Howard: It is just a huge honor for me to be in downtown Sydney talking to probably the most legendary dentist that I know in all of Sydney. Dr. David Dunn, the principal dentist of… How do you say it? Macquarie street dental?
Dr. David: Macquarie.
Howard: Macquarie. What is Macquarie?
Dr. David: Well, Macquarie was a governor of Australia, the first governor of Australia here on New South Wales. So, Macquarie streets been a famous street and it's considered the premium medical street in Australia frankly and certainly Sydney.
Howard: Yeah, Dr. David Dunn is committed to providing you with the highest standard of treatment and believes passionately in continued education and excellence throughout all aspects of his dentistry. After graduating in 1981, from the University of Sydney, with a Bachelor of Dental Surgery with honors, he’s practiced the latest techniques in dentistry over the past thirty years and frequently lectures both in Australia and overseas. Dr. Dunn was instrumental in the establishment of both the osteo-integration society of New South Wales, being chairman of the Inaugural committee and later the Australasian Osseointegration Society. He has been a senior clinical associate at the University of Sydney, Faculty of Dentistry and also been a faculty member for the teaching of the Diploma in Implant Dentistry, University of Sydney. Dr. Dunn has lectured both nationally and internationally, including at the rail Australasian College of Dental Surgeons in Two thousand Congress, the Australian Dental Association Congress, Asian Pacific Dental Congress, New Zealand Dental Association Congress, Nobel biocare world conferences and numerous local programs. He also conducts mentor training programs to educate and improve the skills of dentists who are involved in dental implant surgery. Dr. Dunn is also a member of the international teaching faculty for the guide UCLA master program in implant dentistry. Dr. Dunn is published in both Australian international journals on Implant Aesthetic Dentistry. He is also dental editor at cosmetic surgery magazine and has contributed to several books on cosmetic and surgical dental procedures transforming your smile. Dr. Dunn's artistic eye and attention to detail ensures that all his digital smile design dental implants, all on 4 procedures and cosmetic dentistry procedures have outstanding results, you'll find many of examples of this life-changing results in his treatment gallery at macquariestreetdental.com.au. It is just an honor to be with you today.
Dr. David: Thank you Howard.
Howard: Most of all my dental friends in Australia say you're just the Australian dental implant guru legend.
Dr. David: Well that's very kind of them.
Howard: Yeah, well would you is would you say that the majority of your practice is dental implants or?
Dr. David: I would suggest now 70% plus is implants. Yeah.
Howard: And what's the other 30%?
Dr. David: Big old cosmetic and full mouth reconstruction, conventional crown and bridge, veneers, cosmetic procedures. So that and implants not from there, they're mixed add mixed in so.
Howard: So, you've started with the implant journey at the beginning. I mean you knew PI Branemark.
Dr. David: Well I did I had the pleasure of knowing PI over many years. And my venture started with Patrick Henry who has probably been Australia's foremost prosthodontist and internationally recognized and Patrick sent me Branemarks ten year study on osseointegrated implants because in those days when I went through my undergraduate training implants were a dirty word.
Howard: Absolutely and talk about that. Because the Millennials don't realize that.
Dr. David: Yeah well we came out and I need (inaudible 03:52) of them, the profession were doing implants and using all different methodologies, different materials, blade implants, sapphires, (inaudible 04:01) yeah, all sorts of subperiosteals all sorts of things. And with a high failure rate and so when Patrick sent this study to Mexico. What's going on here? I said read it and I want you to get over and see PI Branemark. So, in 1984 I just finished my royal college exams and I went over to spend time with PI in Sweden.
Howard: In Sweden? In Stockholm?
Dr. David: In Gothenburg Sweden with Gunnar Kaasen a prosthodontist there, a well-known prosthodontist and PI. And that's where my journey started and then I came back and did training under Patrick and to give you an example, today implant teaching, we teach as a starting point, a single tooth implant in generally a non-aesthetic zone and so forth. When I started we had to produce ten edentulous mandibles. In our first cases, ten cases were edentulous mandibles and also there was quite a differentiation because a restorative and surgical and there was no crossover then. So, it was a team approach in treatment. And then we've gone now to a single operator methodology. Today most implants are placed that way and now for some reason I'm happy to talk to you, I think we're going to be moving back to a team approach delivery system.
Howard: Because it's just too much knowledge to master placing and restoring or what?
Dr. David: No, because for most clinicians to do surgery today you've got to be able to do soft tissue and hard tissue grafting and I say I will pick your cases, the easy cases. Well, what may look an easy case you open it and despite having cone beam scans and all of the wonderful diagnostic tools that we have today, software planning tools, still there are situations where we are surprised. And you've got to be able to respond to complications and situations like that. So, you've got to be able to have good management of soft tissues and hard tissues to be able to do GBR grafting and so forth and have all of those materials on-site.
Howard: GBR grafting?
Dr. David: Yes, Guided Bone Regeneration. So, we've got different membranes, you've got resorbable membranes, collagen membranes, you've got PTFE, non-resorbable membranes, with or without titanium frameworks and you've got to have tacks and pins and different bone grafting materials and you've got to have PRF perhaps, Platelet-Rich Fibrin, so try to improve wound. So, you've got a lot of technologies just in the surgical side of things then, you're having to run multiple implant systems and have a range of implants, then you’ve got to have staff right up the pace and being able to work together efficiently. So, you pull all of these factors together, you've got an ideally, you have a cone beam scan or new facility, you've got intraoral scanners, you've got software programs that you must be very familiar with and be using all the time. So, if you're only doing a few cases you know, a week or a month it's just not gonna work out but you can provide cutting-edge implant dentistry or what's contemporarily needed and patients are demanding higher and higher quality of care. Their expectations have gone up a lot higher. So, the old... well it's you've got a tooth and it's functional just doesn't cut it for most people. So, the pressure's gone on performance, we're seeing higher litigation, certainly here in Australia, we've seen different insurance companies now responding to that by; if you're doing implants the premiums are going up. So, you put all those factors together and I think what we're going to find is for most practitioners, unless they're very surgically committed and they've got the patient population or referral base to justify doing the number of cases that they're going to work in a team methodology with a surgeon that they trust and again with the digital technologies, we've got available today, that can work very smoothly even though the patient is between different offices. There'll be a surgeon servicing his referral base back to that team approach and you, the restorative dentist, will be a restorative dentist without the surgery there.
Howard: There seems like a lot of young kids come out of school and their goal is to be a super-dentist. They want to master implants and bone grafting and endo and cosmetics and sleep apnea and Invisalign.
Dr. David: Yeah.
Howard: And all these things and I’m like ‘do you believe that a dentist can be a superwoman, wonder woman dentist and master everything in dentistry?’
Dr. David: Yeah, in Australia we've got a saying probably international, “Jack of all trades master of none.” You can't be everything to everybody and you need to be able to focus on those areas where you've got higher learning and are experienced, you've been mentored well and certainly we have seen that trend towards the weekend warriors, they do a two-day course and off they then start on Monday then experimenting sadly with their patients and the All on 4, in the application of that protocol, we're seeing frankly bastardized too with people not following protocols as an example of that. And then I'm sure endodontics is the same and so forth rotary file techniques and they go and do a course and off they hop into it.
Howard: You know, I want to go back to a story of when I was in dental
school from eighty-three to eighty-seven, the instructors would openly trash talk the one oral surgeon placing implants, the butcher, the barbarian. I remember I opened up at eighty-seven there's a guy across the street from me was placing implants and what's really sad about that is, a lot of those early pioneers the first implant case that failed and showed up before the local state board, they’d take their license away and remember that because a lot of these times you're seeing these new ways of thinking and you automatically, judgmental throw them under a bus and a lot of these guys are just pioneers.
Dr. David: Yeah.
Howard: And it was kinda sad.
Dr. David: But today, that's not the case and that we have very well-established protocols and some good evidence-based for those protocols. So, where people need to be thrown under the bus is working outside their level of experience and knowledge and taking on cases that are beyond them and the trouble is, with the economics of Dentistry being quite tight, it's very hard and for young practitioners I can really appreciate this, that they're not wanting to refer out in the old days, there was a much more accepted referral basis in treatment that you'd handle what you felt comfortable with and refer out. Today they'd rather go on YouTube and look at a video of how to do crown lengthening and have a crack at that rather than refer to the periodontist. Now, please I'm not meaning to suggest that that's they are incapable with appropriate training of doing that procedure. But, with appropriate training and commensurate with their level of experience and knowledge too.
Howard: I want to ask you some controversial questions in implants.
Dr. David: Please sure.
Howard: It seems like how many implants do you think you placed in your life, what would you guess?
Dr. David: We'd place around five hundred a year or so.
Howard: Five hundred a year?
Dr. David: Yeah.
Howard: So, five hundred a year? So, how many you think you might have placed in your lifetime?
Dr. David: Thousands and thousands of thousand it.
Howard: It seems like the people who placed thousands and thousand, thousands don’t use surgical guides. The people who have placed under a hundred are convinced you have to have a surgical guide and some of the older people who have placed thousands say, "Come on, you gotta be a surgeon you need to learn how to put a scaffold to bone and punching a hole through tissue and place the implant, that'll go great but you need be a surgeon in case something goes wrong you learn how to lay a flat, manage a tissue". So, some of the people that are our age baby boomers say, "You need to be a surgeon" and a lot of the younger kids say "No, you don't have to be a surgeon you could do all of these with a surgical guide."
Dr. David: Yeah.
Howard: So, what percent of your five hundred implants this year were placed with a surgical guide.
Dr. David: Okay, before I answer that let me take you back. Because I was very involved in early days using CAT-scans and software programs in trying to get better placement of implants. Now, I suggested earlier in the old days, it was that team approach and at the start was predominated by.o0r l the majority places were oral surgeons and success was getting an implant in bone and for the surgeon that was success, for the restorative clinician it had to be an anesthetic success and they would often say to the surgeon, "Yes it's in bone but I can't restore it or it looks ugly” and the come back when they’re well and that's where the bone was. And the restorative guy didn't really have much room to work with and then we came to the concept and realization that implant placement must be restoratively driven. So, the endpoint drives the implant placement and to do this we needed more information and the restorative dentist needed to have that information. So, we used scans, instead of bone sounding and single periapical because no PJs which were used. We then had CAT scans and some people regarded that as overkill. But with software planning systems, I’m thinking about dentist scan we had with CT scans we were able to, with appropriate diagnostic templates let's say, well that's our restorative plan. How does that relate to the end of the bone and where can we then place an implant ideally? And then the extrapolation of that was well, how do we control the placement, we do that for the surgical template. And then I was involved with clinician noble guide and the surgical templates and that is nobel mentioned them on various, sophisticated, software program and templates. But the problem is, that is the cost of the templates and the time and so a lot of people thought, I'd like to do guided. But that's too expensive or that's an added cost and everybody's trying to drive down the cost and compete and so forth. And today we've got now the ability with inhouse like, we've got a cone beam scanner here, we've got an intraoral scanner, we can merge those two databases, plus then using sophisticated implant planning software, we can then do our planning and we can print a guide very, very quickly and very, very cheaply. So, now there's been a resurgence in guided surgery. Now a little aside to that was your comment about surgeons- yes you need to be a surgeon because we don't like flap lips because we want tissue, we don't want to be blind and also there are errors in guided surgery systems, despite the best of so you need to be able to know your Anatomy and you need to be able to work with tissue and often we are augmenting, we're grafting, parts of tissue at the same time. So, yes there's more guided surgery but you need to be a surgeon too, you need to have all those skills. So it's not just guided surgery is now going to eliminate having those surgical skills, absolutely not. The other part of guided surgery is using some of the ceramic systems or ceramic reconstructive options that we've got. We need to be able to control emergence profile, otherwise for high-end aesthetics it's going to violate that. So we need to control very accurately the emergence position of that implant with screw retained restorations. That's why in the States you have a lot of cement retained restorations because they're having to correct for fixture angulation. So if you're going for a screw retained restoration in multiple units, you need to be very accurate three dimensionally with your implant placement. Now, I think I've got pretty good hands. I can place implants pretty well. But I can't do it as well as I can with guided even if that's using just a pilot drill as a starting point and I was with Francesco Mintronia an Italian dentist yesterday we were on digital dentistry and we we were
talking about guidance and he does the same. Highly skilled dentist but using surgical guides at least two in the planning, all the planning’s done and the guide even just to get that starting point of a pilot drill. Now that's a long answer but I hope that helped.
Howard: Now would it be different, for a single tooth replacement- your percentage of surgical guides versus an edentulous patients?
Dr. David: Yeah, it depends. There are some straightforward singles. Because you've got so much more information around you from the approximating teeth and of clues from opposing occlusion and so forth. But it may be a very tight placement or whether a guide might need to come in there or for the experienced surgeon they may not need a guide in that particular situation. But as the complexity of the case increases the number of implants increases, so does the need for guidance.
Howard: You mentioned a screw retained or cement.
Dr. David: Yeah.
Howard: Do you try to go screw retained over cemented?
Dr. David: Absolutely.
Howard: And why?
Dr. David: Well, in the old days, say a single tooth implant situation, we did not have the componentry to correct angulation. So, we in the aesthetic push too, we went to all ceramic systems. So, we have zirconium abutments and combined with Emax or zirconia crowns or whatever and so we couldn't correct the angulation. Say it such as the anterior maxilla, the angle of the crown is offset to the root angle so, there's very few that with appropriate implant placement you can get a screw retained out of that situation. So, often we are having to correct and the only way we could correct was a custom abutment and a cement on crown. Now the literature is replete with data on the incidences of complications, soft tissue complications, mucositis and peri implantitis associated with cement on restorations. And again, as the case becomes more complex, you've got not only that issue but well what happens if they fracture or chip some porcelain or something like that so you lose retrievability as well. So, it does though up the anti on accurate three-dimensional fixture implant placement.
Howard: You just mentioned them twice in that answer is zirconium abutments.
Dr. David: Yeah.
Howard: Now there's zirconium implants.
Dr. David: Yeah.
Howard: Did you like any of the porcelain zirconium implants?
Dr. David: I've got no experience with the zirconia implants. I still regard them as experimental. We do not have the long-term data on those implants at the moment to justify ( 20:38 unclear). But I'm open-minded and I look with interest.
Howard: So, if somebody was listening right now and they just got out of school is there a single implant system that could do all cases or someone like yourself? What implant systems do you use and do you have to use more than one system to do all the cases that you see?
Dr. David: There are many implant systems, popular implant systems out there today that frankly you could be very comfortable using. I use a lot of Nobel, I use a lot of Straumann, I use a lot of Astra. They're probably the three that I use and we referred some others I've got to place as well. But a practitioner starting out needs to be able to get very familiar with one system. And so I would suggest that they would investigate those top three that I mentioned and go with one of those. Because not only that it’s that you're treating a patient for life and you want an implant company that is there for life and will support and back there componentry and if something fractures or you need a replacement whatever they're there for you and today we've got, you know, hundreds and hundreds of different implant companies, little clones, look-alike type products and you know here today gone tomorrow. Try to identify. One of our big issues is we've got patients coming from around the world or whatever and they've come with this implant try to identify the implant and find compatibility and components I have been fractured an abutment screw, it's a nightmare.
Howard: I've read that forty percent of Australians were not even born in Australia.
Dr. David: Yeah we are Multinational, multicultural.
Howard: So you are placing implants from every corner of the Earth.
Dr. David: Yeah.
Howard: So, same line of questioning, CBCT, are they all the same or which one do you use? Did you just use one? I noticed right outside your office next to you is...
Dr. Davide: Oh the radiologists.
Howard: It's a radiologist.
Dr. David: Yeah.
Howard: So, didn't you even have to buy a CBCT?
Dr. David: Yeah, that's a good question.
Howard: Cuz' they have one down the street from you.
Dr. David: So, let's think about that because that radiologist has been there for years and years and years and in the old days they did my CT scans. But a patient comes in, they’ve, been referred in- they've come in on friends referral whatever, for an implant consultation. Now there's only so much information I can obtain from that. So, I've got to write them a referral they've then got to go down and make a time to see the radiologist. Radiologists, excuse the description but they're like gonna a cattle truck, they push them in, there’s not a great personal sort of... They're generally one off type relationships is not at high personal care and all the rest of the management. So, it's a very deep personalizing, thing that the patients are waiting, you're next sort of thing. They're scanned. Yes. We'll, send that to your doctor, sort of thing. So they go away and then they finally get a consultation so they're coming back now and they've got the scan and then we can complete the consult. So, that's required the patient having three appointments and often in a situation where it's not that nice for them and people's time is so important to today. So, we have our own cone beam scan and it is just one of the most wonderful tools. I don't think I'll practice without it. So we're able to do a consult we've got the information we need and we can put it straight into our software programs and off we go.
Howard: What CBCT did you use?
Dr. David: Okay, so we have a Newton, the latest Newton which were they were the developers of CBCT Newton.
Howard: Newton, N. E. W.
Dr. David: Newton, N. E. W. T. O. N. and...
Howard: Who MAKES that?
Dr. David: Italian.
Howard: Italian?
Dr. David: Yeah.
Howard: Italian Newton, where in Italy?
Dr. David: Yeah in Italy.
Howard: About where?
Dr. David: I don't frankly know where they are. But there's Inline as people that we get looked after out here and they've been fantastic in their support which is another important thing.
Howard: In line is another CBCT?
Dr. David: No, Inline are the people that service that out here are market our service.And that's a very important part, I mean you've got to have a high quality CBCT, you've got to have low exposure and
Howard: Can you send me that link?
Dr. David: Yup. So, low exposure, high quality CT, able to import easily into software programs and you can utilize like dicom data.
Howard: So an open source
Dr. David: Such as the Sirona Galileos is very restrictive. That's not a dicom system and you can't import that easily until you read them.
Howard: That's with Dentsply Sirona
Dr. David: Yeah.
Howard: Or Galileo's?
Dr.David: Yes, Galileo's. So, you're restricted to their software platform there. So, they're many good... There's iCAD there's some of the Planmecas, the Newton. There's numerous good CBCT's out there, I'm not saying there's only one. There's numerous that you could use, but from my investigation when I looked at all of the criteria of footprint, radiation exposure, time of exposure, cause even the time is the critical factor, because you don't want patients moving. So, time of exposure ability to move into software, support. Some of these are just being supported by dental marketing companies or suppliers that are selling composite resin and other bits of equipment and so forth so they're not as specialized, whereas Inline is supporting only that radiological machinery. So, support is a very important issue. If we have a problem, I want a them there straightaway and get up and going again.
Howard: You know...
Dr. David: I wouldn't work without a CBCT that's...
Howard: Is it raining outside?
Dr. David: Beg your pardon? It should be but I don't know.
Howard: It sounds like it's raining.
Dr. David: Yeah.
Howard: This is really neat. This is the first dental office I've been in, where you actually have a camera on all the rooms. That’s just so you know the flow? Is this security or just management?
Dr. David: Yeah. Both so I can see what's going on in any surgery, any part of the office, any part of the facility. It's also on at all times so even when we're not here overnight if we had a break-in and whatever it’s at all recorded.
Howard: Nice. That's interesting. So, he's got a big screen TV with three six, nine, twelve, eleven pictures so, every operatory, waiting room, everything's being recorded around the clock. But yeah, you can sit here knowing where your next patient is?
Dr. David: Yeah, I can see, is anybody waiting or what's happening.
Howard: Yeah, you talk about intraoral scanners.
Dr. David: Yeah.
Howard: What intraoral scanner did you go with and what…?
Dr. David: I went with the Trios, 3 Shape Trios.
Howard: 3 Shape Trios out of Copenhagen, Denmark?
Dr. David: Yup.
Howard: And why did you go with them and what do you do with 3 Shape Trios?
Dr. David: Okay, so you know the digital world in dentistry in both conventional and implant dentistry is exciting space at the moment. It's probably as an overview overpromising and under-delivering at the moment but it's certainly it's only a matter of time before it really does deliver. I went with Trios because again an evaluation of all of the systems out in the market whether that be a Carestream whether it be the 3M True Def. I went through all of these systems and determined that the 3 Shape was the right system for us and I'm very happy with that choice, yeah.
Howard: And what do you do with that?
Dr. David: Okay. So, we would utilize that scanner for scanning every new patient. So, we've got a record, of when their first attendance was and we can see changes in their occlusion, where all sorts of things orthodontically and so forth we can have a sort of a reference all the way through, we do a lot of occlusal splints here, a lot of para function, so we do a lot of splints. So, we scan for splints, we do a lot of pre-prosthetic orthodontics In other words, say we're doing a veneer case and teeth are out of alignment and we don't want to be as aggressive so we'd have to aggressively prepare teeth, so we do Invisalign pre-prosthetically.
Howard: So you are doing invisalign too?
Dr. David: Yeah and so we'll move teeth into a better arrangement and so we scan and we do invisalign via Trios scanning then we go to implant so, we scan for our - in our implant cases and we are able to emerge that with our CBCT data and we can then do our planning and produce a surgical guide from that or even if we're not doing a surgical guide we've got all that information bringing both parts the information. At the moment with our next step is looking at facial scanning and how we incorporate facial scanning tying them the whole package together.
Howard: What are your thoughts on All on 4? some people joke that All on 4 is none on three. What are your thoughts on All on 4?
Dr. David: Oh, look you get All on 4, all on the floor and all sorts of things so we have good data out there, good research out there to indicate that properly done following protocols, it is a valid treatment option for certain patient types. The issues I find are that people don't follow protocol or alternatively that they're getting the patient to fit their methodology. In other words, it's not a personalized prescription to fit what that patient's needs are, it's sort of saying ‘ well we do All on 4 now. Now take all your teeth out and you'll fit All on 4. So, it's over prescribed, its many don't follow protocol with it and there might be concerns but properly undertaken it is a very good and very valid treatment option and for a group of patients either the edentulous patient, the struggling with dentures or other reasons that would like to have fixed, the dental phobic that really goes to see the dentist only in when in times of need, they get out of pain and then they're off again and we're seeing these baby boomers a select percentage of them where they've got debilitated dentition with the iatrogenic, trauma, neglect whatever you like and they want to go transition from where they are now to fixed restorations without an interim denture phase. Their greatest fear is to have a denture and so they want to be able to get into a fixed prosthesis and have the advantage of that quickly and they don't want surgery or if they have surgery is like one procedure and it's quick and it's done and then you've got another group of patients economically driven. Now doing full mouth reconstructions, that's fantastic but you know they're costing in excess of $100,000, you've got endo, you've got pero, you've got the pro crown and bridge and you've got some implants here and so forth and you say well we can rebuild your mouth can open the vertical dimension, do some orthodontics and so forth there's over $100 000. Now for a select percentage of patients they go well that's fantastic and off we go but many would say I just can't afford that so where do they go? Where do these patients go? So they're patched up with amalgam and composite resin and and some failing endo's and some perio issues and a whole mix and match of treatment approaches just to sort of keep them going and again the All on 4 offers those patients aesthetics, function, minimum maintenance needs and with good long-term prognosis. So, All on 4 is a good modality for the right patient and with the right people doing it.
Howard: Are you using any CADCAM technology?
Dr. David: Yeah we use a lot of CADCAM technology.
Howard: In the office?
Dr. David: No, I don't think doing CAD - we try out at all here and so forth but it doesn't I need to be in the clinic not in the lab. I've got the best of ceramists and lab support so I believe the efficiencies of it don't justify having it in my practice in-house so again with digital if we're doing a digital workflow that can be electronically sent straight to them and they can do all of the laboratory procedures and generally with better and bigger sort of milling machines and so forth.
Howard: Yeah, the chairside milling CAD/CAMS aren't as advanced as the laboratory milling machines.
Dr. David: No.
Howard: Will you agree with that?
Dr. David: Absolutely, you just see the Cerec style even to see the quality of restorations- they’re comparative to say laboratory milled and finished and so -
Howard: Do you think that's significantly different?
Dr. David: Oh it is and again the pressure goes on the dentist that what sort of materials are they going to use because say, Emax they've got to centre it and stand it and so forth and they go ‘gee, that's a lot more time’ and then if I've got multiple adjoining restorations, I've got contact issues. So, you put all of these things together and I don't think is viable for most clinicians to be doing that unless they're not busy.
Howard: Yeah and the adoption rate shows that- there's according to the Australian Dental Association website it says there's ten thousand nine hundred and eighty four dentists in Australia, do you agree with that number?
Dr. David: No, I thought we had more I thought we were up around twelve maybe fourteen thousand dentists.
Howard: Okay, well those - let's say fifteen thousand.
Dr. David: Yeah.
Howard: Or twelve to fourteen.
Dr. David: Yes.
Howard: Somewhere between twelve and fourteen thousand. What percent of them do you think have adopted chairside milling CAD/CAM technology here in Australia?
Dr. David: I would suggest maybe 10 - 15%.
Howard: And what percent have digital x-rays?
Dr. David: I would say a lot higher. I would probably say 15% plus.
Howard: So that -
Dr. David: So with a doctor digital radiography a lot more readily and then I think for many they go well, I need a scanner and I've heard and many of them may be perhaps uncomfortable with Cerec and what they've heard about it although I think Cerec has had a huge development over time and for some, I think that's better than frankly doing some of the crummy composite resins that we see but comparative to good laboratory constructed restorations they don't compete. So, having an in surgery or in-house mill unless you've got an in-house technician I don't think is viable.
Howard: So, what about 3D printing?
Dr. David: Yeah, 3D printing, that's one of the big issues in digital dentistry at the moment, is that you can go model us but then you've sort of forced to monolithic restorations. You want to do some layering, you need a model to work with and the models just aren't frankly accurate enough but again we've seen huge developments in models and printing and so forth so.
Howard: Are you doing any 3D printing in your office?
Dr. David: No 3D printing in the office, all I have again that's printed externally for me like a..
Howard: How far away do you think - right now we extract a 3 rooted tooth but then we have to drill a hole to fit our implant system. How close do you think we are just scanning that extraction site and doing a 3D custom printed implant to replace?
Dr. David: Well, maybe we are overly complicating things in doing that anyway but I still think we're a way off in doing that even if that was the right way to go and I don't think that's necessarily the right way to go anyway.
Howard: So you know the answer on it.
Dr. David: No, just because a tooth is lost doesn't mean we have to replace the anatomy of the anchorage system of a tooth.
Howard: Okay, a lot of Americans are saying that 20% of the implants placed in America within sixty months, five years are have peri-implantitis. What do you think of that number and what are your thoughts on, do you think it's at high 20% implants in five years?
Dr. David: I would think. I'm surprised at five years but certainly I think that percentage would be around the mark then you've got to ask yourself well why is that implants or are there other factors and to me the peri-implantitis percentage is high but it's artificially high basically due to some iatrogenic factors in implacement or cement on systems and people leaving cement there or huge flanges and non-cleansable areas around prosthetic design and so forth. So, there's what I always say there's true peri-implantitis and there's iatrogenic peri-implantitis and I think it could cut that - I wouldn't do implants if I had 20% fail at five years, I couldn't sustain to practice like that. So, I would suggest our peri-implantitis rate would be in the order of 3% to 4%.
Howard: So how do you go from 20 to 3%.
Dr. David: By being meticulous in diagnosis, planning, placement, not having them half out of bone, having good bone around them. If we don't have a good bone, we build the bone good soft-tissue thickness attached gingiva, screw retained, emerges profile appropriate cleansability, hygienists motivating beforehand and maintenancing the cases and so forth. So, it's not one thing, it's a whole list of things that contribute to reducing that down.
Howard: For full mouth
Dr. David: Yeah.
Howard: Would you rather have full mouth fixed or full-month removable for cleansability and to reduce pre-implantitis.
Dr. David: Sorry, full mouth fixed implant bridge. No, well if your parameters are only cleansability, a removable can be easier but patients have other concerns the functional capacity is much better with fixed. The psychological sort of feeling of self and confidence and so forth is much better fixed. So, aesthetically you’re better...
Howard: So, does the market in Sydney want full-mouth fixed.
Dr. David: Yeah.
Howard: And what percent of your cases would be full mouth removable on fixed?
Dr. David: 1% would be only those that we believe for anatomical reasons or that they cannot maintain hygiene that we put them into a removable.
Howard: More questions on that, not to be crass or rude or whatever but when you're talking about peri-implantitis, a lot of the people that need implants, I mean, there's reasons they lost all their teeth to begin with.
Dr. David: Yeah.
Howard: A lot of them weren't necessarily they didn’t..
Dr. David: They weren’t a gold medalist, like hygiene gold medalist.
Howard: They didn't lose her teeth from brushing and flossing them too much so does behaviorally change I mean if you didn't take care of your teeth and you lost them all now you're going to all of a sudden be a brusher, flosser and waterpick cleaner and….
Dr. David: Yeah, that's how - that's a really good question and it's a one that's often brought up and I can show you in fact my last patient - a full over full reconstruction implant, reconstruction fix and her hygiene and situation was terrible in fact the periodontist sent to me saying we're at the end of the game here. So, what do you do with the patient like that? Because she would be immediate full over full removable dentures and will be miserable because the worst denture patient is the patient later in life with if they have limited adaptive capacity to accept a prosthesis like that. So, I think there's several things, firstly, if we can produce some prosthesis that are easily cleansable, so say an All on 4 on those situations, you’ve got, four implants four ( 42:51 unclear) penetrating parts they've got to clean around and if you can do a good alveolectomy me so you're down more basal bone more than alveolar bone and you've got good attached gingiva around these implants plus you're giving these patients an opportunity of a third dentition another chance they thought they would never have and if you can help them at the start- motivate them I'm not going to say that they're all going to turn around but they're new feeling of self esteem and so forth that they've never looked like that and been to eat like that for so many years, they don't want to go back to where they were. I'm not going to say they're perfect but, we keep hard on them as part of that recall program and so I say that those patients that your risk is higher your risk of peri implantitis is higher and you will accept that risk if you're going to go ahead with the treatment. That's part of our informed consent but we don't just abdicate it to a piece of paper, we try to say, ‘these are the factors where you can improve your risks’ and many of them are what we do but a lot of them are what you've got to do and gotta do that ongoing. So, and thankfully we've been doing this for a long while and we've had some really good results in those cases. You would think otherwise, they were doomed here and they gotta be doomed there.
Howard: Same line of questioning a lot of the people that need implants are smokers, yet they just walked out of dental school and when the first consultation for implants is smoking and then you got into the real world and it's like well the non-smoking yoga instructors who are eating tofu usually aren’t your implant patients.
Dr. David: Yeah.
Howard: So what do you do when walk out of dental school ..
Dr. David. Well smoking isn't an absolute contraindication for implant treatment. Okay, point one: in poor quality bone ED is a factor of increased risk, now, to me our bigger concerns is para function with so many patients today with para function they're the ones that can really do the damage so with smokers again, we try and get them to reduce or we like to get them off but again, we're not going to have a 100% strike rate doing that hopefully there's a motivation that making this investment that is appropriate that they try and protect their investment and so forth but many of them still keep smoking but again if we design our prosthesis properly, they go through our hygiene and maintenance protocols and we can stick them with it, then we can ameliorate that risk we can handle that risk. So, we haven't said, we don't go and see a huge difference in implant failure rate with the smokers.
Howard: In Dentaltown, we had to separate the children on the playground under implants between implantology and mini implants because any time someone posted a mini implant - we also just separated on Cerec, CAD/CAM and Planmecca E4D because whenever someone would post..
Dr. David: Yeah.
Howard: Well you should have bought this and... so then we had to go there and say ‘look they've already bought their CAD/CAM machine’, so it doesn't add any value to go in and say -they're not asking , there are asking about help with their current situation
Dr. David: Yeah.
Howard: But there seems to be a lot of dentists who are adamant that mini implants have their place and a lot of implantologists say there's no place for mini implants.
Dr. David: Yeah.
Howard: But what is your belief on mini implants?
Dr. David: Firstly let me say that I have very limited experience with mini implants, my only comments are that the only mini implants we've ever placed were again, as identified, those patients wanting to avoid a denture, one of the treatment approaches Nobel Biocare brought out these mini implants with sleeves that we used because we're using it like a two-stage of protocol in those days we were placing an implant to support a fixed prosthesis but they were then removed when we loaded the final implant so that's the only experience I've have a mini implants; however sadly we do a lot of medical legal work and I've seen a lot of failure rates with mini implants and perhaps that's not so much as the case that the implant is the issue but the case selection... people are using mini implants because there's so little bone or they're thin ridges or there are really sort of edgy cases that perhaps they're not comfortable in going ahead and doing grafting or doing other procedures which should have been done so perhaps mini-implants are getting a bad rep, not so much because the implant is not viable but because they've been put in high-risk cases and failing.
Howard: When you see these legal cases what are some of the common mistakes? How could dentists stay out of this trouble? I mean, why are implant cases is going to court?
Dr. David: Yeah, look there are so many. The worst thing is implant placement. So, the implants are all sorts of placement. The angles too close together. The angles are basically unrestorable or it's compromising hygiene, the prosthetic design they've got huge ridge laps in prosthetic design, no concept of occlusion, no concept of patrolling cantilevers, so they were huge cantilevers they've got fractures through sub structures and so forth. So, like most things whether it be conventional dentistry or implant dentistry the failure occurs at the start- lack of diagnosis and treatment planning that's the first part and then the second part is then, in the technical placement of the implant and knowing how to base them and respecting the protocols that are established.
Howard: There's a lot of people saying that whenever these young dentists extract a single tooth they should be bone grafting that. There's all kinds of bone grafting technologies. What would you say to a 25 year old dentist that just walked out of school and she's wondering, I just pulled a first molar on Mrs. Jones should I have put something in that socket?
Dr. David: Well that depends upon what your intended treatment of that space is going to be and what the patient's needs and wants and financial capacities are, because if you're going to do socket preservation that is try to maintain the ridge for future implant placement. If you're going to be doing say a fixed bridge or a partial denture, you don't need to do that, it's going to be completely different or if the patient is looking for the cheaper solution or the lowest cost solution that's going to influence things, if you're wanting to achieve- how can I maintain the three-dimensional volume of this ridge as best I possibly can, then yes you're going to do your socket preservation procedures, GBR procedures and you're going to have to have the skills and tools to be able to do that. So, if you are going to go down that road yes you need to learn those skills and that's not rocket science that's a pretty good starting point.
Howard: You've been so generous with your time. You are amazing. We lost two of the greatest implantologists in the last two years. We lost Dr. Brian Mark and we lost Carl Misch. What are your RIP thoughts on Brian Mark and Misch?
Dr. David: Well I've heard Carl, I'll start with Carl I've heard him many a time and read many of his books and articles and so forth and he was a great thinker and a very good clinician but I think and it's been a great loss to the profession. Branagh Mark though I think stands the god of implantology, I mean to have identified and developed that whole concept of osseointegration to have established the science with multicenter studies and shared that with the world and then what Branemark said is how can I bring this to the people? how can we make this simpler, cheaper, less surgical procedures and so forth and he pioneered it. He was always looking for...the zygomatic implant and then maxillofacial application of implants and then his other orthopedic areas. So, Branemarks stands head and tails above any other clinician and researcher in my book and I knew him and he had a great sense of humor but he was always inquiring, how can we do this better, simpler, faster, cheaper and bring it to the people? How could he improve quality of life and I'll never forget that slide he used to shows that nobody deserves to die with their teeth in a glass beside them and it was all about quality of life for PI and how his contribution could improve their quality of life. So, he's was a very, very special human being.
Howard: Do you know his son is an orthopedic surgeon in San Francisco?
Dr. David: Yeah, I know - I don't know him but yes.
Howard: Ryan we need to get him on the show, we should do that. I've only got you for a couple more minutes. If someone said to you what are the top three or four or five reasons implants failed? What would you say the top five reason implants fail are?
Dr. David: Well, there's two parts of failure, there's a biological failure, in other words the implant fails to integrate. All poorly placed implants integrate when they're the wrong angulation, they're coming out horizontally, they will integrate for sure. So, biological failure in implants today is very, very rare. Okay? you've got to be a real klutz or poor patient selected or whatever to have a failure it happens so rarely but failure of implants is more than a biological failure, you can have a beautifully integrated implant that is a failure because prosthetically it can't be used appropriately or in doing so there is a huge cosmetic or complexity or laboratory complexity in order to do that. So, again why do implants fail? lack of diagnosis and treatment planning and people placing implants without building this up, without having bone grafting or soft tissue grafting because soft tissue is the biggest giveaway aesthetically around implants.
Howard: And how do you - you said that bruxing.
Dr. David: Yeah, powerful..
Howard: Was concerned you far more than smoking?
Dr. David: Yeah.
Howard: How do you change your treatment plan when someone's a severe grinder and all their teeth are worn flat versus someone who still has all their anatomy.
Dr. David: Yeah, good questions Howard, okay. So, firstly we're going to inform our patient that they are a high-risk patient, that they are going to risk failure of implants or fracture of prosthesis ongoing. How can we improve or mitigate that risk? well firstly, we've got to design an occlusion so, we would be restoring their vertical dimension and their envelope of disclosing is with anterior guidance as flat as possible so we don't want deep overbites and so forth. So the design of their occlusion to minimize unfavorable loading is one it would be, we would be placing more implants, we would be using monolithic materials like monolithic zirconia with no veneering or the veneerings firstly protected they would be on splints and we would use Dysport or Botox as a muscle relaxation as well. So, again it's not just one factor. We identify and we inform our patients, we then design the occlusion the planning by minimizing cantilevers, appropriate number and distribution of implants, desired of the prosthesis, material selection, splints Botox and maintenance.
Howard: Last question, we’ve only got three more minutes.
Dr. David: Yeah.
Howard: And you've been so nice at the end of a very long day you were still doing surgeries when I walked in here and it was already way past dark. There's a lot of different sinus lift procedures.
Dr. David: Yeah.
Howard: Did you have a favorite? did you have to use them all? do you..
Dr. David: Yeah you gotta use, well there are a whole lot of different scientists lifts from the through the osteotomy site and if you're looking to get just four millimeters more of bone that's probably the limit going through your osteotomy site. There’s care systems, hydraulic lifts or there's the summers osteotomy technique and so forth there's lots of those techniques. So, that the sinus lift if you’re only after four millimeters and you've got some good residual bone obviously for anchorage of your implant that's a good appropriate way to do but it if you've got say, no bone or three or four millimeters of bone, you need to do a lateral window technique. So, again you've got to be comfortable opening into the sinus knowing your anatomy of the sinus, being able to have a good scans and so forth so if you see if there's any compartmentalization beside the sinus so forth and we use piezo a lot there. So again we're minimizing the risk of tearing the membrane and we're using mixtures of bio oss and autogenous bone and PRF methodologies in doing that we get very high success rate.
Howard: So, what percent of your patients are you drawing blood and spitting blood?
Dr. David: Nearly I would say 80% of cases.
Howard: 80% and why those 80% and what are the 20% when you're not?
Dr. David: For many it's just trying to get the blood and the veins really fine and because we need to get that blood very quickly and quite a volume we will take six, eight vials plus and some of these cases. So, in the majority of cases we use it and it improves our wound healing and also in handling bio oss is a very difficult material when we're mixing it with some of these blood products it becomes much more manageable and stable material to use but mainly the wound we've seen a significant improvement in our wound healing and success in that regard.
Howard: Alright, final question.
Dr. David: Yeah.
Howard: Would you ever, ever honor us, you lecture all around the world would you ever honor us with an online lecture on dental implants?
Dr. David: Yes sure. Howard I've done some for DentalED which I think that goes in nationally and so forth.
Howard: And that's with, Emanuel?
Dr. David: Yeah.
Howard: Emanuel Recupero.
Dr. David: Yeah he does a very good job in presenting online material around the world and I've done the lectures for him and yeah we see if we can do something.
Howard: That would add a lot of prestige to our website. No, I've been coming down here since 1990 and all my Australian friends think you are the leading authority of implant dentistry in the land down under.
Dr. David: Thank you.
Howard: So, my final question should be.
Dr. David: Yeah.
Howard: Have you ever placed an implant on a kangaroo?
Dr. David: They don't stay still for long enough for fast enough.
Howard: It was a huge honour, thanks for going to dinner with us last night.
Dr. David: Yeah thank you.
Howard: And thanks for doing this.
Dr. David: Thank you and you have a great rest of your trip down under and we look forward and Ryan we look forward to seeing you next time you down.
Howard: Alright, thank you very much.