So basically like once or twice a week, I actually map the cases in my area. I have a little graphical program in PowerPoint that I use. I plug the data in the Excel spreadsheet for that, and I kind of look at what’s going on and trying to see how the cases are going. So I think that each of us needs to kind of assess what we’re doing.
The biggest thing that I would say that I’ve focused on is really trying to get everybody comfortable with coming back to work. I really did not try to set any production records. My goal was really to get the team comfortable with coming back to work and treating patients and getting used to wearing all of the equipment that we’re now expected to wear. I think this comes from a very different experience for me than from some other practitioners, because I was in dental school during the AIDS crisis. That was the first big change that we had during that era was, you know, wearing gloves, mask, and eyewear because of the blood-borne pathogens that were suspected. But watching all the hysteria that people went through during that time, people kind of overreacted because we hadn’t been wearing that stuff before. My class was actually the first class to wear gloves, mask, and eyewear from the first day in clinic. But the class ahead of me, they did truly wet finger dentistry with no eye protection, no masks, no gloves, and, you know, they put their bare hands in people’s mouths and did dental work. So having lived through that, this crisis has not given me a lot of heartburn that way, because I knew that things were gonna be changing. The question will be, are these changes going to be sustained.
What you have to understand is that COVID in this country was around probably in December of ’19. You look at all the gloves, masks, and eyewear that we were wearing during that time, and, you know, we weren’t really getting dental cases from dental care… I should say, cases from dental care being brought to light. We just needed to be careful because as dentists, we’ve been using good protection for a long period of time. Now the question is, you know, we have these hot spots and different other risk factors, because now that they talk about the aerosol…so we need to be careful. But, that’s why they’ve come out with these ADA tool kits, and now I sound like the poster child for organized dentistry! But at least the powers that be have tried to come up with some thought provoking and potentially suggestive ways that we could try to manage our practices, and I think it’s important for us to take a look at all of those resources.
MK: Have you found your patients are expecting a certain procedure or level of safety or cleanliness so far?
KN: Well, perception is a big part of it, and this past week we had a nice review from a patient who came in who felt like we were doing all the right things, and we’re putting our best foot forward. I have to tell you, I had a lot of anxiety when this hit, because originally we were supposed to be closed for two weeks, and then it changed to three weeks, than it ended up changing more like to three months or whatever. So I did have a lot of anxiety. My treatment areas were carpeted, for example, and I felt that there was something that from the beginning when I had hired the architect to do my office. You know, they had suggested putting carpeting in and I thought, “really, in a dental office?” and they said,” “Oh, no, it controls noise and stuff like that.” So when we were dealing with this, I decided, “You know what? Now is the time. It’s been 16 years that I’ve been in this location.” So I called them up and I said, “Well, what recommendations do you have?” because they were excellent in terms of recommending very durable materials for my fabrics in my office. They said, “Oh, well, you want to go with vinyl plank now.” So we took the carpet out, I had vinyl plank installed, we ended up with something that was really nice. It really opened up the look of my office and gave it a much fresher, cleaner look in the clinical space than what we had before, you know. So that was kind of one change that I did.
MK: Have you ended up changing any procedures since you opened? Have you learned anything about your expectations or your patient’s expectations that made you change anything?
KN: Well, it was very interesting. We added a new technology to the office. I’m not endorsing anything, but we added guided biofilm therapy into the practice in February, and one of the things that came out of that was the use of source-controlled suction. They’re several products out there. One was recommended during the LANAP training, and that was a product called Isolate. There’s a very kind of a clone type of a product called Dry Shield, and then there’s kind of a lesser expensive product called Relief. And so when we were doing our training, they said, “Oh, you should consider one of those source high speed evacuation systems.” So we put that in by our own choice before all of this COVID stuff came about, and then the literature started to say, “Hey, you know, you should have sourced suction.” So people are getting these funky devices in their operatories, and you know whatever you have to do to make yourself feel comfortable. But you know the number one source for protection of anything in the dental op is a suction at the source, not just a regular evacuator, but a high speed evacuation, not a saliva ejector.
So when it comes to specific things that patients have asked for, patients have just been very complimentary of seeing how clean the office is. We went through all of the operatories when we went through the minor remodel that we did, and we took everything out and off of the countertops. So when you come into the operatory, everything is contained in a drawer and only the instruments that are gonna be used for that appointment are exposed, and we really try to keep everything off the countertop so that we have a very clean and, you know, basically sterile-looking environment for patients to be seen in. I think that’s something that they appreciate. But I think that’s what patients have appreciated, just coming in and looking and seeing things are really clean and the fact that we’re following some protocols to make sure that they are healthy and we’re screening them before they come in. I would say, you know, a lot of this stuff we may end up seeing as a protocol that we continue with even after the pandemic passes through.
MK: That’s great. Now these are all great suggestions. I do want to give a shout out to your website for anyone who wants to see more about you and your practice. That’s docperio.com I’d like to invite everyone listening to subscribe if you haven’t already to this podcast. We have new episodes every Monday, or you can go to LANAP.com/podcasts. Dr. Noraian, thanks so much for being our guest today.
KN: Thanks for having me, Marty.