Dr. Michael DiTolla: Natalie, you have an impressive list of accomplishments and credentials, so I’m going to break them up a bit. You graduated from the University of Toronto in 1996 and then you didn’t become a prosthodontist until 2007. What did you do from 1996 until 2007?
Dr. Natalie Wong: Well, I’m a bit of a slow learner! (laughs) It took me about seven or eight years to realize that I needed to learn a little more! But, in all honesty, when you finish dental school, it’s quite an arduous accomplishment, and you just want to get out and practice. So I was fortunate enough to be able to get into a great private practice. I was an associate with a very progressive general dentist as my principal, and he got me involved with everything, starting with implant dentistry within my first year.
MD: Wow. Did you place or restore any implants in dental school? Was that even in the curriculum?
NW: We were very fortunate because back in the early ’90s, I don’t think a lot of dental school programs incorporated dental implants in the curriculum. But we had Dr. George Zarb; he’s one of the founding fathers of implant dentistry, especially in Canada. He really put us on the map. He was our head of prosthodontics. So as dental students, we were already introduced to the prosthetic components, with O-rings and overdentures and a little bit of fixed crown & bridge. So I feel really fortunate that as a dental student I was already introduced to implant dentistry.
I feel really fortunate that as a dental student I was already introduced to implant dentistry.
MD: Most of my friends who went on to become orthodontists, oral surgeons or prosthodontists did it right out of dental school. I would tend to think it was better that you had a decade of experience as a GP before you went back and got your prosthodontics certificate. Did you feel that way while you were going through training?
NW: Absolutely. But it’s certainly harder to go back to school when you’re used to running a practice and earning an income. It’s hard to give that all up, be under someone else’s thumb, have someone else check off your medical history, and make sure the anesthesia takes effect. They oversee every step of the treatment plan. And they want to see the prep before you take the impression. So it’s a bit of a change to have to go back to that. But I would not change my path for the world because, having had clinical experience, I went into my program with a thirst for knowledge. I knew what I was lacking and what I wasn’t strong in, and I asked to be given cases with a certain level of complexity because that’s what I was there to learn. If you go right after dental school, you’re pretty much just an extension of a dental student, and you don’t know what you don’t know. So without a doubt, I would do it like that again.
MD: At some point you were helping to run the prosthodontics program at the University of Toronto, correct?
NW: Yes, after I graduated.
MD: I would assume you would prefer to accept a student who had been a GP for 10 years and had some real-world experience, as opposed to somebody who had just come from dental school.
NW: Absolutely. But different programs look for different things. Certainly a fresh, young student straight out of dental school is able to have more of an open mind. But a mature student, someone who has been out a while, can also bring a world of experience and clinical expertise to the program.
MD: Right. So you’re board-certified in the U.S. in implants. You’re board-certified in the U.S. in prosthodontics. You’re board-certified in Canada in prosthodontics. You’d be board-certified in implants in Canada if that board certification existed. Can you tell me a little bit about which one was the most difficult and what the process is like to get board-certified?
NW: It’s not an easy process, nor should it be. The hardest one for me to attain was the board certification in implant dentistry. I say that because I did that as a GP prior to my prosthetic program. As a general dentist, there’s nothing in your training that starts to prepare you to take a written exam, to take an oral exam, and prepare cases to defend. So as you’re trying to figure out how to study, how to prepare, and what to look for in cases that you’re going to present, you’re all on your own.
MD: Wow. If 100 people get board-certified for implants in the U.S. in a given period of time, how many of those will be GPs versus specialists?
NW: I’ll be honest with you: It’s mainly GPs. I think it’s just not as well-known that there is a board certification in implant dentistry. A lot of specialists feel that once they’ve finished their specialist program, they’ve achieved enough of an accolade with implant dentistry. But I feel very strongly that specialists and GPs alike should challenge the implant board because implant dentistry is multifactorial. It’s not restricted to one discipline alone. There’s a prosthetic element, a surgical element and a soft-tissue element. In each specialty program, you’re well-trained in your aspect of implant dentistry, and you might be exposed to some of the other elements. But a three-year implant program covers all of implant dentistry at a much higher level than any individual program.
MD: Implant dentistry really is more multidisciplinary than, say, operative dentistry or oral surgery. How long does that board certification take from start to finish?
NW: You can do it all in one weekend, but the preparation takes a lot of work. I would say it’s at least a two-year process because the board demands that you show radiographs one year out — post-prosthetic. Success is not immediate; it’s a long-term definition. So they want to see that the case is successful at least one year out.
MD: Having to show radiographs one year out is a pretty high standard to be held to. Wouldn’t you agree?
NW: I think so. When we look to quote success stories, we try to find something at five to 10 years out. But because you lose patients to other practices over time and people move, it’s hard to follow a patient for that long, unless you’re in an institution or a university where you’re able to maintain the patient base for a certain period of time. So we want to make the exam doable for the average practitioner.
MD: Right. You’re also a diplomate of the International Congress of Oral Implantologists (ICOI), and a fellow of the Academy of General Dentistry (AGD), the American Academy of Implant Dentistry (AAID), and the Misch International Implant Institute (MIII). I know that you also teach with the Misch Institute. How often do you do that?
NW: I feel very lucky and fortunate to be able to count Dr. Carl Misch as a mentor. He really gave me my entire fire to do implant dentistry and to pursue prosthetics as a specialty. He’s really been a great supporter for me emotionally as well as professionally, so I spend a lot of my time with his institute. He runs four sessions of his surgical program in Canada, as well as two prosthetic programs, and I’m a part of each of those. So we’re teaching six times a year. It’s been over 10 years now.
MD: That’s great! Are most of the people coming into the program GPs looking to start placing or restoring implants?
NW: We get a mix, but the majority of the people who sign up for the program are GPs. I think that’s wonderful. I don’t feel that implant dentistry is restricted to specialists. I think that a well-trained GP can do something as well as a well-trained specialist. It’s about having proper education, training, mentorship, follow-up, caring about your patient, and trying to be the best that you can be.
I don’t feel that implant dentistry is restricted to specialists. I think that a well-trained GP can do something as well as a well-trained specialist.
MD: When it came time to place my first implant, I did it with a surgical guide. I know that you like digital treatment planning. How do you feel about surgical guides for placement?
NW: I use a CBCT-generated guide the majority of the time. I think the biggest limiting factor is cost. But with today’s technology, hopefully the cost will start to come down. Digital implant dentistry has really raised the bar for treatment and care. The faster you’re in and out of surgery, the lower the chance of infection and the less pain, swelling and bruising the patient will have. We want to increase the success rates with predictability, but we also want to decrease the morbidity, so that’s where the guides help us significantly.
I do respect that you need to have surgical skill. You need to know how to freehand an implant because God forbid the guide doesn’t show up, or the guide breaks, or for some reason the guide isn’t in the right position because the plan wasn’t as accurate to the mouth as it should have been — these things happen. So the ability to do freehand placement of implants is a very important skill. I suggest working with an experienced mentor for the skill to place implants freehand. In the meantime, do some guided surgeries so that you can improve the outcomes for your patients.
The ability to do freehand placement of implants is a very important skill. I suggest working with an experienced mentor for the skill to place implants freehand.
MD: You surprise me because most people who really like surgical guides are anti-freehand. But knowing how to freehand makes sense because you’re going to be thrown curveballs every now and then, and you will need to know how to react. As a GP, I imagine that every case you do as a prosthodontist is a full-mouth reconstruction. Can you tell me about a typical day in your practice?
NW: My practice is a little bit unique, so I don’t think I can compare myself to an average prosthodontist. I was fortunate enough in my GP career to just work on implant cases. My practice is focused on implant dentistry alone because I do a lot of teaching. I started the Toronto Implant Institute, and my goal there is to train people. Whether you’re a GP or a specialist, we train you on whatever you want to get more experience in. I’ve had the luxury of being mentored by some of the greats in implant dentistry. You learn a phenomenal amount just by watching great people work. So I want to be able to share that. My experiences and what I’ve learned from people all over the world has shaped the implant dentist I am today. So I believe in one-on-one training, which you can’t get very often.
MD: Can you tell me a little more about the Toronto Implant Institute?
NW: We started out as a small group of GPs, actually. We didn’t know which courses were good and which weren’t. So it was a group of us that was dedicated to learning and to finding the best courses. We would meet a few times a year and bring cases and troubleshoot with each other. At that point I was on faculty with Dr. Misch, so a lot of the GPs looked to me for some of the bigger cases, especially the bone grafting cases because they are often a little less predictable. So we would share. I fly all over the world to learn from people. This institute started with just sharing information because not everyone is fortunate enough to be able to go to different places. If I felt there was a value to a speaker, I would bring them to Toronto and run the course there. I would bring these big-name speakers and pay them their honorariums to teach us. So that’s where we all grew together.
MD: So it really started as a study club?
NW: Yes, it did, and then it grew into hands-on teaching. A lot of the higher-end surgical techniques can’t be learned from watching a video or a lecture. You need hands-on training. So that’s what I’m offering. You can bring your patient to my clinic, and we’ll cone beam them, optically scan them, do a digital wax-up, and decide what we need to do. Then you’ll come in, and we’ll do the surgery together. I’ll stand over your shoulder and guide you.
MD: You’re right about that one-on-one interaction; significant learning takes place. Tell me about the Toronto Implant Institute’s programs. How does it work?
NW: Well, at the present time we just go one-on-one. So you approach me and say, “You know, I haven’t placed a single implant and I’d like to get involved.” Then I’ll set up six sessions. We’ve got to go through treatment planning and considerations, and we take cone beams and optical scans and learn how to merge and evaluate data. We’re not trying to make radiologists, lab technicians or IT people out of participants, but you’ve got to know your anatomy. You have to know occlusion. You have to know how things fit together. So we run one treatment planning session, several surgical sessions, and two prosthetic sessions. Someone with more experience could say: “Listen, I’ve done about 50 to a hundred implants. I want to learn how to do some grafting, perhaps some particulate grafting around some implants.” Then we book probably three sessions. We work up cases, and we do three surgical appointments with patients.
MD: That’s an amazing opportunity. It’s literally one-on-one training like you’d get in a prosthodontics program?
NW: Yes. And we customize it because it depends on what you’re learning and how much you know. There are enough courses out there that will group people together, so you have to be different. I asked myself, “How am I going to separate my teaching institute to give people a different learning experience?”
MD: You could probably make more money if you ran 20 people through there at the same time.
NW: Exactly. But, you know what, we make enough money. You pay it forward. If you treat people well and teach them well, it comes back. I get more referrals from other dentists because they’ve taken one session or three sessions or six sessions, and they’ll tell their associate, “You’ve got to learn from Dr. Wong.”
MD: Let’s say a dentist reading this has never placed an implant and keeps hearing that GPs should be placing implants, that it’s something they can do whether or not they have a cone beam. What would you say to a GP who wants to get started placing implants today?
NW: It’s important to get well-trained. It behooves anyone who’s learning a new technique to understand not only the didactic but also the clinical. You want a program that takes you step by step through the didactic, anatomical, surgical, prosthetic and treatment planning considerations. But it should also give you hands-on; first with a model, then perhaps with a cadaver or pig jaw, and ultimately with patients. Then find a local mentor. Most courses don’t give you one-on-one treatment, one-on-one mentoring; it’s too expensive to do that as a large course. Once you’ve completed a course, find a mentor, someone with experience to look over your shoulder. Join an implant organization such as the American Academy of Implant Dentistry. Most specialists are willing to help you because there are enough patients to go around. This whole fear of stealing patients from each other and never having enough patients if you help someone else learn is unfounded. There are so many people in need of implant dentistry that we’re never going to run out of patients.
Most specialists are willing to help you because there are enough patients to go around.
MD: I can see how a GP might be nervous to ask a prosthodontist for help because he or she could be embarrassed about their lower level of skill. Are you saying that the prosthodontists should also reach out to their GPs?
NW: I would hope that GPs and specialists could overcome that barrier because, yes, GPs are often afraid to ask their specialist. But GPs are still going to refer to their specialist. There are going to be cases they can’t do. So it’s a give and take. And I would hope that specialists would reach out to GPs as well because, again, our goal is more predictable, higher-level treatment for the patient. Certainly GPs who are well-trained with technology can do just as good a job as a specialist. It all comes down to training.
MD: Has your placing of implants evolved since you started? Have implants changed? Or are you largely using the same implants that you started out using?
NW: Oh, it has absolutely changed! Something that I love to spread the word on, a mantra that I have, is: The implant you’re using today should not be the implant you placed five years ago, nor should it be the implant you will be placing five years from now. If you are using the same implant for 10 years, then you’re not utilizing the technology that advances on a monthly basis for the benefit of your patients.
The implant you’re using today should not be the implant you placed five years ago, nor should it be the implant you will be placing five years from now.
MD: You’re saying that there are actual real improvements in implant dentistry being made on a monthly basis? I don’t think there is any other area of dentistry that changes with that frequency.
NW: I would even say on a daily basis. We’re just not aware of all the technology and all the research that goes on behind the scenes. We complain that implants cost a lot, but all the research and development that goes into the 95 percent success rates that there are today is a result of implant companies dedicating so much money. As clinicians, we may not see it on a regular basis, but certainly the research that goes on behind the scenes is phenomenal. All the nanotechnology that we have in implant dentistry has also changed a lot of the success rates for us. Just look at any implant company and how many times they’ve changed their implant. In the past, we’d say, “Oh, they can’t be that good; they keep changing all the time!” But, no, it’s actually the reverse. They’re changing all the time because the technology has shown that this surface is better, or this geometry is better, or this nanotechnology is superior. Whereas we used to downgrade an implant company for changing, we are now looking to them for improvements.
MD: The field of implant dentistry is still so young that many changes are being made that are actual improvements.
MD: What are some of those changes that you’ve seen with implants? Is it surfaces, is it thread patterns, or is it all of the above?
NW: I would say all of the above.
MD: Do you remember your most challenging implant case?
NW: The most challenging implant case would have to be an edentulous maxilla on a patient who was a chronic smoker and an uncontrolled diabetic. In hindsight, it’s a case I wouldn’t have treated. The patient presented with a medical history where he claimed he was under control for his diabetes, but he wasn’t. You learn from every case. I now have a glucometer in the office. So if a patient tells me they’re well-controlled, I’m still taking a glucometer reading to be sure. It’s really for the health of the patient. I actually do a set of vitals now at the preoperative appointment. I make sure things are well-controlled. Patients say they’re on high blood pressure medication, that they’ve been on the same medication for so many years, and it’s well-controlled; but if I take a blood pressure reading and it’s a little high, it might mean a visit with their doctor. So that case taught me a lot. I was probably a little too trusting of the patient in terms of his medical condition.
MD: So did that case not turn out well?
NW: It failed. I did bilateral sinus grafts, and the lateral windows and the lifts failed. It got all infected. In hindsight, I shouldn’t have even started the case. So that was my most challenging. Once you start to treat a patient, you feel responsible to help them along the way. I couldn’t leave him in the lurch, so at that point it became counseling. But backpedaling is always a lot harder than going forward. All of a sudden it became: “OK, let’s have some diet counseling. Let’s have you see an endocrinologist. Let’s get this under control and retry the graft.” And so we redid the grafts, and another side failed. So the first time it failed bilaterally. Then the second time around, one side failed but the other side didn’t, and we were 50 percent better than where we were. It took us two years to fix the patient and get him into a comfortable prosthetic condition.
MD: Did everything about his health changing finally make that possible?
NW: Yes. He started to see that when he changed his habits, the success would increase. He was also feeling better about himself. A positive attitude makes a huge difference as well. So it took two years, but he is in a very comfortable position now. I was pleased to be able to see that through, but boy was it a challenge!
MD: Well, you can’t build a house on quicksand. A patient has to give you some sort of foundation to make it work. Where did you learn how to do the sinus lifts?
NW: Through multiple programs: Dr. Misch’s program, Dr. Mike Pikos’ program, watching Dr. Hom-Lay Wang in Perio. Those three were probably my biggest mentors in the sinus lifts.
MD: Did they scare you the first time you did one?
NW: No, I’d watched enough of them. As the adage “see one, do one, teach one” goes, I’d seen plenty done by the hands of many different people. I’d seen when they had complications. So when there was a perforation or a tear, when there was a septum in the way, I saw how to handle those situations. When the roots were close by, I saw how to avoid that. When there was a mucous-retention cyst or a pseudocyst in the way, I saw how to retrieve that and get that out of the way. I saw how to evaluate the anatomy on the cone beam to make sure the ostium is open so that bacteria can clear out if an infection develops. So with all of that armamentarium I actually felt pretty confident on my first one.
MD: Did you do it with a mentor?
NW: Absolutely. It was on a patient, and I brought them to a course.
MD: So you practice what you preach?
NW: Yes. I brought them to one of Dr. Misch’s courses. We worked up the case thoroughly, and I had one of his faculty, one of the mentors, look over my shoulder, and I felt very confident.
MD: Is that something that you teach now at your institute?
NW: Absolutely. We teach bone grafting, soft-tissue grafting, sinus lifts, sinus grafts, the indirect as well as the direct. We teach block grafting. We teach immediate load, All-on-4, All-on-6, all-on-whatever.
MD: If somebody wants to get in contact with you about taking a course, what’s the best way to contact you?
NW: They can reach me through my website: torontoimplantinstitute.com.
MD: Natalie, it’s been an absolute pleasure having you here today. You’re a delight, and I love your approach to education.