By: Shelagh McNally for Dental1
Bruce W. Johnson maintains a full time private practice limited to Periodontics and Implantology in Poway, California. He received his D.M.D. degree from the University Of Pittsburgh School Of Dental Medicine in 1978 and his Certificate in Periodontics from the Wadsworth VA Medical Center Residency in Periodontics in 1981. Dr. Johnson has lectured nationally and internationally on topics of implant dentistry, periodontics, esthetic periodontics and pain control to many audiences including the American Academy of Periodontology, the Western Society of Periodontology, the USC Periodontal Symposium, the New York School of Dentistry Implant Symposium and the Northeast Society of Periodontology. Dr. Johnson has published several clinical manuscripts involving implant dentistry and pain control. He is a member of the ITI.
Dental1: When did you first know you wanted to be a dentist?
Dr. Johnson: It was towards the end of my college education. I had been on a pre-medical dental track and I got to know some dentists in the community and observe their lifestyles and practices and I found it very intriguing. It was actually the defining event that led to my application to dental school.
Dental1: What was it that attracted you to the field?
Dr. Johnson: Dentistry is a strongly science-based field, which blended well with my aptitude throughout high school and college. I liked the caregiving aspect of treating patients and being a caregiver in the community, and I liked the ability to have my own practice and make my own decisions as to how to direct my career.
Dental1: What do you find to be the biggest challenge in your career?
Dr. Johnson: Well, there are many challenges. I think the one that, of course, has to be the greatest challenge is to constantly be ready to provide a very high level of treatment and service to patients. You need a good night’s sleep every night and a good lifestyle so that you can show up to the office in the morning and be ready to not just perform but to really be at your best.
Dental1: We have seen a lot of new technology in the last 15 years, particularly in the field of cosmetic dentistry. Do you think that we are expecting more from dentists now because of all this new technology?
Dr. Johnson: Certainly. I think that has been a trend for quite a few years, as dentistry moved away from a need- and emergency-based service where people would have cavities and emergencies and toothaches to drive them into the dentist. As that has become more under control for a large segment of our population, dentistry has steadily moved into more elective procedures that are enhancing lifestyles. Cosmetics are a good example of that; dental implants are a good example of that. Technology has moved along with us and as a result, the dental consumer does expect more from the dental care provider.
Dental1: You do a lot of dental implants in your practice. How has that changed the field of dentistry, being able to do this quite advanced procedure?
Dr. Johnson: The technology of dental implants has – in my opinion – been the most significant change in the last 30 years of dentistry. What implants represent are titanium replacement for the roots of teeth that bond directly to bone with an extremely high success rate and can be used as anchors, just like the roots of teeth, to rebuild individual teeth that have been lost, groups of teeth that have been lost, or even entire mouths of teeth that have been lost, and restore them to full and natural function. Dental fillings and dental bridges all take a damaged tooth and repair it as well as possible. Ultimately, a great deal of these repairs fail structurally. Dental implants are the first time in my career that dentistry has been able to provide something new that is actually stronger and more biologically and structurally sound than what we had to work with before.
Dental1: Do you think that we are ever going to see a point where dental implants replace the traditional bridgework and other techniques that are used, and bridges are going to become so outdated that the industry standard becomes implants?
Dr. Johnson:Well, in terms of standard of care, I think that time is here now, given the time that implants have been in the field with proven success rates and continued evolution in the technology and the sophistication of delivery. It is clear that implants as tooth replacements in the majority of cases are superior to fixed bridges and I think that as the profession as a whole becomes more experienced, this will become even more of a common opinion.
Dental1: When you read it about it, it sounds like an almost too good to be true technology. Are there any drawbacks to dental implants?
Dr. Johnson: It does sound almost too good to be true, the success rate being solidly in the mid 90th percentile, the surgical procedure being so sophisticated, and the recovery rate generally fast. The downsides to the procedure are relatively few. I guess I would say that like many things it starts with experience and a sound treatment plan so that the right treatment is being applied to the right set of circumstances. There are rare occasions where the individual is just not a good dental implant candidate. Usually that is due to the bone foundation being damaged through either disease or trauma. Then the alternative could be a better way to go given risks of treatment versus the benefits, but that is a small percentage of the cases that present themselves.
Dental1: Do you find that the cost is factored into it? The very first dental implants were certainly more expensive that what we are seeing now. As dental implants become the industry standard are we going to see the price come into par with how many are being done?
Dr. Johnson: As implant treatment becomes more widespread and its techniques evolve, I do think the costs will modulate downwards somewhat. I do not see them becoming low cost. There is too much that goes into the entire treatment plan. I explain to patients that when you are getting bridges you are using the teeth that you have. When you get dental implants, you have to start by replacing the teeth with implants and then the bridges come on top of that. And in the cases where bone grafting and a phase of preparation of the bone foundation is involved, those are the cases that will always remain on the high end of the cost scale within dentistry because there are so many different types of treatment that have to be carried out.
Dental1: How do you go about creating a treatment plan with your patients? Do you sit down and determine what the needs are first or do you basically give them recommendations, saying this is what I recommend you do?
Dr. Johnson: Well, I work in concert with a number of very fine restorative dentists. Most of the patients I see are referred to me from this group of dentists who have identified the problem, a failing tooth, a failing bridge, a denture that doesn’t fit or isn’t satisfying any longer and they’ll start the recommendation and send it to me for my opinion and further recommendation. From there, I will do a complete evaluation both clinically and with radiographs, then put together a series of solutions that range from optimal to second and sometimes even third tier, but acceptable solutions
Dental1: What level of patient education do you find? Do you find that most are fairly knowledgeable or are you explaining the procedure from the ground up?
Dr. Johnson: My patient base is fairly knowledgeable but I still explain all the aspects of the treatment, pretty much from the ground up. I tend to do some pretty simple drawings and go through the manner in which implant surgery is carried out. There is lot of verbal discussion and I use photographs that show before and after cases that represent similar problems and treatments that we are looking at in my patient’s case.
Dental1: Do you use the Straumann implants?
Dr. Johnson: Yes, probably 98 percent of my practice is with the Straumann dental implants system from Switzerland. It is an outstanding system. They are going on their 27th year in the field and they have just consistently been leaders in the field in terms of research, machining, metallurgy, and support to the profession.
Dental1: And have you started using the immediate load implants?
Dr. Johnson: I have some experience with immediate load implants. That is an area of the profession that is gaining a lot of notice. What it really means is that a dental implant that requires two to three months to integrate with bone to where it can be loaded without question can, under certain circumstances, receive some type of load immediately and still be highly successful. If we are dealing with groups of six or more implants, which is usually an edentulous case, meaning no teeth, the implants are all joined together immediately and are actually loaded, meaning they receive chewing forces. However, they have a high success rate since they brace each other so well. A single implant, like a front tooth that is lost and has an implant placed, really doesn’t receive immediate load because it can’t tolerate it. What it receives is an immediate crown. It is carefully made so it does not have contact with other teeth and it maintains the space and is cosmetically working in that you can smile with it but it is still a two-month or three month time frame before the final crown can go on that single implant and receive chewing or loading force.
Dental1: So even though we have immediate load implants there are restrictions with it?
Dr. Johnson: Yes, you have to choose the correct cases and it does require a higher level of technical expertise because you use fresh implants that can be unscrewed right out of the bone with normal forces and you’re putting the teeth on it under those conditions. In the traditional way, by allowing the implants to achieve integration in eight to 12 weeks, you no longer can move those implants out of the jaw, which is the most understood and sound way to do the cases.
Dental1: Well it sounds like erring on the side of being conservative is probably the smart way to go with these dental implants
Dr. Johnson: Yes, I think so. I have been in practice now for over 25 years and come from the era when implants were viewed as experimental and had problems. I went through the phase of getting my colleagues to feel it was acceptable to even recommend implants to their patients for fear of the problems that could develop. I think those experiences have stayed with me because a high degree of success and predictability is in the forefront of my recommendation and treatment planning.
Dental1: And are you seeing any botched jobs or repairing implants that another doctor has done?
Dr. Johnson: Unfortunately, that is seen in the profession. Most of what I see are errors in judgment or procedures that were flawed.
Dental1: When you’re talking about implants going in and adhering to bone, is it difficult to repair once the post is part of the bone system?
Dr. Johnson: Yes, it is possible to repair it but, unlike the first eight weeks when the implant can be easily removed, once it integrates or fuses, it has to be removed through a surgical process of drilling it out, which is much more traumatic.
Dental1: That sounds painful.
Dr. Johnson: It is not as bad as it sounds, but it is unfortunate. A very important thing about every dental implant is its three dimensional location. If it is in the correct location, what we call the green zone, it is usually a straightforward application of restorative dentistry to put the crown or the bridge on it. If the implant is three dimensionally not in that zone, crowded up into another tooth, too far to the tongue or the lips, then it becomes difficult.
Dental1: What should someone look for when they are trying to find a reputable dentist who deals with dental implants? Obviously, you have been trained, but what would be some of the criteria that they need to look for?
Dr. Johnson: I would tell people to look for a practitioner that has a track record and solid experience in the field. Getting a second opinion is always a good idea. It is simpler if your primary care dentist works with and knows somebody that meets all those requirements and has a consistent track record of excellence and expertise.
Dental1: So, getting a referral or recommendation is a good idea?
Dr. Johnson: Yes, you can get patient testimonials. I have found that patient satisfaction with implant treatment is extremely high and is definitely an enhancement of life. In fact, for people who have been struggling with failing teeth it is a life-changing event to move forward into healthy teeth that function and smile with total confidence. These people are usually very receptive to receiving a call from a patient who is nervous and uncertain and has a fear of the unknown and just needs to talk to somebody to get through it.
Dental1: Do you have any favorite pieces of equipment that help you do these dental implants?
Dr. Johnson: Well, every implant system has its own surgical kit so I am certainly partial to the Straumann implant regimen and instrumentation that goes along with that. In terms of other technology that helps I think that CAT scan radiographs have been a significant area of technology that has developed to the point where it is much easier to acquire these scans for patients and interpret them in a variety of ways. We are using them more and more frequently with patients’ treatment plans.
Dental1: How do you balance keeping up to date with all the new technology with having a full time practice, because you also lecture and write papers. How do you find your balance between the need to stay updated and also keep your practice going?
Dr. Johnson: Well that is a big challenge. You asked me earlier about the biggest challenge and I focused on treating patients but yes, managing the practice, keeping the staff happy and motivated, all of those are significant challenges as well. For a practitioner like myself who has many years of experience, an important challenge is staying up with new developments in the field. One way of doing that is attending major meetings. Straumann is a particularly outstanding organization in this area in that they provide not only several annual focus group types of meetings, but every other year either in Europe or the United States, they have a major international congress in which the various areas of the field are discussed from traditional treatment and how they’re evolving, to cutting edge technologies and how they’re being applied, and even future projections. I should mention the ITI, the International Team of Implantology. This was a group of individuals founded in Switzerland over 20 years ago. This international team was comprised of highly experienced and skilled professionals in the field of dental implants, ranging from practitioners in private practice to educators and researchers. They are supported by Straumann but completely independent and just a huge resource to all of us in the field for evaluating what is currently being done, making recommendations, and looking to the future.
Dental1: Are there any future improvements or new technologies that you would like to see coming up with the dental implants?
Dr. Johnson: Some of the latest things that have been produced are surface treatments to the titanium that enhance the speed and vitality of bond to bone, which is making the ability to finish treatment in a shorter time frame possible and also improving success rate in very soft, spongy bone conditions. I feel there is some exciting development ongoing at this time with the use of computer technology merging information gained from CAT scans of bone anatomy and combining that with similar CAT scans of the proposed prosthesis. Being able to interface those in order to have accurate placement of implants through surgical guides that can even perform the service without opening up the area to find the bone but being able to use guides based on all those technologies is exciting too. The procedure can be delivered to patients less invasively and even more accurately.
Dental1: That sounds really fascinating, that there are so many changes. Do these changes happen fairly quickly with this new technology or has it become fairly stabilized at this point.
Dr. Johnson: I think changes come over time. Changes in our field that happen too quickly wind up being tested on the patient and if problems develop, they are the ones that suffer for it. So even though it’s exciting to think and dream of changes for the better I think it’s wise to take a very cautious approach. We always want to be able to know that we’re not wavering from the proven predictability, which is really why implants as a dental treatment have become so successful and satisfying.
Dental1: My final question is back to cosmetic versus necessity, do you ever have to draw the line with patients between a procedure they think they need when it is really unnecessary and more vanity dentistry?
Dr. Johnson: I think that’s just a good bit of advice for everyone in the profession that you need to be sure in your own heart and mind that the treatment you’re carrying out is indicated and accomplishes some benefit of significance for a patient. It is down to risk versus benefit. With all procedures there are risks. What makes it work is when the risks are low and controllable and complications can be managed – and the benefits are high and outweigh the risks.