Carl: Well, like I said I'm very happy that I get up every morning so far. It really has made me appreciate this last year step by step rather than taking it for granted.
Howard: We probably all take our life for granted don't we?
Carl: Yep. Certainly I was.
Howard: Tell us about your journey. Where are you at right now? What are you doing every day?
Carl: Working on my sixth book, just finishing it up. There's a book that I'm doing with Randy [Resnick 00:00:51] on complications. We're just about done with that. I guess that primarily fills my day up.
I'm no longer seeing patients so that's freed up quite a bit of time. I've lost my three dimensional adaptability on my left side of my body so I'm not able to practice at this point. I've got great memory and my lectures are going real well and The Institute is strong so I'm counting my blessings.
Howard: Just in case, since this is downloaded on every country on iTunes, there possibly could be one person listening that doesn't know the man, so I'm going to read your bio.
Dr. Carl E. Misch is Clinical Professor in the Department of Periodontology and Oral Implantology and Director of Oral Implantology in the School of Dentistry Temple University Philadelphia in the US. Dr. Misch served on the board of trustees at the University of Detroit Mercy where he is also an Adjunct Professor in the Department of Prosthodontics. He is Adjunct Professor at the University of Michigan School of Dentistry in the Department of Periodontics Geriatrics and Adjunct Professor at the School of Engineering in the Department of Bio-mechanics at the University of Alabama at Birmingham. He was Director of the Oral Implantology residency program at the University of Pittsburgh School of Medicine from 89 to 96.
Dr. Misch has maintained a private practice restricted to implant surgery, bone grafting, and implant placement and related prosthetics for more than 30 years. He previously practiced Beverly Hills, Michigan. Dr. Misch graduated Magnum Cum Laude in 1973 from the University of Detroit Dental School then went onto receive his prosthodontic certificate, implantology certificate, and Master's Degree in Dental Science from the University of Pittsburgh, The University of Yeditepe in Istanbul ... what is it?
Carl: Yeditepe, yeah.
Howard: In Istanbul, Turkey and Carol Davila University of Medicine and Pharmacy in Bucharest Romania, each awarded Dr. Misch a PHD. He holds several other post-graduate honors including 12 Fellowships in Dentistry, including the American College of Dentists, International College of Dentists, Royal Society of Medicine, American Association of Hospital Dentistry, and the Academy of Dentistry Implants.
Dr. Misch holds diplomat status at the American Board of Oral Implantology, Implant Dentistry and served as board president and member of the examining committee. He has also served as president of several implant organizations including the International Congress of Oral Implantologists, American Academy of Implant Dentistry, Academy of Implants and Transplants, and the American College of Oral Implantologists. He is currently co-chairman of the board of directors of International Congress of Oral Implantologists which has more than 90 countries represented and is the world's largest implant organization.
In 1984, Dr. Carl Misch founded the Misch International Implant Institute, a one year continuum for implant education. That's where I met you. I got my fellowship there. The Misch International Implant Institute which now has locations in Florida and Nevada. Over the years, MIII has been present in Brazil, Canada, France, Italy, Japan, Korea, Monaco, Spain, and the United Kingdom. This program has or is currently the primary implant education forum for six dental school specialty residencies.
As director he has trained more than 4500 doctors in a hands-on yearly form of education in implant dentistry. Programs are offered in both the surgical and prosthetic aspects of care. Dr. Misch has more than 10 patents related to implant dentistry and is co-inventor of the Bio-Horizon Maestro Dental Implant System.
Dr. Misch has written three editions of Contemporary Implant Dentistry, which has become the most popular book in dentistry and has been translated into 9 languages, including Japanese, Spanish, Portuguese, Turkish, Italian, and Korean. He has also written Dental Implant Prosthetics. He has published over 250 articles and has repeatedly lectured in every state in the United States as well as in 47 countries throughout the world.
Carl is there anything you haven't done?
Carl: Well, I don't have much on my list anymore but ...
Howard: You were also a swimmer.
Carl: I was at one point.
Howard: Were you a swimmer or a diver?
Carl: I was more of a diver. I was on the swim team as a diver so I swam the butterfly and I would not win but I was a diver. I took first in every competition I ever had in diving. At one point my coach wanted me to try out for the Olympics but I was too much involved in baseball and that's a summer sport along with diving at that point of my career so I elected not to do that.
Howard: I've got to tell you my first meeting of you ... I live here in Phoenix and I flew all the way to Pittsburgh. I think it was a 7-3 day weekend continuum. I went there on the the first day and I think I was 24-25-26 ... I forgot I young I was. I was in my twenties.
Carl: You sat two rows back on my right hand side the first day. The second day all of a sudden you were right in the center, right in the first row, and such a face of enthusiasm compared from the second day to the first day. I remember you coming up to me saying, you know, I've learned more in the last two days than I did in all of dental school. Every dentist should take this program. How excited you were about it ... yeah I remember that first program you were at.
Howard: Thanks. I told everybody it was like you just saw Beethoven play the piano. I watched you do surgeries all throughout that curriculum. You would do these surgeries and what blew my mind the most is how you would be doing the surgeries while you were looking up at dentists talking to them. It was like Stevie Wonder, that's really what you were. You were Stevie Wonder playing the piano because half the time you were even looking down you just were ... I mean I've never seen so many implants placed so seamlessly so easily. It was mind blowing.
Carl: It very much is like somebody playing the piano in that you can't learn how to play the piano by watching somebody play the piano and you have to practice the piano and it's the same in implant dentistry. You can't learn implant dentistry by watching somebody do surgery. You can definitely learn it by having somebody sit next to you and just like teaching you how to play the piano. You practice for 8 hours a day for 30 years, you get really good at it.
Howard: Carl you started first though in removable. That's where you cut your teeth wouldn't you say? Prosthodontics?
Carl: In those days the primary patients that would be sent to me were be completely edentulous patients because people were still doing three unit bridges. The primary way to replace a tooth was with a three unit bridge. The community that would send me patients, since I had an implant restricted practice as far as I understand probably the first one in the country, they would send me cases that traditional dentistry had trouble fulfilling. For example a single tooth implant for a central incisor, many patients would tell their general dentist, I dentist want a bridge I've never seen a good looking bridge, and they'd say, okay Misch here's an implant and a lower denture. They're having trouble with their lower denture, there wasn't anything in traditional dentistry that would solve the problem of a lower denture so they'd say go see Misch.
In some circles in that era I was the crazy guy from Deerborne that was putting titanium in people's jaws and who knows where this would lead in the future maybe I'll end up giving cancer to all these patients. There was quite a bit of discussion about the bacteria, what happens at the implant's softest, does it directly go in the blood stream? Are you putting your patients at risk? All of the institutions of dentistry were telling their students, stay away from implants. Then all of a sudden by 1985, Nobel Pharma had enough money to come in with marketing to the dental schools and started with oral surgery programs and almost overnight everybody started talking about and referring patients for dental implants.
Unfortunately the dental school faculty had no experience in it, had no knowledge in it. As a consequence the field was taught by things that were perceived as what is easier, what is faster, what is simpler. Like any discipline usually the things that are simpler or easier or faster do not correspond directly with what is the best method to do something, or what lasts the longest, or what has the fewest complications. Rarely are those on the same page. The thing that The Institute did very early on realizing there was no science. There were very few clinical studies. I had a mission statement to help set and elevate the standard of care in implant dentistry. Everything taught within my institute would be science based, clinical studies, and reformatted implant education at large.
We had this hands on program also so that my faculty could sit there next to the participant and do the surgeries with them. That was the first hands on program in dentistry. We had no hands on program in restorative. We had no hands on program in endo. There was no hands on program in dentistry other than dental school. Once you graduated you were on your own. You'd go watch somebody talk about a subject for half hour to a day and come back and your an expert.
Implant dentistry is a different field than that. Unfortunately still the driving treatment planning concepts often is what is faster, easier, simpler, and cheaper. Those things still is the driving force in our field. It is not the most predictable aspects of it.
I rewrote the mission statement a couple years ago for The Institute to have that rather than was is faster, easier, simpler, looking at what is most predictable. Within that concept then it evolves into what is taught from the program at large.
Sorry I have a tendency to ramble.
Howard: I love your rambling. Carl, when anybody emails me for these podcasts, they're usually under 30 so all the data I have on who's going to be listening to this, it's going to be several thousand dentists and they're mostly going to be young. I want you to take them back because a lot of these guys forget, when I was in dental school, there was one guy that started to place implants and all the other faculty at the University of Missouri Kansas City called him the quack, the butcher. When I opened up my practice there was a guy across the street that was placing implants. A lot of these states crucified a lot of these dentists. A lot of these dentists were doing these cases and the first time one failed, they took their license away, those were tough pioneering days. Isn't that true?
Carl: Yeah. The handful of us that were doing implants on a regular basis were put up in front of the board. It's amazing that we continued through the process, guys like [Lynn Cowl 00:13:33] and [Ken Judy 00:13:33] and [Jack Han 00:13:35].
Dentistry at large was against implant dentistry until the staple implant which could only be done by oral surgeons opened up the door because then all of a sudden oral surgeons accepted implants because only the oral surgeon could do this extra-oral approach and putting the implant through the chin. Within the Branemark system came in and would only sell implants to the oral surgery community. Again the oral surgeons of the country started saying, yeah implants are a good thing and by the way we're the only ones that can place them. They used it primarily as a way to promote their practices.
Once the universities got through that system, the periodontists went to Nobel and organized dentistry and said we're a surgical specialty too we should be able to do this. Most recently prosthetics has changed it's definition. Now they're doing implant surgery. Although organized dentistry kept implants out of the private practitioner office, it was the private practitioners that developed it. It was the private practitioners that developed ... most of the implants that were on the market were designed by private practitioners. The vast majority of implants placed in the United States were by private practitioners but the university based education would tell graduating dentists, stay away from it.
As a concept then, even today when people enter the field, they're looking for something that is easiest to do. It's perceived for example, that a central incisor veneer is probably the treatment of choice today because every time you get a great one they put it on the front of Dentistry Today and dentistry at large has gotten used to looking, you're going to fix a central incisor, the best way to do that to change the color and or size of shape would be a veneer. People who do this for a living know that of all the teeth in the mouth, that's probably one of the hardest ones to get the color right and the shades right and the value right and all the rest of it. There's a lot of easier teeth to restore in the mouth than a central incisor but the same thing happens in implant dentistry.
Most of my patients were central incisors because the patient did not want a bridge. It took me years to figure out that they were absolutely right. They would say I've never seen a good looking bridge to replace that incisor. I don't want a bridge, and they're absolutely right. They've never seen a good one because the good fixed prostheses you don't see and you're not aware that it's a three unit bridge. You only see the bad ones and every time you see one, you say, see I've never seen a good one. You emphasize to yourself, I'm not going to get a bridge.
The same thing was happening with implants. If there was ever a problem, almost the whole school would be brought in to see the mobile implant or [exit A 00:16:58] coming from an implant site. I used to tell them look, you don't judge teeth that way. If a tooth has a periodontal defect that doesn't mean all teeth don't work. Why are you evaluating an implant different then a tooth at that point? Indeed there are reasons to look at it differently but the concept is your preconceived opinion acts as a screen for the information that comes in.
It's the reason why Democrats and Republicans go to the same person they hear, let's say Trump, and one walks out and says, that's why I'm a Democrat, and the other guy walks out and says, that's why I'm a Republican. They hear the same thing but they hear it through a different screen.
In that era in the 70s, the screen was implants are dangerous, implants don't work, stay away from them, and anything that got through the screen would only support that preconceived idea of organized dentistry.
Howard: I want to stay back historical for just a little bit. I remember one of my friends in Phoenix did a sinus lift and an ear, nose, and throat saw it later and reported to the board and him doing a sinus lift in 87, it was like the Catholic church back in the Inquisition. I remember the ear, nose, and throat guy, I even remember his name, I probably shouldn't say it. He was going on about this is the absolute craziest thing he's ever heard of his entire life and anybody who does that should have their license taken away.
Carl: Then flash forward 30 years, [inaudible 00:18:47] Hospital right across the street from Pittsburgh had me train all their ENT residents in how to do a sinus graft because they figured this may be a way to treat some conditions of sinusitis that's chronic. Here we go again, we go from one thing saying it's outside the standard of care, flash forward, well let's start teaching all of our residents how to do this procedure.
Howard: Whatever happened to subperiosteals, ramus frames? Talk about the things that came and gone because now you're writing ... are you working on your 4th edition of the book? What'd you say? What edition?
Carl: Complications, it's a new book. The surgical edition has several editions. The prosthetic book has a couple of editions and then there's a new book that will be coming out is primarily complications and the treatment thereof.
Howard: Talk about the things that came and gone like ramus frames and subperiosteals because in a way isn't ... who's doing the most advertising on television in my area, Phoenix, is that [all on four 00:19:59]. It kind of reminds me of ramus frame because they're not really an alveolar bone they're going straight back into ...
Carl: Yeah it's true. The all on four concept is perfect for the environment of which implant dentistry is being taught. What is fastest, easiest, cheapest? Well, all on one was attempted for a very short time. It did not work. All on two turned out to be ...
Howard: What was all on one?
Carl: They had this guy in Europe who thought he could put one implant in and hang twelve teeth on it.
Howard: I'd never even heard of that. Is that right?
Carl: I've got a couple pictures of his cases. He literally got booed off the stage, but there was all on three for quite awhile in Europe. There were 9 different countries that at their major meetings would show all on three. Again it did not last very long, all on three means none on two basically. You lost an implant, you lost everything associated with it.
The all on four concept certainly can be used in selective cases but the threshold of problems is risky. What many people forget is that these restorations especially on the all on four type are screw retained. An abutment screw or a prosthetic screw loosening is a very common complication. You're putting three implants in to try to get the triangular, like a tripod, for support, but if one abutment screw gets loose, not an implant failure, if one abutment screw gets loose, worse yet if one prosthetic screw gets loose ... and if you look at these prosthetic screws, they're only 1 and a half millimeters in diameter. They have 7 threads and if one of those prosthetic screws break or get loose, which occurs in more than 28% of the time, now it's all on two. All on two blows out one or two of the implants.
You've got this 10 thousand dollar treatment, some people are charging as much as 20 thousand, all based on a metal component 1 and a half millimeters in diameter and 7 threads touching metal. It doesn't make sense. It doesn't make sense to balance a treatment plan so perfectly that if one thing happens the whole case breaks down. Faster, easier, cheaper usually is not the best thing to do. It's better to have something back up so if you have a complication it doesn't automatically lead to a catastrophic failure.
A couple years ago I opened up a practice in Chicago, an implant complication practice. My thought in the beginning was, treating complications takes more experience, doesn't have as high a success rate, and as a consequence the profession needs a vehicle to treat complications, so I developed this practice thinking that it was something unique and I was never so busy in all my life. All these problems start flooding the gates in Chicago. Many of them all on four because all on four was coming into a treatment center in Chicago. Since then they've had 3 different surgeons. They've had 4 different restoring teams. They come, they go, because they give the impression to the patient that this can be a lifetime device and if it doesn't last a lifetime all of a sudden the practitioner is forced to do it again for nothing and they don't know how to treat it again. The second time is worst than the first time. There's usually less bone. There's more of a complication associated with it.
It doesn't make sense to balance your mission statement, and whether you're aware of it or not, when you're in private practice, you have a mission statement. The way that your practice primarily runs is based on some underlying theme that you may be aware of or not. No matter what practice development course you take, they tell you very early on to go into a mission statement. If you take any patient that walks in the door primarily your new patients are emergency patients, well that's your mission statement. We're here to handle emergencies. If you broke a filling or have a hot tooth come see us we're always open. Your mission statement may be we're cheaper than anybody else. We'll do 2 for 1. We won't accept a co-pay. Your mission statement is we're cheap, so let everybody know that we're cheap.
It seems to me that my newest mission statement within my practice when I opened it in Chicago was I wanted to develop a practice in which I could maintain your teeth and/or implants in health for the rest of your life. That's a mission statement that can be done with modern dentistry. If you look at then the primary reasons why people lose teeth, that's where the practice focuses on. If plaque is a problem where people could lose teeth, well then you've got to develop a hygiene aspect to the practice. You let the patients know we need to see you periodically because decay can be a major reason you lose teeth. Gum disease, plaque related. We need to see you every 3 to 6 months because gum disease is a major cause of lose of teeth and our mission statement is to maintain your teeth the rest of your life, which we're able to do in modern dentistry.
You lose a tooth. My goal is to return the patient to normal control, comfort, function, aesthetics, speech, and health. That's my mission statement for replacing teeth. That mission statement it turns out that the best way to replace the tooth for longevity would be with an implant. Once the implant's in place, the mission statement transforms to I want that implant to be maintained in health for the rest of the patient's life. Within those overwhelming conscious choices you make as a practitioner you run your practice. All of a sudden in your waiting room you've got your mission statement to maintain your teeth and/or implants for the rest of your life in health, and when a patient has decay, well I've got to fix the decay because I'll run the risk that I won't be able to maintain your tooth in health for the rest of your life. You need endo, okay we're going to do endo because I want to maintain that tooth for the rest of your life. Now you need to replace a tooth. I want an implant because that will help me maintain the rest of your teeth with the highest predictability.
It goes back over and over again to your mission statement, what you do for every service you render within your practice. If gives your patient a reason why they should show up every 3 to 4 months because the bacteria change. It gives them a reason why pocket depths greater than 5 millimeters increase the risk of anaerobic bacteria so that pocket probing, sulcus probing, is part of the practice and the monitoring of that and taking care of conditions that start getting deeper.
It underlies all the decision making aspects within your practice and for your patients. Whether you know it or not your practice is run by these mission statements. Change of subject ...
Howard: This is ... these dentists listening to you, they're individuals and they go to a dental conference because they want to start getting into implants and they see literally 275 different people selling a titanium implant. My question to you is, what should these individual dentists be thinking about when they're trying to invest in an implant system? Some of them, their mission statement is we're the cheapest. Some of them of are very expensive. Some are in the middle. What should a dentist be thinking when they're going to pick a system? Can they just pick one system or when you look at it do you really need a couple of systems to do everything that you need to do?
Carl: It depends on your training, your experience level. Certainly an experienced practitioner can use one system for most everything they do within their own practice. However they probably shouldn't treat every patient that comes in the door. There are some patients that should be referred regardless of who you are. Very few dentists, oral surgeon or not, are familiar with iliac crest grafts and implants, and edentulous maxillae. Perhaps that's not the type of patient that you should challenge, especially in the beginning or I question even at the end. All of us need to refer somebody. You do a filling on a patient. They get endocarditis. There's not too many dentists that would do the flap replacement although when I first got out of dental school I thought if I saw the lecture on it, I'd be able to do it. Boy, if one of my early patients got endocarditis, I'd probably admit them and do the flap replacement myself but as I've matured I've realized that there are some cases that regardless of your training you should refer to somebody else.
If they have a problem, they are less likely to have an oppurtunity to have a litigious action against you. Use other practitioners around you or their expertise, whether it's ENT or oral surgery or cancer, send it to an oral surgeon that treats cancer, don't send it to an oral surgeon that the only cancer they saw was in their residency. Fly them down to go see Marx. There's certain individuals that have expertise in certain aspects of treatment that we don't see on a regular basis as a general practitioner and therefor have the guts to be able to send a patient out. It doesn't mean you're inferior. It doesn't mean they're better than you. Every physician knows they treat a patient with a team approach. Every surgeon that I'm aware of at every hospital, before they do surgery they have to send the patient to an internist who then does a medial review of the patient in internal medicine and clears them for surgery. They're a world renowned heart transplant surgeon but to do surgery they've got to send it to the internist department at the hospital before they can do their surgery.
A dentist should be aware, it's not something against you if you get a second opinion or if you refer a patient for one aspect of care. You don't have to do everything for the patient if you put the patient first rather than your ego first.
Howard: Who are you talking to, Marx? What's his first name and where is he at?
Carl: Marx is in Florida. He probably treats more cancer patients than anybody else, does a great job at Miami and that whole department is setup to primarily treat cancer, oral cancer.
Howard: What's his first name?
Carl: Bob Marx.
Howard: Bob Marx. M-A-R-X?
Carl: Yeah, University of Miami.
Howard: Back to, can you recommend any implant systems or would you rather remain agnostic?
Carl: The most important thing is not the system, it's the treatment plan. You can have the best system possible but if you have a stupid treatment plan then it's not going to work like that one implant replacing 14 teeth. It's not the system that's going to make that treatment plan work. The most important thing is the treatment plan. If you've noticed programs that when you go through The Institute the vast majority of the time isn't talking about the rotation of the bur and what the RPM should be, although we've done studies on it and that's generated and all the rest of that aspects of it. We spend more time talking about where the implant should be positioned, how many implants should be used, what is the quality of bone related to determine the implant number, so that the treatment plan is the most important aspect of the care. What makes it last predictably long term is more related to the treatment plan. The angulation the implant's placed, the position the implant's placed, the size of the implant.
If I look at my evolution, talking about treatment planning, we used to talk about implant design rather early in a lecture series and talking about the different [sub of crest 00:33:07] implant, the threaded implant, and surface area because stress equals force over area. As it's evolved and the studies have evolved the implant design is number 9 on the list as far as importance now. Much more important are for example things that people often ignore, patient stress factors for example. If stress is the major reason for complications, and it is, bio-mechanical stress. Then we look at what is the bio-mechanical stress in this particular patient and under these particular conditions? Are they a bruxer? Are they a clencher? What is the quality of the bone to be able to handle the stress that's going to be applied to it? Then you apply all these factors, you're looking at it ... when an engineer designs something they look at where is it most likely to fail and then they start designing things that make that not the most likely place to fail.
If you know for example that the most common reason this prostheses has a problem is that your abutment screws get loose. You look at the 9 things that contribute to abutment screw loosening and implant diameter is a major one. Platform size is a major one. The torque you put on the screw is a major one. You start looking at where do these systems fail? Now we're going to build up a stop against those most common failure systems and then I'll have less complications. The reason why the people that go through The Institute have the highest success rate and the fewest complications, much fewer than the literature averages, is because the decisions that are based within The Institute are science based, not what is the easiest thing. What is the easiest thing? One implant.
I go back to the one implant. One implant has been used. There are some pretty good studies showing that one implant in the symphysis for an overdenture is equivalent to two implants. When I see two implants I've got an hour and a half lecture on complications related to the two implant overdenture. It's the most common thing done. It's the most common thing done because it's simple and it's less cost, but even simpler is one implant in the midline. There's a number of studies now that show that one implant in the midline is probably better than two implants. Two implants have more complications than one implant. If we look at where are the complications coming from and then what is the cause of the complications then you can build treatment plans or concepts that reduce the complications and increase the success rates. It rarely is related to faster, easier, simpler.
Howard: A very common question with a single implant placed with a single crown is do you cement that or screw it? What are your thoughts on that?
Carl: I wrote an article years ago, it isn't much different today. I've got 17 reasons why a cemented crown has an advantage over a screw retained crown. If I look at that article it was primarily where multiple implants were being joined together. If multiple implants are being joined together, it is almost impossible to screw retain the prostheses and have it passive. The metal metal connection in implant prosthetics means you can have zero tolerance for error in fabrication of the prostheses. Zero tolerance of error is impossible in multiple unit prostheses. All impression materials shrink. All stone expands. Metal constricts when it's cast, when it's machined. What is the quality of the impression that you're taking? Is it a digital impression or is it a conventional impression? Analogue variance. The analogues in implant dentistry are not exactly the same as the implant components that they represent.
There are so many variances that it's kind of like the joke with somebody applying for a job and the interviewer says, okay I've got three people here I'm going to ask you all the same question. The first one is a teacher and the interviewer says, what's 2 plus 2 and the teacher says, 2 plus 2 is 4 always was, always will be 4. The next one is an engineer. He says, what's 2 plus 2 and the engineer says, well it's between 3.999 and 4.001. The next one is an attorney. He says, what's 2 plus 2. He says, what do you want it to be?
In engineering, there's a variance that you can't have absolute values. Therefor when you're splinting things together using a screw you get variance of fit. A 20 Newton centimeter force on a screw is enough mechanical force to move two railroad cars if they're on level ground. Literally when the screws are applied the implants move in the bone with immediate load of quick of bit of result and it increases crestal bone loss, it increases the risk of early implant failure, and it increases the risk of screw loosening later during prostheses function. If I look at a major advantage of multiple implants being splinted together when they're cement retained, is you have a cement space. As a consequence it's much easier to get a passive casting. As a consequence cement in many cases is a better alternative. However if you put the margin of the crown down near the level of the bone and you leave residual cement, it comes back with peri-implantitis. The most popular cement that's used in implants grows anaerobic bacteria. The most popular cement that's used in dental implants is radiolucent. You don't see it on a post-op x-ray.
The most popular cement ... if I was the devil and I wanted to screw dentistry, and I say I'm going to tell you to use this cement because it will hurt more patients than anybody else, that's the number 1, 2, and 3 cement that's used in the United States. It's ridiculous, but because of the lack of training and understanding we end up using products that actually put use at a higher risk than at a better benefit. It's not related to the manufacturer. Well it can several of these manufacturers sell their own cement, and their own cement is radiolucent and grows anaerobic bacteria, and they put the name implant cement on it, and they don't make it themselves. They get it from Europe and then they put their name on it so it's another money vehicle for them, and yet it's a cement that should never be used in implant dentistry.
We need more science. We need more studies. We need less, how do I play the piano with no lessons and never practicing. That's basically what we're doing in implant dentistry. Then our teachers have never played the piano and they take a one day course and they come back and they regurgitate what they heard from some guy who said it before. Lately they take my book, my book is now the number one book in the history of dentistry. My implant books have sold more books than any other book in dentistry. Why? Nobody has any training. At least now the instructors are buying my book and reading the chapter and then giving a lecture instead of literally just going to a lecture for an hour and trying to regurgitate the jokes.
If you're not using implants on a regular basis within your treatment planning within your private practice, the world has passed you by. To get that training, it doesn't come through the air. Indeed it is a treatment planning skill based on science and clinical studies and it is a hands on approach. You can't learn dentistry without hands on. Italy opened up it's first dental school in the late 90s. To be a dentist in Italy you went to medical school and then you came out and you practiced for a few weeks with somebody that did dentistry in their private office, and you'd assist them for a couple weeks, and then you're qualified to be a dentist in Italy. It did not work well. It did not work well for the country so they finally opened up their own dental schools. There was a lot of politics against, because the physicians did not want to go back to school or they did not want to go to school longer, but they found that you need to do some hands on approach.
Prior to the 90s you were a dentist, you've never given an injection, you've never cut a tooth, you've never did a prophylaxis on a patient, but you practice dentistry. That's the way we are in implant dentistry now. The teachers in the universities ... 6 universities now use my institute to train their oral surgery residents, their perio residents, their prosthetic residents because they've realized their teachers don't have the experience and the knowledge and the training to be able to teach this to especially resident, especially at a specialty level. It's cheaper for them to send their residents to the Misch Institute, get the didactic training, have my faculty go in their dental school and supervise their surgeries and it's more effective and it's cheaper for them to have The Institute train their oral surgery residents or perio residents than it is for them to develop their own faculty.
The general dentists that have taken the program at The Institute, they're getting the same lectures and the same training as the oral surgery programs or the perio programs that are using The Institute for that same purpose.
Howard: That's at ... they can find that at misch.com which is M-I-S-C-H dot com. What cities are those in? Will you talk about that? How many different sessions and programs do you have at your ... what cities are they in and how many sessions do you have?
Carl: Over the years it's evolved into different selections, I guess. For years the primary place this was was Michigan because that's where my private practice was. Then it evolved into Pittsburgh because I had an implant residency there. Then it evolved into Temple because I had an implant residency there. Now we're currently doing the program in Miami, Las Vegas, and in California, in LA. It changes from year to year. Depends on where the greatest need seems to be for the following year. The person that's helped me run The Institute, her name is Heidi Cartagena, and she is been with me for 20 some years. I did implants for her maxillary cuspids when she was 15 years old and that was about 30 years ago. She is been with me ever since.
If you were going to say I want to take the program as soon as possible where is it going to be? I guess Vegas. There's a program in California, LA, relatively soon after that. It's broken up into these Friday, Saturday, Sunday sessions and each session concentrates on a different region of the mouth so there's one session that concentrates on the anterior maxilla. There's another one that concentrates on the anterior mandible. There's one that concentrates on the posterior maxilla and the sinus grafting procedures. Each program concentrates on a different anatomic location, on a different prostheses type for that particular patient type, and then there are laboratory setups so that my faculty and you go through these hands on programs on Sunday.
We've trained 1 out of every 20 dentists in Canada, has gone through The Institute. We've got 10s of thousands of doctors we've trained from 47 countries and every state in the United States for now over 30 years so that the faculty and I have lots of experience at level that you enter, whatever level it is. I don't care. Mike [Pecos 00:46:20] has been through my program 5 times. He's got a great program but he comes through the program because the program is always changing. It's updating. There's clinical studies that are added to it.
Don't get fooled by people who say, don't take Misch now, take my program first because his program is so advanced, take my program so that you learn the beginning of implant dentistry then go take his program afterwards. Those guys were trained by me. They were sitting in the same seat that you're sitting in now. You might as well take it from the person that wrote the book, rather than somebody who reads the chapter and attempts to give a lecture outside the book. I would suggest you get involved soon and that you come to the original source. There's got to be a reason why my book is the number one book in the history of dentistry. It's based on science, organized studies.
Howard: Two things on your book: would you recommend they read that before they go to your course?
Carl: Yeah. The course simulates several chapters in the book and so before you come I tell you which chapters in the book will be discussed at that particular program. For example, the book has 440 pictures in it. Each weekend we go through more than 4500 slides, so it almost becomes a moving picture. You're seeing so many pictures of the topics that we've selected to talk about that particular weekend.
If I look at the best way to get the information is to: number 1, treat ... for example if you decide to take it this year, treat this year as if you were signed up for a full time implant residency. I did not understand when I was a general dentist why a prosthodontist that does literally 6 to 10 cases in a prosthetic program of two years would be better off than a guy in general practice like me that did a full mouth rehab every week. I did 20-30 of these things every year. They're doing 6 in their whole residency. Why are they a specialist and I'm not?
What I realized when I went back to get my specialty is that you spend that year or two years thinking about that subject 24/7. You're talking to your friends, your other residents 24/7. You have a literature review of which you're reading about the different topics 24/7. You have supervised surgical training so that when you're doing the procedure they're sitting right next to you and they're saying, no put your hand like this or use this instrument next. By the end of the two years you did not do 1 case 50 times. Indeed you did 50 cases and each one was different.
That's the difference between a residency and general practice, of which you're doing more but you're doing the same thing over and over and over and over again. Nobody's challenging you. You're not taking pictures and blowing them up so that the teeth are 300 times the size so that you can see every problem that's associated with the treatment that you did. It's a completely different environment between a hands on supervised training or sitting in a class and looking at some slides.
I would suggest that you come to the program. You spend this year as if it was a residency program. I'm going to read articles. I'm going to read the chapter. I'm going to read the book. I'm going, after I hear the lecture, go back home, read the chapter again. Take pictures of my cases. Bring the pictures, send the pictures to Misch faculty. Have the faculty comment on the pictures, and comment on what you could do a little different, meaning what you should do a little bit different. Use this year then as a learning curve and if you do that for one year you'll never have to go back again. It's just like you never go back to dental school again.
You studied pharmacology deep enough. You studied histology deep enough. You studied whatever clinical sciences deep enough that you don't have to go back to dental school. You can take programs that accelerate your learning in one area or not but you don't have start from scratch, because you spend a lot of time and effort the first time around. You go through The Institute and you train it like it's an implant residency, you'll never have to never have to go through the program again. You'll have to go back to see updates. You'll have to go back to see why all on four can be used in some situations and why it shouldn't be used in others because that's a more relatively new concept. You'll go through other aspects of when do I do this particular thing and why we shouldn't do this anymore with more of the studies that we've done.
It is something that, if you're going to wear the title of doctor, most everybody from the time of G.V. Black that says you have no other right then to be a continuous student. We say it, but we sometimes forget it. We have a tendency to, been there before, going to practice next year the same as I did the last 5 years. The practice sells more dentistry when it's cheaper and you evolve into what's cheapest, what's easiest, what's fastest.
All of a sudden after 15 years you go to me and you say, I hate my practice. The patients, I'm having problems. They expect me to do these cases over again. I'm fighting with the staff on a regular basis because I can't pay my overhead and it's because you created you're own demon. The way that you setup your practice and the way you practice on a daily basis is what's going to follow you until you decide to retire.
If you set it up one way, you're going to have a great end of your career, and if you set it up some place else you're going to hate dentistry. I constantly get people that come through The Institute that say, you know I've practiced dentistry for 45 years, I hate it. The one thing that I like about The Institute is now I love dentistry again. I can see what I should be doing. Not what I can do but what I should do. There's a big difference.
Can you rob a bank for living? Sure. You shouldn't. Can I steal that piece of gum when I'm checking out at the grocery store? Yeah, it's right there, you'll get away with it all the time but the one day you get caught you'll get embarrassed and have to go down to jail and have to file a report, do all that shit. Don't steal the gum.
The Institute will show you the ways that are most predictable to get to the end of treatment so that the patient's care will last them the rest of their life. That's the mission statement for your practice and for The Institute to teach you that.
Howard: Carl, you know how you talk about faster, easier, better, and cheapest isn't always the most predictable? Do you think there's too many immediate loaded implants being done today?
Carl: Yeah. It's a fashion topics. What happens in dentistry, implant dentistry's no different, you get these fashion topics. In fashion what is the new color this year? Are the skirts high? Are the skirts low? Nobody's going to go hear a lecture talking about the RPM of a drill and they can make two implant overdenture, things that we've been talking about for 30 years. There would be nobody in the lecture hall for that. Nobody's going to get on a plane to go across the country to learn about a two implant overdenture, although they probably should take mine because I'll show you the 28 things that you're doing wrong more often than not.
In order to be popular, you need to have a subject that wasn't discussed before. The fashionable color at the present time is immediate load over the last 5 years. The concept that was tried and tested was submerged healing, making sure integration was complete, fix the problem prior to making the prostheses if any bone loss exists et cetera, and go ahead with making the prostheses. Test it. Time tested. Immediate load, compressing all this together, became fashionable because it was different and because it was faster you collected your money earlier.
If you're doing implant dentistry primarily for the money, which unfortunately a lot of people are including the people that are giving the lecture, the most predictable way to make money in implant dentistry is to schedule a long surgery appointment in your office with sedation. That means the patient is going to be in your office for several hours and because it's with sedation they have to bring somebody from their house to bring them their and take them home. Now you have 2 people out of their house. Then you schedule the appointment. You know where they're going to be for the next couple of hours along with their ride and you go to their house and rob them. Nobody's going to be home. Very predictable, you'll be able to rob them. You won't get caught. You'll be able to sell their shit at the pawn store. That's a very predictable way to make money. I'm not suggesting you do that, but if you're doing it for the money that's basically what you're doing. You're robbing from the patient and you're just doing because what, because a patient says yes.
The thing that protected many patients early on in somebody's early learning curve in surgery is that the fee is so high most patients say no, so they hurt fewer patients. I can't tell you how many doctors have been through The Institute and said, god I wish I had taken this course 3 years ago. I've treated 50 patients the wrong way. I'm seeing these complications. I did not know why I was having all these complications.
For example, the two implant overdenture. The average post-operative complications are 4 to 6 that take 6 to 10 post-operative appointments. That's multiple studies. If you're going to have a prostheses and a treatment plan of which you are going to spend 4 to 6 appointments fixing complications, it's not cheaper what you're doing. Every time you see a patient for a post-op complication for a two implant overdenture you lose a 150 dollars. By the time you schedule an appointment, clean up the room, talk to the patient, how's your friends, how's your family? Oh you're having a problem with retention let me see what I can do. You change a little ring or an attachment. It costs you 150 bucks. Clean up the room before you see the next patient. They show up back in your office, two weeks, three weeks later. The average post-op visit, 6 times they come back to you.
After the 6th time you do a re-line. The second most common complication is doing a re-line because you changed the attachment three times, now you're doing a re-line. You've lost the whole profits of the case, and you've got the next 40 years that's this patient's going to keep bothering you. You setup a nightmare for the practice. It doesn't make sense to sell a case faster, easier, cheaper, if it's going to come back to bite you in the butt 4 to 6 times on average. Then every few months until that patient dies or goes to somebody else.
When you have an implant restricted practice, you learn real quick, 90% sucks in implant dentistry. If you have 1 out of 10 patients have a problem, that's a terrible practice management issue. I don't want to do that. I want to make sure that you have a much high success rate and a success means success of the prosthetic device also and a much lower complication rate.
I'm going to show you why certain things should be done and why you should stay away from other things and usually the things that are most popular end up driving a number of patients in your office but too many of those patients that are coming in the office, you're treating for free because it's a complication, which you end up treating for free. Doesn't make sense. You might as well double the fee or send that patient to your busiest competition. It fills up their office with complaining patients and you have more room to see the good ones.
Howard: Carl, a very frequently asked question on Dental Town is, some young dentists to rule out complications, one thing they get rid of is any smoker. Is that too harsh on a patient? At the end of the days, they're humans. They come in. We're not judgmental, but if they're just a smoker, is it just no? Is there like a time period where you say well if you quit for two days or 6 weeks or ... what's your thoughts on smoking?
Carl: This is a personal decision within your practice. I did a rather large study on 50 consecutive sinus graft patients and it was theorized that smoking may affect the sinus graft more than other grafts because the smoke can be right there and so you may have ... an issue was you may have more complications in smokers than any other type so I did in Europe ... I had a practice in Monte Carlo for years. In Europe they are much less inclined to have litigious action against you, so I did 50 consecutive cases of sinus graft in smokers and I did not find any difference in the smoker than in the non-smoker. There was a slightly higher incidence of tearing the mucosa during the procedure but they did not become infected. All the implants that were placed, which was more than 120, were still there 5 years later. In that particular study smoking was not relevant to the particular procedure.
However in the United States, every periodontist in their literature review reads papers that show smoking is directly parallel to periodontal disease. They have diagnosis of smoking periodontitis and they spend a lot of literature review and discussion on smoking and periodontal disease and alteration of bacteria and the other aspects of it. As a consequence if you're a general dentist and you do an implant on a patient that's a smoker, and the implant fails, if that patient becomes litigious because you decide not to do it again for nothing or they don't like your breath or whatever the reason they decide to sue you. They will most always be able to find a periodontist that says, you shouldn't smoke when you do surgery.
As a consequence you're apt to lose the litigious case. Therefore to protect yourself medical-legally in the United States, I would tell the patient don't smoke, it increases your risk of complications and failure as a consequence of this so I don't want you to smoke with this. Then it's up to your personality whether you're willing to take the risk or not. If smokers had a direction correlation to failure, we would have seen it in Europe a long time ago. I was in Monte Carlo every month. Restaurants over in Europe would have a smoking section and a chain smoking section. Everybody smoked. If I review the literature, the European literature and the American studies, they're very similar. They're very similar in types of complications, percentage of complications. I don't see this much higher incidence of complications related to smoking.
I did a study so I can say I did a study. I did not see any difference in the two groups and as a consequence with my background and experience and level of expertise, I may choose to work on a smoker because I don't consider it a major issue. I'll tell the patient to protect myself medical-legally and because I'm a doctor and I'm trying to help the patient's health. My goal is to keep them in health for the rest of their life with their teeth and or implants. Smoking increases the risk of decreased health. Therefore as a doctor I tell them don't smoke but if I look out the window and they're sitting in their car smoking before they come in for the surgery, I'll do the surgery. I'll pretend I did not see them. We're not recording this are we?
In my clinical studies, in my observation, I haven't seen a major difference. However one of the best residents I ever had, he was my associate for 2-3 years before he became my resident. He was one of my best residents, Craig Misch, my brother. He will not work on a patient that smokes. He says, Carl I don't get that many complications but if I look at the couple of complications I have a year, they are most always smokers, so he's decided within his practice, he's not going to work on any smokers anymore. He'll put them on a patch. He'll help them stop smoking and he doesn't work on them unless they no longer smoke. That's his choice. I did not go to that extreme. That's why I say it's a personal thing but I can tell you if they have a problem and if they sue you, you'll probably lose the case. If nothing else patients feel sorry for them that they have to go through the surgery again and they always bring their wife in saying they can't get oral sex like they used and all this other BS that the legal system does to us today as American dentists. It's a personal decision.
It's just like the CAT scan. Do you have to take a CAT scan? No we did implants for 50 years without a CAT scan. It's obvious you don't have to take a CAT scan to have a successful case. However if you do something and it fails, and the expert says you should have taken a CAT scan you'll probably lose the case. I put it in if you do it without a CAT scan, it's not malpractice. It's not outside the standard of care but it's stupid because you're going to lose the case if it fails. Same with smoking. It's not outside the standard of care in my practice but it's stupid. It increases your risk, so I can partly defend it to the point that maybe I'll win in the court but it gives another sword on the other side. Unfortunately these cases now settle for so much money that it becomes a particular risk within a private practice.
Therefore don't do something faster, easier, cheaper that's more likely to have a complication. Then you have to go back and say, you're a smoker, do something that you're less likely to have a complication so you won't have to deal with that stuff.
Howard: Carl, we call this Dentistry Uncensored and I think that's why the show is so popular. I want to ask you probably the most controversial question in implant dentistry. There's a lot of people who say, you buy my hundred thousand dollar CBCT and you mill out a surgical guide, Stevie Wonder can place this implant, you just snap in the surgical guide, go right through the hole. Then there's other dentists or implantologists who have placed thousands of implants that say, I never use a surgical guide. What is your thoughts? What percent of your implants in the last 10 years did you use a surgical guide?
Carl: If I go to your developmental period as an individual, did you grow up in the era of which you did not have a CT? For example, guys like Tatum, and myself, and Han, and [Lynkow 01:07:34] we did not have CTs back then. We were arguing should you take a panorex. The people that were against taking a panorex would say, oh the panorex will show some pathology from the carotid and if you don't diagnose this you'll get sued for it so don't take a panorex because it's showing bigger areas and you're going to be held to a higher standard because your taking a panorex instead of periapical x-ray. This whole discussion of which 40 years later there hasn't been one lawsuit against a guy that took a panorex instead of a PA. It was all bull shit.
The new aspect says the same thing about CT. Don't take a CT it opens up a whole wide area of pathology and if you miss to diagnose the cancer in the sinus you're held to a higher standard and that. It's the same bull shit we had with the panorex with here. We've seen enough cases. I've changed ... as a director of The Institute I've seen enough altered anatomies within the CAT scans that are taken with the hundreds of surgeries I review a year that I now say, take a CAT scan and if you don't, it's not outside the standard of care but you're stupid if something happens. You know? You're adding an element of risk so it doesn't make sense to me to add an element of risk on an early learning curve.
On an early learning curve don't skip any steps. Don't go to immediate load. Don't go without a CAT scan. Take all the steps and once you've got 20-30-50 surgeries under your belt, then you make a decision patient by patient. In my career, I look at the ridge and if the ridge looks like it's wider than my finger and I look at a periapical or a panorex and it looks like there's 30 millimeters of bone in height, I'll open up the ridge without a CAT scan. I'll look at the middle foramen and compare it to where I thought the middle foramen was. If the middle foramen distance to the crest of the ridge is greater than 12 millimeters I'll place the implant behind it because I've checked it with an anatomic landmark that I know in the area, compared it on the x-ray, and I've got 40 years of clinical experience.
However this is your first case and you're all worried about hitting the mandibular canal because you probably should be, it makes sense to take a CAT scan. Now my brother and I because of these hands on surgical courses we've seen quite a few dentists come into our hands on surgical courses that have a CAT scan and a surgical guide. They put the surgical guide in the patient. They drill the holes through the surgical guide. We reflect the tissue because in these hands on courses we always reflect the tissue prior to closing up the case to check to make sure there's bone completely around the implant and the implant's in the direction you want, and the implant can be restored.
In more than half the cases when we reflect the facial and the palatal tissue the implant is out the facial or out the palate. The reason for that is the bur creeps in soft bone. It creeps away from harder bone, so you drill into a ridge and if there's hard bone on one side of the osteotomy and softer bone on the other side, which it often is not homogeneous, the bur creeps away from the hard bone and creeps toward the softer aspect of bone. Even if the osteotomy is correct when a threaded implant goes in it hits the harder bone side and it gets pushed and the implant gets pushed to the softer bone side of the osteotomy. When the implant goes in you go, what the shit, it's 2-3 millimeters more distal than it was when it started out or I've got to use this angle post to bring it back toward the palate because it' sticking out toward the cheek too much. It's not like endo.
Endo seems to have this problem less than an implant drill within bone, and as a consequence if you are going to use a surgical guide, prior to closing up the case, incise and reflect the tissue. What many will end up doing after they do a handful of these guided surgeries is say, I'm going to reflect the tissue and then use a guide after the tissue's reflected to make sure that the drill isn't going out the facial prior to placing the implant out the facial. I'll do a modification of a surgical guide and a conventional reflect and position placement. Very few times have I seen somebody that uses a surgical guide not have the implant in the wrong place at least half the time.
At the end of the year I have the students grade their surgeries. They get a grade for implant position, the depth of the implant which is hard to determine when you're using a surgical guide, how deep did you place the implant, the angulation of the implant, what's the restoration ability for that, patient management associated with it, suturing of it. You'll grade 5 different aspects of you're surgery and you'll give yourself a grade of 1 to 10. At the end of each month you look at your surgeries and you say, this one step, let's say suturing, this one step suturing I get real high grades and this other step I'm giving myself very low grades. I've got to concentrate more on the ones that I'm getting low grades on. It allows you to assess what you're doing.
To often in implant surgery if the surgeon sets up the kit, the implant's going to go in the mouth regardless of what happens during the surgery. The implant's going to close to an adjacent tooth or it's going out the facial plate, they keep going. Once the implant's in the mouth, once it gets threaded in it's there. It's successful. Success purely in implant dentistry means it's in the mouth. I got it in. Most anybody can get an implant in the mouth once you start the surgery. The bone is soft. The implant spins a little bit. Ah, it's in the mouth. I'll just bang on the top or I'll close it up or I'll make the sign of a cross and a star of David and get my floor mat out and it'll be right. How do you want to play this game?
I chose to play this game at the highest level I know. I chose to take the term doctor to the extreme. Not what is easiest, but what if the world was watching me, what should it look like? I chose if I'm working on the Pope, I'm going to give this patient the same treatment as the Pope because they expect me to do my best. They don't expect me just to collect the money. They expect for that, what is the best possible thing that I can do for them at this particular time? If it's not right, I've got a saying at The Institute, don't compromise the potential 30 year prostheses for a 3 month procedure. The procedure is done. The implant's in the wrong place. Take it out. Do a socket graft. Come back in 3 months and next time keep both eyes open. Don't make the same mistake twice in a row on the same patient.
Howard: You actually did place an implant on the Pope.
Carl: I've treated the Pope, the King of Guitars, several ... two of my most famous patients died the same week. Prince Rainier and the Pope died the same week. Yeah.
Howard: How many implants do you think you've placed in your 40 year career?
Carl: I don't know. I've had that question a few times. I don't know. In excess of 20 thousand but I don't know if that's high or low. In the old days if you had place one you were ... none of the audience had placed an implant.
Howard: Carl, I want to ask ...
Carl: Today you place an implant and you start teaching it right away. See one, do one, teach one. That's most of the implant lectures I see are guys that have done the procedure a couple times and now they're modifying it.
Howard: Carl, I want to ask you a question that I have a hard time personally understanding. We're taught by the pediatric dentist that the child is born without testing positive to streptococcus mutans, p gingivalis, Herpes all these things and then the mother most likely is the one who infects the child, but when the baby is edentulous there's no place for anaerobic bacteria to grow so she doesn't really transmit the infection to the baby until the first baby tooth pops out and there's a layer of tissue over there. Then the anaerobic bacteria for streptococcus mutans, p gingivalis, whatever can now live in the place. Then if you look at the other end of life and you look at peri-implantitis, if you extract all the gum diseased teeth and they go fully edentulous does that eradicate the p gingivalis in the mouth and then if you placed implant cased there would not be peri-implantitis is that an over simplification?
Carl: There's been 4 studies that have looked at this exactly what you're talking about. Comparing peri-implantitis to the completely edentulous patient to one that is dente. In all those studies the patient that is completely edentulous has less peri-implantitis than the patient that's dente. That is more or less, relative to the study. If I look at the studies of which peri-implantitis exists, the vast majority of the more recent studies show that the probing depth of the implant's sulcus is in excess of 6 millimeters when there's peri-implantitis. One of the maintenance protocols I have for when I'm evaluating an implant we're evaluating it of course for rigidity, should be no clinical mobility that's the easiest test. Is there any mobility? I had a sulcular evaluation and for some reason this is controversial. In Europe, they believe you shouldn't probe next to an implant, that you can induce bacteria into the sulcus by probing into the area.
My teaching I say we should evaluate the pocket depth, the probing depth, so that if the probing depth starts to get 6 millimeters or more an anaerobic environment is more likely and the incidence of anaerobic bacteria will go up. That doesn't mean that every pocket depth of 6 millimeters or more has anaerobic bacteria. In one study we did, 10% of the time it would have anaerobic bacteria so you're risk factor goes up by 1 out of 10. It would have anaerobic bacteria once the probing depth got greater than 6 millimeters. If it was less than 5 millimeters we did not see anaerobic bacteria. Apparently the oxygen tension is such that anaerobic bacteria isn't in sulcus depths of less than 5 millimeters.
I'm looking at what are the primary things that cause marginal bone loss. Look at implant design is one of the factors. An implant that is rough at the very top will collect bacteria more than one that's machined or smooth at the very top. On the other hand one that's machined or smooth bone has more trouble staying attached to so it's a discussion that literally I could have for 6-7 hours. The bottom line is if the patient is partially edentulous, if they have teeth, they should get prophylaxis on a regular basis to decrease the risk of anaerobic bacteria around their natural teeth which they should anyway. Once the probing depth gets greater than 6 millimeters around my implants, I'm going to monitor it and if it's out of the aesthetic zone, I'll do a gingiplasty. I'll decrease the pocket depth to get it less than 6 millimeters to decrease the risk of peri-implantitis contributing to a future problem for the patient.
It's a concern that I have in the monitoring of the patient but if you're in Europe they'll tell you don't probe.
Howard: Back to the peri-implantitis, a lot of people are talking about cleaning around the peri-implantitis with a laser. Like a LANAP procedure where you can clean around it. The other major questions are, if you're scaling around that peri-implantitis, some people you can't use a metal ... the hygienist doesn't know she can use a metal scaler, other hygienists are told you need to have special plastic implant cleaner.
You have a case with peri-implantitis, would you use a LANAP procedure around it, or would you use a laser to clean, or would you use metal scalers, plastic scalers? Would you put them on antibiotics, mouth washes?
Carl: When it comes to the laser, if you're going to quote me, date me, Bob James used to say that. If you're going to quote me, date me because we just don't have enough information on this. I can tell you one study that we did at Temple with John Suzuki. He was given a laser for the school. We infected the bacteria with an anaerobic bacteria with Rams, probably the top microbiologist in the country. We had this Difco medium of which we grew this bacteria on the surface of the implant that could contribute to peri-implantitis, and reported to be involved in peri-implantitis. We hit it with the laser and then we put the implant back into the Difco medium to see if the anaerobic bacteria could still grow. It grew. It did not get rid of the anaerobic bacteria. I've got one study the laser did not make a difference.
I've got a couple of faculty members that I really value their evaluation. They've been involved in several clinical studies with me and they say that in their clinical practice they've had some really good results using a laser in conjunction of treatment of peri-implantitis. They're documenting their cases. We're going to find somebody that's not having good results and have a similar protocol. This is something I'll have to report to you in the future. I'll you what I'm currently doing.
I take a cross cut fissure bur from [rassler 01:23:22] and I mechanically go around an implant. Since primary implants I use are threaded, have some type of thread depth, I go over the surface of the implant and I reduce the thread depth so that the outer thread depth and the inner thread depth become more similar. I don't have these niduses where bacteria can hide out within the implant body. Then I apically position the tissue.
Then I take acid and because I'm a restoring dentist, I can take these acids that I have a gel, instead of applying it enamel, I take the acid and apply it to the implant body so it doesn't leech into the bone and kill bone cells and things like that. I put the gel on the implant body and have it there for a minute or two whatever my patience allows for this particular case to help the acid denature any aspect of it. Which is really important if the implant has any hydroxylapatite coating on it because hydroxylapatite acts just like cementum. The reason why you add a tetracycline or an acid on the surface of a tooth is it gets contaminated, the cementum does, so does an implant body.
This bacteria smear layer the best way I've seen to get rid of it is mechanically. Chemical things don't work effectively on bacteria smear layers so that's why I use the bur, not a cross cut, it's a bur that has parallel flutes in it, that when it cuts it leaves a shiny surface. I get rid of the surface of the implant body and reduce the thread depth of the implant body. Then depending if the implant is in the aesthetic zone or not aesthetic zone ... it's easier if it's out of the aesthetic zone. I apically position the tissue so that the sulcular depth will be less than 6 millimeters.
Antibiotics before, hygiene appointment with the remaining teeth before. If it's in the aesthetic area usually I'll put in a material that I don't expect to grow bone something like a Bio Oss or a dense ceramic material to plump up the tissue with or without a collagen membrane, that doesn't seem to be the difference in the result that you get. You follow it up with antibiotics also, chlorhexidine and antibiotics. It's harder to treat than a periodontally diseased tooth.
Howard: Back to peri-implantitis and it's kind of close the cement, when you said the number 1, 2, and 3 cements used for cementing crowns on implants were radiolucent and grow anaerobic bacteria, what were the brand names of those three crowns?
Carl: Funny, they have the word implant in them. If it says implant cement those are the worst. They're the most common ones used so it's like we should bring a class action suit against them. You know?
Howard: Can you say the brand names?
Carl: It's been awhile ... I remember they have the word implant in them. I remember that several of the companies like 3I purchased the rights to sell it so the implant company then sells it. If it has the word implant in the cement don't use it.
Howard: What would you recommend for cement?
Carl: In order for cement to be radiopaque, at least the last time I did this study, it had to have zinc in it.
Howard: Zinc phosphate.
Carl: The best cement was zinc phosphate. It was the most radiopaque. It was the easiest one to clean. It had the longest working time if you used a cool slab. You don't have to worry about the acid causing irritation, any dentinal tubules, or anything like that. It had the highest compressive strength. If you're looking for a non-retrievable cement. The best one was zinc phosphate.
Howard: Doesn't it also have the lowest water solubility?
Carl: Glass ionomer has a little less water solubility but that doesn't seem to be a major factor for implant prostheses.
Howard: I remember back in University of Missouri Kansas City they wanted us to cement the mandibular second molar crowns with zinc phosphate just because that was the hardest one to isolate to keep dry when you cement. Our instructor said, you might get water contamination so mandibular second molars use zinc phosphate.
Carl: Yeah. From the study we were involved in, if you're going to have moisture contamination, glass ionomer worked better than zinc phosphate. However if water is taken out the issue, zinc phosphate won on everything. Bacteria grew less. Longest working time. Easiest to clean up without scratching the surface. Radiopaque in minimum thicknesses. By far the best cement was zinc phosphate.
Now the disadvantage is zinc phosphate has the highest compressive strength. Well the highest is resin cement, which happens to also be the most popular cement. Resin cement is not radiopaque. Resin cement grows anaerobic bacteria like crazy and it's hard to clean up. You often have to scratch the surface to clean it and often you end up leaving some behind because it's radiolucent so probably the worst cement is the most common one that's used. That's anything that has to do ... The same cements that you're using for veneers don't use it on implants. That's the worst. That's the worst one, okay?
If I want something retrievable and I call it soft access cement. I tell the patient it's soft access cement, I don't use the word temporary cement because the money's due. It's not temporary, it's the final cement, but it's temporary cement, you know? The temporary cements that have zinc in them are good implant cements. It allows the restoration to be retrievable. It's radiopaque. Bacteria doesn't grow on it. It's got a long history of use. Temporary cement, the crown comes off.
For example, a single tooth crown, temporary cement the crown often comes off. For a single tooth crown temporary cement is too soft access many times but I start with a temporary cement anyway. It's easiest. It's cheap. Easy to clean. Lots of advantages to it. Temporary cement.
Howard: Any brand name?
Carl: Anything with zinc in it, which almost all of them do. Tempon. Anything. Whatever you're using. Temporary cements.
If that doesn't work I go to polycarboxylate cement.
Carl: Durelon, that's a brand name that I use. The only issue with Durelon is it is more retentive than the Tempons, than the temporary cements. I use it for single teeth much more satisfactorily than the temporary cement. It doesn't come out as often. It's got a better tensile strength basically. That's where the cements break down is from their tensile strength rather than anything else. Compressive strengths, most cements if they're put under compression won't break down. Durelon the package insert says don't use with titanium because it can cause corrosion. I've been part of a study at Alabama.
For about 30 years Alabama has had this study in which any failed implant gets sent to the dental school and we evaluate the implant with OG analysis and electron microscopy and we look for the cause of failure and what's happened to the metal and things like that. We have never seen corrosion related to titanium with Durelon. Never seen it once. We have seen an anode cathode effect of gold and stainless steel crowns next to each other affecting an implant with an anode cathode effects, but we have never seen corrosion of a margin because of Durelon. The manufacturer put down that it could increase the risk of corrosion if used on an implant, on titanium. Because of that manufacturer statement, you'd be wise to at least one know that and just say that you're using outside the scope of that ... you can do it as a doctor. You can take an antibiotic and use it outside the directions on an individual basis. You have that right as a doctor so I decide as a doctor to use the cement on implants on a patient basis. Patient by patient basis.
I've been using it for 30 some years. I've never seen corrosion. What the fear of corrosion is it could decrease the PH especially if you were in an infected implant sulcus. Infection accelerates corrosion and if you have corrosion of a surface it can decrease the PH and therefore dissolve the bone in the area. I don't have any pitting corrosion, crevice corrosion. There's 6 different types of corrosion. We've looked for all but haven't seen any of it but the manufacturer has that. Some smart ass that reads package inserts, which is almost nobody in dentistry, may ask you a question, well what about corrosion? Tell them, Misch has evaluated, has never seen it, and again until I see something that's documenting that indeed there's a clinical problem associated with this, Durelon is the cement that I've used the most often in an implant practice.
Howard: It does have zinc in it too.
Carl: I'm sorry?
Howard: Durelon has zinc in it also.
Carl: Yeah. Durelon has zinc in it. It's radiopaque. Bacteria doesn't grow on it. It's an excellent implant cement. Has a higher sheer strength, tensile strength, than the temporary cements. If that breaks loose, if that doesn't work, you need something harder than Durelon, then I'd go to zinc phosphate. If you use zinc phosphate though, you're not trying to make it a retrievable restoration. Indeed, you may have trouble getting the restoration off.
Howard: How you doing for time Carl? You good? You need to take a break? You want to keep going?
Carl: Up to you chief. Up to you. Once I start talking about implants there is no clock I just ...
Howard: I want to go back. Back to the biology of peri-implantitis. Is it an over simplification to say that someone who lost all their teeth from dental decay, streptococcus mutans, would have a far higher success rate than someone who lost their teeth from periodontal disease, p gingivalis? Is periodontal ...
Carl: No. There is one guy that wrote a paper that talked about advantages of implant prostheses in which he said that patients that lost teeth from trauma in theory would have a higher success rate with implants because implants can resist trauma more than natural teeth. They don't break as readily. A patient that lost their teeth from periodontal disease may be at a higher risk for implants because implants do get periodontal disease. That patients that lost their teeth from decay in theory would have a higher success rate with implants rather than teeth because implants don't decay. It was an interesting article. Largely bull shit. I mean, it's one of those things if you're a university professor you've got to write a paper every 5 years. That's an interesting paper that requires no clinical study just hypotheses, and will entertain you for the 3 minutes to read it.
Howard: Let's move over to sinus lift. I remember back in the day when you'd take a boiled egg and you would chip around the boiled egg and learn how to do a sinus lift on a boiled egg. Tatum had his ... by the way Tatum I guess he moved from Florida to Europe?
Carl: He did. He got married to a wonderful woman, and she lives out there in France. Basically it's a castle, beautiful place, has it's own church on the property. A huge garage of which he hand makes these instruments. It takes him all day to make one instrument and he sells it for like 25 dollars and his hands are all chewed up. Nails broken off his fingers because he has them in these lathes making his own instrument but he likes doing it. Yeah, I love the guy. He's a good guy.
Howard: They you only change countries for 3 reasons and it's a third for a love, third for a job, and third's running from the law so she must be one hell of a woman to get him to move from Florida to France.
Carl: She is from France. She did not move. It's her home that he moved into.
Howard: Yeah. There's so many different sinus lifts being taught and of course I'm going back to your theme sometimes better, faster, easier isn't the most predictable long term. I'm going to try to aim this at the most common implant placed, would you agree, is replacing the first molar?
Carl: Yeah. Let's start off by saying a sinus graft of which we've agreed in the profession ... there was a sinus graft consensus a number of years ago of which we all agreed to call it a sinus graft. The sinus lift is used for those individuals that attempt through the implant osteotomy, attempt through then the lifting up the floor of the sinus, the sinus mucosa lifts with it and they call that a sinus lift.
If you're a periodontist you may call that the Summers technique because in the perio literature a guy named Summers first published a couple papers on it and developed an instrument that he put his name on, of which you impact the floor of the sinus and you elevate it and hopefully the sinus mucosa comes up. That's what we'll call the sinus lift.
The sinus graft is where we'll typically most often come through the lateral wall and put graft material on the floor. What has become very popular is this lift procedure from the crest of the ridge, which I should say a couple things. One is, that technique was developed by Tatum. Tatum, 20 years before Summers published a paper, was teaching, taught me, many others, that technique of lifting up the sinus floor through the implant osteotomy. Therefore don't call this the Summers technique. Call it the Tatum technique. If you choose to put a season on the technique I'll call it the Winters technique because Summers was two seasons too late and 20 thousand implants too few to put his name on it. I'd never call it Summers, I'd call it maybe Winter or something like that.
The reality is he attempted to steal the technique from Tatum. Kind of like the Caldwell Luc technique. An American ENT invented the Caldwell Luc technique. His name is Caldwell. A French guy came over on the boat, learned the technique, went back to France, started teaching the technique and put his name on it. Called it the Luc technique. They argued their whole life, who originated the technique and when they died the profession put both of their names on it and called it the Caldwell Luc technique. Well this should just be called the Tatum technique. Summers has no claim to anything related to it other than maybe making an instrument for it.
Howard: Should the Caldwell Luc technique just be called the Caldwell technique?
Carl: Just call that Tatum technique or ... give Tatum his rightful due.
Anybody that has done a few sinus grafts knows that the bigger the access window to the antrum, the easier it is to elevate the mucosa. Stress equals force divided by area. If you have a very small window, there's higher stress put against the sinus mucosa and you're more apt to tear it. That's why people I train, I say that the lateral access window should be somewhere around 10 by 10, or 10 by 15 millimeters. If you put a 3 millimeter diameter osteotomy which basically if you're going through the implant osteotomy to lift the floor of the sinus, the diameter of that hole is about 3 millimeters in diameter. In addition it's often 10 millimeters deep in the bone. You can't see to the sinus floor so you put this instrument in and you bang it and you pray that the floor goes up along with the sinus mucosa. Then you take an x-ray because you put some graft material in there and you see something radiopaque and you say, yeah it's successful. That's all BS.
At Temple one of the residents did a sinus lift technique on cadavers and every time the sinus membrane was torn. If you put graft material into that osteotomy like we used to do amalgam in the old day, you increase the risk that you'll tear the sinus mucosa. It you tear the sinus mucosa, the implant and/or graft is in the sinus proper. If it's in the sinus proper there's a chance that a bacteria smear layer will get on the implant body because sinuses often get infected. If a smear layer gets on the implant body, the body is not able to get rid of the bacteria. It grows on the implant body. There's no blood vessels that go to the implant body and that bacteria acts as a nidus for future sinus infections and you can't fix it. I've had to multiple times go in and cut off the end of an implant sitting into the sinus proper to get rid of the bacteria smear layer to get rid of the chronic sinusitis that the patient was having.
The worst technique you could use is this sinus lift Summers procedure. If you're going to graft the floor, it's one of the most predictable places to grow bone. One of the most predictable places to grow bone is the floor of the sinus if you don't tear the mucosa. It's very simple to do. It takes less than 10 minutes. You've seen me do it at The Institute in probably 5 minutes. It's a rather simple procedure and it's very predictable if you come in from the lateral wall and you don't tear the mucosa. If you come through the crest of the ridge then it becomes unpredictable.
Howard: What type of bone would you put in there?
Carl: I'm sorry?
Howard: What type of bone would you put on that sinus graft through the lateral wall?
Carl: Almost anything works. The only material that in a study was done that did not work was demineralized bone. Demineralized bone evidently in sockets ... we did a study in sockets. Another study was done in sinus grafts and it was not predictable because the bone has no hydroxylapatite crystals left, the bone is broken down rather quickly through a cell medium resorption and doesn't maintain the space long enough for new bone fill the site. The worst material you could use on a socket, or the worst material you can use on the floor of the sinus is demineralized bone allograft. A better material is mineralized bone because the hydroxylapatite crystals are still present. The resorption of the material through the monoblast in the body circulate and form osteoblast in the site and the osteoblast start to break it down and then a blood vessel comes in from bone and brings osteoblasts with it and forms bone in the site. That's the scientific reaction that we've established and have published in every text book that I've got. The studies that I did on the monkeys and in humans and the re-entry biopsies that I have of the cases.
Almost anything works. Bio Oss works. It doesn't have ... something that maintains the space long enough for bone to be able to grow into the space.
Howard: Would you always prefer harvesting something from their jaw in another area? Back in the ramus or somewhere?
Carl: It's interesting. In theory you'd think a autologous bone would be the best material. In a study done out of LSU they compared different materials. It was presented at a sinus graft consensus that I was at. The material that worked the worst was iliac crest trabecular bone. Autologous bone turns out to be the worst because it acts very much like demineralized bone. It doesn't maintain the space long enough for it to work predictably. I wouldn't use iliac trabecular bone. It's not dense enough. I wouldn't use the tuberosity. It's not dense enough. I can use the tuberosity with a mineralized bone source. I can use it as a filler but if I'm looking at using one material, a mineralized bone source works better than a demineralized bone source and the tuberosity wouldn't work as well as cortical bone. Cortical bone from the chin.
As a general rule I try to treat my patients like I'd like to be treated. I'd rather not have to have part of my hip harvested to do a sinus graft if I have a easier solution like mineralized bone. Maybe if I was working on an ex-wife, fine, okay harvest the hip. If I'm working on a patient ...
Howard: Someday we'll have to be at a bar and compare ex-wife notes.
Carl: Yeah that's right.
Howard: By the way that Dental Town continuing education class you put up a year ago, that socket grafting and clinical assessment of missing teeth. That's our hall of fame online c course. That was amazing. That was beyond amazing.
A lot of people are talking about spinning blood. Are you a big spinning blood fan?
Carl: Well, if I look at first growth factors ... growth factors is a very popular subject in orthopedics and in oral surgery and in implant dentistry. Some people give 4 hour, 5 hour lectures on growth factors now. Some are very expensive like infuse. Some are relatively cheap like spinning blood down without adding anything to it. Where do I stand on this? Well I have been involved in multiple studies. What I can say is that too many lecturers, especially ones that are selling you something, if their selling you a product ...
Howard: What percent of lecturers in dentistry are trying to sell you something? What percent would you guess?
Carl: Probably half, because that's how they're getting their lecture fee. The company gives them money to give the lectures and so they may not be getting 10% of what you buy but the company is giving them 4 thousand dollars to give the lecture and you don't know about it. If we're looking at the effectiveness of platelets to grow bone, if platelets had half the ability to grow bone as what some lecturers say, we wouldn't have red blood cells in our vessels, we would have bone. That's true right?
Howard: That is hilarious.
Carl: On the other hand if I'm looking at blood vessel growth in soft tissue, I've got several studies showing that there is an enhancement of blood vessel growth in soft tissue. When it comes to bone grafting the soft tissue growing over a graft site is important. If I have an incision line opening I'll have decreased success rate of the graft so that if I'm trying to get soft tissue growth in the area, platelets may enhance that a little. A little because it does increase blood vessel growth in soft tissue.
If I'm trying to decrease pain I've heard there's less pain because of the platelets. I've seen no study supporting that if you use platelet growth factors, either dense or non-dense, whatever double spin or not ... I've seen no difference in the number of pain pills that are taken or no difference in a pain index study, whether you use platelets or not. I'm not using it to decrease pain.
However, in my private practice I have a general rule that says if I'm going to do an implant surgery and/or tissue graft, one of us have to be sedated. It's better if it's the patient who's sedated rather than me, so that most all of my surgeries that I've done in my clinical practice have been with IV sedation. As a consequence since I'm already got a needle in a vein to do the IV sedation, it's very simple for me to draw up some blood and spin it down. If I use the platelets and I choose to use, for example, mineralized bone, it sticks the mineralized bone together and makes it a little more clinically friendly so it doesn't get sucked up by the aspirator. I can position it more friendly within a sinus graft, so I use it and I've got more than 20 cores with and without it. I can tell you it's probably the least important factor. A little bit of bone, even if it's tuberosity, is better than a whole bunch of MLs of blood.
There are more growth factors in cortical bone ... a hundred times more growth factors in cortical bone than in blood. If you scratch some cortical bone in the nasal spine, or the symphysis, or the ramus, and you put some of that cortical bone within your graft, that's a hundred times better than drawing 50 CCs of blood and spinning it down.
Howard: Do you remember that movie Fargo where at the end they put that person in a wood chipper and pulverize him? That cult movie? Megagen has that little machine now where you take an extracted ...
Carl: I don't know of any study I don't think I've seen the one that you're talking about. However if I look at a natural tooth ... a natural tooth the enamel is dense hydroxylapatite. The cementum and the dentin is a less dense hydroxylapatite. That is at least in theory, could be a bone substitute material. In theory you could take out a tooth, chip it up, grind it up, use that in conjunction with your graft and it should work.
Now is the tooth infected. Is the cementum infected. You would want to decontaminate the cementum of the tooth somehow because you don't want to carry the bacteria with it. Cementum is a great carrier for bacteria smear layer but it is true that a tooth is made of hydroxylapatite. Therefore in theory could be a good bone graft material.
Howard: Would you buy it? Would you start using it or would you wait for ... do you think it's bleeding edge technology or do you think it's worth a buy and leading edge to get a ...
Carl: I would put together a team and do the study for them if they ever came to The Institute, I'd grab my faculty. We never show anything at The Institute unless we've done a study. It doesn't mean that I personally have to do it. If I know the people that did the study and if I look at the protocol and I evaluate their data. Many people don't know that when you write a scientific article that gets published, let's say in The Journal of Implant Dentistry, nobody has reviewed the data of that publication.
I can literally write a paper tonight saying that I did something 300 times and that it worked 299 times and I had 2 incision line complications and I put that data in the article. I sent it to the publisher and nobody ever asked to see the original data. Which is really a joke because I personally know at least 3 people that have made up sinus graft studies, made up implant studies, in which they never even did the procedure. They just wrote down some numbers and hypothesized what the percentage should be and that's one of the biggest fallacies we have in refereed studies.
I'm talking about refereed publications. Nobody looks at the original data. Now before I teach anything either I do the study or I see the original data with researchers that I know aren't cheating because I know it's so easy to do.
I have not done a study grinding up a tooth and putting it in. I'm willing to do it. It makes sense from a hystologic point of view, but because no study was done I don't know what the incidence of infection would be. I don't know how long it would take to resorb. I don't know what the protocol of getting rid of contaminated cementum or decay may be, but I'm willing to have my team do the study because on a science based level it shows potential.
Howard: Do you talk to the founder of Megagen? Are you going to ask him or do you want me to ask him for you or ...
Carl: Never called me. I don't know him. I don't know anything about it.
Howard: What's the best way? You want me to email you or call you? What's the best way for me contact?
Carl: Contact The Institute. My faculty at The Institute that's who I would enroll for the study.
Howard: You would do that in Florida or Vegas or LA?
Carl: What we do is ...
Howard: [crosstalk 01:58:50] Michigan?
Carl: First I put out a memo to the faculty. Which of you are interested in doing this particular study? They need to have enough patients. For example this study should be easy to enroll because it's related to extractions and so the faculty that do extractions and socket grafts enough that they could contribute data to the study, are they willing to have a signed consent form and have a ... patient is evaluated as far as risk and the patient knows that this is a study that they're enrolling in so it's a ... Once those papers are put in order I'm willing to sign off on it because it makes scientific sense to me. I'm sure that I could get faculty to enroll. Then we have to do the study.
Howard: I think it'd be an amazing study because it's just one of those things where you saw it and you thought, oh my god this is too good to be true.
Howard: Does that interest you to be able to just grind up the extracted tooth and use that? Wouldn't that be just too easy?
Carl: As long as cementum isn't contaminated like I told you bacteria smear layers are not easy to get rid of. You'd probably have to take a bur and strip off the cementum that's exposed to decrease any infection risk. Again I'm hypothesizing. I've not done it. I'm just ...
Howard: I want to go back to a statement you said that when you place an implant usually the person is under sedation. I noticed there's a lot of international noise about the fact that in the United States if you go into hospitals the surgeon never is doing the anesthesia, they separate that. The you know noticed that when their oral surgeons were also doing the sedation and the oral surgery there was more problems than when you separated. Do you think it's standard of care to be able ... a lot of dentists are learning IV sedation and they're learning IV sedation because they want to place implants. Do you think that's a good idea or do you think you should focus on the implants and have an anesthesiologist come in and do the sedation?
Carl: Oh Howard, there are very few things that we do in dentistry that one mistake you lose your license. One of those is IV sedation that leads to death. I know of 3 implant dentists that had a patient die during implant surgery and they were doing intravenous sedation and it was an anesthetic death. Although one of them the assistant said the patient bled to death. It was doing a synthesis graft and it was a lot of bleeding so she told the evaluator that the patient bled to death which I'm sure was not true. Indeed there was a death, and the other were anesthetic deaths.
In each case the doctor lost their license. Here we go back to the risk that you're willing to take as a doctor within your private practice. Are you willing to do procedures that if they fail the patient will sue? Are you willing to do procedures of which a complication includes death? This is a decision that you personally have to make.
I know that If you don't do any procedure often, you're not very good at it. Those of us that do IV sedation we do several cases every day, well we get pretty good at it. You do hundreds of cases a year. You do one case a year ... if you're only doing two implant surgeries a year therefore you only do two IV sedations a year, bring somebody in.
Howard: Do you like to do your own sedation or do you always like to have someone else do it?
Carl: It's easier for me to do my own because coordinating the schedule with an anesthesiologist is another issue for staff. However, when I've done that, if I have a patient that is an ASA, let's say 3, I'm not as comfortable with this patient as I am with an ASA 1, I'll have an anesthesiologist come in. It's nice. They come in. They review the history again and they call the patient up afterwards and they make sure the patient's all right. They stay with the patient afterwards and they give them a lot of TLC. It's like having another staff member for that particular surgery. Once you do it, you come up with 10 great reasons why it makes sense.
The one disadvantage, you don't get the income for it, instead of an income producer. It is an income producer if you add 400 to 500 dollars for every surgery you do, and I used to do 2 a day, that's another 800 to a thousand dollars every day that I worked in my practice, just because I did sedation. It makes it easier to draw the blood so of course I would do platelet enriched plasma. Why not I've already got the thing drawn? You charge another 25 to 50 dollars for the procedure.
It's just like a CAT scan. Once you buy the CAT scan you realize hell I'm generating enough income every year to buy a new one. It's not a detriment, this hundred thousand dollars. I'm generating more than a hundred thousand dollars a year because I have it. It's kind of like what we talked about before. The screen that is in front of you that lets certain facts in and certain facts stick is modified as your experience is modified.
Howard: While we're on the subject of anesthesiology, they're trying to get recognized especially. Do you think some day dental anesthesiology will be ... the American Dental Association recommends 9 specialties that dental anesthesiologists are trying to get recognized as a specialty. There's always been movements for implantology to be a specialty. I've heard that the periodontists actually put it up for a vote. They just missed by a couple votes trying to change their name from periodontist to periodontist and implant surgery. My direction question: do you think implantology should be a specialty? Do you think dentist anesthesiologist should be a specialty?
Carl: I'm prejudiced to that. I'm the one that wrote the first specialty application, which was sponsored by the ICOI. I'm the one that wrote the second specialty application which was sponsored by the AAID. I'm the one that was on the head of the committee that wrote the third application. I am highly prejudiced on this.
However in my personal belief, which means religion basically, it makes no sense to me that endo and some of these other things we have for example radiology is a specialty, and implants is not.
Howard: What about pediatric dentist is just a small patient?
Carl: To me if implants was a specialty we'd have more research money coming into the field. We'd have better clinical studies that would be done because all the residents would be forced to do clinical studies and write papers. Patients if they had a complication could go to places that just like an endo complication probably is best treated by an endodontist. Well an implant complication could be treated by somebody like myself that had an implant complication practice, that's done procedure for 30 years, and has taught the procedure for 30 years.
It will probably never happen because the politics of dentistry, that within a dental school implant dentistry is a income center because it is such a good income center every interfacing specialty wants to control it within the dental school. In every school there is a fight, who controls the implant patients? When I was at Pittsburgh, the dean made me the implant czar and every implant patient that came in I would have a Tuesday night meeting in which all implant candidates would be reviewed. Oral surgery, and perio, and ortho, and endo, and every specialty was invited. At the end of the night I would decide which of the groups would treat this particular patient for this particular treatment plan that we came up with that night.
It was a great experience for me because you see how different specialties treatment plan the same patient and indeed there are differences from one specialty to another as far as what they see and what they therefore do treatment planning. It's not a coincidence that a doctor that likes aesthetic dentistry ends up doing a lot of veneers. It's not a coincidence that a guy that likes implant surgery ends up doing a lot of implant surgery. They treatment plan for it. They like. They see it. Every oppurtunity with every patient they bring it up. Within a relatively short time your practice is molded into your likes and/or dislikes based purely on your prejudice on what you see. It is the way you say it is within your practice.
I think we should have an implant specialty so that we can have standards of care, so we can have more research, so that we can have more documented studies, so that we can have patients treated by people that do this for a living. For all the other reasons we have these other specialties. Certainly in my opinion, implant dentistry is much more complex than some of the other specialties that have been developed.
Howard: I agree. My litmus test is, I'm not dentist focused thinking about the needs of the oral surgeon and the periodontist and all this other stuff, I'm looking at the patient. The patient has the right to know of someone who this is all they do. If we are a profession of patient centered people and you're sitting there and you've got a mess in your mouth for a myriad of reasons whether it was complications ... you should be able as consumer to be able to go to a website and look up, yeah here's Carl Misch he's a implantologist specialist, do you know what I mean?
Carl: I mean, the only thing right now that the public is aware of is the service is provided at this ... for example, all on four ad. You have a television ad, who decides if you're on that ad? You pay 20 thousand dollars. You give the money and it's like a pyramid scheme of which the first guy that's in gets the most and the second guy that got in gets the second most and they distribute that money between everybody else that's already been into it. They all agree that they're going to spend 200 plus thousand dollars a year on advertising and you can get on that site with no training at all.
You can still be a dental student and be on that site just by calling them up and saying I want to be there and here's my 250 thousand dollars so put my name in there too. All of a sudden you're being interviewed and oh implants have an advantage because you read the chapter in my book as far as what to say, and you never even done it yet.
This doesn't make sense to me. You could never do that in endo. You couldn't put a TV ad out saying, endo done in one appointment and cheap material and you take a tooth pick and you shove it down the canal and break it off and fill it up with amalgam. Now you can do it because you're a doctor and you have the right to do stupid things but the public isn't protected doing that. Certainly you shouldn't be advertising but you can if you do implants.
You haven't even done one yet and you've got a TV ad. One of the most common questions I get, the guy's gone through one weekend course with me, how do I get more patients? Slow down. If you haven't done any implants yet, you don't want to advertise yet. If you're making a mistake, you've made that mistake a hundred times before you realized it. Get the training first. Walk into this field. If you're going to learn how to play the piano you don't book a concert. You don't book a concert and have people listen to you play the piano on your first lesson.
Howard: Carl, I'm going to only ask you one more question. I feel like I'm being to greedy. I have so many questions I'd love to ask you. The question is: mini-implants. On Dental Town we had to separate implantology from mini-implants because when people would start talking about mini-implants there was just ... you could just name the people that would go on there and start trashing minis. It was kind of like ... so finally we just separated them and said okay, because we have a report abuse button and you just go in and say mean things but ...
What's your thoughts on mini-implants? I almost think mini-implants is where homosexuality was in the 70s. It's in the closet. You're not respected. If go give a lecture you've got to place big boy implants, not these little gay mini-implants. What's your thoughts on mini-implants?
Carl: First of all, I question ... you've been with me for a long time, 20 some years. People that I train I try to develop them into a positive mold that I've seen is positive toward the profession. Certainly somebody of your stature I'm going to try to influence as much as I can because you're going to reflect a positive image of what dentistry should be, is what my goal would be. You have a position of oppurtunity to have your .. the easiest thing to do in any discipline is copy something that working for somebody else. It's much easier to copy it than to create it yourself and go through the learning curves and all the [associated 02:15:02]. Pick out some leaders that are successful in the discipline that you're coming into and copy what they're doing. Make sure that that leader has integrity and is doing the right thing.
In that mold my attempt as a teacher is to where ever possible lean on the science and clinical studies to answer any question. Therefore when somebody asks me a question about would do you think about, it kind of is stabbing me in the gut if the person is somebody that is held in high esteem because what they're telling me is studies and clinical aspects don't matter. What do you think? It's kind of like saying, what's your religion? Well, I'm a Catholic so yeah. I'm a Republican. That's what I think.
When it comes to implant dentistry I put myself in a higher regard. I'm an educator therefore I'm going to base my answer on clinical studies, personal experiences along with those studies, and the science so I'd reformat this question. If you say what do you think about, I could say anything. I think it's shit. What studies do you have? I think it's the best thing we ever did. See?
I want to say, okay have you done any clinical studies? What was the study involved? Then what does the science say and then what does your observation of 30 years experience say? I'm going to rephrase the question to be that way.
Have I done any studies? Yes. In fact my niece won the periodontal award the year that she graduated from peri at University of Michigan. Her master's theses was on the mini-implant. Wanted studies done on it. We did studies based on these smaller implants holding lower dentures and looked at the things that were being said. There were things being said like, there's less pain, you don't have to reflect the tissue, there's fewer drills, duh duh duh duh, there's less pain.
We did the study. We gave a pain index of regular implant size surgeries and the mini implant sized surgeries. We found the post-operative pain reported by the patient was exactly the same. We found the number of pain pills that they took after the surgery was exactly the same for a regular sized implant or for a mini-implant. We found that at the suture removal the tissue looked very similar. Whether the tissue was reflected or whether it wasn't two weeks later. Many of the claims of the mini-implant we found to be bull shit based on no studies.
We pulled every article on the mini-implant out for her master's theses. We found many of them completely dishonest. They would have articles that would say long term study and you'd actually read the study and it's 18 months. We found one, I think was [Petrin Gare ull 02:18:12], long term study, wasn't even a year. In the title they give you this bull shit so they can reference or whatever. If you actually pull the article and read it, it doesn't even say anything about what the title was about. People manipulate this shit because they're trying to sell you something or sell their course or doing whatever. The major proponent of this mini-implant was a guy that never even placed them. He goes on sabbatical for a year and he comes back and he's the mini-implant expert. Maybe instead of religion a guy talked to him about implant surgery too but he had no experience because he wasn't practicing dentistry that year. How can you come back from a sabbatical and be the number authority on something that you've never done? I just ask myself questions, you know.
I know that if I was going to design an implant that was going to be immediate loaded, I want an implant that would have great fixation and great surface area. Now in my study of implant design ... and you know that I've really studied implants. I've literally measured the cellular turn over rate of bone cells next to different surface conditions and different implant designs. My residents and I have gone into the extreme of implant design and surface conditions and things like that.
Definitely what we've seen is there's a direct correlation to the strength of the bone and to the percentage of bone implant contact to the area of an implant, and to the area of the implant that is under compression rather than tension or sheer. For example, if you measure the strength of bone in compression before it breaks and then measure the bone intention, pulling force rather than compression, it's 30% weaker before it breaks than tension. In sheer, it's 70% weaker in sheer. This is numbers. You're doing the study.
There's a big difference between the type of the load. Then you look at the surface area and you look at the surface area before bone resorbs. It's directly correlated to the area. Then you look at the bone implant contact and fixed it next to different designs. Your conclusion ... so I don't rattle because literally I could talk two weeks on this subject. Your conclusion is if I'm going to immediate load an implant I'd like maximum fixation and maximum surface area. If I look at the general design of an implant does that mean it would look closer to a screw or look closer to a nail?
Many mini-implants look closer to a nail than a screw. The depth of the thread is very minimum. The number of threads is very minimum. The fixation is very minimum. Every carpenter in the world knows that if you're going to drill a hole in different types of wood that you're not going to use the same screw device in balsa wood as you are in oak. A nail works pretty good in oak. You're just pounding the nail in and you're putting it in by pure spreading compression against the bone and that nail holds a pretty good picture. You put that same nail in balsa wood or in plaster and you put a picture on it, the picture falls down.
Somebody that's not a doctor knows. The only one that believes this shit is a dentist because we have no studies on bio-mechanics. That a carpenter understands these qualities better than a dentist. If I look at the mini-implant I would look at the design. Not all mini-implants are the same. I would look for one that has deeper threads. I would look at one that has more threads. I would look at one that's made out of titanium alloy.
We looked at the bending fracture resistance of the implant. The bending fracture resistance of materials in general is pi over four times the radius to the fourth power. Which means if I have an implant half the diameter it's 16 times weaker. We did cyclic loading. We found that these mini-implants, they would often break after 16 thousand loads. You have up to 500 loads a day if you don't have parafunction on a lower denture in the area because of the 4 meals you have. If you look at the number of strokes that you have per food and all the rest of it. You're well above 1600 within a couple years. You want a material that's going to take a cyclic load so that it's not going to break. What we found is many of these things broke.
Most dentists don't know that when I started implant dentistry back in the 70s, mid 70s. The most popular implant around are world was the mini-implant in the subperiosteal in the blade. We stopped doing the mini-implant almost immediately because they would either fail or fracture. The ones that were successful fractured and they had a higher failure rate. If I use a two piece implant that's regular size, I have the advantage that I have a whole selection different abutments I can use. I can cover it up. I can have it exposed. I can use a ball. I can use an angled abutment. I can use a cemented abutment. I can use a screw retained abutment. I got a whole bunch of options how to restore this thing. I know that the implant is integrated before I make the prostheses. Whereas the mini-implant you're putting it in and making the sign of the cross.
I hear lecturers say, well you lose 1 out of 4. We lost 1 out of 4. They'll say, you lose 1 out of 4 but you just add another one. You take one out you put another one in. You [cold cure 02:24:20] the next one into the dentures. It's not a big deal if you lose one. When you lose them you lose bone, and you're not putting them in the ideal implant sites. When you're looking at attachment replacement ... the attachment, the ring, most of them are using some type of O-ring, the O-ring attachment replacement is related to where, and the where is related to mobility, and the mobility is related to the position and the number. If you look at all those factors, the prostheses stability, and the attachment replacement, and the complications of failure, it doesn't make financial sense.
It is something to promote on the radio perhaps because it seems like the two things you do, you take the course on one weekend, and you take the radio advancement course, how do you get the patients in, on the next weekend. Most of those people stop doing it after they've done their first 10 cases. You look at their practice 10 years later, they're not doing the mini-implant anymore. You do the regular sized implant, submerged healing, you're guaranteed it's integrated before you start the prostheses. You don't have to worry about the patient's diet. You don't have to worry about all the other factors related to it. Can it be done? Obviously. You can do a lot of things in medicine. It doesn't mean you should.
When I had my back surgery done. I had one surgeon wanted to go through the front. He pushes over the vessels and pushes over the lungs and he says I can get better access to where your surgery is if I come through the front. I don't want you going through the front. It might be easier for you but it's not going to be easier for me if cut through my belly button to get to my spine. I go to another who's done it a whole lot. Some guy saying I could wait 6 months and some guy say I could get in right away. What do I want to do? I'd like to do it around Christmas time. Are you working during Christmas time? What's the most important thing for this?
Finally this guy, the one that ends up doing it, says you should have it done as soon as possible when you have a nerve injury the longer you wait the harder it is for the nerves to regenerate back at the site. You won't be able to defecate without a bag, you won't be able to have sex again if you have any complication prior to this. I say, you know how to sell a treatment plan, don't you? Faster, easier, cheaper wasn't what I was looking for on that, or easier for you. Don't go through the front because it's easier for you. What about me? I'm the patient. Treat your patients like you like to treat your current wife.
Howard: Your current wife ...
Carl, I think a lot of people might have been confused. Can you explain how an implant ... can you explain the difference between the three forces and how they fail an implant? Sheer versus tensile versus compressive? You said, earlier in the interview that they don't fail from compressive strength, they fail from tensile strength, and then there's sheer. Can you explain that or clarify that?
Carl: Sure. If I look where bone is most at risk, bone is most at risk to sheer loads. It is the weakest under sheer loads.
Howard: Will you explain the sheer load versus the tensile load versus a compressive load?
Carl: A compressive load is two forces opposing each other so that like I'm doing a push-up and my hands are putting a compressive load on the ground and then my body goes up. That's a compressive load, okay?
Cement. Zinc phosphate cement 15 thousand pounds strong in compression. I bite on the crown, 15 thousand pounds before the cement breaks.
Tensile load. I lift up on the crown. I put a crown bridge remover underneath the margin and I bang up on it. That's a pulling force. A pulling force. The cement goes from a 32 thousand pounds per square inch, it goes down 30%. The crown pops off. That's why you can get the crown off pulling up on it rather than ... you don't take a hammer and bang on top of the crown until the cement breaks. That doesn't make sense to you because you're putting it under compression. You lift up on it.
A sheer load is angular deformation. An angled load. The most common angled load we have in implant dentistry is either the implant body is put in at an angle and you put an angled abutment on it, of which that angled abutment means I'm going to put an angled load on that implant body. If you look at the literature clearly, if I have an angled post, the abutment screw gets loose 30% more often, the crestal bone is lost with higher incidence because it's an angled load on the bone and the angled load on the bone, the strength of the bone goes down.
There is a bull's eye in bio-materials and bull's eye are compressive loads. Porcelain is strongest in compression. The marginal ridge of a implant crown and you bite on the top of it. Now that's actually a sheer load to the framework and the porcelain breaks on the marginal ridge because the type of the force changes from compression to sheer and porcelain isn't as strong in sheer as it is in compression.
Whether it's cement, or whether it's porcelain, or whether it's bone, different types of load, compression, tension, sheer, result in different clinical results. The strongest resistance to problems is under compression. There's a consistent thread in bio-materials. The porcelain's strongest compression. The cement is strongest compression. The screw works best under compression. The bone works best under compression. The bone implant interface works best under compression.
My last studies, which surprise the hell out of me ... you know you get used to, as a bone researcher at least what I did in the beginning was I treated bone almost as though it was inanimate, like it was wood. In fact I compared bone to wood, different types of wood. Being a carpenter assistant, my dad owned a construction company and a labor consistent, I knew that carpenters and construction people treat different materials with different respects as far as loads they take and design of things that you fixate them with.
I was basically early in my career treating bone more like wood than as a viable organ. This is a thinking organism. We now know that when an implant ... we know that the implant design ... we can design it to put more compressive load. For example, a square thread will put more compression than a cylinder. A cylinder puts more sheer, okay? If you start measuring bone implant contact, where the tire meets the road is where the bone is touching the implant. It turns out that the highest areas bone actually is touching the implant that transmits stress, is where the areas are compression.
For example, a B shaped thread, the Branemark implant is a B shaped thread. There is higher bone implant contact on the compressive portion of the thread than on the tensive portion of the thread. Where these different types of force ... not only is the strength the bone affected, the bone implant contact is affected. The cellular turnover rate is affected. When the bone remodels it goes through a state of what's called woven bone which is unorganized and less mineralized. Turns out when there's sheer load put on bone there's more woven bone around the implant. The bone is weaker because it's a bone of repair. The bone is repairing because of the type of load at the interface. It turns out this bone is probably smarter than most dentists.
A 30 micron bone cell is smarted than a 6 foot 6 dentist. It doesn't make sense but that's the way it is. That's the science of what we do. That's why we should be called doctor. That's why the carpenter is called mister. We should be called doctor and we should hold the criteria of what that entails.
Howard: You just mentioned Branemark. How will you remember Dr. Branemark?
Carl: Really favorable. He and I had great respect for each other. He came to me when I first started Biorizon and came to the guys that were selling the product. He said, Misch is going to change the field of dentistry more than anybody else in it's history and that you should really focus on his science and what's he's doing. He had great respect for me. I had great respect for him. Unfortunately he died this last year. I had great respect for him. We were both on the same path. We were both trying to elevate the standard of care. Elevate what we do as clinicians. I wish he was still around because he had the right vision. He was trying to elevate the science of dentistry, although he wasn't a dentist, orthopedic surgeon.
Howard: Carl, you have the number one selling book in dentistry? In fact I think it was the number one selling book when I bought it 25 years ago.
Carl: It's now translated in 14 languages.
Howard: I was just wondering. These kids these days, Amazon now over 50% of their books sold are audio and the actual physical book is now less than half. Dental Town has 205 thousand members and next quarter we're launching our audio book section. Do you sell that book through ... what is it called el-va-sar?
Carl: Elsevier. It's the largest ...
Howard: Where's Elsevier out of it? Is that out of Manhattan?
Carl: I think they're out of New York. When I meet them they're in New York.
Howard: I was wondering if you ... i think you'd reach a lot more dentists if you did a audio book. Do you think your book could be an audio book? You have 400 images in it. If you read that book in an audio file or you had someone read it, do you think the message would get across or do you think that an audio book really can't be done for something in a profession that's hands on like dentistry, especially surgery?
Carl: It sounds like you just gave me another project to do Howard.
Howard: How long do you think it'd take you to read your book?
Carl: As I said, earlier you should copy somebody that's doing something successful. It's a whole lot easier to copy than to do this yourself. You just told me the advantage of doing an audio book, I'm going to listen to you. I'm going to call the publisher up after we're done here and tell them why don't we put out an audio book? According to Howard Farran we should do this so you may get a call from them.
Howard: I would love to because Carl when we were little it was the IBM mainframe. Then we lived through the personal computer and last year now 51% of the traffic is on the smart phone. Amazon ...
Carl: When I found out I had brain cancer and had a two month life expectancy, one of the things that Biorizon and The Institute did was to video me giving my session lectures. I think four sessions, maybe even five sessions, they brought in somebody to video me giving the lectures and they showed the slides and me giving the lecture for The Institute to document what I was doing. We could probably use that as a mechanism ... no it'll probably be better just to read the book because some people like to hear it and see the words at the same time. I learn best when I'm hearing it and I see it at the same time.
Howard: Do you sell the book now as a digital book like on a Kindle?
Carl: It is provided on Kindle or something where you can carry but not Audible. There's no Audible.
Howard: How can we get those courses on Dental Town, those five courses filmed by you?
Carl: Contact firstname.lastname@example.org, www.misch.com. If you've been through The Institute you get to see them free. If you haven't been through The Institute, then there going to say, take session one if you want to hear session one, type of thing.
Howard: I'm talking about on the DentalTown.com website.
Carl: Talk to Heidi. I'd love to put them on anything that you want. You and I are on a similar road and the road is what should be done. Let's share what works and let's do the right thing and you've always ... you're not into how to rob the patient, you know? That's what stood so well for your career is people look to you and the things that you talk about and that you put in your magazine work. It's a good format of information. I'd love to provide some of that vehicle through you. Talk to Heidi, what do you want, and it will happen.
Howard: Aw Carl, you're so sweet.
Carl: [crosstalk 02:38:59] I'll see if this audio thing will happen because of you.
Howard: It would be so special for you to read that book. How many hours do you think it would take you to just sit down and read your book?
Carl: If I was going to read it ... it's a large book. It's 1200 pages. I was taking 15 of them out of the trunk of a car in China and I blew a disk so it literally broke my back it was so heavy. It's a heavy book. There's 4000 pictures. It's ... yeah.
Howard: I'd bet it would take you 30 hours to read that book.
Carl: That would be worth it. If it would help somebody do the right thing it's certainly worth it. The one thing that could be an issue, is what I'd probably put in are little scenarios, I would get to the end of some paragraph and it would remind me of some story about some patient or whatever ...
Howard: That'd make it better. That'd make it even better. Oh my god, that'd even make it better.
Carl: It's because otherwise I'd fall asleep so I'd have to add these stories that come to mind while I'm reading it.
Howard: Talk about the pictures. I think they would bite. I think 50% of the dentists would buy the audio book. Amazon's data is overwhelming. As they listen to the audio book it would make them go back and buy the physical book because you would talking about all the pictures. They'd want to go back and see it.
Carl what should we name this video? What should we name this podcast?
Carl: Howard Farran: Live.
Howard: No no no. What should we call it?
Carl: Oh I don't know. [inaudible 02:40:51] Saturday Night Live.
Howard: I think ... are you still there?
Carl: I don't know. I'm not a marketing guy. You're the marketing guy. You're the genius, I'm just a dentist.
Howard: I'll name it. Okay Carl ...
Carl: That's it. I'm just a dentist. That's probably my most famous thing I say is, I'm just a dentist.
Howard: I'm just a dentist with Carl Misch that's cute.
Carl seriously you're my idol. You're everyone's idol. You're dentistry's rock star. You're just a legend beyond a legend. You did so much for my career and everyone I know's career. Thank you so much for spending time with me today. I can't tell you how grateful I am and I'm sure our listeners are just going to love it.
Carl: Thank you Howard. I really appreciate it. Thanks for being on the same team.
Howard: All right buddy. If you eve want to do it again you know who to call. Just call me. Bye. Bye.
Carl: Okay. Ciao.