Gordon J. Christensen, DDS, MSD, PhD
The Founder and Director of Practical Clinical Courses and Senior Consultant for Clinicians Report offers his views on issues, including what dentists want to know, how they learn it best, and changes coming to the profession.
INSIDE DENTISTRY (ID):You are probably the most sought after speaker in dentistry on a variety of topics because of your diverse background. What do you think makes you such a success in this realm?
GORDON J. CHRISTENSEN (GC): I have been asked this question many times. As a high school and college student, I was very active in public speaking and debate. My first formal dental CE presentation was for the ADA Student Clinician program in New York in 1959. After graduating from dental school, I went into the Army Dental Corps. I found that the dentists from each dental school had different strengths and weaknesses, which were directly related to the emphasis of the faculties in the respective schools. I started to mentor study clubs in the northwest United States, where I was stationed. The groups grew. The interest in practical vs. esoteric education was obvious. Graduate school at the University of Washington followed, where I became involved as a member of some of the very active study clubs in the Seattle area. I was invited to speak at local meetings. The invitations soon grew to state meetings, then national meetings, then international meetings, and finally to a level that I could not satisfy because of time constraints that included family, church, and civic commitments. I did not seek to increase the educational involvement. The only words that might be related to my apparent success are that my presentations are practical, real-world, timely, up-to-date, realistic, day-to-day, research-supported, financially successful, humorous, and—I hope—not egotistical.
ID: What’s the most common question that dentists ask you either at your group seminars or your private teaching and how do you answer it?
GC: Dentists want to know "what works" for myriad dental challenges. They don’t need volumes of research to convince them. They either trust or don’t trust the person teaching. I answer the questions with research as a base, much of which we have done ourselves, backed by the clinical observations of thousands of experienced clinical dentists. To paraphrase the originator of the now trite phrase evidence-based medicine (dentistry), David Sackett, MD, "Neither research nor clinical observation can be used alone. They must be combined to make a clinical decision." In my opinion, we have lost the real intent of Sackett’s definition. Research plus clinical observation equals clinical decisions. Neither alone is enough—I strongly believe that statement. American dentistry has married the phrase evidence-based dentistry ad nauseam. In my opinion, we need to return to our roots. We are dentists; we prevent and treat oral diseases; we are honest, educated people; and our clinical judgments after experience are valid. Combine your personal judgment with whatever research appears to be legitimate, and you are a genuine professional who can stand behind clinical decisions.
ID: As a teacher, what can you tell us about how dentists learn?
GC: Dentists, and all others for that matter, learn by doing. At the very height of the educational pyramid is hands-on activity on patients. Second is hands-on simulation on dentoforms or models. Third, in my opinion, is watching another person accomplish the procedure at hand. That is what I emphasize in the hundreds of clinical videos we have made over the years—my hands moving in high-definition, close-up, real patient treatment. Our videos from Practical Clinical Courses (www.pccdental.com) express my strong support of well-done hands-on video instruction. From that level onto other methods of teaching, the real retentive value of the education depreciates. Verbal CE and reading are on the bottom of the educational pyramid.
ID: How much do dentists rely on others, like you, to interpret the science for them?
GC: As I stated before, dentists trust or don’t trust the instructor. I consider myself to be an observer of research, an observer of the opinions of the thousands of dentists I see annually, and a condenser and interpreter of that information. Much of the current research that is published in dentistry is not clinically relevant. In fact, it can actually be misleading. Someone has to sort the wheat from the chaff. That is my job, along with many others.
ID: Everyone is interested in delivering excellent healthcare. What needs to be changed or improved to increase quality?
GC: More emphasis should be placed on conservative dentistry—providing more complete treatment plans with an emphasis toward the long-term service, and providing realistic "informed consent" to patients, having them participate actively in accepting or rejecting treatment plans. People are living for an average of 80 years, and they need to understand their potential treatment thoroughly. I see a major need for more clinical education in dental schools. As I see thousands of young dentists, they are extremely bright and capable when educated/trained adequately, but I do not see an impressive level of clinical competency in many of them as they graduate from dental school. Realistic, practical CE is one of the answers. Too many of the current "show and tell" CE courses are out of the realm of typical general practices, and many are just company infomercials.
ID: Based on your experiences and outreach within the education and practicing community, what do you think are the two or three of the biggest challenges facing dentistry and dentists?
GC: Managed care in dentistry has been a blessing and a curse. I have seen it from the start. As managed care began, the third-party payers paid a benefit, and the patient paid the remainder up to the dentist’s legitimate fee level. That was a logical and realistic approach to paying bills for oral care. It is well known that, currently, the initial intent of managed care is no longer the case. There’s major rebellion in the practice community about the dictates and mandates of third-party payers. Significant change needs to be implemented before the practicing community rebels, as has been done in the British National Health Service: Dentists are refusing to work in that system.
Funding for dental education needs enormous upgrading. The lack of dental teachers is appalling. Our dental students need complete, practical, research-based education—and that takes money. More funding would attract more dental educators.
ID: What is dentistry’s next big unrealized opportunity?
GC: Providing care for the underserved.
ID: What has been the most significant change that you have witnessed in the profession in the last 25 years?
GC: The advent of dental root-form implants is obvious. As a prosthodontist, seldom do I make a treatment plan without some consideration for dental implants. However, very few Americans have had a dental implant—estimates state only about 1% of the adult population has had an implant. That statistic is far below other developed countries. There are about 200 million adults in the United States; it’s been estimated that 178 million of them have at least one missing tooth. We need to stimulate implant placement with great enthusiasm. I have long promoted the placement and restoration of root-form implants by qualified, educated/trained general dentists for healthy patients who have adequate bone. The more complicated implant cases should be treated by oral surgeons, periodontists, prosthodontists, endodontists, and others. However, 90% of currently placed implants are singles. If that is a guide, general dentists have a marvelous potential to increase their activity with implants.
ID: Much of your lecturing is on new materials and research findings from your testing at Clinicians Report, a practical hands-on resource for product review. With the confusing plethora of choices these days, are dentists listening to you as a way to get practical advice on what to use and how to use it?
GC: One of the major challenges for dentists attempting to select an adequate product is the hype produced by many manufacturers. To the uninformed observer dentist, every new product is the best product in its category. Ethics in advertising could be greatly improved by some companies. When a successful concept comes up, every company remotely related to the new concept develops its own brand, usually by copying the original product. As the original and still the only non-profit dental product evaluating group, Clinicians Report has the responsibility to identify products that are faster, easier, better, or less expensive than others on the market, or to identify new promising concepts after research and sufficient clinical observation.
ID: How do you ensure that there is no conflict of interest in your reviews?
GC: Clinicians Report’s scientific and clinical staff meets on a routine basis with manufacturers who present information about their products to us. We then evaluate those that appear to be promising. There is no money exchanged for the evaluations. If a product fits the characteristics listed above —ie, it is faster, easier, better, or less expensive—it is likely to appear in the Report, for which, again, there is no exchange of money. We are entirely supported by subscriptions from around the world, income from courses, and donations. Whatever works well in both basic science research and in clinical observations wins, regardless of the company.
ID: Tell us more about the work that is exciting you these days.
GC: CAD/CAM in-office and lab is taking over the indirect restoration marketplace. It’s moving faster than any other concept I have seen, other than perhaps air-rotors many years ago. I see the metal age in dentistry rapidly disappearing—for good or bad. Zirconia and lithium-disilicate restorations are taking over the market.
ID: I know one of your concerns is the state of educational support for the dental laboratory industry. Can you comment on this problem and offer suggestions for improving it?
GC: In 6 years of independently sponsored laboratory summit meetings, we’ve identified several major challenges in the current laboratory profession:
- The lack of accredited dental laboratory technician educational programs and the need for active recruitment for dental laboratory students. The ADA and NADL need to be stimulating these programs.
- The need for dental laboratory certification and dental technician certification. This must come from state legislative mandate, not weak national "resolutions".
- The growing grey market and the continued expansion of laboratory products from offshore laboratories. This will continue to grow until China has a middle class, raises fees, and uses more of its own crowns and prostheses.
- The almost total absence of interaction between dentists and laboratory technicians in dental schools, continuing education programs, organizations, or in clinical dentistry. Again, there is a need for an ADA mandate that lab schools and dental schools should interdigitate.
- All of these areas need significant observation and change. The ADA and the NADL are now working with the Laboratory Summit group to attempt to solve some of the problems. The final outcome is still to be observed.
ID: What are dentists sharing with you about the economics of practice during the last couple of years?
GC: In response to the recession, patients are resistant to spending significant funds. Fewer patients are coming in for recare appointments or accepting elective treatment. They want more conservative fixes and are questioning treatment plans. In general, dentists are not as busy; some have had to postpone retirement.
ID: How do you regard the dramatic growth in large group dental practices and what does this trend portend for dentistry?
GC: It’s both good and bad. Many dentists going into corporate dentistry are young practitioners, and this is good for them to build speed and gain experience. Quite obviously, the corporations want to be efficient, so their orientation will streamline procedures. On the potential negative side, financial necessities may dictate procedures. I have no question that this trend will continue.
ID: How good are dentists at the management and operational elements of running a business?
GC: Good to bad. Dentistry needs more business education in dental school.
ID: .What advice would you have for transition planning for those dentists who are nearing retirement?
GC: First of all, I have no plans to retire. If you enjoy dentistry, don’t fully retire—slow down and enjoy it, teach, do research, volunteer. However, I know that many dentists want to retire as soon as possible. Some dentists sell their practice and stay for a few years as an associate. That’s a good method for phasing out of practice. Others sell the practice and leave, which is the cleanest method.
ID: What is one characteristic that you believe every leader should possess?
GC: I have actually studied this question over many years. The observed biographies of major leaders in all phases of life are quite similar. The concept that permeates all of their statements relative to the single most important leadership characteristic is optimism, positive thinking, enthusiasm, passion—all of which are near synonyms. I concur completely and have also identified another 10 characteristics of well-known leaders.
ID: As an organization becomes larger and more complex, there is a tendency for the inspiration to be lost. How do you keep this from happening in your organization?
GC: Constant communication with the staff, and seeking their suggestions. Observing all new concepts coming into the profession, and being in constant communication with the practicing and research profession about what they don’t know. Comparing research and identifying areas for improvement. Taking on at least one unknown major project per year. By doing all of the preceding things, I have never burned out.
ID: If you got a do-over, what would you change about what you’ve done or not done in the profession?
GC: I love dentistry—I would do it again without any hesitation. I wouldn’t change much in my life or the life decisions I have made. I sincerely wish that dentistry and the other phases of medicine were still one. It was a mistake for our forefathers in 1839 to separate us from our colleagues. If I were doing my education again, I would probably get the MD union card to augment, but not replace, my dental degree. However, in spite of that misdirected decision by the leaders in medicine of long ago to segregate, dentistry has done very well for patients, and for those of us fortunate enough to be dentists.
ID: What’s the best lesson you learned along the way?
GC: History repeats itself. Just wait long enough and "whatever" will come around again. Don’t be too fast to accept the newest thing on the market. Wait until many others have had some experience. Don’t think that technology will replace us. Some of the currently hyped technology is merely a replacement for, but not better than, conventional treatment. The dentistry of 30 or 40 years ago actually lasted longer and perhaps served better than some of our current dentistry—however, it was metal and ugly!
About Dr. Christensen
Gordon J. Christensen, DDS, MSD, PhD is Founder and Director of Practical Clinical Courses (PCC) and Senior Consultant for Clinicians Report (CR). PCC provides continuing education courses and videos for dental professionals worldwide, while CR conducts research on thousands of products in all areas of dentistry. In addition to authoring numerous articles and books, Dr. Christensen has presented over 45,000 hours of continuing education.