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VIDEO - DUwHF #854 - Hilt Tatum
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AUDIO - DUwHF #854 - Hilt Tatum
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Dr Tatum is widely regarded as one of the world’s most skilled dental implant surgeons and is unmatched in his surgical and conceptual talent. For over 40 years he has been most gracious in giving his time and knowledge to advancing the discipline of implant dentistry to the dental profession. The lives of many patients and dentists have been enriched as a result of Dr. Tatum’s innovative thinking, research and implant techniques that he developed. In 1955, while a student at Emory Dental School, he attended the first program on dental implants to be given in a dental school. Throughout his career Dr Tatum’s goal has been "To bring the compromised dental patient back to normal comfort, function and esthetic dental health".
Emory University Dental School 1953-1957
1969 - began the bone expansion concept for the placement of implants
1970 - introduced autogenous bone grafting techniques into Oral Implantology
1974 - developed the Sinus Lift Operation
1974 - began to perform the Inferior Alveolar Nerve lateralization technique
1975 - developed the Sinus Graft Operation
1978 - Designed Sinus Grafting and Bone Expansion instruments
1979 - designed the first 2 stage Titanium Root Form System in the USA and was granted FDA marketing approval in 1981
1982 - Introduced the Vascularised Osteotomy Technique with interpositional bone grafting
Presented over 2000 professional presentations worldwide
In 2003 Dr Tatum was awarded the Chevalier of the French Legion of Honor by French president Jacques Chirac in recognition of his contributions to the healing sciences.
www.TatumSurgical.com
Howard: It’s just a huge honour for me today to be podcasting interviewing with Dr. Hilt Tatum who is widely regarded as one of the world’s most skilled dental implant surgeons and is unmatched in his surgical and conceptual talent. For over 40 years he has been most gracious in giving his time and knowledge to advancing the discipline of implant dentistry to the dental profession. The lives of many patients and dentists have been enriched as a result of Dr. Tatum’s innovative thinking, research and implant techniques that he developed.
In 1955, while a student at Emory Dental School, he attended the first programme on dental implants to be given in a dental school. Throughout his career Dr Tatum’s goal has been "To bring the compromised dental patient back to normal comfort, function and esthetic dental health". He graduated from Emory University Dental School in 1957. In 1969 he began the bone expansion concept for the placement of implants. In 1970 he introduced autogenous bone grafting techniques into Oral Implantology. In 1974 he developed the Sinus Lift Operation and began to perform the Inferior Alveolar Nerve Lateralization technique. In 1975 he developed the Sinus Graft Operation. In 1978 he designed Sinus Grafting and Bone Expansion instruments. In 1979 he designed the first 2 stage Titanium Root Form System in the USA and was granted FDA marketing approval in 1981. In 1982 he introduced the Vascularized Osteotomy Technique with interpositional bone grafting. He has presented over 2000 professional presentations worldwide.
In 2003 Dr Tatum was awarded the Chevalier of the French Legion of Honor by French president Jacques Chirac in recognition of his contributions to the healing sciences. It is an honor and a privilege to be talking to you today. How are you doing?
Dr Tatum: I am just wonderful. I am amazed I am here. At my age I never thought I would be alive to this age. But I am so fortunate.
Howard: How old are you now?
Dr Tatum: I am eight three Howard.
Howard: Eighty-three. Well you look fantastic. You look just marvellous. And I love the room you are sitting in . It looks like you’re sitting in Chirac’s house.
Dr Tatum: It is a lovely place. The walls were built in the fifteen hundreds, the chapel and guest house in the fifteen hundreds. This home was rebuilt in the seventeen hundreds, so there is much history in our area here. Great history.
Howard: That is the amazing thing.
Dr Tatum: William the conqueror lived less than a half mile from our home here as a child. William the conqueror, who conquered England in 1066. Joan of Arc spent her last night alive a half mile from where we live. Morne’s home is sixteen or seventeen miles up the river from us. Richard the Lionhearts castle is about seven miles up the river from us. So, there is much history right around us here. It’s a lovely place to live.
Howard: What made you go from being born in Alabama, practicing forever in St Petersburg, all the way to France?
Dr Tatum: Howard, I came here by accident, I fell off of a horse and had a serious injury and my wife is French and she had a home here. So, I came here trying to recover from the injury thinking I had retired. Had a couple of heart attacks. I was certain I had retired but then survived it and I am still here and still somewhat functional.
Howard: Fantastic. You were in oral implantology at the very beginning and contributed many of the major techniques we use today. How do you view the world of oral implantology today?
Dr Tatum: It’s a real paradox. I am literally one of the antiques that’s still alive from the early period. I am not from the very earliest period, but right after that, in the fifties, I was introduced to the field. The earliest, I think started in the US in 1948. I think today implant education is a tragedy. I think that it’s largely commercially controlled. In the teaching and the talks I give to the students I work with, I liken the present field of implantology like the world was flat in 1494. I think that what we have learned, and what we, and others, are able to do, is like the world is round of 1494. 1493 and 1494. It’s a totally different dimension from what is traditionally thought of as conventional implantology today. It’s so mechanical. There is so little skill required to do implantology. If you buy a kit and take a weekend course you can drill holes in bone, put screws in. My whole concept is I want to take a patient at any stage of dental disease, atrophy or trauma and have the potential to restore them to normal contour, comfort, function and esthetic dental health. That’s a big mouthful. I made that slide first in 1977 as being the goal of modern implantology. I feel like my life has pretty well been like a carousel. My learning has been like a carousel that I have been on. I entered the carousel back in the fifties and have been on it around. When I left the US, I think I was about three quarters away around my journey. Fortunately, the accident I had incapacitated me for a period of nearly two years, year and a half anyway. During that time, I was alive and I could function but I couldn’t do anything physical. We live here in the same valley, the river is out less than a quarter of a mile in front of our house and we can’t have clients over because you get water about four feet down. But we live on the edge of the valley and have a cave that goes into the hillside which is the client side. It’s been there I guess for nearly a thousand years, well it’s probably been there about seven or eight hundred years. I got an old furniture crate from a furniture store, put a top on it, put an umbrella over it to keep the water from dropping on my head and for a year I sat there and made instruments. It occupied me. I ran an electric cord in it, put some lays and dental equipment and I made things to occupy myself not knowing that the things that I made were going to totally explode my knowledge and ability to do things better than I had ever been able to before. So that was one of the greatest gifts I have had, not only the gift of surviving, but the gift of being able to create things that allowed me to do things better than I ever knew before or ever dreamed was possible. And it has allowed me to complete the circle on the carousel to come to the point that I am right now. I feel like, with the rarest of exceptions, that it is possible for us to complete that goal we had of taking, almost any patient and bringing them back to normal contour, comfort, function and esthetic dental health. And by that, I mean rebuilding the bone to its normal dimension, putting implants within the areas where the root’s occupied, rebuilding the soft tissue in the correct gingiva in the correct places and then doing restorative dentistry that simulates nature. That’s my dream and that’s what is within our capability. It’s rather exciting to be able to live long and have to achieve your dream.
Howard: So, talk about your website tatumsurgical.com. What are you excited about on these instruments and implants that you have?
Dr Tatum: That website is the cockney of the implants that I created and I actually have very little to do with that website. I still teach and I am a director, or co-director, of Maxi Course in Puerto Rico. I will be leaving day after tomorrow if the storm doesn’t block it, to go to Puerto Rico. It’s supposed to be right in Puerto Rico on Wednesday. When I get there, I will pair up with a number of the other Maxi Courses. My main endeavour is through these educational outlets. I have almost no role in the commercialized and of selling implants. I designed them and developed them and I certainly am interested in it but I know very little about that website so that is not something I can really talk with you about much.
Howard: We just had six thousand children graduate from dental school three months ago and another six thousand just started dental school this week in the United States. A lot of them come out of dental school and say, we never placed a single implant. What advice would you give to a young, twenty-five-year-old dentist. How she could learn how to be an implantologist like you?
Dr Tatum: I think education is a tragedy. As you say, most dentists graduate from dental school with very little knowledge or introduction to implantology. If they have introduction it is very rudimentary and very basic. I think that is expanding and becoming better but in my opinion implantology now is the most complex field of implantology. I mean implant dentistry is the most complex field of dentistry today. We have won the legal battle of being able to announce, in most cases, and certainly over the whole country, announce the specialty of implant dentistry with those people who have been credentialed through the American Board. We are now challenged with developing the education to compliment that so, that we have the widespread education, not only for the general dentist and the other specialty areas to do implants but to train people to be the teachers and to treat any patient with complex treatment for those patients who need and desire it. That’s our real challenge today, is to develop the education to enhance and to train teachers to teach the young dentist and the practicing dentist into a more complete area of competency in the field. That is our challenge and I have thought this for a long, long time and have had some part in the development of the legal challenge to create the rights of dentists with comprehensive education and experience to announce their competency through specialty recognition. As you know, we have achieved that. Now we’ve got to develop the education on a widespread basis in the dental schools and outside. I have a whole plan of education that I think is appropriate and I hope will be implemented within the American Academy of Implant Dentistry as the driving force to develop this education, and I hope that will happen.
Howard: So, how is the American Academy of Implant Dentistry Maxi Courses coming along now?
Dr Tatum: They are expanding but the Maxi Courses are just an introductory level of education. What we’ve got to do now, Howard, is we’ve got to develop multiple graduate programmes, university and hospital based, that will allow for three and four year, or more, graduate education and we’ve got to develop the teachers. We have so few people in America with the capability to do the most complex procedures. There is so much commercial education and there is so little sincere, deep developmental education within the field. So much of it is controlled to sell this product or that product, promote this or promote that, as I am sure you are aware. I dream and hope that the American Academy will use its resources and its leadership to develop this in-depth graduate education that we need for the most serious people and for the introductory people so that we raise the whole level and take it from this flat world concept into the world is round concept that I know is possible. Where a person fits into it will depend on their desires and their capability and their training. It’s a big dream as you perhaps can see.
Howard: Are there any textbooks that you recommend for reading?
Dr Tatum: It hasn’t been written yet.
Howard: Are you writing it right now?
Dr Tatum: I wrote a book in the early eighties but I am so glad that I didn’t finish it and have it published because it was incomplete. There is not a book covering the things that are possible. But, perhaps there will be. I am sure that the things that are being learned are going to survive and be taught. Probably not so much in book form as per digital form because with digital, as you know what we are doing right now. You can do so much digitally. A picture is worth a thousand words and I could never be satisfied with anything I wrote because it took too many words to describe and you couldn’t print enough pictures to show. Now with the digital format you can show and tell, with minimal words and with examples and pictures and video and pictures combined. So, with your interest in the digital world I would imagine that you can grasp and appreciate what I am saying here. That’s where education is going to develop.
Howard: A lot of the young kids ask, when they get into an implant system there is a big variety of premium pricing implants, north of $500 and then more value implants in the middle and with over four hundred dental implant companies to choose from, what advice would you give the young kids coming out?
Dr Tatum: I laugh Howard because the cost that is involved is absurd. There is no base, no reason, no basis for these massive costs that you just recited, in some cases. The manufacture of implants, properly designed, is not complex and it is not expensive and there is no reason for it to be so expensive. You’ve got these thousand, not thousands. You’ve got these hundreds of highly paid people, maybe it’s in the thousands, around the world, that are the sales people and that create tremendous costs for the commercial end. The actual cost of implant components and parts should not be great and the cost has very little to do with the quality. The quality can be had inexpensively or expensively in a final sales price but with the machining capabilities and with competent people that are designing, and there are many people that fit this bill, there is no reason for the costs to be the way they are. I hope and I expect to see the costs dramatically reduced in the coming years for the cost of components of implants. There is no justification for it. Just like there is no justification for the cost of dental education today. I think it is a tragedy and a travesty to have students three and four hundred thousand dollars in debt with a dental degree. When I entered into my dental practice in Heure we had no eight-hundred-pound grill on our back to pay for our education and I fear that these great debts that students have will corrupt their morality of cost and fairness to patients. We all should treat every patient the way we would want to treat our brother, our mother or father, with care and competency and with fair expense. When you go and you have any service, you want to be treated fairly and you want to be treated competently and you want to be treated the way that I am sure you have treated your patients in your lifetime. Am I right or wrong?
Howard: You are absolutely right. We certainly live in strange times with this amount of debt. And the schools don’t seem to be focused on cost containment.
Dr Tatum: It has become a business, it’s been commercialized. It’s been commercialized just like our field of implant dentistry has been commercialized. Some of the things that I see in dentistry should be treated as criminal assault, and that is a tragedy.
Howard: That is strong words, criminal assault, on some of these diagnosis and treatment plans.
Dr Tatum: Some things, if I was called as an expert witness, some of the cases I have seen treated and if I were called as an expert witness, and I was asked a question I would have to say I think it should be considered criminal assault, and that is about as strong as you can say.
Howard: What do these cases look like?
Dr Tatum: It is damage to the patient and it is being done for money and I don’t think I need to go any further than I have right here.
Howard: Since you’ve lived and practice in Alabama, Florida, now France. When you go around the world there is such a huge variance of adoption rates of patients getting implants per ten thousand people and the percent of dentists even placing implants. Why do you think there is such a wide variety of implant adoption?
Dr Tatum: Education. Lack of education. It should not be cost. The cost of implants should not be a limiting factor in the utilization. The thing is, we have large numbers of implants that are competently made. The vast majority are overpriced but there are many good quality implants available but we have so little education that the results that are been gotten, frequently are far less than there could be or should be, if we had quality education starting in the dental school. To have quality education, what do you have to have first, you have to have teachers. You have to have instructors who are trained competently and know what they are doing. We don’t need turfs, we need competency and experience and education. I am older than you and I have had very little benefit of education, it’s largely been self-education. But, today that’s not the way it needs to be. We need to offer quality education to these kids when they are juniors and seniors in dental school and we need to introduce them to good principles of surgical asepsis and soft tissue management, implant placements, bone manipulation. Probably there’s less than one tenth, or less than 1% of dental student in the world have taught anything about bone manipulation, and bone manipulation is just absolutely fundamental to maximize the placement of implants. Any pure dental site you have is going to be bone deficient because you lose bone from the buckle or when you extract teeth it heals. Typically, almost every case. So, if you drill a hole in that bone, you are putting an implant not in the location that a root was in, but you are putting it in the wrong place, and a smaller size than the root. But, bone is plastic. It’s amazing the plasticity that’s in bone, both mandible and maxilla. I didn’t appreciate this until the last twenty-five years, that my nebular bone is as plastic as my maxilla bone, when you understand how to treat it. To do this type of treatment you’ve got to utilize conscious sedation. Conscious sedation should be a basic principle that’s taught in dental schools. Not only for implantology, but for restorative dentistry, pediatric dentistry. I have been patients for dental treatment traditionally and I have been patients with IV sedation. Have you ever had IV sedation?
Howard: I have.
Dr Tatum: Alright, what kind of procedure did you have?
Howard: I had a kidney stone removed.
Dr Tatum: Okay, you have not had dental treatment.
Howard; No, not for dental treatment. I have seven (26:39 inaudible).
Dr Tatum: No dental treatment done with IV sedation. It’s absolutely marvelous. There’s no stretching of the mouth. It’s like a colonoscopy, they say roll over and you don’t remember anything else until you say thank you as your leaving.
Howard: You’re right.
Dr Tatum: Have you had a colonoscopy?
Howard: You’re right. I was just reminded, I have had IV sedation twice then because I had a colonoscopy when I turned fifty and now I have to get one, I just turned fifty-five. You just reminded me to schedule for my five-year update colonoscopy.
Dr Tatum: I have had five of them in my life, five or six now. I have had two without, and then I have had sedation for four of them. Oh, my goodness, what a difference it is. All I remember is them saying turn over and then thanking them as I leave. Your dental patients can be the same way. I have used sedation since 1957 in my dental experience. I started using Promethazine, Demerol and Nembutal and when Valium was introduced I immediately went into Valium. I just can’t imagine practicing dentistry, not only implantology, but practicing dentistry without IV sedation. It’s just a gift to mankind but we got to train people. It ought to be a basic dental education. Every dental student should be trained, not only in implantology but in basic IV sedation.
Howard: When you talk about bone manipulation, it seems that many kids think that is not necessary because they are just going to get a surgical guide and they are just going to drill through a hole on a surgical guide.
Dr Tatum: I don’t use surgical guides at all, Howard. That’s backwards to me. In training that we do with our kids, I say kids but we have had students as old as sixty-nine that started our training programme. What I want them to do is take mounted models, use radio opaque teeth, and set the teeth exactly where the final restorative needs to be, with the same length as the crowns needs to be. And then do scans. Almost all of the kids we are having now have access to CT scans. And once you get the scan and the radiopaque teeth in the correct position, then you see exactly what the bone relationship is. You know whether you can do bone manipulation, expand the bone for the implant to be exactly where the root was or whether you need to increase vertical height and move it. The most predictable way to recreate vertical width is with a vascularized osteotomy. If the bone is suitable, you move the bone to the correct height with an interpositional guider. It’s much less risky than an onlay bone graft, and you get a precise bone height. Then with bone manipulation you create the width that you need. If that’s not possible, then there’s vertical, then you have to do Omle. But the world, again, is backwards in my opinion. 99% of the bone grafts that are done are crystal incisions. That’s not the way they should be done. You should almost never have an incision on top of a bone graft. You make the incision so that you keep your flaps completely vascularized and you put your grafts into place and then you bring the tissue over them and close them with remoulding incisions and your flaps are completely vascularized. This is what I am talking about as being a different dimension from what is, but it’s the way it can be and the way it should be.
Howard: What do you think of a lot of dentists when they bunger up their drawing blood and they are spitting blood. What do you think of this?
Dr Tatum: That’s tremendously useful. We use PRF. It increases results and it’s very safe. It takes a little bit of equipment to do it and a little time. But I am very, very favorable to the use of these additives that we use in conjunction with grafts.
Howard: When you are diagnosing a treatment planning for a missing maxillary first molar, what do you think the pros and cons are of a three-unit bridge versus a sinus lift? Because in a three-unit bridge you are removing tooth structure, but in a sinus lift you are invading the sinus.
Dr Tatum: The sinus augmentation is as safe when it is competently done as an interpositional graft. An onlay graft always has greater risk than a sinus or interpositional graft. But, if you have virgin teeth then I think that sinus augmentation or sinus lift where you just elevate the floor of the sinus to deepen the socket is the appropriate treatment. But if you have teeth that have been restored and are severely worn, I think a three-unit bridge is the appropriate treatment. It’s what I would do for myself or for you or for a member of my family. But if there were sound teeth then I would definitely want to use an implant if possible.
Howard: What do you think of the American Academy of Implant Dentistry?
Dr Tatum: I think that I joined early in my career because I didn’t know any better but I think it is the leader in implant education and I think it is going to be the organization, its non-commercial and it’s a dental (33:48 inaudible) organization and it’s my hope and prayer that it’s going to be the leader, of course it’s responsive to the American Board of implantology and it’s expected to be the leader in developing graduate education that we need and will see developed over the next five and six years. It’s a very ambitious plan and I hope it, or something like it, comes about.
Howard: Talk about implant education. In the United States there is a lot of turf between the oral surgeons versus the periodontist versus the general dentist. Do you think their idea will pull all surgeons and pagans in or do you think those will remain three different turfs?
Dr Tatum: They are, and always have been oral surgeons, periodontists and prosthodontists in the Academy of applied dentistry. I think that specialty as they develop, will train people to become competent in all phases of implant dentistry. But I don’t, and never would want to exclude an oral surgeon or periodontist from being a part of implant dentistry. The specialty of implant dentistry, there is no specialty training in the world in any of the recognized specialties from the American Dental Association that trains a person competently and comprehensively (35:28 inaudible).
Howard: What do you see as the most common mistakes today in implant dentistry?
Dr Tatum: Lack of education. The teachers are not teaching the right things. So, the challenge is to train teachers and develop the graduate programmes. We’ve got to develop programmes to teach the young graduate, but we have also got to develop programmes to teach the practicing dentist, whether they be thirty or forty or fifty or sixty years old. In our programme in Puerto Rico, we have had people, the oldest we have had I think was sixty-nine when he started the programme. This year we have a gentleman whose daughter graduated from the programme the past year and the father is coming this year. It is great. I think the daughter finished dental school a year ago, no, two years ago. I think she came to us right out of dental school. She did two sinus augmentations, during the course, and I think now she is probably done a total of either five or six sinus augmentations and she is out of dental school just over two years. Now, her father, who must be well into his fifties, he has enrolled and he is going to be a part of the programme from this year. How many children do you have Howard?
Howard: What’s that?
Dr Tatum: How many children do you have?
Howard: I have four boys, ages are twenty-two to twenty-eight.
Dr Tatum: Do you have a dentist in the family?
Howard: I do not yet have a dentist in the family.
Dr Tatum: I have two. One of mine is already retired.
Howard: Your dad was a dentist and there are eleven dentists in your family?
Dr Tatum: My father was the first, then there have been eleven dentists in the family. I have a granddaughter who graduated a year ago, two years ago.
Howard: What school did she graduate from?
Dr Tatum: From Columbia, New York.
Howard: Nice.
Dr Tatum: We have been spread out over a number of schools. My two went to Florida, I finished at Emory, my father finished at pre-cursor to Emory. My brother finished at Emory. My brother’s two sons went to Alabama, some cousins to Emory. We’ve been spread out.
Howard: Emory was a private school, wasn’t it?
Dr Tatum: It was private, yes.
Howard: Was it Jesuit?
Dr Tatum: No, it was a Methodist school.
Howard: A Methodist school. Interesting. Speaking of your father being a dentist, implant dentistry has lost a few legends lately. Leonard Linkow, Carl Misch, Pierre Brandmark. Your thoughts on those guys?
Dr Tatum: I guess Carl was almost like a son to me, we were so close. Lenny, I have been a friend for forty-five years. Pierre, I met and knew him, and I said when we were starting, I am one of the, I don’t know the word I used, but one of the old ones left. I am not of the oldest generation but I am just under the oldest generation and there is almost none of that generation left. There are a number of my generation that still are around.
Howard: I just think of what you four people brought to implant dentistry and it’s mind boggling. Why do dental implants fail? We have a huge problem in the United States where there are studies showing that five years out 20% of the implants have peri implantitis and it also seems like we don’t even have a consensus yet on a diagnosis and treatment plan of peri implantitis. Would you agree with that, or not?
Dr Tatum: I pretty well understand the cause here, Howard. To start with your drilling into deficient bone and leaving very thin walls at the time implants are placed and only a small percentage of dentists understand how to handle soft tissue to create stable gingival around every implant that is put in. Those two factors right there contribute to most of the peri implantitis that you have. If you have vital, stable bone around the implant and you have good, stable gingival, so you have circular collagen fibers that create a tight cuff around the implant then you reduce the microbial invasion in the sockets and that’s the primary cause of the peri implantitis today. So, with education most of those things will end.
Howard: Would you say that’s more reasons not to use the surgical guide?
Dr Tatum: Not for me, I have never used them. I come at it totally different. I think all implant treatment for fixed bridge work should be prosthetically planned. You should plan your prosthetics and then see whether it is possible to do the surgery to put the implants in the same relationships that the roots were in. And, at the same height. I want to build it from prosthetic downward, not from surgical guide and then build the prosthetics wherever the implant is. I want to put the implant where the root was and put the bone where the normal alveolar bone was. We do that with a combination of surgery, osteotomies and bone grafts, but principally, with bone manipulation. If bone is (42:07 inaudible), only a small percentage of cases. Is it not possible to manipulate that bone and expand it so that you can have the implant in the same location that the root was in. It’s a whole different dimension from what you’ve been exposed to, Howard.
Howard: Exactly. But what would you do if a patient walked in today with peri implantitis? There are companies out there saying their laser works well with it, others are saying flap it, open it up. How do you get your mind around diagnosing and treatment planning existing peri implantitis?
Dr Tatum: You first want to understand what caused it. Usually it is a cause of inadequate stable tissue and poor bone on the buckle and once you lose that bone it’s problematic. It’s possible it can be restored but you have got to have stable gingival and if you are going to restore bone you’ve got to have stable gingival around the implant. Prevention is the best treatment. The problems that we see with peri implantitis are they do exist but there is such a minimal part of the problems we see because we try to create stable gingival at the time that every implant is placed. How do you create stable gingiva? You might have thought you move tissue from the palette over to (43:52 inaudible) implants. In the mandible you expand the (43:56 inaudible), if that’s not adequate you do a graft at the time you put the implant in. How is that been taught in the world? Either one of those. It’s very, very little, but that’s the way it should be done. And that’s the way it will be done some day.
Howard: You brought to implantology in 1974 the sinus lift operation. The inferior alveolar nerve lateralization techniques. Now a lot of people are trying to avoid those techniques by going to shorter implants. What do you think of these shorter, fatter implants?
Dr Tatum: I try to always maximize the use of available bone. I am not going to use a very short implant if I’ve got more bone than that. There are seldom situations that I’m not able to create more bone when it’s not there. I did a nerve lateralization on my wife three days ago and I did one thirty years ago right after we married on one side and I had to treat the other side three days ago but when we finish we will be able to, in three months, we will put implants of probably 17mm in her mandible and she still has the implants I placed thirty years ago after the nerve lateralization on her left side. I hope she can have another thirty years. She’s only eighty-one right now. I hope she can have another thirty years on the right side.
Howard: That is the most romantic implant story I’ve ever heard. That’s the Romeo and Juliet of dental implantology. That is an amazing story. When these children who just got out of school they see these sinus lift courses, sinus augmentation. There are several different types of sinus lifts. Will you talk about sinus lifts for a while?
Dr Tatum: Sinus lifts. When I first had the idea of using the sinus to enhance the implant placement the first procedures I did were from the crest and I would cure it. I was making the implants. All the implants that I used I was making them myself and I made them to fit the area of bone they were going into. In the posterior maxilla, I would curate the bone to the floor of the sinus, saving the bone, and then with a tray in that I would make just smaller than the implant, I would crack the floor of the sinus and elevate it and put the bone around that elevated floor of the sinus and elevate it and put the bone around that elevated floor and then put the implants in. That was in 1974. That was part of the prelude to doing sinus augmentations without autogenous bone, extraoral autogenous bone from (47:24 inaudible), and a year later I began to do full making windows, first from the crest, the first few cases, and then from the lateral wall. Of course, to do these procedures, Howard, you’ve got to do them with a level of surgical asepsis somewhat of general surgery. The general dental environment is not the environment you’re going to do these procedures consistently well. Our young dentists are not trained in surgical asepsis. So, that’s another of the great challenges. In fact, in the training that I do now, I teach the students that the two most difficult things they’ve got to learn is competency in surgical asepsis, because it’s a second language. Dental asepsis is the first language and surgical asepsis is a completely different language. Bone manipulation is a skill and an art and that takes time and effort to develop that skill and art. Everything else is pretty mechanical. If you are to have surgical asepsis you use remodeling incisions, you understand how to manipulate tissue, you learn how to create stable tissue around your implants, they learn how to perfect IV sedation, to do them comfortably for the patients and to build them successfully and comfortably for the surgeon.
Howard: Are you using a lot of membranes?
Dr Tatum: You are talking to a pretty radical person here today.
Howard: It is an honor to talk to you. I can still remember meeting you in St Petersburg, Florida, and I was star struck then and I am still star struck now. What about membranes, are you using many membranes?
Dr Tatum: Howard, since I started doing bone grafting in 1970 I was using many core filters then. I have always used barriers. We use dissolvable barriers today. We use a lot of Alloderm. We use different other tissues. We use pericardium and collagen. In the different teaching environments, I use what they have available. I have always used barriers and we use PRF in conjunction with the barriers in most, or many, of the surgeries that we do and I think it enhances our results. I haven’t done comparatives but I feel strongly that it is a positive product. Not having my own practice and not being able to comparatively evaluate things, I have to make assumptions that I can’t be certain if they are correct because I haven’t been able to evaluate them. I feel comfortable using the PRF, I think it’s a beneficial.
Howard: One dilemma dentists have around the world is the patient wants the implant immediately loaded. They want to come in, get an implant and leave with a tooth. What are your thoughts about immediate load, when it’s applicable, when it’s not?
Dr Tatum: There are many places that you can do that and do it very well. That comes back to the experience and knowledge of knowing where it is appropriate to do that and where the success rate would be good. And, in the absence of para-functional habits of the patient. If you’ve got a patient with parafunctional habits and you do most immediate implants and load them, you are probably going to overload the crestal bone, because the crestal bone can get most of the load from the loading implants. I am so impressed about the possibility and potential of immediate placement and loading but it has got to be very carefully done. I think the future for one-piece implants is tremendous. In these cases, where the indicating can be used and the cost is so much less than the cost with many of the things that are being used. I am very impressed with the potential. In the anterior mandible, my goodness, we put 23mm implants in the anterior mandible and load them. I can do that every day. There are a few patients where teeth have been extracted between the anterior mandible, that you can’t use 20mm or 23mm implants. They are tremendously strong and you use one-piece implants in those cases.
Howard: So, a very successful, ClearChoice, are doing immediate placement of the All-On-Four. How do you like the All-On-Four concept?
Dr Tatum: The only sense I have is probably the best All-On-Four is the All-On-Three. I think that for fixed restorations that you’re putting any patient through, most patients are at risk with four implants when it’s always possible to do if you are going to do full arch and much of this is basically dentures screwed in for implants. That should be a very cost-effective type of treatment but it is not a cost-effective type of treatment the way it is being delivered. Frequently these entail removal of a lot of bone and for fixed restorations that goes completely opposite to my view. I want the bone supporting the implant to be at the height of the original bone and my whole goal is to try and create that for the parient.
Howard: Are you cementing implants or screwing them?
Dr Tatum: I cement implants.
Howard: Any why is that? What are your thoughts on that?
Dr Tatum: It’s my goal, when I place an implant for a patient, it’s my goal for that implant to be there for the patients lifetime. I have a number of patients that I still have contact with that have implants that I placed in function over forty years ago. That’s what I would hope for every patient that I treat. Certainly, you have patients where you have unsuccessful outcomes, and I have patients with unsuccessful outcomes, but, it’s my expectation that any in ploy and out ploys for fixed restoration, it is my expectation that the implant has the potential to last for that patient’s lifetime. With that said, a cemented restoration has got far less maintenance and far more predictability for long term service than something that is screw retained. Plus, they are aesthetically more natural.
Howard: What are your thoughts on socket grafting?
Dr Tatum: I think socket grafting is a real benefit. I don’t think it is an absolute requirement when you understand bone manipulation. If I were in my practice, if a facial wall is there, I don’t need to socket graft it, because, you know, the timeframe for one cycle of bone healing is somewhere between sixteen and twenty-two weeks. If you place your implants between eight and twelve weeks, you can place them without losing width and you place them and you place them (57:17 inaudible) you place them and you don’t have the need for socket grafting. Also, when you perfect your skills with bone manipulation you can take the fan ridge and expand it outward. But that is after your become confident. And that’s quite an education. I have no complaint or hesitancy for the young dentists that I work with, frequently doing socket grafting, but I think they’re learning to handle soft tissue so that you get uncomplicated healing on the socket grafting. In a maxilla you can advance palettel tissue and get primary closure. You can use barriers, dissolvable barriers, over the mandibular socket grafting that enhances the healing. I wouldn’t do much myself with socket grafting because it is an unnecessary expense for the patient in my hands. But, I think it is very useful for the young dentist who is developing his skills and is learning.
Howard: Do you think any implant have gone extinct? You used to make your own implants, there are subperiosteal, blades. Would you deem any implant system extinct?
Dr Tatum: Of course, yes. The vitreous carbon implant system took the country by storm in 1970 and 1971. It was a space age material developed by NASA. It was university tested and promoted by USC. It was a total failure within four years. The aluminum oxide implants, the Kyocera implant from Janet Farming from Japan, and the American Polycrystalline aluminum oxide implants were beautiful implants but they lasted about five years and were considered complete failures as systems. The blade implants, subperiosteals, preceded all of them. That was the first modern successful implant done in 1942 with Gustav Dahl. He did it in Norway but he was Swedish. And then, in 1948 Ira Gershkoff did he first subperiosteal in the United States and they have been used since that time. There is very little use you will get out of them today but in an atrophic mandible and properly done tripodal subperiosteal is still a very excellent device when it is done properly. The blade implants were the primary implants from about 1967 until perhaps 1984, maybe 1987, for about twenty years. The rootform implants are the principle implants today but there still are people who successfully utilize the blade concept but it would represent a very small percentage of implants that are done.
Howard; Do you think we are around the corner to having custom implants instead of buying an implant that already exists? Maybe taking an image and using CadCam to reduce titanium or using the 3D printing technology. Do you see custom made ones around the corner?
Dr Tatum: I don’t see how the 3D printing is going to be utilized with the titanium implants. With the tremendous selection and sizes of the titanium root form implants that are available it’s pretty difficult to not have a choice of a suitable implant for any site or any location that you need to have one today. I can’t see how, printing, at this point, how you could have a place with titanium. I think there is, and will be, certain availability of fresh, well-made economical implants that there would hardly be a need for a custom made, more expensive device.
Howard: What about cantilevers? What do you think about how cantilevers are used in the implant dentistry today.
Dr Tatum: Anybody with long-term restorative experience knows that crystal cantilevers are trouble spelt with a capital T whether they are on implants or on our teeth, mouth, I have seen cantilever lateral in sizes that have lasted many, many years with minimal damage. But I have seen few freeman distill cantilevers in restorative treatments that has had long-term good success. You know, implants are teeth. There is no need to have to use cantilevers because you can create suitable sockets in bone for almost any location in the mouth, for the reception of a titanium root form implant.
Howard: If someone asks you what book could they read to learn about dental implantology?
Dr Tatum: Howard, I don’t think the book has been written yet, the way that I think it should be. Today, in the education, most Maxi Courses are principally didactic or principally lectured. What we need is clinical training. We need surgical training. I mentioned to you I feel like I have been on a carousel all of my life to the point I am right now, I feel like I have essentially completed the carousel and the concept that I have arrived at, I have given it a name, and it’s NERSAB, which means natural lithium plant restoration in stable alveolar bone. That’s what I, and the ones that work with me, try to achieve. As I mentioned, or I had thoughts when we were talking, about the digital component of education and I think that that’s where my future lies in trying to impart and to teach this NERSAB concept that I have arrived at. Because, digitally we can guide and direct, surgically, through surgical procedures with pictures and video that it is impossible to do in a textbook. In the time I have left, and the people working with me, what we hope to do is to digitally transmit the knowledge that we’ve learned and the techniques that we’ve learned into the students that we encounter and the students to follow. That’s where my future lies, it’s not in the hands-on teaching because it’s very limited, the number of people you can reach. Digitally, if we can transmit the ‘how to’ accurately with the many different procedures, then that’s what I hope we can accomplish.
Howard: That would be an amazing accomplishment. When you do it digitally you can scale out, you can teach so many people around the world at the same time.
Dr Tatum: And it opens you up to anything that’s interesting. Now, in dental implantology, if I speak to a group of a hundred people, if I excite two or three or four, that was about the most you can hope for because you can awe a lot of people but to excite people to want to do it, to want to be part of it, that is a very, very small percentage of people. That’s where the teachers will come from and that’s what I hope we can expand this to, is to reach more and more people and to create a core of teachers that will be the teachers and instructors in the confidence of education we are going to develop.
Howard: You promised me an hour of your precious life and you gave it to me and it was just unbelievably amazing. I just love this so much. Dentaltown now has a quarter of a million dentists around the world and sixty thousand of them downloaded the app on their Iphone. We put up four hundred, hour long digital courses and they have been viewed almost a million times from every country and territory on earth and it would just be the greatest honor ever if you have an hour digital course. I would love to put that on Dental Town. You’re a hall of famer and if you ever have time to put up an hour course it would be beyond amazing.
Dr Tatum: Thank you Howard, I have enjoyed speaking with you tonight. I wish you could be in this beautiful country that I am in right now.
Howard: Well, Ryan and I were in Paris last year. What’s your favorite recommended French wine?
Dr Tatum: I have no taste for wine at all. We have a collection. My wife’s first husband was a connoisseur and collector and we have them from 1933, Chateau Acanz up through Petrosen and Romany Contez, and yet, neither she nor I have any taste for wine. We sometimes serve wines to people who appreciate it and we have a beautiful collection in the cellar. I was raised in Alabama. The only wine I knew anything about was Blackberry Hill and it costs 25c a quart. I never drank any of it. So, I am not one to talk about wine. We have a wine cellar if you want to come and look at it.
Howard: Next time I am in Paris I am definitely coming by your house.
Dr Tatum: Alright, well you have an invitation.
Howard: Alright, well that’s an honor and a privilege I will never forget. Thank you so much for coming on the show today all the way from France to talk to these dentists around the world today. It has been an honor and a pleasure.
Dr Tatum: Alright, thank you very much Howard.