The commentary below goes back over a ten year period. The most recent comments are at the top of the page. these comments are strictly my own personal opinions and do not necessarily represent the opionions of anyone else. SRD

Dr. Niznick Re-enters the dental implant market

Niznick’s First Public Showing of New Implant Portfolio On 26 January 2006, Dr. Niznick announced his new dental implant system that will be sold under his recently established dental implant company, Implant Direct. His press release also confirms that he has won the binding arbitration with Zimmer, which has allowed him to re-enter the dental implant market following the expiry of his non-compete clause on 8 January 2006. With the regulatory submission almost complete, we estimate Implant Direct will be in a position to start selling its product portfolio in 2H CY06.

Nobel-Imperfect

We are in the midst of a great competition between dental implant manufacturers to secure the multimillion dollar market that dental implants represent. There have been several battles that have been drawn over the years in this competition. One has been the basic shape of the endosseous dental implant. Another is the micro surface configuration of the implants. A third has been the prosthetic connection war. And, the latest is the configuration of the implant-abutment interface.

The Nobel Biocare company has just released their NobelPerfect Implant, a design developed by Dr. Peter Whorle. The purpose of this implant is to mimic the hyper parabolic curve of the cemento-enamel junction of a tooth. The premise is that if we do this on the implant, we will create an environment for the proper formation of papillae around our implant restoration. There are several other competing companies who have gone a different route by providing implant abutments that have this contour milled into them for much the same purpose.

I have looked long and hard at these designs and can only conclude that there is a great deal of wishful thinking going on here. I am particularly annoyed with the Nobel Biocare company who has switched horses so many times in the mid stream of dental implantology that they have now completely lost all credibility. NobelPharma was the original company and they only wanted to deal with specialists. They froze out the general practitioners for years until they finally realized that the general practitioner is the key to the future of the dental implant company (I told them that somewhere in the mid 1980's.). They then went to a “simplified” dental implant approach and now they are selling a $550.00 implant that seems to me to be fraught with complications (I won’t get into the complications of the new 3I Implant which is a whole different story). There is nothing that is simple about an implant system that will cost about $1500.00 (That means that the patient will have to pay almost $5000.00 per tooth) in parts for the millions of patients who are hard pressed now to pay for dental implants.

The simple truth is the determination of tissue contour and tissue health is based on a very complex series of events that starts with adequate tissues and proceeds through to the contours of the restoration. Implant location is also one of the keys. It doesn’t matter to the soft tissue the prosthetic connection, the shape of the implant or the contours of the abutment (within reason)... only the factors that I just mentioned are important. If you add to this that most of the patients we see are just real hard pressed to get some sort of prosthetic teeth in their mouths so they can go on with their lives, the very expensive Nobel-Imperfect idea does not seem to be very important at all. And, it is certainly not in keeping with the ideals that Dr. Brånemark himself tries to live up to.

SRD

Supreme Court Finalizes Specialty Advertising Rule – FDA Wins!

On Dec. 9, the U.S. Supreme Court declined Dr. Richard Borgner’s request for further review of Florida’s specialty advertising statute. The petition for certiorari that Dr. Borgner and the American Association of Implant Dentists filed was denied in Borgner v. Florida Board of Dentistry, U.S. Supreme Court case number 02-165.

The statute prohibits dentists from holding themselves out as specialists in areas of dentistry neither the Florida Board of Dentistry nor the American Dental Association recognizes as specialties, unless they so indicate in capital letters on the advertisement. The statute also applies to dentists who advertise membership in boards the ADA or the Board does not recognize as accrediting organizations.

The FDA’s victory is noteworthy. The last time the U.S. Supreme Court looked at Florida’s regulation of advertising by professionals, it concluded the state could not prevent lawyers from advertising that they also were licensed as certified public accountants.

Court Won't Consider Rights Of Advertising Dentists
Appeal Of Florida Restrictions Denied By High Court

POSTED: 2:29 p.m. EST December 9, 2002

WASHINGTON -- The U.S. Supreme Court is refusing to jump into another free-speech dispute, this time over advertising restrictions Florida put on dentists.

Justices Clarence Thomas and Ruth Bader Ginsburg say the court should clarify how far states can go in limiting ads of lawyers, doctors and other professionals. But none of the other justices joined them, and at least four must agree before the court will hear a case.

Dr. Richard Borgner of St. Petersburg, Fla., attended 400 hours of classes on implant dentistry, passed multiple exams and was certified by the American Academy of Implant Dentistry. But under a 3-year-old Florida law, any ad listing Borgner's certification also must say in capital or bold letters that the academy is not a "bona fide" organization according the Florida Dental Board.


The law applies to several dental specialties, including cosmetic dentistry, with professional associations that that are not accredited by the American Dental Association.
Copyright 2002 by The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

Court Restricts Specialty Advertising in Florida

The U.S. 11th Circuit Court of Appeals recently ruled on Borgner vs. Brooks II. The court decided to uphold Florida's restriction of dentists advertising credentials awarded by the American Academy of Implant Dentistry. The advertisements must include disclaimers that neither the American Dental Association nor the Florida Board of Dentistry recognizes the AAID, and that neither the ADA nor the Board recognize implant dentistry as a specialty area.
Florida dentists who wish to portray themselves as specialists in a non-approved specialty must incorporate these disclaimers, in a distinguishable way, in any announcement, solicitation or advertisement:


(Name of announced area of dental practice) is not recognized as a specialty area by the American Dental Association or the Florida Board of Dentistry.
(Name of referenced organization) is not recognized as a bona fide specialty accrediting organization by the American Dental Association or the Florida Board of Dentistry.

The AAID Attacks The Dental Implant Homepage

Well, this month (June, 2001) I finally received a letter from the General Council of the American Academy of Implant Dentistry (AAID) siting that the contents of this web site regarding the AAID and Implantologists are "misleading, false and defamatory". The letter specifically cited this page, my FAQ and my comments in Beware of Deceptive Advertising. Interestingly enough, I also recently received a letter from Carl Misch and the American Board of Oral Implantology/Implant Dentistry (ABOI) urging me to become certified as a Diplomate of the ABOI and siting recent California and Florida rulings on this "credential". It is obvious to me that the AAID and the associated ABOI are making a huge move to enroll as many dentists as possible into this program in order to establish a feeling that implantology is really a specialty of dentistry. I would hope that the readers of this web site will always understand that there is a vast difference between a legitimate specialty in dentistry and an organization which is merely trying to carve out a niche in terms of patient care.

I regard the recent communications from the general council of the AAID as an attempt to censor this site and I just want to inform everyone who visits this site (There are 6,000 of you per week) that I will not yield to this pressure. I still believe freedom of speech trumps the aspirations of an organization which, in my opinion, confuses the real issues and promotes a situation which might not be in the best interests of the profession and the patient population.

Shameless Self-Promotion

I went to the 3I meeting this weekend (January 26-27, 2001) entitled "Pursuing Conclusive answers to Clinical Questions", and I must tell you how disappointed I was in the shameless self promotion of the the meeting. All of the lectures were designed to promote 3I products and it wouldn't have been so bad had the speakers really shown some serious advantages to the products, but what we saw was many conclusions drawn on absolutely false assumptions.

I have been to many 3I meeting over the years, and I have always enjoyed them and found the information quite useful. I'm not sure whether this departure is a result of the new ownership of the company or just an aggressive need to get a larger share of the market. It seemed like there were about a thousand attendees to this meeting, many from Europe. I talked to some of them and the awareness of this self promotion attitude was very evident to all of them.

It has not been unusual for manufacturers to sponsor meetings and bring in good speakers who use their products. In the past, this has not been a problem because you could always take what is said with a grain of salt. In this case however, the level of bias was so high that it made the meeting absolutely useless.

Carpe Diem

Recent events have inspired me to think about two giants in the dental Implant field, Richard Lazarra and Gerald Niznick. I am pretty sure that when both of these men graduated their respective dental schools, neither one of them expected to become entrepreneurs. They both went on to pursue PG programs in dental specialty areas, Jerry Niznick in Prosthodontics and Rich Lazarra in Perio and had they stopped there, I am sure that both of them would have had wonderful careers in dentistry and would look back on their accomplishments with great pride.

However, both of them through foresight and understanding of the needs of the profession went way beyond their expectations. They both recognized the importance of another man's discovery and they proceeded to take the initial discoveries to a much higher level of clinical understanding. Dr. P. I. Brånemark made the initial discoveries and did the ground work to make dental implantology a reality. Drs. Niznick and Lazarra took that discovery to its potential and made dental implantology available to the masses.

Both Dr. Niznick and Dr. Lazarra showed tremendous initiative and innovation in the development of products that met the demands of the patients and the profession. They never stopped looking for better ways to design implants and components to help people who were missing teeth. Along the way, they both made tremendous amounts of money and they both were very generous in supporting dentistry, dental education and humanity.

Now that there companies have been sold, I hope that they both stay as prominent as they have been in dentistry. A recent communication from Jerry Niznick tells me he will continue to contribute and innovate and my knowledge of Rich Lazarra would tell me that he to will continue to be a contributor. I just want them to know that all of dentistry salutes them and thanks them for their contributions.

SRD

The following is a copy of a letter sent out last year to the Implantology and the Prosthodontists mailing lists:


I'm posting this on the Implantology list as well as the Prosthodontists list because I think both groups would be interested...

Two weeks ago, at the ACP meeting in New York, I had the pleasure of sitting in on a presentation given by Dr. Clark Stanford. The title of the lecture was "Evidence Based Assessments of Osseointegration and the Proliferation of Implant Systems". For those of you who do not know Dr. Stanford, he is currently an Associate Professor in the Dow Institute for Dental research and in the Department of Prosthodontics, College of Dentistry, University of Iowa. He also holds an appointment in the department of Orthopedic Surgery, College of Medicine, University of Iowa. Dr. Stanford received his BS, DDS, Certificate in Prosthodontics and Ph.D. (Cell Biology) from the University of Iowa and he has been on the faculty there since 1992. He also maintains an intramural clinical prosthodontic practice within the College of Dentistry.

In light of the ongoing discussion about faster loading of dental implants as advocated by various manufacturers and individuals due to various coatings and micro surfaces, I posed the following to Dr. Stanford:



"At any rate, I have been disturbed with the number of claims that are coming
out from different companies about how much better their implant will
integrate than others. There is obviously a race on to see which system will
emerge as the fastest and most predictable of them all.

My personal opinion from my own clinical work and from reading the
literature is that there is no real evidence at this time that anything
works any better than anything else with the exception of HA coatings which,
of course, open up other areas of concern. I am especially irritated by the
companies such as 3I and Strauman who claim that their implants can be
loaded within 6 weeks. I don't doubt that under specific conditions that
this is doable, but it can be achieved with any plain vanilla implant as
well."



He responded with the following,

 

"You've hit the implant head on the nail with your comments about "faster,
better, quicker." What is amusing is the concern and care expressed 10-15
years ago about the healing process and time needed to now where the rules
seem to be "violable" without care (and these comments or "rumor" are often
based on anecdotal cases. One of my greatest concerns is with
extrapolations made to general implant care based on a few rather "ideal"
implant scenarios (e.g., fixtures in the ant mandible of Type II bone and
15-17mm fixtures) being proposed as the standard of care for immediate
loading (at stage I) and therefore this can be offered to all of our
patients as the treatment modality of choice. I fear the dikes will have to
start to break again (I.e., increased failures) for people to be more
cautious again. This is the same argument I have with large multicenter
studies (which I'm also involved in) in which the conclusion (success rates,
etc.) are generalized to populations or clinical situations which were not
represented in the study populations and in which the results do not
directly apply. Case in point is studies which profess to look at type IV
bone situations but in which type IV bone only represents 10% or so of the
fixtures at risk. In terms of your comments about surface coating, I agree
about the Ca/PO coating history although there is interesting working coming
out of Europe with magnetron sputter coating (<1nm). I also believe bulk
roughening procedures (e.g., it blasting or etching) does play a role in
increasing surface area an issue especially with type IV bone) but that the
surface per se, especially in high risk situations does not change the
healing rate of the body. Rather it give more potential area that the body
can heal against."


Some people on the Implantology List have been a little PO'd because I have objected very strenuously to input about diagnosis and treatment planning from dental implant companies, Dental Hygienists who work for dental implant companies, Laboratory Technicians and others who do not place and restore dental implants. I would certainly prefer to go to someone like Dr. Stanford, a Prosthodontist with a degree in Cell Biology, to discuss this type of information over the other people I mentioned. I don't mind discussing the oral hygiene status of one of my patients with my hygienist and I certainly do not mind discussing many aspects of dental technology with my lab techs... In case a lot of you haven't noticed, most of the general Dental population gets a great deal of their information from dental implant companies and their representatives and dental laboratory technicians. There is a lab here in Florida that sends out a tech to the dental offices with instrumentation to "help" dentists restore implants... This is wrong and the fact that it is tolerated as a matter of course only undermines our professionalism.

If you want to get the real answers, ask the real researchers and the real specialists.

 

Dr. Gordon J. Christensen's Comments on Dental Implant Therapy

Dr. Christensen is a Prosthodontist and Director of CRA. CRA (Clinical Research Associates) is a nonprofit organization dedicated to serving dentists by evaluating dental materials, devices and concepts for efficacy and clinical usefulness. Findings are reported as rapidly as possible in written and oral forms, including the monthly CRA Newsletter. I had the pleasure of attending one of his CRA Dentistry Updates in Fort Lauderdale, Florida on Friday February 4, 2000. I was very interested in what he had to say about dental implants and I will attempt to summarize his comments below:

The title of this section of his presentation was BAR AND CLIP RETAINED PROSTHESES.

He stated that 5% of General Practitioners place implants and 30% of Prosthodontists place implants. He would like to see 90% of GPs do implant surgery.

The average fee for a full lower denture is $800 and 90% of lower denture wearers hate their full lower denture.
The average fee for 2 implants and new denture is $3300.00. The average fee for a Bar and clip implant overdenture is $6900.00. This fee breaks down as follows:

$800 for the Denture
$200 for the clips
$4400 for four implants ($1100 each)
$1500.00 for the Bar

Dr. Christensen feels that the clipbar overdenture is the best service available for treating mandibular edentulism. He really likes this and says that this is what he would want in his mouth.... Hates fixed-detachable because it is very hard to clean and very expensive...

He teaches GPs implant dentistry in a two and a four day course. He recommends the following:

Attachments from Attachments International. He likes very long distal extensions on his bars and he keeps the bars as close to the soft tissue as possible. He likes lots of clips and uses spacers to establish resilience. He uses a tear drop shaped bar with metal clips. For two attachment denture he prefers a small ball and O-ring attachment....

Dr. Christensen also talked about the IMTEC transitional implants (SENDAX). Recommends them for long term use...
It looks like he is raising a flap to insert them..... After he spoke, I went up and asked him if he would consider the SENDAX transitional implants used with a no-flap approach. He said that would be fine. I asked him if he would then consider this to be a NON-SURGICAL IMPLANT? He said "YES".

Kentucky Oral Surgeons Petition State Board to Stop Periodontists from Extracting Teeth and Placing Dental Implants

This could very easily go under the "Now I've Seen It ALL" category, but as amazing as it sounds, the President of the Kentucky Society of Oral & Maxillofacial Surgeons has sent a letter to the Kentucky State Board of Dentistry requesting, "The Board of Dentistry make a ruling and render advice concerning the authorized scope of practice of persons licensed to practice the specialty of periodontics". They go on further to say, "KSOMS is concerned that periodontic specialists are increasingly performing dentoalveolar surgical procedures such as apicoectomies, and removal of teeth, exposure, bonding and ligation of teeth and dental implantology, and are holding themselves out to the public as specialists in some of these procedures. These procedures appear to be outside the accepted scope of practice of periodontics".

Next, we'll have the prosthodontists petitioning to have general dentists banned from providing full crown restorations for their patients.... (--------). If you are interested, you can read the full text of this letter.

JADA does it again..

 

Check out the September 1999 issue where the venerable journal of the American Dental Association published an article on how to retouch your radiographs to bilk the insurance companies... I'm not kidding!!!

 

 

Poly-Grip and the Journal of Prosthodontics

As long as I have been in dentistry, I have felt that denture adhesive represents a failure in dentistry. It's like when we can't do anything else for a patient who is missing their teeth and uncomfortable with complete dentures, we hand them a tube of denture adhesive and send them on their way. To tell you the truth, I have always felt uncomfortable receiving the denture adhesive samples that some companies hand out to us dentists so I usually chuck them!

So perhaps this will give you a little idea of why I am so upset when I pick up a recent copy of the Journal of Prosthodontics, the official journal of the American College of Prosthodontists, and turn to a full page add for Poly-Grip. I don't think this ad should be in this journal. Maybe it might be more appropriate in the ADA Journal, but not in the journal that represents the specialty that is supposed to allow patients to live without the indignity of denture adhesives.

Today, with dental implants and all of the techniques that we Prosthodontists have at our disposal, there should be no need for denture adhesives. But the sad fact is, denture adhesive is big business and big business does what it has to do to promote itself. Over the years, I have seen an insidious creep of "support" for prosthodontics by companies that make their major living selling denture adhesive. I think it is wrong and I do hope that some of you agree with me. If you do, please send an E-mail to The American College of Prosthodontists at acp@prostnodontics.org and express your feelings. SRD

ADA Advetorials

Below is the text of a recent letter to the editor of JADA about the publication of an Advetorial disguised as a scientific article. As a 30 year member of the ADA, I think that this is reprehensible.... To see a letter that was actually published, Click here....

December 9, 1998

Dr. Lawrence H. Meskin
Editor. American Dental Association Journal
211 East Chicago Avenue
Chicago, IL 60611

Dear Dr. Meskin:

One would think that with all of your degrees, you would know the difference between an Advetorial and a legitimate scientific article. It is a shame that the ADA has descended to aiding dental manufactures in their advertising campaigns. I am referring to the article in the December, 1998 issue of JADA on page 1732 entitled Affordable Implant Prosthodontics. Forget the fact that the article itself is full of non-truths and half-truths, it should never have been published as a scientific article in the first place.

I understand that the JADA is going to publish that Dr. Shepherd actually owns the company that he is writing about, but that is an afterthought that just adds insult to the injury. This article could have been written, and indeed it has, by almost any dental implant company showing that they are superior in this or other aspects. This is what is called advertising and has no business being published as a scientific journal.

I just mailed the ADA a rather large check for my 1999 dues. Does this money go to support the advertising efforts of other companies? Does this money go to support manufacturers of other products so that they can have favorable relationships with the ADA? Your total neglect in publishing this article is an affront to your membership. It is irresponsible and entirely unprofessional and now you are going to have many of your members buying Dr. Shepherd's product because of the scientific endorsement in the ADA Journal.

Sincerely,
S. Robert Davidoff, DMD, FACP

 

Sub-Periosteal Implants and other things that go Bump in the night....

I recently was asked to speak at the American Academy of Implant Dentistry (AAID) and I found it quite an interesting experience. In the introductory remarks on the first day, the speaker claimed that Periodontists were not really trained to do implants and therefor should not do them. You have to understand that this organization, the AAID is composed primarily of general practitioners who do implants and that there are very few specialists, especially Periodontists, associated with the organization. This is a group that feels that continuing education in a given area is equivalent to Specialty training in a three or four year academic program. This just ain't so guys...

 

On another day, the speaker compared the AAID to the Academy of Osseointegration (AO) as the academy of "Antibiotics" compared to the academy of "Penicillin". The feeling of the AAID is that because they have a multi-modal approach which includes root form endosseous implants, sub periosteal implants and anything else that you can sink into or around bone, they are superior to a dentists organization that only endorses root form endosseous implants. Their "Board Certification" procedures require demonstration of this multi-modal approach. Forget about all of the research available today that shows there are severe limitations to the sub-periosteal implant techniques and the fact that root form endosseous implants have a much higher success rate!

I have included two slides here to show something that I have often seen with dentists who do a lot of sub-periosteal implants: FAILURE! The first slide shows a five year old case where the implants are failing. The second slide shows the patient after she paid thousands of dollars to have the failing sub-periosteal implants removed. Now she is a candidate for normal root form implants which not only have a much higher success rate but more importantly do not fail with the causation of excessive damage and expense to the patient.

Pre-OpPost-Op

The really sad issue here is that the AAID has just won the right to present their credentials to the public in the State of Florida. That means that these individuals can advertise that they are Board Certified in implant dentistry the same way someone might be Board Certified in Periodontics or oral surgery. We know that these two credentials are not in any way equivalent and the entire concept is misleading to the public.

Nobel Biocare discovers prepable abutments and cemented dental implant restorations...

I never cease to be amazed at how stupid the dental implant manufacturing companies think we dentists are. Witness the latest newsletter publication of Nobel Biocare where they introduce their new, simplified approach to implant restorative dentistry:

From their inception, the Swedish company Nobel Biocare (formally Nobelpharma) has been an elitist element in the dental implant industry. To their credit, the development of the dental implant field is very much in debt to the work of Dr. P. I. Brånemark, but Nobel Biocare, while it does employ Dr. Brånemark, is not Dr. Brånemark!

In the very beginning, they would only train oral surgeons and prosthodontists to place and restore their implants. You could not buy their product unless you took their courses so about 90% of the dental profession was barred from using their components. This proved to be very good for dentistry and the dental implant industry because it promoted the growth of such companies as Core Vent (now Paragon) and Implant Innovations (3I). It was no accident that these two companies and others now significantly outperform Nobel Biocare in this market. For years, many of us have pleaded with the company to be more "user friendly" and open up their product line to what dentists really want. They have always refused. Cementable restorations were blasphemous and there is a rumor that they even once tried to buy out a company that had a cementable system so they could retire it and hold the pattern so no one else could use cementable restorations. Now, after years of falling income, they have introduced, for the first time ever, "Shapable" implant abutments for "Cement-Over" implant supported restorations. "...A treatment option even for dentists who have not invested in the additional training necessary to produce Brånemark System screw-retained solutions". They go on to say, "It is only possible to implement today because of the vast amount of experience that has been accumulated by osseointegration teams since Brånemark system was first introduced". They have even trademarked the term, "Simpler in Practice".

I do not object to their adding these products to their product line. I think it does enhance their system. I do object to them pretending that they invented these products and I object to the fact that they now say that this will allow implant dentistry to become simple. Implant dentistry is not simple. Whether you use screw retained restoration or cemented restorations, implant dentistry is very very demanding!

Wake up Nobel Biocare... We are all not that stupid!!!! SRD
The Cost of Dental Implants
There are many different implant systems out there and the manufacturers are constantly touting the superiority of their product over someone else's product. Manufacturers make, inspect, sterilize and package dental implants. They sell the final product to the dentist. The dentist, in turn, utilizes it for tooth replacement procedures in patients.

If you have researched the field at all, you are well aware that the fees to the patient for dental implant services vary considerably! Fees can range from a low of $500.00 to as high as $2,000.00 and more per implant. Why the tremendous difference? Yes it is true that some implants that the dentist buys are more expensive than others, but the actual product price varies from $85.00 per implant to about $250.00 per implant... Not a very big difference compared to the charges seen by the patient.

What the patient is paying for is more than the product. The patient is paying for the dentist's expertise in placing the product as well as the dentist's responsibility for maintaining the product and carrying through on any additional services that may be related to the product. In terms of implant placement, each dentist has to make a significant investment in terms of both time and money in training and equipment to provide implant placement for patients. Oral surgeons and Periodontists merely place implants and do not restore them so they are apt to charge more for their services. Prosthodontists or general practitioners who place implants and restore them might be in a position to pass along some savings to the patient for one or both of these procedures. In the end, the patient usually gets a fee that is very realistic for the dentist to charge based on a number of variables.

If you pay more do you get a better product? Not necessarily! Fees in dentistry have never had much to do with the delivery of a superior or inferior product. They are based upon the fees in the area and the business of the dentist. A dentist who is busy and works on a smaller number of large patient treatments may charge more for his services than someone starting out or someone who is trying to build a practice. Neither one of these is a reflection on quality of care.

What then is the best implant system? Well you will get a different answer from every dentist or manufacturer you talk to depending upon what system they actually use. But, there is one thing that I want to share with you: The $250.00 implant costs the same amount of money to make as the $85.00 implant.... about $6.00! If they cost the same to make and they are all made out of the same material and the most significant part of the procedure is the EXPERIENCE OF THE DENTIST, What do you think?
Board Certification and Other Questionable Credentials
It took me years to gain my credentials in Prosthodontics. After dental school, I practiced for almost ten years before returning for two years of Post Graduate Prosthodontic training. Five years after completing my training, I successfully completed the Board Examination and was elevated to Diplomate Status, A Board Certified Prosthodontist. In those days, the American Board of prosthodontists would not allow us to even use that title in corresponding with patients.

Today, there are eight legitimate specialties in dentistry. All these specialties have very strict educational guidelines requiring formal training in approved two, three or four year programs. The problem is that these legitimate specialty areas are competing with the phony specialty areas and probably the biggest offenders are involved with dental implants. Dental Implantology is NOT a specialty! And, while there are lots of places you can go to take courses and get training in this field, it it unlikely that this area of dentistry will in of itself become a recognized specialty. The specialty areas of Prosthodontics, Oral Surgery and periodontics are steeped in procedures that involve dental implants. These are the specialty areas that patients should consult when they are considering dental implants.

Dentist who are proponents of the phony specialty and board certification status will always say that because someone is a Prosthodontist or an oral surgeon or a periodontist does not mean that they are qualified to place or restore implants. I would always answer that any of these trained individuals who have taken the time to get involved in implant dentistry have the proper background to do so... Much more so than someone who takes a bunch of continuing education courses and then a test and feels they have the right to specialty status. Continuing education is not the same thing as formal education! Check out what I mean....
Educating Our Own
Four years ago, I started giving courses in my local area to dentists who were interested in dental implants. Most of the participants were general practitioners, but we have had an occasional periodontist and Prosthodontist join the group. What I provided was an eight month course that covered all facets of the restorative phase of dental Implantology. The course met one evening a month and for the first year there was no charge at all. Subsequently, I instituted a $25.00 per session charge to cover expenses.

I usually get between 15 and 20 dentists signing up each year, but by the time the course ends, it is usually down to about 10. I provide Florida CE credits, coffee,tea and soft drinks and my personal view on how implants should be handled in the restorative practice. Each year I add a little something to the program to try to keep it interesting for my self and the participants. Last year, at the last meeting, I brought in several of my patients for a panel discussion on their experiences with dental implants. I also have an occasional guest speaker to fill in some of the material that I can't provide.

Last year I started my first class for dentists who want to learn the implant surgery. We meet once a month for eight months, but they also come to my office to assist in implant surgeries and they even have the opportunity to bring their own patients and do the surgery under my supervision. We had ten dentists go through the entire program last year and this year we have eleven signed up. The charge for this program was $550.00 last year and is now $950.00... this year I can actually buy some new projectors and stuff to improve the course...

Course like these, run by specialists in the community, can only serve to strengthen dentistry as a whole. By sharing our knowledge in a local format, we can improve everyone's ability to deliver state-of-the-art dental care to our patients. By putting together a "mini-residency" every year instead of just a bunch of guest lecturers who would often present conflicting views of the same process, we set up a better educational standard in the community. I have gotten tremendous feedback from these courses and if any of you out there would like to start something similar in your areas, just let me know and I would be glad to help...
ADA CERP Program
Over the past year or so, I have had come across my desk, and I'm sure you have too, several advertising pieces that are disguised as educational materials with the blessing of the ADA's CERP program. I initially notified the ADA CERP program about this and was told that they don't "police" the organizations and companies that they bestow their CERP accreditation on. After many phone calls, I got James J. Koelbl, who I believe heads the program for the ADA, to look into the matter. Eventually, he sent me notification that they had advised the offending publication to remove any reference to the ADA CERP from the publication. Unfortunately this was a one time publication which had already been sent out so there was no penalty at all to the company which is basically free to do the same thing again.

Today, I got another one of these publications delivered to the office. It was entitled Clinical Contours and published by Montage Media. It was very nicely done and contained two good articles, one by Robert Nixon and another by Gerard J. Chiche. The problem was not with the articles or the publication per se, the problem is that it is definitely an advertisement for a particular product and, as such, should not qualify for ADA CERP CE credit.

CERP is there for our benefit. The ostensible purpose is to protect us, the dentists, from bogus CE claims. I think that the CERP committee should take a much tougher stand against individuals or corporations that abuse this privilege. If you agree, please e-mail James J. Koelbl and tell him so. By showing some concern about this, perhaps we can bring about some change. Show the ADA the true power of the Internet.
August 16, 1997
ITI Defect
July 11. 1998
Last year, The Strauman Company had a problem with their solid abutment. According to Bill Ryan, President of Strauman USA, The problem has long since been solved and Strauman has fully backed up its claim to make restitution for any problems caused, "in some cases paying as much as $10,000 to redo a big and complicated case...". Their response and support is appreciated...
Misleading Advertising....
In a recent issue of the Nobel Biocare Update USA, Jim Derleth, president of Nobel Biocare, USA, Inc. wrote an article entitled Nobel Biocare is a Solution Company. Mr. Derleth's article refers to a recent JOMI article that talks about the concept of "clinically proven" techniques and then jumps from there to show how his product has been scientifically shown to be safe and effective and should, of course, be the only implant product that we should use. The part that really got to me was the pull quote saying, "Would you really want any other implant in your mouth or in the mouth of a Loved one?"... Bull feathers!!!!

Nobel Biocare is the only implant company that was ever suspended from selling their product in the United States. They have consistently scored low on the manufacturing quality of their product and they consistently try to promote the myth that their implant is better than everyone else's. Implants are implants and all the hype and controversy that is generated by dental implant companies is only directed at selling product to us. What determines the success of a dental implant? Four things: 1. Patient selection 2. Good surgical technique 3. Good prosthetic technique 4. Good maintenance. The body does not care a twit about what kind of implant you use and if anyone thinks there is a real difference in the manufacture of these devices, you are really misinformed. It costs about $6.00 to manufacture an implant. The technology to do this has been around a long long time and it can be done effectively almost anywhere on the globe. What is important is what you do with that implant after you open the very expensive package.

It's about time that we, the dentists, take a good long look at this technology. Stop the infighting about whose implant is best... This is just another form of penis envy anyway... Start looking at what you have to do as a professional to insure that your patient is in good health. If implants are used, you choose a system that works well in your hands. Don't suffer any remorse because someone else says there is a "better" system. In actuality, they are all the same, only the techniques vary.
Are the Implant Manufactures Missing the Point?
Which implant is the best? What parts can we use for a given implant and are the prosthetic connections of one system better than another? What surface should an implant have? Should an implant be threaded or cylindrical? Should restorations be screw retained or cemented? These are some of the questions that we see bantered around in relation to dental implants. The manufacturers try to address these issues by making more parts and more claims about how effective their parts are. They sell implants and that is what everything they do is aimed at... selling dental implants and components to dentists. But, they're missing the boat! They are missing the boat because they are preaching to the congregation and missing all the millions of people who are not in the church. Who do the dental implant companies compete against? They compete against The denture adhesive companies! Warner Lambert and Proctor & Gamble make a lot more money selling denture adhesives than all of the implant companies combined. Denture adhesive is a billion dollar market and the dental implant companies, so far, have totally ignored that market instead concentrating on things such as wide diameter abutments for single tooth restorations and different shaped implants for "better integration".
There are 50 million people in this country who wear dentures and probably 500 million around the world in a similar situation. That group of people should be the major target of dental implant manufacturers. Last year, maybe 100,000 patients in the United States had implants placed. There are only a few thousand dentists in the United States out of 170,000.00 who are placing ten or more implants per year. Why aren't there more dentists placing implants and why aren't there a lot more patients receiving their benefits? There are two reasons that have limited the spread of dental implants: The first is the cost and the second is the lack of patient marketing. I got a call from a patient in Jacksonville Florida the other day. He was treatment planned for 12 implants: six in the upper and six in the lower. The fee for just the implants was $15,600.00 and the restorative work was another $10,000.00. The surgeon placing the implants explained how each implant cost $750.00 (surgeon's cost???) and that this is what the total fee would be for his four hours of work.... He's still making about $1,500.00 an hour although I have never seen a $750.00 implant! If we said the average family income was $50.000.00, could we say that many of these people would be willing to spend half a years salary for this service... I think not and as indicated by the declining curve in implant placement, most of the people who could afford implants have had them and we are left with the rest who can't afford the telephone numbers....
Here was my solution for these patients on the local level....
I put an ad in the local newspaper advertising that I would provide lower denture wearers with two implants and two attachments to their existing denture for a fee of $1500.00. Naturally I got an overwhelming response. After a while, responses to the ad slowed a bit so I lowered the price to $1350.00 (This was during the summer months when it is normally fairly slow down here in Florida). With the new advertised price, we were grossing $20,000.00 per month all summer long on just this one procedure! Now you might ask if I was making any money placing two implants and two attachments for this ridiculously low price. The answer was definitely YES. I did the math in terms of time, expense and profit and it was way more profitable to do this procedure than my crown and bridge procedures (My fee for a single crown is $850.00). During the first full year that this advertisement and promotion was run, I placed almost 500 implants and the gross revenues were $150.000.00 and the expenses were less than 50%. In addition, this procedure brought in many other procedures, some related, some not so the overall income of the practice grew appreciably.
It is really a very simple concept: Find a need, meet the need in a way that is acceptable and reap the profits while the patients benefit. In this case, the need is definitely the need to stabilize a lower denture. Meeting that for a cost of !500.00 or $1350.00 or whatever reasonable fee will make the needed service affordable for a large number of patients.... OK, you have that one.... It's really a no-brainer, but what can the implant companies be doing here that can benefit their business while meeting this need? A valid question and here is the answer:
The implant companies can package implants and attachments in a convenient, low cost kit that will make it more available to the general practitioner. It costs about $6.00 to manufacture an uncoated titanium screw. With packaging and sterilization, the cost jumps to about $12.00 per implant. Attachments can be produced, packaged and sterilized for a similar cost. If you put the two implants and the two attachments in one package, you have about $30.00 tied up in production. Sell the kit for $150.00 and you have a profit margin of $120.00 per package. Now you start advertising to the public right up against the Denture Adhesive market. TV commercials that tell the public that the two implants and the overdenture concept are a better buy and more affordable than all that messy gooey denture adhesive. The need is already there, the demand grows because of affordability and public awareness. The net result is that there are considerably more patients helped by this technology than ever before, the dentists increase their market share of implant production and the manufacturing companies become significantly more profitable due to the increase in volume sales.....