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AUDIO - Gordon Christensen - HSP #80
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VIDEO - Gordon Christensen - HSP #80
The evolution of implants and x-rays. Why general dentists don't place implants, and dentist turf battles. Why do new graduates have zero quality implant training? How do they get proper training? "If a grad can't learn in 2 or 3 days how to place an implant in a healthy person, it's hopless." Listen as Dr. Christensen shares his solution
"I would like to see every general dentist put an implant in a healthy person with good bone." Listen to Gordon Christensen explain part of his life mission
Gordon J. Christensen is Founder and Director of Practical Clinical Courses (PCC) and Senior Consultant for Clinicians Report (CR) in Utah. PCC is an international continuing education organization that provides courses and videos for all dental professionals. CR offers unbiased research on thousands of dental products.
Gordon's degrees include: DDS, University of Southern California; MSD, University of Washington; PhD, University of Denver; an Honorary Doctor of Science from Utah State University, and an honorary Doctor of Dental Education and Research from Utah Valley University.
Gordon is a practicing prosthodontist in Provo, Utah. Gordon and Rella's sons are both dentists. William is a prosthodontist, and Michael is a general dentist. Their daughter, Carlene, is a teacher.
Gordon J. Christensen - Practical Clinical Courses
3707 North Canyon Road, Suite 3D
Provo, UT 84604
Fax: (801) 226-8637
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Phone: (801) 226-6569
Howard: It's an honor to be with my idol, Gordon Christensen, the god of dentistry in downtown New York City at the- Where are we at? The Grand Hyatt.
Gordon: Grand Hyatt.
Howard: At the 11th Annual [00:00:18] convention.
Gordon: Right on.
Howard: Great to see you again.
Gordon: My pleasure.
Howard: Gordon, you were the first person who ever talked to me about implants on one of your two day weekend courses in Provo, Utah 25 years ago. I was up there with [00:00:34]. We went up there two days every month for a year. How have implants changed from when I first met you 25 years ago to now?
Gordon: Unbelievable change, Howard. What we've had is simplicity that's been instituted by many, many companies, as you know. The cost has lowered dramatically, although there are still some that are running as high as $600 or $700 dollars for all of the accouterments that go the implant. There are some that are low to medium cost that are equal in quality and easy to use with good service and with education.
Howard: Do you think, when I first met you all the x-rays were 2d, now it's going to 3d, the cone beam technology. Do you think that's a game changer?
Gordon: The program I'll give this morning will indicate- I had 25 years of no cone beam. I've now had 13 years with cone beam. I would never go back. I see things daily that I've never seen before. I'm able to judge quantity of bones, facial lingual quality of bone, able to make predictions as to whether or not an implant is actually going to work were before you were just lucky to find the bone.
Howard: Right. I remember sometimes we'd think we had an inch of bone, [inaudible 00:02:04] by the time you smooth it down to get 5mm of width you didn't have any bone. Gordon, one of the problems for general dentists is you want a cone beam that will find a fourth or fifth canal on a molar, yet you want one for an implant and you might even do a little ortho. Is there a cone beam technology that could find a... First of all let's go to endo because far more dentists do root canals than place implants.
Gordon: Of course.
Howard: What cone beam could find an MB2 or a missed canal?
Gordon: Okay, I started out with Planmeca thirteen years ago and then there was some competition, not a lot. Over that period of time, now we have many, many companies. Shine Patterson, Benco, Burkhart, Goetze, the time you add them all together you have 20 or 25 devices. They are as difference as night and day. If you take little periapical radiographic sensors, their [inaudible 00:03:09]. They're all too thick and they're all miserable to use. They don't show initial carries. If you go into cone beam, however, they are very, very different. Some have higher radiation, some lower radiation, some will have two images you can do, some will have as high as nine images you can make, different small or larger segements. I still find myself going to Planmeca fairly often because it has two major softwares. One will do a very fine pan for me, one will do 3d, but yet there are some others highly competitive. The South Korean brand, since we're in a South Korean company here, South Korean Vateck.
Howard: How do you spell Vateck?
Howard: Vateck, okay and that is South Korean?
Gordon: THat's one of the most popular ones in the world. In America Icat is the most popular, Sirona about second. Third would be probably Planmeca, fourth would be Gendex. You've got a whole meilou of those, but they are like a sports car and an SUV.
Howard: I noticed you mentioned carestream.
Gordon: I've got Carestream in right now. What we're doing, I have one major one that I use all the time if we do cone beams for the community where I live, but we also have these consignment items that come in so it's easy to compare. We have Carestream right now, low radiation, easy to use, two major devices, higher level a lower level. The lower level serves most general dentists very adequately, the higher level for oral surgeons.
Howard: Now you mentioned Planmeca out of Helsinki, Finland. They just bought E4D out of Dallas.
Gordon: Right, right on.
Howard: Is that going to be a game changer for...
Gordon: Oh, absolutely yeah, because there is obviously financial resource there and lots of engineering capability. It's interesting, though, over all the years I have been associate with the various Scandinavian countries I've never seen a sober Fin. So i wondered how the heck they made that sophisticated device. It really is excellent.
Howard: Is that right? Are they heavy drinkers up there in Scandinavia?
Howard: I think it's funny when Americans, you hear all these redneck Americans that are against like socialism, they've never left the state. Whenever they talk about socialism it's always Scandinavia. It's always Denmark, Sweden, Finland and Norway and I think those are the most nicest societies in the world.
Gordon: That's my heritage, Denmark.
Howard: Yeah, I mean, you look at these countries like, "Really, these are the bad socialists?" It's like, it's the greatest society every. Hey, Gordon, I wanted to ask you specifically about this new dentin grinder.
Howard: When I saw this, the dentin grinder is this new thing for bone grafting. You just throw the extracted tooth in and grind it up. I swear when I saw that I had a flashback to you 25 years ago saying that there's coral in the ocean that's a billion years older than human hydroxyapatite. Will we be throwing coral in that things someday or what do you think?
Gordon: When I saw this first it was about, would have been a year ago, at the greater New York meeting. This is obviously an Israeli invention, and I though, "why didn't I have that idea?" Then we took it back to Clinicians Report and we have several who are now using the thing. Several of our evaluators and so far so good. My initial thought on the device, which is very simple. It's a grinding machine that you throw away the perpetual grinder and you keep the motor and you're taking both enamel and dentin and whatever cement there might be left on there, grinding it up and then dissolving off any organic crud that might pulp, periodontal ligament that's still remaining and so forth. Then subsequently filtering it out and sticking it back in and one tooth creates about three times the volume that it appeared to be because obviously you've got spaces between the little ground up particles. For $40 give or take, which is about the cost of the grinder device, the top part of the grinder device that you're looking at there, top part you throw away the bottom part you keep. I'm not...
Howard: Why is it one time use?
Gordon: Apparently because it would be contaminated enough that it would be difficult if you are using it on another patient...
Howard: [crosstalk 00:07:55]
Gordon: No. So I am not particularly promoting it at this time. We just have it out in preliminary use. We've had a couple of DAR evaluators have had six months of successful use of it, so we'll keep watching. To answer your question, how many other things are hydroxyapatite. Oyster shells, I don't even know all of the things that could possibly be similar rather than a $100 for a little bit about the end of my little finger. That's about what we're paying for a bunch of ground up dead guy's [crosstalk 00:08:28].
Howard: Is it true that the idea for this came when someone was watching the last scene of the movie Fargo?
Gordon: Who knows, Howard?
Howard: Is that true? Do you remember that movie? This is the end of April. Next month 5000 American kids will walk out of dental school. What would you say to them about the future of... Should they be thinking that someday they'll be placing implants and if they were going to, what percent do you think place implants now, ten percent?
Gordon: It's not even ten. This week I've had four speaking events and I've asked that question in each one and I'll get two or three hands that will go up in a huge group, had 900 recently, and I won't mention the state because it will embarrass them. In 900 I had half a dozen. Now, here's a good example.
Howard: First of all, why is that?
Gordon: Why is that? We're very, very behind other developed countries. A lot of the developed countries that I get into it'll be 75-80% of dentists. I was in Israel a while ago, it was somewhere in that ballpark. It's because we have turf battles abounding here that makes some feel superior to others. We did a survey about a year ago, of thousands of dentists see how difficult a single implant in a healthy person with good bone, qualified that, now. That's 90% of the implants, healthy person, good bone, single implant. We found that as they compared it with the other over 100 techniques in dentistry that it compared very equally to a class 2 composite. Why somebody would not do an implant but will take on a huge class 2 composite with sensitivity, contact areas, color, margins and so forth.
Howard: A lot of people listening to that are calling bull, they are saying, "Gordon did you just say that placing an implant is the same difficultly as a class 2 composite?
Gordon: That's right.
Howard: Now are you qualifying that because you're talking about a CBCT to make a surgical guide?
Howard: Explain how placing an implant could be the same difficulty...
Gordon: Let's say it's a first pre-molar, let's make it even easier, second pre-molar one root and the bone is not the parallel or sagittal plane in the head, it's slightly inclined, isn't it. 15 degrees give or take, so out comes the tooth and if they can't do that it's time to sell shoes or something else. There's nothing particularly problematic about that. Now they've got a hole. Are they going to graft it or not graft it? That's what I am going to go into in just a minute. Obviously there's good research saying you don't have to graft it. You can go ahead and stick something in the hole right there.
Then, once they've found it, they're going to go between the two teeth. How hard was that? This one and this one, go down the middle. Now they're going to have to look at the facial and the lingual, but down the middle. Do I need to $400 to $1000 guide to do that? I think not, in fact it really irritates me that the companies continue to push, push, push, push, push, we've got to guide this. Well, geesh, years ago they had guidance for crown preps. It took longer to put the guidance on than to do the crown prep. If they've had a lot of experience doing crowns and paralleling things, how hard is it? Go between the teeth, go between the bone. A single implant, healthy person good bone, slam dunk 20 minutes.
Howard: I agree. I think if the dentist can't do it or feels nervous about it they should have their assistant do the first ten while you just watch. Gordon back to the graduates, do you think the 5000 graduates have quality implant training? Do you think they're ready?
Gordon: Zero, sub-minus, inadequate.
Howard: These 5000 graduates, if they want to do what you just said, give them a pathway. Do they need a CBCT to do this? They're coming out with $250,000 in loans, do they need $100,000 cone beam?
Gordon: No, they need access to it in their own facility. We have the two cone beams at any one time and we do cone beams for the community. They can come in, they will get a cone beam done for about half the price of a normal clinical exam with a cone beam. I don't interpret it, although we do give courses on how to read cone beam. I do it with Dale Miles, oralmaxillofacial radiologist. They need access to it. Find a little community clinic whose got a cone beam and pay them half/half or so of the normal clinical fee and go for it.
Howard: What percent, if you're a practicing dentist, what percent do you think of your area specialists like periodontists and oral surgeons and orthos would let you take a cone beam for your patient? What percent? If this young dentist came out of school and starting practicing?
Gordon: Oh, I see what you mean. I'm thinking more along the lines of a radiographic clinic. You may remember I had panoramic clinic for 40 years so everyone had panoramic. I think we're going through the same thing right now with cone beam. We will have, I'm going to guess, 5 - 10 years when very few have cone beams and then slowly it's going to grow as they go down in price and people get more involved with cone beams.
Howard: I know in my backyard in Phoenix, I don't know a single periodontist with a cone beam that if a general dentist sends a patient over there they won't take one for them.
Gordon: Sure. They need access to cone.
Howard: Okay, you said need access to cone. More specific with that graduate, how does a graduate, graduates next month in May, get to placing an implant on an upper tooth, baby steps.
Gordon: Now I'm going to irritate some of the people. Let's think of this. If they can't in a couple of three days learn how to put a single implant in a healthy person with good bone, it is literally hopeless. Go back to doing class 1 amalgams. I think it's that simple. Getting out of school however...
Howard: So you're saying a two or three day course?
Gordon: We have two levels of courses.
Howard: Okay, specifically talk about those.
Gordon: The first level of course is how to put small diameter implants, which talk about simple.
Howard: Mini implants?
Gordon: Yeah, that would be 1.8 to 2.0ml in diameter. That in one day, they can do that. The second day we go healthy persons with good bone, so two days now they've got very rudimentary knowledge about it. They can do it on dentoforms, they haven't done it yet on people. I suggest they go to the local slaughter house and get a cow head or pig head, slash the lower jaw off, which we actually do in one of the courses, and start boring holes in that bone or go to the grocery store and get some cow ribs. Start boring wholes in those and get some slug implants from anyone at the companies, not the real implant, but ones that are mimic and start screwing them into bone. The only difference when they jump to a patient is there's blood and they have to anesthetize it.
Now the next course we give goes into sinus lift. It goes into socket grafting and the various things that are related to a little more advanced technique. Many don't want to go there.
Howard: Do I have some more time with you Gordon or are you trying to take a break?
Speaker 3: Maybe ten minutes.
Howard: Ten more minutes?
Howard: Gordon, how does a listener found out information about these? What website would they go to to find out about your implant courses?
Gordon: P like Paul, C like cat, PCCDental.com.
Howard: For practical clinical courses?
Gordon: Yeah, practical clinical course.
Gordon: PCCDental.com. They are two day courses. There are two of them on implants and then we have another one called Christianson comprehensive that's another two days. It puts together a lot of treatment planning. They bring in their own cases, we look at them and make them do the treatment plan and go from there. So really two that are surgically oriented and one that's more restorative oriented.
Howard: By the way, me and my buddy Mike [inaudible 00:16:48], you know Mike [inaudible 00:16:49]. We both think that going to a two-day course once a month for a year at the very beginning of our career skyrocketed us five years ahead. I mean, I don't think there was a way to blast yourself into the future.
Gordon: We enjoyed having you there.
Howard: So, doc, and this is 2015, in ten years do you think it will still only be 10% or less of dentists placing implants or do you think these graduates will be different?
Gordon: I've been hammering on it now for 20 years, saying general dentists, general dentists, wake up, do this, I did it as recent as yesterday in a big meeting and it's just hard to get them to go that way because there's been so much turf fight. Oral surgeons think they're the only ones that are smart enough to do it. Periodontists are not quite as smart, but they can do it. Prosthodontists, myself, we're dumber than a rock. General dentists can't even count to ten. You see, there's that hierarchy that is impeding it enormously. One of my kids practices in Canada. He'll do anything from brain surgery to circumcision and he's a general medicine, you see what I'm saying. You get somebody in a big city, like I was yesterday, in a big city there's that hierarchy that exists. I've even seen some and I hate to be hard on any surgical specialty, but they'll want to take out the implants that have been done by some general dentist.
Yes, the turf battles will abound forever, think.
Howard: We're here at the Megagen. I lectured yesterday, you're lecturing today. I got turned onto Megagen by my very good friend, Gerome Smith. He's a hardcore Megagen. What do you think about Megagen?
Gordon: Megagen is a company that's attempting to do just what we're talking about and that is get- Here's my strong, strong feeling. I would like to see every general dentist who is not afraid of blood be able to put the single implant in a healthy person with good bone. If he does or she does that is 90% of implants. 90% are singles. Where you see cases where they're all on four or I did all on six for twenty years, but that's a few people. That's people making $200,000 and $300,000 a year to even be able to do it. When you come down to a normal person in a typical town, in a typical general practice, with family making $54,000 a year, the whole family, they're not going to afford the $20,000 or $30,000 thing, they don't want to, but they will afford two implants there or one here.
Even ABA says we ought to be putting two single implants in a [inaudible 00:19:29] our primary treatment plan as you know and I'll expand that to four little ones. If there's not enough bone, four little ones, if there is enough bone, two big ones. That's $5,000. Anyone can afford $5,000 if they are making that $50,000 a year, $54,000.
Howard: What I'm hearing Gordon say is what Henry Ford said, if you focus on the classes you'll be poverty and eat with the masses, if you focus on the masses you are going to be rich and eat with the classes. Isn't also, so you're saying, basically 95% of crowns are done one at at time.
Howard: You're saying 95% of implants are down one at a time.
Gordon: They are definitely done that way. We need implants for the people, not for the dentists.
Gordon: I really mean what I just said there. 97% of them can't afford half of the stuff we talk about on implants and the other 3% can and that's the hobby dentistry. The real dentistry is for the people and that's these simple things.
Howard: Gordon, you're saying 90% of implants, healthy patient healthy bone, I would think a lot of people are listening thinking, well no most people lose their teeth because they're sever gum disease, diabetes, so why are you saying 90% of teeth loss that need implants are healthy bone?
Gordon: Well, as you know the data on periodontal disease and subsequent healthy implants is still a moot point, still controversial. Nobody has really said you can get down to meta analysis both sides of that that a person with perio is going to have bad implant health. Once the teeth are out it appears that the bone is still going to be adequate to hold an implant, so it doesn't really relate as you might think.
Howard: [inaudible 00:21:16] seen periodontal disease around a tooth with [inaudible 00:21:19] versus the perio-organisms around implant [crosstalk 00:21:23]
Gordon: Very different.
Howard: Is it very different? Is the peri-implantitis, can it be as aggressive as the periodontal disease or ...?
Gordon: No and I have a strong theory there that really needs to be followed up that I have not had the time, interest or money to do and that is we are seeing titanium allergies and that's the thing that's trying to get people into zirconium implants. I'm not pushing zirconium implants, but I'm saying a lot of people will say, you've got peri-implantitis, when in fact you go on any website that's evaluating leucocite changes and so forth you'll see anywhere between 3% and 30% sensitivity to titanium. Peri-implantitis may have nothing to do with organisms and I know I'm out in left field according to the perio...
Howard: No, you explained it to me very well 30 years ago that you know, some people can put on a base metal ring and be fine and others will get a green tattooing.
Gordon: Yeah, right on, right on. I think we're dealing with that with implants. The few where somebody will apparently scientifically say, oh peri-implantitis, put some chlorhexadine, put some orestin in there, do something exotic to it when in fact it's probably an allergy to titanium, venadium or aluminum and that's what we got in the mean time.
Howard: You see it with the braces where some kids put on braces and the gums go crazy.
Gordon: You do, yeah, right on.
Howard: Take off the braces and it goes away. How much more time do I get him? Am I on time?
Speaker 4: I think you might want to...
Howard: We're out of time.
Gordon: We're close.
Howard: Gordon, I just want to end with saying, seriously, from the bottom of my heart, almost every dentist I know, if I said, "name the person who is your role model, you're idol, who took you from the beginning to..." probably 99% of the times they say it was Gordon Christensen [crosstalk 00:23:10]. Thank you for all you've done for dentistry.
Gordon: Thanks for all you're doing. My gosh, you've influence more people than any...
Howard: I'm not a rounding error on what you've done for dentistry.