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AUDIO - Burton Langer - HSP #81
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VIDEO - Burton Langer - HSP #81
Would you treat someone for chlamydia over and over again without checking their partner? Maybe you shouldn't treat for perio disease without checking their partner either!
Dr. Burton Langer earned his dental degree from Tufts School of Dental Medicine. He received his Certificate in Periodontics and Masters Degree in Science from Boston University School of Graduate Dentistry in 1966.
He was a former Associate Clinical Professor of Periodontics and the Director of Post Graduate Clinical Periodontics at Columbia University School of Dental and Oral Surgery. He is a Diplomate of the American Board of Periodontology.
Dr. Langer was one of the first periodontists trained in osseointegration by Professor Per-Ingvar Branemark in 1983. His development of new modalities of therapy, such as the early re-entry procedure for bone grafts, the ridge augmentation procedure, the subepithelial connective tissue graft and various flap procedures for implants, have become standard methods of treatment.
Dr. Langer has lectured extensively throughout the world, has written over 40 articles, and chapters in 6 textbooks, many of which have original concepts that have enhanced the clinical practice of periodontics and implant dentistry. He is the 1992 recipient of the Hirschfeld Award for Clinical Excellence and the 1997 recipient of the American Academy of Periodontology Master Clinician Award.
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Burton Langer, DMD
933 Fifth Avenue
New York, NY 10021
Phone: (212) 772-6900
Howard: We are live at the 11th annual Mega'Gen Convention in New York City and it is a supreme honor to be interviewing you today. Thank you so much for giving me some of your time Dr. Langer. I've been in dentistry 28 years. You've been in it longer. You're an elite periodontist in the biggest city in America. How has periodontist changed in your career from when you graduated until today?
Dr. Langer: Well number one, some of the disease has changed. People are more conscious about their oral health. They are schooled in the proper method of brushing, flossing, going to the dentist. The dentist are more acutely aware of periodontal disease. So you don't quite see the severe cases of periodontal disease that we used to get when I first went into practice on a routine basis. We still get them but not in the same volume of patients.
Howard: So you saying that there was actually more periodontal disease 34 years ago then there is today?
Dr. Langer: I think so and there are certain types of periodontal disease that we don't see anymore. For example there is something called acute necrotizing, ANUG, that we used to see with people under stress. We rarely see it now. Once in a great while we'll see something like that but nothing like we used to see.
Howard: I'm going to ask you a very difficult question. So it seems crazy but it's a really true question. You see dentist who see the Mom every three months for perio recall for ten years, and they've never seen the husband. Now if you were seeing her every three months for say, chlamydia, wouldn't the doctor after ten years say "maybe we should check your husband"? I mean can you really treat a woman every three months for perio and have never seen her spouse if she's going home and kissing him every morning, every night? Is periodontal disease transmittable above the belt, the mouth, like an STD is below the belt?
Dr. Langer: That's a great question. Actually I used to feel that when I had the opportunity to see the husband or the wife and then the husband the type of periodontal disease was very similar. And I used to say it's almost like a communicable disease. Women of course, go to health care providers much more often than men do. But I certainly haven't studied it practice has changed so dramatically in the last 20-25 years, that I don't see quite the volume of periodontal patients and then see women, and then see their husbands so I can't say that it's current. But I used to see that and I used to comment on it. It was very similar. If the wife had an advance case the husband did. If she had a moderate or localized the husband had it. Of course, I've never studied it so it's just an anecdotal discussion.
Howard: But if we do know a baby human is born without p gingivalis of the mouth [inaudible 00:03:40]. They've got to catch this from somewhere. So I want to talk about another subject. Describe implantology from when you graduated until now and how has the change the profession of period-ontology?
Dr. Langer: Well that's a large topic because when I graduated from perio school, implantology was the treatment of last resort for patients that were desperate. There was no research done on it. I don't want to use the word carpentry but the implants weren't sterilized. The surgical procedure was never defined. While some of them worked there were many of them were horrific outcomes. That in later years we had to rescue. once ...
Howard: Now are you talking like subperiosteal or ramus?
Dr. Langer: All of them
Howard: There were some crazy ...
Dr. Langer: All of them. Some were good. Some, because of the resistance of the patient, did pretty well. But many of them deteriorated badly. And I have to say that while I never did many, I did some of them. I did some subperiosteals. I did some ... a few blades. I did a few other things but I was never pleased with it. And I gave it up because I didn't think that as a health provider that I wanted to do something that absolutely could turn really sour. But Professor Branemark changed all that.
Howard: And he just passed away last month in brazil.
Dr. Langer: Yes he just passed away. But one of the most important people, I would say, in this 21st century because his discovery paved the way for introduction of implants into the dental field. As a periodontist we never would have deprogrammed at the American Academy of Perio on implants. I think I gave one of the first ones and now I would say 80% of them have to do with implants.
Howard: So what was Dr Branemark's discovery?
Dr. Langer: Well basically it was two fold. One, working with blood flow, he was able to put in these titanium chambers into the arms of his students to measure blood flow, the influence of smoking on blood flow and etc. Then on the healing of bones he was also able to put the titanium chambers into the long bones of rabbits to see certain effects on healing. And when it came time to remove the devices, the titanium devices, they were fused to the bone. So where they said the prepared mind discovery favors the prepared mind, he realized that he had something. And in Sweden, as you know, lost their teeth very early. As a matter fact, the families often times extracted the young people's teeth before they got married. And so they had a lot of dental cripples. Those were the ones that he started his treatment on. Plus or minus a few other ones. But that paved the way for the introduction of what we call osseointergration into dentistry and also parts of medicine too.
Howard: Last month we lost a legend in dentistry, Dr Professor Branemark, who died in his retirement home in Brazil. He's from Sweden. What do you think of Dr. Branemark? How did he change your profession of periodontology?
Dr. Langer: Well first of all he was the most important person in my professional career that I've ever met. I was interviewed just recently about it and they asked he who was the most important person in your career. It took me about 3/8 of a second to say Professor Branemark. And the reason why he was so important is because as a periodontist obviously we were trained to try to save people's teeth. And sometimes to the best of our abilities, patients mouths were going downhill. They were deteriorating. And we really didn't have any viable method of rescuing them to keep them away from full dentures.
I was fortunate enough ... Before I knew things about Professor Branemark, I was fortunate enough to listen to him in the latter part of 1982. And he presented his life's work. Of course he was that old at that time, but he had started in 1963 or 64, at the meeting, the Greater New York Academy of Prosthodontics here in New York. And he presented a carefully scientifically well documented results of placing implants in patients and having them survive with, in health, with the steady state of bone levels for long periods of time. He showed it not only in the lower but also the upper jaw. When I saw it I said: "Wow this is something that we could use on our patients that are losing their teeth". And again I was fortunate enough to get into one of the early training courses in Toronto where he came with his group from Sweden to give us a week long training intensive seven hours a day of training surgically conceptually, scientifically to learn the technique which was kind of alien to me. And we started about a year later doing our first patient. And from there it was straight uphill, uphill I mean for the patients. I shouldn't use that term uphill. It was a rescue for them because we started to treat these horribly down, deteriorating periodontal cases and these patients were rescued. They couldn't believe that they had new teeth with no abscesses. They had very few problems afterwards.
And it was really the biggest breakthrough in modern dentistry.
Howard: And he wasn't even a dentist
Dr. Langer: He wasn't a dentist. That's the most amazing thing.
Howard: Would you tell the story to our young viewers?
Dr. Langer: Basically he was an anatomist and an orthopedic researcher in Sweden. He was studying. He was a professor in Sweden and he was studying blood flow. So he commandeered some of his students to allow him to put these titanium optical chambers in a little pedicle in their arm. I guess he said if you don't do that we going to fail you. But they agreed to allow him to put these chambers in their arm. And he studied blood flow. And one of the studies by the way was the effect of smoking on blood flow. He could show that a person who started smoking the vasculature in the blood flow decrease. Which we know now is one of the effects of smoking. But the tissue was so well tolerated, now this was soft tissue, around these titanium implants. It was like it was ... instead of being an alien substance, it was almost homogeneous with the tissue.
Then he was also at the same time studying the healing of long bones in rabbits. And again, he put in these optical chambers. Optical chambers means he could look through the chamber into the site that he was studying. And when he came to remove the titanium optical chambers he couldn't get them out. They were fused into the bone. And of course brilliant people have that prepared mind. So he able to take that what he visualized and of course study under the microscope and then realize that he may have one of the most important ways of putting a structure into the skeleton system and not have it rejected. Because up until this time there was no way, no effective way of putting a piece of metal into the body. For example if you lost your ear and you wanted hearing aid, you couldn't just screw something into a piece of stainless steel into your skull. When he discovered this by the way he was able to put in a titanium threaded screw into the skull and it would be well received and not rejected. And this started the whole field of osseointegration.
Howard: For not just dentist but orthopedic surgeons ...
Dr. Langer: For people that have let's say cancer and had to have part of their face removed. And they will, I hate to use the terminology, but they were freaks because you would see them and half of their face was gone. He was able to use his discovery of the titanium screw to put in a series of screws and then have a prosthodontist make up some sort of a prosthetic device to look like a face and attach it to the person's face and rejuvenate the respectability of that person.
I know he had given a lecture here to the plastic surgeons. I don't remember whether it was at Memorial or NYU and he got a standing ovation, in which he got every place he presented it.
Howard: So Branemark's company is from Sweden and went on to become a noble bio-care [inaudible 00:14:43]. So let's fast forward all the way to 2015. It's kind of confusing for young dentist to look at the implant field. I mean you see noble bio-care implants are probably $500 more. And you see 20-30 companies all the down to $100 implants. So I'm going to ask you is an implant, an implant, an implant? Is titanium, titanium? What do you make of the 100% variance in price?
Dr. Langer: Well we don't know. We don't know whether the lower price implants is as good as the noble implant or another implant? The reason is that noble at least studied the implants. So they know what the track record is. So they've analyzed it over the long haul. Just like we have analyzed our implants. Laurie, my wife, has a tracking system that determines, and we upgrade it every single day of patients that we've treated, patients that have come back, the success rate. So we know whether we're dealing with something that looks good for three or four years and then deteriorates or continues to look good for all of these years which at this point is, I don't know, like 30 years. Pretty close to that. These other implants, well they maybe just as good. We don't know if it's a similar type of titanium but there's no studies on it. So back to your question ...
Howard: So from your research with you and your wife ... so you're a husband and wife periodontist team?
Dr. Langer: That's correct
Howard: You've been married 42 years?
Dr. Langer: Right
Howard: So you should get a Nobel prize. So in your 42 years are there some companies you like or are there some you should avoid?
Dr. Langer: Yes there are. Well I should say that I like some companies because the success rate of doing them seems to be quite good and similar to what we have at Nobel.
Howard: Can you share names?
Dr. Langer: If you want me to.
Howard: My own motto is with [00:17:02]. So if there is some woman dentist driving to work all by herself, she's got an hour commute. She's all alone. She's sitting there wondering did your rock star in New York for 40 years. What advise would you give her?
Dr. Langer: Well we use Nobel. We use Straumann. We use three eye, which is now BioMed. I use some Megegen and they seem to do fine. But people say why don't you use more of them. And I say because we have such a large inventory of implants. We can't use everybody's implant. One of the reasons why I accepted to lecture here is because Dr. Park did develop some really good surgical instruments that I use all the time and I think it's terrific. So he's a smart guy if you've read his textbook. And I'm not saying it to make the Megegen people happy.
Howard: Could you hand me that textbook?
Dr. Langer: So I would think, as I've said I've never done any studies on Megegen implants, but I would think he probably has a very good implant.
Howard: So this is the textbook you're talking about. So I don't think I ... So are there any companies you don't like?
Dr. Langer: In the early years there were some cylinders made out of plasma sprayed. Actually Straumann had a plasma sprayed implant that was not really threaded, etc. And there was a company, IMZ, that had a hydroxy appetite cylinders that looked great for 3 or 4 years and in the 5th year they got violent breakdown. Then we had to remove ... we had to bone graft to get them back and we put Nobel implants and they've done fine for them to last 15-20 years. There's a lot of aspects to implants but these cylinders were not good. Either because of the geometry that they weren't threaded or the surface treatment either HA or plasma sprayed that caused this destruction.
Howard: So do you think that's the end of HA? Is that kind of gone now?
Dr. Langer: No actually what interesting is that Nobel bought a company called Asterias which had a threaded HA ...
Howard: Where were they at? Was that Sweden? Switzerland?
Dr. Langer: No they were on the west coast. I think it might have been California. And they had a threaded HA implants. They disregarded it but I've used a number of them. Not a lot of them but a number of them and they have done very well. But, you know, once they've discarded it then it was no other that I knew of threaded implants that I was going to try. But I think the story really isn't totally in on HA.
Howard: What percent of your implants are you bone grafting around? Can you talk about bone grafting? Is that something you ... if this dentist wants to get into implantology and start placing some single implants for a missing tooth do they need to get into bone grafting?
Dr. Langer: Probably
Howard: For single tooth replacement?
Dr. Langer: Probably
Howard: Talk about bone grafting.
Dr. Langer: Well actually when you take a tooth out, which I'm going to show this afternoon. We've always believed, people didn't always agree with us but we've been doing it since 1989. Extracting a tooth, and putting an implant in and bone grafting it at the same time at a success rate , which I'll show this afternoon. It's not only is good as placing in the healed site but it's slightly better. Because when you take a, well call it an infected site, or a damaged site and you change it from a pathological entity into a surgical entity, sometimes the repair is so dramatic that it's better than if you take ... If you extract a tooth, let it heal and let it collapse and then have to go back. Now people fought with us about this and said well you can't do it, etc. now these people are now proponents for this treatment because we have the proof and other people have the proof too.
But in order to do that you have to know how to bone graft it. You should know how to suture it. How to close it. Do all of those surgical things we do on a [crosstalk 00:21:54] basis.
Howard: How would ... okay so dental town now we're just coming up to 200,000 members. How could we get online course for you on dental town. We would love to have...
Dr. Langer: Well I must say that I, you know ... we do surgery everyday. I don't give courses on surgery. And why don't I give courses on surgery, because I'm not convinced that a person who takes a weekend course, and I'm not against the general dentist doing some of these things, but I think some of them are doing it and getting slightly above their training. But I think if I was a general dentist I would make sure that I could do the prosthetic phase of it which they are trained on a daily basis to do it perfectly. Because the prosthetic phase often times is the major co factor in the long term success of implants.
Howard: So I want to switch gears here. I think we both realize that 90% of the general dentist in America are never going to place an implant.
Dr. Langer: Right
Howard: So I want to switch gears. So this is April. Next month 5,000 kids graduate from dental school? I want you to talk about it's tough when you are a young dental student and you try to treatment plan dental implants. Because sometimes you see a missing tooth and it's a first molar and all you see is a sinus cavity and they're like gosh I don't even know does the sinus lift even really work. Is she a candidate for a sinus lift? And then the second question you get is that well this person's got gum disease and this tooth is wiggly and loose. I can't pull a tooth and then put an implant in an area where she has full mouth gum disease. So switch gears to diagnosing and treatment planning for these kids walking into school next month. Are sinus lifts predictable? Do you place implants in people with gum disease? Talk treatment plan.
Dr. Langer: Well first order of business is for the most part you should treat the periodontal problem first. You don't want a mouth that's teeming with bacteria when you're doing implants. Does it always work out that way? No. But that's the first course of business. For young person that's going to practice, be it his own office or going to work with somebody else, there's another aspect. I believe that the practice management of what could be done for patients is often missed. People ... I've told the powers of people that don't listen to me, that if a dentist, be it a young dentist or a dentist that has a practice that wants to bolster their practices ... wants an honest quick way to bolster their practice ... It would be to take people who are wearing a removable prosthesis and tell them they have the opportunity to have a fixed prosthesis. We're thinking of at least one person that we know who is be in practice much longer than I've been in practice and he's transitioned his whole practice into an implant style practice by converting people who were in the mode of wearing removeables and things like that into fixed bridge work. And if you can believe it, he's in his 80s and his practice is so viable.
And I've said for people who want to rejuvenate their practice they have to, as they call it the paradine shift, they have to look at their patients and see that they have a wealth of new patients in their old patients by educating them of what is possible now.
Howard: And I don't want to say some of the young kids also. You know dentist positions or lawyers, there's a lot of book smart people who aren't street smart. Like a lot of times when a young dentist wants to learn some information, they fly clear across the country, pay $4,000 for a course, have to stay in a resort, all that to just learn this much. I was street smart. I was amazed when I got out of school. I could call a local periodontist or an endodontist and say "can I come in a talk to you? Can you help me set up a perio program in my office? Can you help me educate my hygienist of the diagnosing? When we refer and the whole deal?" I got all my CA for free? You're in Manhattan. How available are you to young graduates that are coming to Manhattan? Do you mentor kids if they call you?
Dr. Langer: Well I speak to them on the phone but I work like a maniac. And my days are really busy. So I don't have much time to mentor young people. Of course I get emails from a variety of different either specialist or other people about problem cases and I answer them back. But of course time for me is the biggest commodity because I don't have much time.
Howard: Right. It's people, time, and money.
Dr. Langer: People, time, and money and I work full time. I'm fully booked almost all the time.
Howard: And that's why I know it was an honor to get you today to do a podcast. I want to thank you so much for spending time with me today. Thank you for all that you've done for dentistry, everything you've done for periodontistry. Can I just end on one question? One question. What would you say to a senior in dental school whose wondering if they should go into a perio program? There's nine specialties in the ADA. Would you recommend a senior in dental school go into perio in 2015?
Dr. Langer: That's a real tough question because I'm not sure that it might be the best choice right now. We feel that the periodontal, the academy of perio and the periodontist have diluted the specialty. And I don't know that there's a lot of periodontist that don't enough to do because of that. The generalist is doing a lot of it themselves because they've taken these courses given by periodontist. And I'm not saying we should be so proprietary that we don't help the young general dentist but you can't give them the impression that taking a weekend course is the same as going to school intensively for three years. So I'm not sure which is the best specialty at this point.
Howard: All right that was great words of wisdom. Thank you again so much doc. Bye bye.