Charles D. Schlesinger, DDS, in an interview with our editor-in-chief, Damon Adams, DDS, discusses his perspectives and opinions as a clinician and educator for the GP who is wanting to learn more about implant dentistry.
Thanks for taking the time to share your thoughts with our readers, Charles! You have been a loyal contributing author, and Dr. Tim Kosinski, our implant section editor, and I wish to thank you for serving on our Implant Advisory Board as well. So, to start things off, how did you get your implant training?
Dr. Schlesinger: When I graduated from dental school, I had very limited exposure to implant dentistry. At the time, the use of dental implants was mentioned in theory to us as dental students, but no detailed academic information nor practical hands-on clinical experience was offered in the course components of the school curriculum. When I was doing my first GPR at the VAMC San Diego, the attending prosthodontist treated many patients using implants, and I got the opportunity to remove a lot of failed blade implants. Truthfully, my opinion of dental implants was not very good at the time. It was when I entered my GPR II at the VAMC in West Los Angeles that the world of implant dentistry came alive for me. We had both periodontal and prosthodontic programs in our department. Along with our daily case reviews, I and my co-resident from the VA attended a year-long series of implant lectures at the University of California, Los Angeles, along with placing many implants from different manufacturers in our clinic. I was hooked and never looked back!
Did you start placing implants right away when you graduated from the GPRs?
Dr. Schlesinger: I really thought I would. I erroneously thought I was going to be slinging titanium like I did in my residency, but the reality of dentistry in San Diego in 1998 was a whole different world for which I was not really prepared. There was a lot of bias against GPs placing implants at that time. In addition, patients were not as well informed about the advantages of implant placement, and since they were not routinely covered by insurance back then, they had a tendency to choose conventional fixed or removable prosthetic treatment options instead. Furthermore, I was practicing as an associate in an HMO-based dental group, and I probably do not have to tell you how that was! It took a few years to get out on my own and finally have the opportunity to get back to what I really loved doing.
You were on the corporate side of implantology for a number of years, so what are you doing now?
Dr. Schlesinger: During a whirlwind experience on the corporate side of dental implant manufacturing, my tenure included heading up clinical affairs, becoming COO, and also running inside and outside sales. It was exciting and extremely satisfying to ultimately drive an implant company to grow well beyond the industry growth per annum; however, it also was exhausting! So, in 2016, I returned to private practice, initially as a “traveling” clinician treating implant patients in multiple offices located from Albuquerque to Santa Fe, NM. In 2018, I partnered with 2 friends of mine and opened up a private practice in Albuquerque that provides comprehensive patient care with an emphasis on implants and surgery. The practice is heavily referral-based, and our success allowed us to expand to a second office in the latter part of 2019 and then to our third location in 2020. Damon, I have to tell your readers and you that private practice is so much better the second time around!
What is different the second time around in private practice?
Dr. Schlesinger: Looking back on my first time around, I learned a lot. I learned what I liked to do and also what made my life more complicated. This time around, I am concentrating on exemplary individual patient care—doing the dentistry I love to do—and most importantly, I am never bringing the office work into my home life. I think the latter is the one aspect that has had the most impact on my life. Life is too short to be overly consumed by your profession. Balance is the key!
You have been a prolific educator and journal contributor for the past 15 years. How did that come about?
Dr. Schlesinger: Education seems to be a part of my DNA. My father was a high school teacher for 35 years, and my brother has been teaching high school for 20 years. I tried conventional teaching and quickly realized it was not for me. My first opportunity to teach in the dental world came in 2005 when I attended a CAMLOG course in Oregon City, Ore. Walking down the dock outside the hotel, I was approached by the 2 implant manufacturer reps that changed the course of my career: Bruce Lazarus and Ted Waller. They approached me with the intent to give me an opportunity to teach. They pointed me in the right direction, gave me my first podium spots, and supported me, and my teaching career flourished from there. So, CAMLOG Biotechnologies was the first company that I taught for, and that gave me the exposure that brought other companies and opportunities knocking at my door over the years. I feel very fortunate to have been able to speak all over the world on implants and grafting. I love the interaction with my colleagues, and I learned that we all deal with the same issues no matter what country we practice in.
In your opinion, what technology has had the greatest impact on implant dentistry?
Dr. Schlesinger: Well, because so much has changed since the first implant I placed in 1997, and since it is pretty difficult to single out just one technology that has had a big impact on implant dentistry, let’s discuss a couple of different technologies. Of course, if I were allowed to only pick one technology that has had the biggest impact, I would have to say CBCT. Not only has CBCT made it possible for clinicians to treat patients in a safer manner by knowing the anatomy before starting a case but it has also spawned other technological advancements, such as guided surgery and the facilitation of CAD/CAM immediate restorations. Although implants can be safely and accurately placed without the use of CBCT, it is one of those technologies that, once you use it, makes you ask yourself “How did I ever treat a patient without it?” I compare it to the revolution in treatment planning and clinical care that occurred when digital radiographs became readily available for dentists.
As a second technology that I want to mention, I have to say that resonance frequency analysis (RFA) technology has also been a game changer for me. The use of an Osstell or Penguin device changed the way I look at implant placement and restoration timelines. If you are unfamiliar with it, when using RFA technology, the clinician is able to quantitatively evaluate the stability of an implant at placement; during healing; and, ultimately, just prior to the restoration phase of treatment. I use this technology on every case to determine initial stability and then to evaluate my patient and determine when it is time and safe to restore. What it does is it prevents me from putting every patient into the same “healing box.” What I mean by that is this: We have been so conditioned to place an implant, determine its initial stability by torque alone, and then wait 4 months to restore it. This is not only highly inaccurate in certain situations but can also make us wait unnecessarily long to place the restoration.
Today, more than 70% of my patients are restored at 2 to 2.5 months rather than waiting unnecessarily for some arbitrary number that was put out as a guideline when implant technology did not contribute to faster healing and load distribution.
Do you use guided surgery to place all your implants?
Dr. Schlesinger: No, I do not. I use CBCT in planning all of my cases, but I do place the majority of my implants freehand. I do utilize guided surgery for those cases where I have difficult anatomical considerations, such as decreased bone volume, nerves, etc. I also will utilize guided surgery when doing full-arch cases to ensure accuracy in the placement of implants and to decrease the surgical and immediate restorative time requirements for the patient.
What implant system are you currently utilizing for your cases?
Dr. Schlesinger: For the past 4 years, I have been using the Hahn Tapered Implant System that was developed by Dr. Jack Hahn and is now distributed by Glidewell. I thoroughly searched among the available systems on the market before choosing the one that I felt comfortable putting on the line with my own reputation. Over the years, I have used a lot of different systems, and when I was on the corporate side of the fence as a director of education and clinical affairs, I had the opportunity to push dental implants and their treatment indications to their limits. What I found out over my career is that all implants will work and will integrate if used correctly. Today’s implants allow a practitioner to successfully and predictably treat patients like never before in our dental history.
So Charles, if they all work, then what makes one implant better than another?
Dr. Schlesinger: That is a great question! I tell the clinicians in my courses that what makes one implant better than another is how it fits into their individual practices and how it works in their hands. My suggestion to all is to find a company that satisfies the following requirements:
• Is the surgical system straightforward?
• Is the system easy and predictable to restore?
• Does the company provide the level of support needed by the clinician?
If you can check all these boxes, then that system is for you!
Is grafting a large part of your current practice?
Dr. Schlesinger: Yes. If you place implants, then you must know how to graft since you will need to utilize this aspect of treatment often. I do everything from socket preservation to grafting in immediate placements. I also do ridge augmentation for patients with inadequate bone volume and sinus augmentations when necessary. For me, grafting procedures are one of the most satisfying aspects of what I do. I love the science behind them and the technical challenges that they sometimes present.
Why is it important to graft after an extraction? And what is your preferred grafting material for socket preservation?
Dr. Schlesinger: Grafting at the time of extraction can prevent many of the negative issues that can occur when a tooth is removed. My intention is to always put an implant in the site down the line, so preserving bone is paramount. The grafting will prevent resorption and potential periodontal issues and give me a solid foundation for rehabilitation whether I’m placing an implant or conventional fixed prosthetics. Over the years, I have used allografts, alloplasts, and xenografts for preservation. Today, my go-to is an alloplast material called OsteoGen Plug (IMPLADENT LTD). Its mixture of resorbable Ca+ carbonate and collagen in a plug form is simple to use, predictable, and cost effective. Over the past 7 years using this product, I have not been disappointed, and we are still finding new ways to utilize this product for everything from defect augmentations to sinus elevations.
Let’s get back to education. What would you say is the one common issue you see among clinicians who are being newly introduced to implant dentistry?
Dr. Schlesinger: I would have to say these are the big 3 that are most common: fear of implant failure, fear of the unknown, and fear of a bad placement. I really try to make them understand that failure is a part of implantology, just as it is in the rest of dentistry. Statistically, as you place more implants, the numbers will catch up with you. Worldwide, we accept a 94% to 98% success rate, depending upon whom you get your data from. I tell them to do the math. There are so many factors to consider, such as the patient’s medical history, past and current dental condition, and current medications. All of these factors play a role, and this does not even take into account the complexity of the human body when it comes to healing and sensitivity to environmental factors.
Regarding fear of the unknown, they must do cases to get better, period. That old adage of “you don’t know what you don’t know” rings true in this case. Unless we are faced with new and challenging clinical situations, one will not only never get better, but one will also never know what additional education may be needed. Still, to this day, I learn something with most cases.
Finally, as far as bad placement goes, always remember that implant surgery is a prosthetically driven surgical procedure. Start with the restoration and plan your surgery accordingly. If you feel more comfortable utilizing guided surgery to achieve this, then do it. Take advantage of any technology that will help you treat your patients in a manner you yourself would expect to be treated.
Are you utilizing digital scanning for your implant restorations?
Dr. Schlesinger: If you are asking if I scan digital impressions, the answer is no, not at this point in my personal office. Many of my referring restorative doctors do digitally scan their cases with outstanding results from many different scanners. When I was doing cases at the Glidewell facility in Newport Beach, Calif, we did scan our cases with an iTero scanner (Align Technology), with which I am very impressed. My plan for this next year is to incorporate digital scanning and an in-office mill into our practices. It will likely be an iTero scanner with a fastmill.io in-office mill (Glidewell). The scanner is well proven, and the mill is appealing due to its small footprint, ability to mill sintered BruxZir Zirconia (Glidewell), and software that utilizes AI. The results found when using this system are excellent. Furthermore, I feel it will allow me to open the door for treatment to more patients by allowing me to bring the cost of treatment down. I am always trying to make dentistry more affordable to my patients and, in addition, to mitigate the issues that we all deal with when insurance dictates treatment and may not support what we think is the optimal treatment for a given patient.
You mentioned full-arch restorations earlier. What is your final restoration of choice?
Dr. Schlesinger: In my practice, I choose to restore all my full-arch cases using BruxZir Zirconia restorations. Unfortunately, my patients and I have suffered at the hands of past state-of-the-art technologies, such as hybrid restorations. Though these restorations were aesthetically pleasing when delivered, their shortcomings were soon apparent as they became stained, the acrylic delaminated from the metal substructure, and general breakdown of the acrylic occurred in the harsh 24/7 environment of the mouth. With the introduction of full-arch restorations that can be fabricated using BruxZir Esthetic Solid Zirconia (Glidewell), I can satisfy the aesthetic demands of patients who want one of the best restorations on the market.
As you see it, Charles, what’s the current status of implant dentistry? Where will it be in the future?
Dr. Schlesinger: This is such an exciting time in dentistry and implantology! Dentistry was relatively static for so many years. Implant placement has now become just another procedure we, as general dentists, do to rehabilitate our patients. The technology on the market, from better implant designs to CBCT to advances in grafting materials, and the talented dentists in the field have made implants more predictable and safer for the patient. In the future, I believe that we will see some game-changing technologies borrowed from our medical counterparts, such as orthopedics, recon, and spinal, with regard to screw design. I also see a bigger role of managing healing with biologics. And, finally, I predict that there will be revolutionary shifts in doctrine that will change and challenge our way of thinking about how we look at the bone-implant interface.
Dr. Schlesinger graduated with honors from The Ohio State University College of Dentistry in 1996. He can be reached at email@example.com.
Disclosure: Dr. Schlesinger is a key opinion leader for the Hahn Tapered Implant System and IMPLADENT LTD.