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Howard:
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It is a huge, huge treat for you guys today. I am podcast interviewing a legend oral surgeon, Dr. Ole T. Jensen. I don't know if you've heard of Clear Choice or not. It's a dental implant center. I love Clear Choice because I'm in Phoenix, Arizona, they have a center, and you're always doing infomercials on implants, which is driving many patients to Clear Choice to get implant surgeries, but I have to tell you, it's driving a ton of patients to my office where my patients for twenty-five years saying, "Yeah, Dr. Farran, I watched this infomercial for Clear Choice," and the next thing you know you're doing this big implant, so I imagine every time Clear Choice does a dollar, the local dental community probably does, it'd have to be at least five or ten because I'm only one dentist out of thirty-eight hundred in this metro and I can't even imagine how many patients you've driven to my office with your infomercials.
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I'm going to read your bio because you really, truly are a legend. Dr. Jensen received his bachelors degree from the University of Utah. He completed his DDS degree at the Northwestern University School of Dentistry and his anesthesiology [residency 00:01:24] at Northwestern University of Medicine. He completed his oral and maxillofacial surgery resident at the university of Michigan. Dr. Jensen is a diplomat of the American Board of Oral and Maxillofacial Surgery, that's amazing, and a fellow of the American Dental Society of Anesthesiology. He is interested in bone grafting, dental implants, and distraction osteogenesis. He is currently clinical assistant professor at New York University, University of Michigan, and University of Colorado Denver.
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Dr. Jensen has held a variety of teaching positions since the early 1980s and also served as a clinical instructor in the St. Joseph General Practice Residency Program. Dr. Jensen has been a guest lecturer at scores of seminars and symposium with a strong focus on implant dentistry, bone grafting, and maxillofacial surgery throughout North America, as well as Europe and Japan. Dr. Jensen holds hospital appointments at six major facilities in the Denver area. I'm sure he's gloating right now about the Super Bowl. If you're a Carolina Panther fan, he won't gloat too long. He has been involved in numerous independent research projects, is the author of three textbooks on oral surgery, more than two dozen scientific papers and publications, and has been a part of implant related clinical research studies. I can't believe you're sitting in my house, dude. It is beyond ...
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Dr. Jensen:
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It's a pleasure, Howard. Thank you.
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Howard:
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It is just a huge honor. Clear Choice started in 2006, it's been a decade, 2016. It was started by Dr. Don Miloni at General Dentists, Steve Boyd, an MBA, and then yourself. When I talked to Don, he says that you were the genius behind the actual implant protocol. How's that been going for you?
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Dr. Jensen:
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Well, the thing about Clear Choice, when I came onboard they had already been working, they had a very fine prosthodontist, Dr. Mark Adams, they had an oral surgeon there, but they were thinking about altering the business plan and doing non-specialty dentists to do the care. At the same time, they were trying to get me to be their primary oral surgeon. Well, I told them I wouldn't come onboard unless it was a specialty care situation because these are complicated cases that I thought required a prosthodontist, an oral maxillofacial surgeon, a lot of these people are very, very sick, we put them to sleep for surgery. It's the kind of thing that requires anesthesia training and medical management.
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I thought if we're going to do this as a business, why not do this very, very first class? Have the best doctors, the best business processes, the best marketing processes, and really do something outstanding. That's what the group did together. It wasn't one person that solved this, but many, many people. As a matter of fact, the present CEO, Kevin Mosher, he was at the open house of our very first office in 2006. We've had some longevity, and some good consistency, and some good interaction from the very beginning.
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Howard:
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It's a high cost implant center, too. I mean, you're not known as the Southwest Airlines, Costco, Sam's Club, Ikea of implants. I mean, Clear Choice is pricey.
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Dr. Jensen:
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No, no, it's not an inexpensive thing. However, I would say that our cost basis for patients is probably somewhat less, maybe 20% less, just because we have efficiency in the system.
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Howard:
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Do you have a standard bread and butter case? Is your average patient coming in with full dentures getting to implant removable dentures? What's 80% of your business?
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Dr. Jensen:
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Well, it doesn't work out that way, but about half of the business is edentulous treatment, so patients who have lost their teeth or are soon to lose their teeth, they don't have a very good solution with going to dentures. Matter of fact, there's a great fear among patients when they're just ready to lose their teeth, maybe they have several teeth left and now they have to lose them, they don't want to go to dentures, they want to have solid appliances they can chew with. That's our bread and butter, the edentulous patient. About half, maybe a little bit more than half our patients are those category.
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Howard:
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You're saying half are edentulous and need improvement, and the other half are just about at edentulous ...
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Dr. Jensen:
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No, the other half they could be partially edentulous, they might be a single missing tooth, or maybe three or four missing teeth. It's just a standard dental implant practice where you're maybe replacing one or two teeth with implants.
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Howard:
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One neat thing about being a dentist for thirty years is you got to see which predictions came true and which ones didn't come true. I remember when we were learning removable dentures at University of Missouri Kansas City in the '80s that dentures were coming to an end, it was going to go extinct. Yet now you look at the data and removable dentures is still growing strong thirty years later.
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Dr. Jensen:
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Right, right. The dentures are not going to go away and we ...
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Howard:
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The CDC says 10% of Americans at sixty-five are edentulous and 20% at seventy-five. Is that what you're hearing?
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Dr. Jensen:
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Yeah, there's a lot of people that are near edentulous. Maybe even 15% of the population, then you have the edentulous population, which is up to 20% or more.
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Howard:
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One of the things I always keep wondering is you're not born with P gingivalis and until a tooth erupts through, you can't catch it from your mom because there's no place for it to grow. When you start with a fully edentulous person and there's really no place for P gingivalis to be living except maybe your tonsils or something, do you have a lot lest peri-implantitis of you're starting as a full denture patient as opposed to the other half who are on their final stages of teeth?
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Dr. Jensen:
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You can if you have periodontitis in the mouth and you put implants adjacent, those bacteria will hop onto the implants, so you can get peri-implantitis, so to speak, in a patient who has uncontrolled periodontitis. In the setting of an edentulous patient, they don't have that reservoir there, so they're starting kind of with a clean bill of health. If they take care of their teeth, they're not going to have a recurrence of their periodontitis now that they've got implants.
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Howard:
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Do you measure higher implant success rate starting with a fully edentulous patient than someone who's got teeth?
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Dr. Jensen:
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Not necessarily. I think that you do have a higher incidence of infection around teeth when you have adjacent teeth that are infected. I will tell you that our results with edentulous treatment with implants, we see an implant loss of maybe 2% to 3% to 4% over a five year span, so we don't see a lot. We do see some peri-implantitis, but that incidence is also very low, a few percent, so interestingly with dental implants you have, in a way, a little bit more resistance to periodontitis type inflammation than with teeth, so implants are excellent and as long as they're osteointegrated to prevent this kind of infection occurring.
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Howard:
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You have thirty centers, your firm in Colorado, I know you're in Arizona, you're from Utah. Are they mostly thirty in the Southwest or have you crossed the Mississippi River?
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Dr. Jensen:
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No, we have them all across the country and we're planning on growing more, so we have them in Florida and California. We're going to go into the Northeast and Midwest. We have four centers around Chicago, for example.
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Howard:
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For the 50% that are edentulous, do you do any set stats about these patients? What would the average age be? Are they more likely to be women than men?
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Dr. Jensen:
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They are a little bit more likely to be ... Let's put it this way, the women tend to come in and seek treatment more frequently than the men, maybe about 4% or 5% more.
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Howard:
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Just 4% or 5%? Just fifty-five to forty-five?
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Dr. Jensen:
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Yes because now the men are starting to take care of themselves, or they have wives or whatever, and they're starting to take care of themselves, so almost half our patients are men, but there's still a little bit more women. The average age is I would say fifty-five to sixty. We do see patients in their eighties and we do see some patients even in their thirties, they are losing their teeth sometimes.
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Howard:
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What does the average patient at Clear Choice with a full denture get? Are you doing two implants in [bowls 00:11:24], four and a [hater 00:11:26] bar, or is it all implant supported fix, is it implant supported removal? What is your main ...
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Dr. Jensen:
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When I came onboard, I had an experience doing implants for many, many years. We had done a lot of cases with two implants and a removable. I really like that approach and I liked it because it was not cost prohibitive, but there was a lot of maintenance. For example, if you had a bar and a clip or anchors that would have to be changed a lot. We saw problems over time with the over denture approach even though I liked it from an access standpoint for patients. Given that, as a strategy to really help people, and give them something that would last, and not require a lot of repairs, we decided to avoid doing the over denture approach and go straight to a fixed approach. That did double about the cost basis, but it increased the success overall.
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In an over denture setting, those patients tend to lose those implants and they tend to get peri-implantitis around them much more frequently than in a fixed setting, so it's healthier to go in a fixed setting. We made a decision to just do that, so in Clear Choice we do not do over dentures at all.
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Howard:
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What is the average person who comes in to the full denture get? What is the average treatment plan? Your most typical treatment plan?
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Dr. Jensen:
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Commonly we do what's called an all on four, but sometimes we would do more implants than four. Bio-mechanically, we have found that four implants is all that's required if you have adequate anterior posterior spread. Now, I understand that most of the people listening would be dentists, so let me just get a little technical. Anterior posterior spread is the key bio-mechanical factor for stability of a fixed appliance. It's more important than the number of implants.
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That's really hard to understand because we as dentists, we think more is better. We want to have six or eight implants, but what we've found out is that the distribution with the implants front to back is actually the most important bio-mechanically. I will give you just a little discussion that I had with John Brunski who is a Stanford bio-mechanist and probably the foremost bio-mechanical lecturer in dental implantology today.
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Howard:
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Can you score me a podcast with him?
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Dr. Jensen:
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I doubt it. No, I don't know. You could ask him. He's a very cool guy, but I really pinned him down because I was very disturbed by this concept of number and the dentists in the dental field, probably almost all of the dentists in your group here with Dental Town think about dental implants as an analogue to teeth, so you think about a dental implant as similar to a tooth in terms of crown and bridge bio-mechanical restoration that you shouldn't quite do that. What I found out when talking with Dr. Brunski is he took a bio-mechanical mathematical model. This is based on the [Skalac 00:15:22] model that Brandon Mark came up with. On a curve, like on an arch, they put six implants in and they mathematically figured out where the forces were and so on. Then he put four implants in, and then he put three implants in, and he checked the different bio-mechanical aspects if the anterior posterior spread were the same.
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If you only had four implants or you only had three implants, but they were spread adequately, guess what, they had similar bio-mechanical capacity, so three, four, five, six were very, very close. Why use eight? Why use six? Why use five? Why use four? Now there's even a debate, especially in the mandible, why use four when you can use three? This is for fixed full arch appliance, the bio-mechanical requirement.
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Having that knowledge, Clear Choice analyzed this also with input from [Beau Rangert 00:16:39], the bio-mechanist for Nobel Pharma and also with [Paulo Melo 00:16:44], the oral surgeon who really helped popularize the all in four, and ...
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Howard:
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He's out of Spain?
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Dr. Jensen:
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He is out of Lisbon, Portugal.
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Howard:
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Lisbon, Portugal.
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Dr. Jensen:
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Then also Dr. Mark Adams, Dr. Steve [Perau 00:16:58], Dr. Steve [Ekhert 00:17:00], many, many prominent doctors in the field. We made a decision that four implants is adequate and that that would be a good strategy for us to use at Clear Choice, so we did that since 2006. Like I've said, we've had the results over that period of time of only a few percent failure rate in both arches using that limited number of implants, so we believe that this is adequate. Just to give you some numbers, we in Denver probably do three- to four-hundred arches per year just in Denver. If you have a business that is related to dental implants, you're not going to do stuff that will put the business at risk, so this has a business, scientific, and a clinical basis of validity, so we stand by the way we treat our edentulous patients with this method.
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Howard:
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When you're talking about bio-mechanical forces, you're talking about the AP spread is very important.
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Dr. Jensen:
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Right.
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Howard:
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Are you also angling the implants and that is a game changer, too?
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Dr. Jensen:
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The angling of the implants is such an interesting thing because that is saying the same thing. By angling the implants you increase the anterior posterior spread, so it's like a table. You're having the table legs on the corners instead of like in the middle of the table where it can wobble. Angling an implant allows us to get our implant access close in the maxilla to the first molar. That's the posterior implant, I mean, that's pretty impressive. Then the anterior implant would be approximately in the canine, maybe a little bit forward of that in the canine lateral location, so these implants are about twenty millimeters apart, twenty, twenty, twenty. That's a very, very solid foundation as long as the implants are individually in bone and solid.
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In the mandible, angulation of the implant was very important to avoid the inferior alveolar nerve, very important. I would say that that's one of the biggest advances in dentistry in the last fifteen years is to be able to angle an implant away from the nerve for safety and yet get increased anterior posterior spread for your mandibular prosthesis.
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Howard:
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Where are you angling the implant on the posterior mandible to avoid the ...
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Dr. Jensen:
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The nerve comes out between the first [bi 00:19:55] and second bi location, so I'm going to go ahead and place the implant at a thirty degree angle in about the first bicuspid region. It's going to angle and emerge back behind the nerve, maybe four our five millimeters, so that it's in the second bi, even the anterior part of the first molar location and avoid the nerve.
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At a thirty degree angle, another thing that's important when you see this in your trigonometry, by angling a body thirty degrees you increase its length 50%, so if there's ten millimeters of bone available, and you put it in straight up and down, you have a ten millimeter length implant possible, but if you put it at thirty degrees, you can put in a fifteen millimeter length implant. These things are sometimes important to gain fixation and strength to the implant.
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Howard:
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That is so truly amazing. Now, you started out originally only with [Nobel Biocare 00:20:59] implants. You changed that recently?
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Dr. Jensen:
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Yes, we did. We have to give tremendous credit to Nobel. What an organization, what a tremendous company, and the research teams, the technology, it's fantastic what they have done. We had made an effort to ... You know in business sometimes you have to negotiate, right? You have to say, "Hey, we're doing so many implants, can we have a break?" The negotiations just didn't work out favorably for Nobel, and Straumann came in and made a pitch. We made a decision to go that direction, but strictly from a business standpoint.
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Howard:
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What implant system did you go with?
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Dr. Jensen:
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Now we use the Straumann implant.
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Howard:
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Now, is that Straumann or ITI Straumann?
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Dr. Jensen:
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It is the ITI implant.
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Howard:
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Switzerland?
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Dr. Jensen:
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Yes, it's a Swiss implant. They also have an implant company that they have acquired that has the same surface treatment as they have and it's called Neodent, so the Neodent implant is basically the new Straumann implant. Then they have a bone level implant and they have a tissue level implant. Now they have coming on board a new [inaudible 00:22:28] implant.
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The Straumann company has sort of caught up with the Nobel company. We just made a business decision. The clinical appraisal between the two is not significantly different.
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Howard:
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You went from Nobel Biocare in Sweden to ITI Straumann in Switzerland.
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Dr. Jensen:
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Well, both of them are in Switzerland now.
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Howard:
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Oh, both are in Switzerland now?
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Dr. Jensen:
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Yeah, Nobel is in Switzerland and next door to them is Straumann. They're both in Switzerland.
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Howard:
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Now, there's a hundred and seventy-five implant companies. Could any of them worked for you or were there some criteria?
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Dr. Jensen:
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I'm a private practitioner. I work with Clear Choice, of course, but I have a private practice as well and in that private practice I have all kinds of doctors that work with all kinds of different implants. I probably have worked with maybe ten or fifteen different implants and I currently work with maybe five or six different implants besides Nobel and Straumann. For example, I have done [inaudible 00:23:44] on a Zimmer type of implant, I have done it on a BioHorizons type of implant, I'm doing one with an Intra-Lock cortex, an Israeli company. There's Astra, there's all these different capabilities now with the different companies, so you can't say that by brand this operation of the [inaudible 00:24:15] is exclusionary. You can't say that anymore.
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Howard:
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What else has got you excited? I want to first ask you a business question because you guys were founded by Don Miloni who's a general dentist, Steve [inaudible 00:24:29], MBA. Let's move passion off the table. I always tell my homies that I want them to be happy and healthy, like if they ask me if they should go into specialty school. I say, "Well, first does something excite you?" If they say, "Yeah, I really want to do that." I always say, "Follow your dreams, and be happy and healthy," but some dentists when it comes to implants, they might be scared and they're looking at should I go learn how to place implants, and invest in all this courses, time, training. Then I sometimes say look at Clear Choice because when you set up a Clear Choice Center like in Phoenix, you don't have employee surgeons that work there Monday through Friday. Don't you bring in independent contractors to come in?
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Dr. Jensen:
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No, as a matter of fact the doctors in Phoenix are both fully employed there.
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Howard:
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They're employees?
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Dr. Jensen:
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Yeah, they're fully employed there. Let me talk a little bit about this question about should dentists do implants.
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Howard:
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Should general dentists.
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Dr. Jensen:
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Yes, yes, yes. Now, I understand that more than 60% of implants done in the United States are done by general dentists.
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Howard:
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Is that right? 60% general dentists?
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Dr. Jensen:
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Of implants that are ordered by two companies are ordered by general practitioners.
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Howard:
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Of the number of general dentists, what percent of the general dentists are placing those 60%?
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Dr. Jensen:
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That is a very good question because some of the dentists don't do it with a lot of frequency, like maybe they might do two implants a year, some might do twenty, some might do more, so the data on that is pretty indeterminate. I would say that a third of dentists now are getting involved in implant dentistry as surgical placers of implants, but probably two thirds of dentists are doing implant dentistry where they're the restorative dentists. In the major metropolitan areas, these percentages go a little higher.
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Implant dentistry is big, but let me tell you one thing that we detected at Clear Choice and which I've seen in my private practice as well is that we want patients to have optimal treatment. All of us do as doctors. We want our patients to have the best treatment. If we're a general dentist, we know that there's certain things that we shouldn't do and we refer those out, but then there's other things that we think we're capable of doing and you should do those. We have a program, for example, with all on four treatment where any general dentists can contact the Clear Choice Center and they can have the surgeon there do the implant placement, and management, and so on, and the dentist can come in as a guest, and do the rest of the treatment, and charge for it. We teach them.
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Howard:
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How long have you been doing this?
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Dr. Jensen:
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We've been doing that for a number of years.
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Howard:
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I wasn't aware of it.
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Dr. Jensen:
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Yeah, yeah, we do that and so I have a number of dentists and even prosthodontists in the area of Denver. They come in ...
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Howard:
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They can bring you a patient. Are they all oral surgeons or are some of them periodontists?
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Dr. Jensen:
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They're usually general dentists.
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Howard:
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No, I mean the Clear Choice doctors.
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Dr. Jensen:
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The Clear Choice doctors are all prosthodontists and oral surgeons.
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Howard:
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They're all oral surgeons and prosthodontists, so explain the details. I bring my mom to you.
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Dr. Jensen:
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That's kind of a perfect example. Sometimes you want you mom to have specialty care, but maybe you want to do her denture prosthesis for her, so you would come in, introduce the patient, we'd set up the surgery. The lab at Clear Choice does the prosthetics, and they pick up impressions, and all that stuff. After the surgery's done, you go ahead and place the prosthesis, you screw in the prosthesis provisionally [inaudible 00:28:50] prosthesis. Then you take your patient, your mom, whoever, home, and follow them, and at the time when you want to go forward with the final prosthesis, then you can take impressions and complete the final case so that Clear Choice is just sort of assisting you in the overall care of your patient.
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Howard:
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All thirty Clear Choice Centers have their own in office lab?
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Dr. Jensen:
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Mmm-hmm (affirmative) and they will help patients, not just for all on four, but any kind of case. There are some very, very complicated bone graft failure cases or management cases. We enjoy helping doctors treat their patients. We understand that there's a competitive dissonance between a corporate entity and private practitioners. We're trying to break that down, trying to be open, and hopefully with this podcast, maybe that will break down some of the barriers. Just give these doctors a call and just say, "Hey, listen. I would like to try to do an all on four on this special patient of mine. Could I work with you," and they're going to say yes.
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Howard:
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I would say that all recorded human history, people do not like competition or transparency. They always want a monopoly, absolute power corruption [inaudible 00:30:13]. I think to bring that wall down completely would be if you or your team got on Dental Town Online CE and did a Clear Choice ... You know, right now on the internet, 2016, there is no A to Z ten, twenty, thirty hour curriculum on how to do implantology from diagnosing, to treatment plan, to do it? It's all bits and pieces, like this guy does an hour, this guy does a twenty minute YouTube.
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If you put an online CE course, and two-hundred and ten-thousand dentists had access to it on Dental Town, and forty-thousand of them had access to it on their iPhone, and explained all this, I think it'd be a huge business opportunity for Clear Choice.
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Dr. Jensen:
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That's a very interesting thing. I will tell you that if you get five dentists in a room and you're talking about any kind of restorative procedure you might get five opinions, right?
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Howard:
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Absolutely.
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Dr. Jensen:
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In implant dentistry there is controversy on what to do, how things should be done. At the Academy [inaudible 00:31:19] we still over and over again are talking about single tooth implants in the anterior zone in an argumentative way. It's not fully solved, there's still different techniques, different styles, different approaches being made. There is not yet this A, B, C approach where we can really say, "Hey, this is a defined evidence based treatment." We're still in the realm of expert opinion, and this is the way I do it, and this is my success criteria, but those kind of things are still valuable for dentists.
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Howard:
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It's a sign of intelligence. I mean, when you're not really intelligent everything is binomial, black/white, yes/no, up/down. As you get smarter, and older, and wiser ... Like there's people who don't believe in bridges. I mean, I can't tell you how many beautiful women, high lip lines that I can predictably nail with a three inner bridge to replace one missing tooth. They'll just think that that's just somehow evil because they want to save enamel because they're a dentist. Well, I'm going to destroy bone if I place an implant. In fact, I want ...
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Dr. Jensen:
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We've gone way overboard on one way, we did go way overboard on the other way. I mean, we probably need to walk back. It's not illegal, unethical to do a three tooth bridge. There's some patients it's indicated for. However, the single tooth implant where you have virgin teeth on each side, I will tell you that that's always been something that we've treatment planned in my practice and also at Clear Choice as a single tooth implant restorations being most optimal, most conservative, and least invasive technique.
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Howard:
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The highest degree of technical because if she's a beautiful woman with a high lip line, and when she shows gum when she smiles, and it's a central incisor, she's going to hold you to the highest, I mean, you have to nail it.
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Dr. Jensen:
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Let me tell you something about what the dentists could do. Don't do the anterior maxillary teeth, just don't single teeth for implants. Don't do that. The periodontist, the oral surgeons, we have a hard time doing those cases and they're not economically positive a lot of times. Just don't do them, but there are cases you can do. What's the most common tooth loss, do you remember?
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Howard:
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First molar.
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Dr. Jensen:
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Right, and what's the most common implant done?
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Howard:
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First molar.
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Dr. Jensen:
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First molar, so is there a lot of risk for you from an aesthetic standpoint for you as a dentist to do those molars? No, so if you're going to get started out do those molars, bicuspids, and guess what, that's going to be a huge addition to your practice just limiting yourself to that. You don't need to do these big [crosstalk 00:34:29].
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Howard:
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I'm going to put your seat on the fire right now because you're talking to thousands of dentists and podcast consumers.
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Dr. Jensen:
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Is this where the real truth comes out?
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Howard:
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This is the real truth. What if she's driving to work right now, and she's thirty years old, and she got out of dental school three years ago, and she's never placed an implant? Can she go to a Clear Choice Center and just watch them?
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Dr. Jensen:
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Yes.
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Howard:
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See, I'm always saying find someone in your backyard, but they always feel like they always feel like they've got to fly across the country.
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Dr. Jensen:
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Let's say they practice in Alabama. She could call me on the phone, she could fly to Denver, and she could watch surgery if she wanted to.
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Howard:
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All day.
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Dr. Jensen:
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Yeah.
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Howard:
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What main states are you in?
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Dr. Jensen:
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Of course she would want to probably develop a relationship closer to where she practices, but I'm just telling you, I am personally open to that. Our practice in Denver is personally open to that. There's a practice in Atlanta, I know they're personally open to that. Fort Lauderdale, San Diego, [crosstalk 00:35:30].
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Howard:
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I know, and they always complain they got $400,000 student loans. When they want to learn something, they always pick a $4,000 course on the other side of the country, and stay at a five star resort to learn like two things on occlusion. I'm always saying, "Why didn't you just walk across the street to the medical dental building across the street from you and knock on their door?" I think when someone's saying, "Oh, give me money," they feel like, "Okay, I'll give you money. That's permission to go." They just feel guilty maybe that ... This is what they're going to say, this is exactly what they say. They say, "Well, why would Ole teach me how to place an implant when his business is placing implants? He doesn't want to teach a competitor," so it's totally counter intuitive.
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Dr. Jensen:
|
There is some level where maybe it's not mutually beneficial, maybe there is some level, but that is not what happens in my experience. Someone is really trying to come in and undercut me or something, they don't come in. They don't have the clarity of conscious to do that.
|
|
Howard:
|
It's the same ...
|
|
Dr. Jensen:
|
People that call up and say, "Hey, listen. I hear you do these small implants for the lower anterior mandible for these single teeth in the lower incisors. I've never seen that, is it okay if I come in and see? I've got a patient that needs one of these." Absolutely because how can we get experience ... I do more than two-thousand implants a year. I have a lot of opportunities to experience things, but if a dentist is doing twenty implants a year, how much opportunity does he have to get experience or she get experience? You have to collaborate.
|
|
Howard:
|
Back to the first molars, she's never done one. I'm talking to the two thirds that have never done one, which is actually a better first candidate, maxillary or mandible first molar? What would you think would be the most [inaudible 00:37:36]?
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Dr. Jensen:
|
The mandible is the easiest one to do. You would ask about a maxillary first molar. That is a little trickier because sometimes the sinus does dip down quite a ways. If that happens, just stay away from that, don't do that one, just go forward. Sometimes in the mandible the nerve is quite high, there's only six millimeters. Well, stay away from that, but a lot of times that's not that way. There's plenty of room to put a ten millimeter length implant and you want to put a wider one for the mandible for a molar, so for example, in the Straumann they have a four-eight wide neck implant. In the Nobel, they have a six millimeter wide implant and the Zimmer they have a wide bodied type implant.
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|
|
There's a company called Southern Implants. They have a very nice implant that's even up to nine millimeters in width that can be used during extraction [inaudible 00:38:39]. Look at the different products out there and you can make a decision on what you like to do.
|
|
Howard:
|
I just want to rattle off a few of the most commonly asked questions and I know I've asked these before, but cement or screw on a single?
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Dr. Jensen:
|
That is such a good question.
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|
Howard:
|
You're the first guest that ever said that.
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Dr. Jensen:
|
You are smart, man. I'm going to give you guys a heads up. The answer to that question is neither, so how can you get an implant fastened to a crown without a screw and without cement. The reason you don't want to use cement is because you almost always get leakage, so if you can cement it outside the mouth and then screw it in, that's one way that people have done things which is kind of crazy, but if you get cement around your subgingival area you're going to be prone for pari-implantitis, so you don't want to cement and that's what the dentists want to do. That's what most of them do, but that's what I don't recommend.
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|
|
Then the second idea is use screw retention. Well, screw tension sounds pretty easy, but people in the general dental office, maybe in the prosthodontist's office they'd like it, but in the general dental offices they don't. It's little tiny screws, they're a nice thing to get suctioned up in the suction, and swallowed, and lost, and it's just not your game to be working with those little screws, so a lot of people avoid those things. Then the screws can get loose, bent, and the restorations rattle, so how can you attach a crown to an implant?
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|
In about three or four months, we're going to have a new technology approved. It comes out of San Francisco, it's a startup. The company's called Rodomedical. They have been studied out at UFCLA and they have publications already. I've done some of the cases for them, so I happen to know about them and we intend to use them at Clear Choice. What it is is it's nitinol is the metal that is the connector between the crown and the implant. Nitinol is what orthodontists use to do their arch wire because it's a memory metal and that's what the cardiologists use when they do their stints. It's very bio-compatible.
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|
|
What memory metal does is that you put it in, it's kind of like a sleeve on top of the abutment, you put the crown in, and then you just activate it with a little electric wand that heats it up a little bit, and it expands, changes shape, and then the crown can't come off. It's very, very powerfully strong. It doesn't ever come off.
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|
Then later on let's say the porcelain breaks on the crown a couple years later. You can cool that metal with a special instrument, and then it contracts, you can take the crown off, repair it, put it back on. This is the future of implant dentistry is to use this Rodomedical device, this nitinol sleeve, for fixing not only single teeth, but also multiple teeth like an all on four.
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Howard:
|
That is so exciting and they heard it first on the Dentistry Uncensored Podcast.
|
|
Dr. Jensen:
|
You can look it up on their website Rodomedical, the mechanical engineer's name's Young Sew, S-E-W, wonderful man.
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Howard:
|
S-E-W is his last name and his first name Young? Y-U-N-G?
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Dr. Jensen:
|
Yeah, Y-O-U-N-G.
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|
Howard:
|
Y-O-U-N-G.
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Dr. Jensen:
|
He came out the University of Michigan where I came and he was a mechanical engineer, he's a genius. Then Benjamin Woo is also a mechanical engineer prosthodontist that also works there, formerly at UCLA. If you want to call out there and talk to a dentist, you can talk to Dr. Woo or if you want to talk to Young Sew you can learn about the product. That's something that's going to be coming down the pike within months, so I think that's very exciting.
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|
Howard:
|
Are these your friends?
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|
Dr. Jensen:
|
Well, I've known them for about four years, so they are my friends, but it's not like ... I'm in Denver, they're in San Francisco.
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Howard:
|
On Skype we can do the Hollywood Squares thing, we can do four, so if you send them an email, I can Skype them both at the same time.
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Dr. Jensen:
|
I definitely think you should talk to Rodo, and especially Dr. Woo and Dr. Sew. I would be happy to also be on it, but there's a lot of other doctors involved, dentists involved. This is big, this is big. This is going to be a big change. I think it's going to be great for the general dentists. Do you know how disheartening this is? I did a two crowns restoration for number eight and nine on a gentleman on two implants about five years ago. He comes in about a year and a half ago. He says, "You know, I've got an infection." I said, "Why in the world do you have an infection?" I look in there and sure enough you got this huge periodontal abscess on one of the implants. I flap it and what do I see?
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Howard:
|
Excess cement.
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Dr. Jensen:
|
You see cement and the cement has caused a little food trap area. He lost so much bone that it extended to the adjacent tooth, so the implant and the adjacent tooth had to be removed. Start thinking about that.
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Howard:
|
You rhetorically said how do you put on a crown, you got to screw or cement, is there another way. There used to be another technology, it was a morse taper.
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Dr. Jensen:
|
Well, the morse taper is still used, but it's not enough of a friction grip to retain only. You still have to have ...
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|
Howard:
|
Was that [micon 00:45:23] out of Boston or something?
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|
Dr. Jensen:
|
Yes, yes, but still, those things are actually going down into the implant. You have to tap it into place because of this taper. It holds it by friction, but it's not retrievable once you're in there.
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Howard:
|
Would these excess cement, would it have been less of a problem on that patient if they would have used a [crosstalk 00:45:56]?
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Dr. Jensen:
|
A [reservable 00:45:56] cement?
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|
Howard:
|
Something that showed up on actually that [inaudible 00:46:00] talked about, zinc phosphate cement.
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Dr. Jensen:
|
Yeah, yeah.
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Howard:
|
As opposed to a resin cement.
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Dr. Jensen:
|
Some of my older cases when I'd looked at them I noticed the cement, I could see it there. Sometimes we've even gone in, and flapped, and removed that cement. Remember, not everybody that has excess cement is going to develop a [pariolesion 00:46:22], just the patients that you absolutely need it not to happen to.
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Howard:
|
Would you say a zinc phosphate cement would be better because it would ...
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Dr. Jensen:
|
I do.
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Howard:
|
You do?
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Dr. Jensen:
|
Yeah, because it's visible.
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Howard:
|
You think because it's visible?
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Dr. Jensen:
|
Yes.
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Howard:
|
I want to ask you another controversy. I want to go through the controversies. Some people make a religion out of drawing blood, and their bone grafting, and spinning platelets, and all that. Then other people say that's just not necessary at all. How do you weigh in on that? Then I want you to follow up with the exact same thing on smokers. On Dental Town, half the dentists have checked smoking no. Other people say I really don't have that big a problem with smokers, so will you answer those two controversies?
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Dr. Jensen:
|
Well, of course you're talking to a person who's very interested in tissue engineering. Matter of fact, I was editor and chief of a tissue engineering journal for a while. Tissue engineering in regards to the mouth is generally creation of tissue, bone, or soft tissue, or cement, or periodontal ligament. When we talk about healing of bone using bone graft materials, if we start using bio-mimetic processes such as platelet derived growth factor, or BMP, other kinds of growth factors like [inaudible 00:47:54], or even the different alligenaic materials, they might have some BMP activity or some growth factor activity within them.
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|
The idea of using tissue engineering principles to try and grow bone is a good one. It has a very good basis. In fact, the best thing to grow bone is BMP, we know that that forms bone, but it's expensive and a lot of people are not experienced with it, so what could we use that might be accessible, less expensive, and still give a little bit of a bump for forming bone? That's where the PRP and these other spend down products where you take blood and spin down the platelets, and other factors that are there. Even within that spin down there are circulating stem cells.
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Within our body, about 3% of the nucleated cells are what we call smooth stem cells, so they're circulating stem cells so that when there is an injury, these guys congregate right there and then they do their repair, they're ready to go. It's not just strictly local phenomenon where stem cells are attracted, you get the circulatory phenomenon. If you can spin down some concentrate and get these cells, get some platelets, get some other positive growth factors that are there, you could increase the healing capacity of a graft or a wound.
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This was studied most successfully with PRP, which I used about fifteen years ago and stopped using. The reason I stopped using it was because in the literature, it was studied many, many ways, we found that there was maybe a 10% or 15% increase in improvement of the healing activity. Like platelet derived growth factor, it also does increase the bone forming and the wound healing capacity as well, but the real muscle is in the bio-mimetic BMP-2, so because of that I switch about almost fifteen years ago to that and went away from the less powerful. BMP is the hundred mile an hour pitcher and the others are the fifty mile an hour pitchers, so if I want to get a strike, I'm going to use that more powerful mechanism.
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Howard:
|
BMP, bone [morphodegenic 00:50:51] protein. Where are you getting that? What are you using?
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Dr. Jensen:
|
There's only one company so far. There are some companies in Europe that are going to be coming onboard, too, that are going to sell that product and it'll be nice because we'll have some competition, but BMP-2 is made by Medtronic in Memphis, Tennessee.
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Howard:
|
Medtronic.
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|
Dr. Jensen:
|
Medtronic, yeah.
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|
Howard:
|
I thought Medtronic was out of Minnesota? I thought they were in Rochester, Minnesota.
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|
Dr. Jensen:
|
They're in Memphis, Tennessee.
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|
Howard:
|
Medtronic's headquarters are in Memphis, Tennessee with FedEx. What percent of your implants do you use BMP? Just only when you bone graft?
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Dr. Jensen:
|
Well, let's just rather say what percentage of my bone grafts do I do use BMP. Maybe that could be 20% or so.
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Howard:
|
20% of your bone graft?
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|
Dr. Jensen:
|
A lot of the bone grafts are very small, just [alogenic 00:51:46] bone or [zenographed 00:51:48] and maybe we're just patching a little hole or something. It's not really indicated to do a big graft with BMP in those settings, so most of the grafts that we do are socket graft, socket grafting. There's no need to do BMP in that setting, for example.
|
|
Howard:
|
What did you think of Megagen when they came out with the take the extracted tooth, and put it in this pulverizer, and use that for your bone graft? Have you seen that?
|
|
Dr. Jensen:
|
Yeah, I have seen that. I think that's okay.
|
|
Howard:
|
You think that's okay?
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|
Dr. Jensen:
|
Yeah, I think it's okay.
|
|
Howard:
|
That would be a very low cost source of bone grafting. Are you using it yourself?
|
|
Dr. Jensen:
|
No, I'm not.
|
|
Howard:
|
Why?
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|
Dr. Jensen:
|
I am a little bit on the controversial side on bone grafting is that I don't socket bone graft very much, just in the anterior maxilla, so I think in most periodontist's offices and maybe most general dental offices they take a tooth out and they graft a socket. I don't do that.
|
|
Howard:
|
Why do you not do that?
|
|
Dr. Jensen:
|
The socket is the best healing place for making bone in the human body, so when you take out a tooth, the PDL has stem cells that are left in the socket and they immediately start forming bone. The majority of extraction sites, as long as there's not a [dihissance 00:53:17] facially, will heal just fine. There'll be a little narrowing of the site, but you can avoid having the complication of an infected graft, or giving that extra cost or treatment to a patient by just letting it heal, so I do not graft molars, bicuspids, canines, anything in the mandible. I basically only graft the anterior maxilla.
|
|
Howard:
|
For [maxilliar 00:53:51] incisors. Is that just in high aesthetic needs, like women with high lip lines? Not a short, fat, bald guy like me? You wouldn't do it?
|
|
Dr. Jensen:
|
No, I'd probably do it for you, too.
|
|
Howard:
|
Then true or false, we know 19% of Americans smoke, at the end of World War II it was half, but it seems like a lot of these people that need implants, or dentures, or things like that, a lot of them smoked. How are we supposed to evaluate a smoker?
|
|
Dr. Jensen:
|
This sounds kind of cavalier. I almost ignore it. If they're smoking, I still go forward with the treatment, we still have success with these patients, we warn them that they have a higher incidence of failure and so on, but we generally ignore it. I will tell you, if you can stop fifteen days before surgery, the nicotine is not in the body because it takes about fifteen days to clear that out, then you're going to have less veso-constriction, which leads to healthy healing, so if you're trying to do a fancy bone graft in a smoking patient, that's going to add risk to your case.
|
|
|
What I tend to do in smokers, I don't tend to try and treatment plan too fancy of stuff. An all on four is a good treatment for them because there's no bone grafting, for example, but if I have to do a sinus graft, I do think that that's an area where you're adding a lot more risk for the patient if they're going to continue smoking.
|
|
Howard:
|
They say you never talk about religion, sex, or politics, so let's go right to politics. You're a fellow of the American Academy of Dental Anesthesiology. They have been wanting their own specialty for years, they've never been given it. We just saw last week the Texas Dental Society Branch, the [inaudible 00:55:56] Branch of the American Dental Association, took these guys calling themselves implantologists to court saying you cannot call yourself an implantologist because that is not one of the nine specialties recognized by the ADA. Basically the court said the ADA's not a government agency, you're a club and you can kick them out of your club, but you have no legislative authority. Am I paraphrasing this right and what are your thoughts on it?
|
|
Dr. Jensen:
|
Well, when I started doing anesthesia for anything that I wanted to do, the anesthesiologist, the physician anesthesiologist, didn't like it. For example, I was just recently doing some stuff in China and I was talking to the surgeons there who were trained just like me. They are not allowed to do anesthesia in their private office, so if they want to do some wisdom teeth under anesthesia they have to go to a hospital and a separate person, an anesthesiologist, has to do the anesthesia because in their legal system in China the operator that's doing the surgery cannot also do the anesthesia.
|
|
|
That's a big extreme and England has a similar type of thing. Here we are in the United States, kind of the cowboy country, we've figured out the oral surgeons if they have a lot of training, they can do the anesthetic and safely do the surgery both at the same time, and we have done that for years, and years, and years. Now, occasionally that gets challenged for the oral surgeons. Most recently in Colorado that was challenged two years ago when we had our Sunset Review. We as oral surgeons had to go fight against the anesthesiologists to maintain our situation.
|
|
|
That's just kind of background to now we've got another group who haven't done residency in general anesthesia, and spinals, and all the other stuff, basically general dentists most of them, and they want to form a specialty to go around not just the oral surgeons, but the medical anesthesiology. Do you see what I'm saying? We are even getting a little bit more far afield.
|
|
|
If there's a death, and there are deaths, oral surgeons have them, we feel terrible about it, we remember it for years, we had one in Colorado, we go to a meeting, we all remember it, we talk about that, we worry about that. To open things up more is going to add risk to the public. Now, should we do it, will we do it, is it inevitable, could there be training programs that would make equivalency? I think there probably could be and I think it probably is inevitable, but take care because what happens if we do have a lot of complications, deaths, and so on? We could end up like they have in England and China where we end up with more restrictions than we had to begin with.
|
|
Howard:
|
Do you think dental anesthesiology should be a new specialty at the American Dental Association?
|
|
Dr. Jensen:
|
I don't right now, but I'm open to a discussion on it and to see what the training would be, and to really see what would be best for the society and also for ...
|
|
Howard:
|
Why are you against it now?
|
|
Dr. Jensen:
|
Well, because of safety and for making sure that the delivery of care is optimal for the patients.
|
|
Howard:
|
Do you think this Texas court case will keep going, do you think it'll go to a federal ...
|
|
Dr. Jensen:
|
I do, I think it'll progress.
|
|
Howard:
|
Do you think it'll go all the way to the supreme court?
|
|
Dr. Jensen:
|
I have a very good friend, general dentist, that took the two year residency program, I use him sometimes for anesthesia for myself. That's kind of hypocritical, isn't it? I trust him, I know he's very good, so just need some standardization and these things can possibly be worked out, but it's maybe more training than people want, like it could end up being three years of residency and it's not going to be a weekend course here.
|
|
Howard:
|
The University of Oregon has a dental anesthesiology specialty, so does Pittsburgh, don't they?
|
|
Dr. Jensen:
|
Mmm-hmm (affirmative).
|
|
Howard:
|
Do you like these curriculums?
|
|
Dr. Jensen:
|
I do, I do.
|
|
Howard:
|
How many of the fifty-six dental schools have a ...
|
|
Dr. Jensen:
|
I think there might only be ... They had one at Northwestern that was a full year.
|
|
Howard:
|
You're probably talking right now to mostly kids under thirty and a lot of them that don't place implants, like you just said, two thirds of general dentists don't. Do you think there's any really major difference in a periodontist placing an implant or an oral surgeon?
|
|
Dr. Jensen:
|
I used to be on the faculty at University of Colorado, I'm not there now, now I'm at the University of Utah by the way.
|
|
Howard:
|
University of Utah Dental School?
|
|
Dr. Jensen:
|
Uh-huh (affirmative).
|
|
Howard:
|
Which one, they have two now.
|
|
Dr. Jensen:
|
Yeah, I'm at the university.
|
|
Howard:
|
Is that in the south?
|
|
Dr. Jensen:
|
It's right in Salt Lake City.
|
|
Howard:
|
It's in Salt Lake City and the other one's in South Jordan?
|
|
Dr. Jensen:
|
Yes, right. Anyway, so I'm an adjunct faculty there now. I had a discussion with Norm [Stoller 01:02:03], who was a chairman of [inaudible 01:02:04] at CU. He said, "Ole, who do you think should do implants, oral surgeons or periodontists?" It was a little tongue in cheek discussion. I made my case and he says, "Okay, I'm going to tell you something. I went through ten categories or reasons that would pit one specialty against the other. You want me to go through it with you?" He went through it. He says, "Who should do the implant when it's supporting an eye prosthesis or a nasal prosthesis?" [inaudible 01:02:46] said, "Well, the oral surgeon." "Okay, so you get a point there," and he went through this whole thing.
|
|
|
Then the soft tissue around implants, he thought periodontists could do that better, so he got a point there on that side. Anyway, when it was all done it came out to be six to five or something in this point span. In other words, both. Both can do it very well. I was trained by periodontists, I train periodontists. Periodontists come in and do work with me, I work with periodontists. I refer to periodontists, they refer back to me. We should be working together and collaborate. They have a great knowledge base, excellent doctors, and then we have the same. I don't see it that it's that much different really.
|
|
Howard:
|
I always tell dentists that you only live once, be happy and healthy. If your passion wants you to go do something, just go do it, worry about the business later, but I want to take the passion off the table. If the general dentist didn't have a passion to learn implants and say they were in a small town or whatever, what do you think of the people who say, "I don't want to go learn how to place implants, I don't want to place a hundred to reach critical mass. I don't want to do all that. I'm going to put all my implant cases on one Friday a month, have an oral surgeon come in or a periodontist, load them up." What do you think of that business model?
|
|
Dr. Jensen:
|
I don't like it. In Colorado, you have to have a separate DEA number for each office location you work in. You have to have also call backup, so let's say somebody did an anesthetic, they did a surgery, and then they left, drove off two hours to another city or something, and there was an anesthetic complication. Maybe the patient stopped breathing or maybe they had whatever. I don't like the itinerant in surgery where you're doing general anesthesia, I don't like that so much. I would rather see a situation where the dentist actually learns how to do some of that and then refers out to a local doctor. I think that's a better model for optimal treatment of patients. In the end, it might actually even be economically better.
|
|
Howard:
|
I always think it's funny how a lot of dentists are lead to believe that if you're going to be successful, you got to have lasers, or place implants, or have a CADCAM, or this, or that, but it seems like if I lined up a thousand dental offices that are just totally general dentists, totally successful, making bank, it's always just restorative dentistry. It's just fillings and crowns, but the market makes them believe they need to place implants, get a CBCT, get a CADCAM, get a laser, get all this fancy, crazy stuff, and I just don't see it in the real world.
|
|
Dr. Jensen:
|
The most successful dentists I've seen have been the ones that get involved in things like [Panky 01:06:00], Dental Institute, Seattle Study Club, Academy of General Dentistry, or a university. We've had them and those kind of people that are really engaged, they tend to get more involved in the holistic care of the patient and not so much trying to do every dang thing. If you know how to do endodontics, great, but if you don't, just think about the whole patient, you're going to be very, very busy. Send that endo out to your friend and you're still going to be very, very successful I think.
|
|
Howard:
|
I see that also a different phenomena. I don't see that Panky, or this, or that helps them. I see that they go to the [inaudible 01:06:52] Center and John [inaudible 01:06:53] is now their Vince Lombardi. They go to Scottsdale Center and Frank [Spear 01:06:58] is their Vince Lombardi. Peter Dawson, I mean, he's motivated. Bill [Dickerson 01:07:04]. I see that these institutes, they fall in love with the charismatic Vince Lombardi guy.
|
|
Dr. Jensen:
|
They do.
|
|
Howard:
|
That makes them be more than they could have been, so those institutes are priceless if you fall in love with some leader that makes you play harder or dive for the ball. You talk about a term that I bet you 99% of the listeners never heard of. What is distraction osteogenesis?
|
|
Dr. Jensen:
|
In the year about 2000, maybe 2001, I wrote a book called Distraction Osteogenesis of the [Albulis 01:07:40]. It sold out worldwide and it was big. Then about three years after that, I hardly ever do that operation again because we found something that works as ...
|
|
Howard:
|
Short lifespan.
|
|
Dr. Jensen:
|
Yeah, and so distraction osteogenesis was invented by an orthopedic guy named [inaudible 01:08:09], a Russian guy who actually treated Valerie [Bromel 01:08:14], do you remember who he was? The high jumper. He jumped seven foot five.
|
|
Howard:
|
That was not one of my sports, high jumping.
|
|
Dr. Jensen:
|
Anyway ...
|
|
Howard:
|
I did not have the body for gravity.
|
|
Dr. Jensen:
|
Bromel got in a motorcycle accident and lost three inches of one of his leg's length, so shortened. [Liserof 01:08:35] cut the bone, put a spreader on it, and grew the bone in Valerie Bromel so he had equal length legs and could return to high jumping. He never did as well, but imagine that. That's distraction osteogenesis. Distract the bone so it grows within itself and we did that in the jaws, but we found a replacement for that.
|
|
Howard:
|
They're doing that to increase height?
|
|
Dr. Jensen:
|
Height, yeah, height and width.
|
|
Howard:
|
Height and width, so short people can go get, and they'll make cuts on their legs, and then ...
|
|
Dr. Jensen:
|
You could get longer arms, you get longer legs, you get longer jaws, so for example, I've used it in the maxilla, the upper jaw's way back, I cut the jaw and slowly move it forward. That's by distraction to get the jaws to line up, so I've used it for that.
|
|
Howard:
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Are there any other things you want to talk about? Any other things you think are what's hot?
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Dr. Jensen:
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No, I'm just very happy to be in the profession. I'm glad that I can continue to be active. I want to make a contribution to patient care. Now I'm teaching, and doing some philanthropy in Israel and Utah. For example, I'm trying to get Israeli students to come to the university here and then send some of our students over there. I just think collaboration is the way that we can help the world out.
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Howard:
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I'll end on the remote control. Everybody has a television remote control and in my office, our mission statement is just treat the patient like you want to be treated. The reason nobody can figure out the remote control is because these cable television monopolies, when they go to build your remote control, every department has to get their five buttons in, their ten buttons in, the DVD people, the movie select. I've never met anyone who can figure out their remote control. Dentistry needs to not be the remote control. If we ask every question what is best for the patient and work back from there, a remote control would probably, the very best ones ... If Apple made it, it couldn't have ten buttons, it'd probably have six buttons, maybe four buttons, but the one from [Kox 01:11:02] and Century Link has fifty because they're focused on themselves. If you just keep it focused on the patient ... Ole, I can't believe I got a legend like you to come all the way to my house on a Friday.
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Dr. Jensen:
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I appreciate it very much.
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Howard:
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It was a huge honor and the takeaway is he just said go to Clear Choice. If you want to watch an implant, if you want to learn. You'll make an oral surgeon friend, you'll make a prosthodontist friend. Can they use your lab, too?
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Dr. Jensen:
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Yeah, they can use the lab.
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Howard:
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They can use the lab, you don't have to pay $5,000, and fly a thousand miles, and stay in a hotel to watch someone place an implant. I hope you guys had half as much fun as I did today. Thank you very much, Ole.
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