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Howard:
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It is a huge honor for me today to be podcast interviewing Dr. Dan Hagi from Ontario Canada, Toronto, Ontario Canada.
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Dan:
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Nice to be here with you Howard.
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Howard:
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I'm in Phoenix and you and I, our cities both have the same baseball stadium and they both have a retractable roof and yours is because it's cool and Phoenix is because it's too hot. You have a retractable roof with heaters and we have a retractable roof with air conditioners.
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Dan:
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It is always open?
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Howard:
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Yeah, they leave it open to air out and grow the grass and all that stuff and then they close it up in the morning for the game and cool that baby down.
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Dan:
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Nice.
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Howard:
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It's absolutely beautiful. You're with the ... Let me read your bio. Educated at the University of Toronto, Faculty of Dentistry. Dr. Hagi has a focus for minimally invasive aesthetic dentistry and metal-free oral implant rehabilitation. Dr. Hagi is a fellow with the International Congress of Oral Implantologists, Academy of General Dentistry, International Academy of Dental Facial Esthetics and associate fellow of The American Academy of Implant Dentistry. The Thornhill Smile Center, Dr. Hagi's private practice, is located in Thornhill, Ontario and is a leading dental center of the world LDCW along with The Centre of Excellence in Implant Dentistry the education center Dr. Hagi brings excellence to dental care and dental continue education.
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Dr. Hagi is an international lecturer, published author and consultant to several dental manufacturers. I was so excited you accepted my invitation to speak because you could talk to 100 implantologist in a row and ceramic implants wouldn't even come up.
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Dan:
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Absolutely.
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Howard:
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How did you switch from titanium to ceramic? When you were little did you fall down and get hurt by titanium and you have some leftover childhood scar from titanium that made you go ceramic or is this just part of the ongoing aesthetic revolution for the metal-free practice.
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Dan:
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Let me dive back into how I started with implants. I started my studies with Dr. Carl Misch who you had here a couple of months ago and he had a podcast with you. S1 was a change in my life.
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Howard:
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S1.
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Dan:
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S1, so the first session, the treatment planning session.
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Howard:
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Okay, with Carl.
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Dan:
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Yeah. That changed the way I looked at dentistry and I started doing the surgeries and it wasn't until about five years later that you start seeing the complications of what happens with titanium implants. Prosthetic complications, the peri-implant disease and I really wanted to see what else was out there and then there was Facebook. You see these guys posting cases on Facebook with implants out of Europe that are not titanium and this fascinated me. I looked at what was going on in the rest of the world and then I discovered this material called zirconium and people are doing implants with it and the results just blew me away. Since that time we started placing ceramic implants.
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It's been about five or six years now and it's been a transition for me going from everything titanium to now the majority of our implants are ceramic. We're probably the number one dental clinic in North American, and certainly in Canada placing these types of implants with tremendous success. That's really been my voyage through implantology to where I got to be playing with ceramic implants now.
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Howard:
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Everyone things ceramic is strong because if you put a ceramic plate tile on the ground and have an elephant stand on it it holds it where if you put him on plastic it would deform it but if you drop plastic tupperware it bounces and if you drop ceramic it shatters. What is the difference in fracture rate of a ceramic implant versus titanium? Wouldn't titanium have a little more flexibility less fracture or not so much?
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Dan:
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Absolutely. The interesting thing is that if you look at a titanium implant now all titanium implants in the market are two-piece and what I'm doing is one-piece ceramic. A two-piece titanium implant you've got to look at the weakest link in this and the weakest link is that interface, the abutment to the implant. Look at the screw that's holding this thing together.
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Howard:
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The screw would be the weakest link, wouldn't it?
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Dan:
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Absolutely. It's a tiny, tiny little screw that's holding everything together. Then the studies, Misch had studies in the late 90s comparing the strength among all implant types and geometries. If you look at those studies and you compare the numbers to the ceramic implants that we're using it's about two to three times stronger compared to same size in ceramic versus titanium as a complete structure of the implant and the abutment. I haven't seen any fractures in my practice of these implants. I've seen plenty of fractures the abutments, screws and implants in titanium. If you compare one against the other at least in my experience and also in the literature you see that there's way more fractures in one material compared to the other.
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Howard:
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Well if you are on Dentaltown do you know how many threads there are on how to get out a broken screw?
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Dan:
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Absolutely.
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Howard:
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You could write a book on that. In fact I'm on my app now I'm doing the search broken screw and oh my God it just ... Broken screwed implant hybrid denture, broken screw and implant, removing a broken screw, broken screw and abutment. Help, broken screw. 3.0 aster broken screw, 3I broken screw. It just goes on forever. You're saying the main advantage is the ceramic zirconium is a one-piece and the titanium implant's the weakest link is that tiny, itty bitty little screw. That one-piece zirconium ceramic implant is two a half times stronger than that little screw. Did I summarize that right?
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Dan:
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Yeah, it's two and a half times stronger than that entire complex together because you get titanium implants fracturing as well. You get the implant fracture because you get a thin implant with very thin titanium walls. You see very often ... Well very often it's ... In my practice I see very often fractured implants that need to be removed. It's interesting that we look at metal and ceramics and we assume that because it's a metal it's stronger, because it's a metal you compare it to a metal plate or a ceramic plate and a metal plate. You drop one one breaks, you drop one it bounces but when we're talking in the mouth it's a completely different ball park.
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We do have one-piece titanium implants so these have been on the market but I don't know anybody that uses them because they don't look like teeth. With the ceramic you get a white implant, one piece what is healthy or the gums, is strong and it looks really good.
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Howard:
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Now, you're probably placing a lot more implants in Americans since your national pastime is hockey so do you have any one in your family that has their upper front six teeth or they just all have that hockey smile?
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Dan:
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No, we're not really into hockey but everybody's got their front six teeth.
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Howard:
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It just so funny watching the Phoenix Coyotes whenever they're panning the bench. Nobody, has their front four incisors on the entire bench. There's not an incisor on that team. If this is such a good thing why are so many doctors afraid of ceramic implants?
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Dan:
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I think it comes from top down. Nobody's talking about them. The entire profession is focused in on titanium and if you look at the lecture circuit the main topics that are being talked about today are peri-implant disease. Everybody's talking peri-implantitis, what happens when you lose implants, how to build buckle bone. Everything, how to fight these complications but nobody's eyes at least at the top have opened up to the potential of ceramic implants. There's a fear. Look back at what Carl Misch said in his conversation with you. He said that in the 70s and the 80s the professionals doing fixed partial dentures and they were sending him the full arches to do the implants. Him, Han, Tatum, they were all the heretics.
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They were crazy to be doing titanium implants. Nobody else was doing it. Now, we look back and we see these guys as the pioneers. These guys started what we now see as dental implantology and I think the same is true with all the guys doing the zirconia today. People look at is and we're like the crazies using ceramics. Everybody else is putting titanium, these things are going to break, they don't integrate. You guys are going to have complications, all your implants are going to fall out but I'm not seeing that and across the board we're all having tremendous success. I look at it as in 10 or 15 years we're going to look back at all the guys doing the ceramics today and that's going to be the pioneers of the next phase of implantology of the ceramic implantology.
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Something that's metal-free. It's an interesting transition that's happening but it's slow. It's slow adaptation. You know how dentists are, we're scared. We're scared to take the leap.
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Howard:
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I'm 20 years older than you. I'm telling you in the 80s the guys placing implants were called butchers, quacks, nuts and some of these guys their first time they had a case fail the board would take their license away. It was like they got one strike and they were out and I know dentists who were financially wiped out because they had done so many of these amazing subperiosteal, [inaudible 00:10:34] frames, all these implants cases. They had treated so many people and were just a legend in their community and everybody just thought they were nuts. Then the first time something failed, peri-implantitis infection, whatever, their license gone. It was brutal and ugly back then. Brand name, there's just one company make this or are there multiple companies? What system are you using? Ones available.
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Dan:
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No, the marketplace is getting flooded with these guys. The ones that I use are from Spain, it's a company called Oral Iceberg and the implant is called CeraRoot.
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Howard:
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What's the www on that?
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Dan:
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I believe it's www.ceraroot C-E-R-A-R-O-O-T. Com. Then there's Z-Systems, there's ZERAMAX. There's about I think close to 20 companies making ceramic implants. Now most of them are European based but the big player in the game and a round of applause to this company who's coming up with it. I think they're getting FDA clearance if they haven't gotten into the US yet they're coming up any minute now is Straumann. Straumann has the first ... was going to be the first large manufacturer to have a one-piece ceramic implant in the market and it's very exciting to see that.
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Howard:
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Was that a merger and acquisition because I know they wrote a big chunk and change ... They're trying to buy Megagen June 1st. We'll find out June 1st if Megagen takes that offer or not. Did they buy someone else or did they bring this to market in-house?
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Dan:
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No, this was brought in-house, it's been about 10 years of research and development for them and it's their in-house product. It's got a ZLA surface and it's looking really good. Having said that the implant that I use the CeraRoot has been a phenomenal implant and it serves my purposes and a lot of clinicians around the world. I think it's probably the number one ceramic implant out there with success rates at five years that were 98% and at 10 years that are very similar. We're getting equivalent success to what we have with titanium out of the ceramic.
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Howard:
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Is CeraRoot is number one right now what's the www on the number two or number three? Do you know any more?
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Dan:
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I think the next one down would be Z-Systems which would be ... and I'm guessing the url is z-systems.com.
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Howard:
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The z would be for zirconium?
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Dan:
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Correct, year.
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Howard:
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Because zebra just wouldn't make sense.
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Dan:
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Unless we come up with a stripped implant.
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Howard:
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By the way just for the listeners out there I don't sign NDAs, every damn week someone sends me a deal and wants me to sign a non-disclosure agreement because they want to talk to me about this idea. The reason I don't sign NDAs is because I've been doing this for 20 years. Anyone who's ever asked me to sign an NDA I've never seen them bring it to market. Number two is 99% of all patents never generate enough money to pay for the patent deal. Most people if they're smart they just spend all their time and money getting a prototype and then they get it working and then they send you a sample. The people who start with patent attorneys and non-disclosure agreements they're never going anywhere.
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Whenever I talk to them I always say I've got four rules, you've got a new dental idea, is it faster? Is it easier? Is it higher quality and lower cost? If you can meet all four of those you're going to crush it. I'm going to ask you, are ceramic implants faster? Are they easier? are they lower cost? Are they higher quality? How many of those four points can you say yes?
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Dan:
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I can hit all four points.
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Howard:
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All right. Well let's hear it. Let's hear it.
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Dan:
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I can do it.
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Howard:
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You're going to hit a home run?
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Dan:
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I can hit a home run. Easier, with a one-piece implant you see the abutment, so you see the position. If I'm going in there replacing a central incisor I'm placing an incisor that has a prepped margin already. I'm putting the tooth or the implant where the tooth was. There's no guess as to position. If I got in the wrong direction, if I got wrong angulation I see it right away.
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Howard:
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That means you're not doing a surgical guide then?
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Dan:
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Sometimes I use surgical guides but most of the time on a single tooth I don't need it. Right? I'm aiming at a point between two other objects we can drill that straight. The great thing is that you see the final result. You see your preparation right at the time of surgery. If you messed it up you know it right away. It's not like the surgeon placed it and it's angled toward the buckle and you ... because you would see it in a second. It's much easier to get a perfect implant. Is it cheaper? I find that in implant dentistry the cost of the implants tends to be all about the same. It's the restorative side of things that really eats up a lot of the cost. Go into custom abutments, lab charges, at least in Canada we're different than in the US but it's huge to restore an implant.
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The cost of restoring a ceramic implant is the same as putting a crown on a tooth. There's no custom abutments, there's no abutment portions. It's just simple. It's just a dead easy impression. If you have CAD/CAM in the office you just mill out a E-max crown and that's it. There's nothing else.
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Howard:
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Do you have CAD/CAM in your office?
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Dan:
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We of.
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Howard:
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Did you go Dentsply Sirona or did you go E4D Planmeca?
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Dan:
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We did the Planmeca route.
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Howard:
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You wanted an open system.
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Dan:
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Exactly.
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Howard:
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Finish your other points then we'll go back to CAD/CAM and E4D and Planmeca.
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Dan:
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The next point was is it better? Really the clincher in this is the soft tissue. Sometimes people think of ceramic implants as metal three and they look at me and think, "This guys is a holistic dentist, non-fluoridate." Look at me as a crazy guy but I'm not. Nothing to do with holistic, I am a GP and I believe in dentistry and there's no hocus-pocus here. What I do believe in is that anything that we put in the mouth has to have a gingival response that is the same as teeth. This is what we get with ceramics. I put a ceramic implant in I know predictably that my probing depths around that implant are going to be two/three millimeters. The tissue is going to feel like it feels around a tooth.
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Not like with titanium where you can ... and you know this in your practice. You probe around a titanium implant it's very rare to get a probing depth of less than five or six millimeters. You take the probe out or the hygienists take the probe out and there's bleeding nearly every single time. The gingiva is just not happy around that material and we get a much nicer result with the ceramics. That's the third point. What's the fourth one?
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Howard:
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Faster, easier, better, cheaper.
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Dan:
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Did I get all of them yet?
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Howard:
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You did.
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Dan:
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There you go.
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Howard:
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When you place this and the abutment is sticking out so talk about immediate load versus if your abutment is sticking out but you don't want to load it.
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Dan:
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It depends on our stability. If we have good initial stability we can put an immediate temp on it just like we do on titanium. Same healing protocol. A lot of my cases I put an essix appliance over it which is going to protect the implant from any premature loading. I put in a composite tooth in that essix appliance. That's my temporary. Most ...
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Howard:
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Explain what essix appliance is.
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Dan:
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Sorry, so an essix appliance is a clear retainer. Almost like Invisalign tray. I use that instead of a flipper or another appliance to replace the tooth. It's an empty shell that sits over the implant and you can't load the implant. It's protected. You can eat with it, you can function with it, you can wear it at night. Your tongue is not going to go to the implant. You have a nice environment for that implant to remain immobile.
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Howard:
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What percent of the United States, Canadian implant market right now do you think is ceramic? Is it less than a percent, is it 2%, 3%? What do you think it is?
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Dan:
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I imagine it's much less than a percent.
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Howard:
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Much less than a percent.
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Dan:
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Yeah.
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Howard:
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Leave it to the next generation to be trying the new things. I really tip my hat for you to ... It's just amazing that when 99% of the market's doing titanium and you went ceramic. I just love minds like that. Do you know what I mean? Like Southwest Airlines when they started 100% of the airlines did the hub and spoke system and Herb Kelleher was a lawyer and he just said, "Well that's crazy I'm just flying direct. If I can't fly there direct then we ain't flying there." By taking that hub and spoke cost system out of the equation he had the lowest cost. One move, fly direct. All the other stuff was lesser stuff like using the same plane, getting rid of meals, only serving peanuts. That was all secondary to just doing direct flights.
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I really applaud your amazing mind that when 99% says, "We're going titanium" and you jump on ceramic. Let me tell you just some of the comments I've heard on Dentaltown. Well if it fractures it's just impossible to remove the implant.
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Dan:
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Same as an ankylosed tooth. I haven't had that experience yet but we found a way to remove titanium implants. Everybody said the implants integrate and it's impossible to remove, that it lasts forever but we unscrew them. Same thing about the ceramics, you can grab a hold of it I'm sure if the time comes either with a forceps or cut a little bit of the cortical bone at the coronal part and these implants are going to unscrew. Everything unscrews out of the head. None of these things last forever. I think that it is a concern when anything fails how do we retrieve it but I don't see it being a problem.
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Howard:
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You're just ... I'm going to call you a rebel. The whole market went titanium you went ceramic. The whole market ... I think the United States has got like 14,000 Dentsply Sirona CEREC systems in and probably only 1,000 or 1500 Planmeca E4Ds and again you went with the E4D. You saw everybody take a right you went left. Why did you go left with Planmeca's E4D instead of going right with Dentsply Sirona CAD/CAM?
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Dan:
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Sirona is not going to like me after this answer. I wanted an open system. I've been scanning with the iTero system for the last almost eight years. I was one of the first ones to start scanning with iTero.
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Howard:
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Is that 3Shape?
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Dan:
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iTero no. iTero is cadent and now I believe Invisalign is the ...
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Howard:
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For scanning for trace.
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Dan:
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Scanning for Invisalign trace, scanning for crowns. We've been scanning for restorations for a very long time.
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Howard:
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3Shape is TRIOS.
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Dan:
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3Shape is TRIOS, correct.
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Howard:
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You went with iTero.
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Dan:
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Yes.
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Howard:
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Okay.
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Dan:
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There was a compatibility between the E4D and the iTero as well. It's a fantastic system. I think it mills out E-max better than the CEREC which is a point of arguing. I know Christensen has spoken about that on numerous occasions.
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Howard:
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What did Gordon say?
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Dan:
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Said that the quality of mill I believe was better out of the E4D for E-max. By the way he also ... I believe the last two times you had Christensen on the podcast I remember now he was talking about the new evidence that's coming out about metal sensitivities. I sure remember him saying that.
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Howard:
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Absolutely.
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Dan:
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How the mental sensitivities might be a cause for the increased rates of peri-implant disease that we're seeing. It's interesting how this is coming out in the limelight at the same time as we're talking and the group is talking about ceramic implants as the alternative to metals as an alternative way of combating these increases in peri-implant.
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Howard:
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You know why us older guys think about metal maybe more than the younger ones is when we were little and gold was expensive and some dentist's shortcut was porcelain to base metal crowns. If they were ... it seemed to me in my opinion, no studies, that if they were people of color it wasn't an issue. If they were Northern European, Scandinavian, Irish like me, English, Latvia, Lithuania, Estonia that their skin would pull the base metal into their gum and you get tattooing. I had never seen it on an Asian, Mexican, Brazilian, African, I'd never seen it there. It was a big error on a fair skin Northern European person. We've always grown up thinking well metal can have an effect on the tissue around it.
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Gordon thinks that more people have metal allergies than they give onto and that he does not believe that medical grade titanium is allergy-free with all seven billion people. That's where you're getting at?
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Dan:
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Absolutely. You look at the material of these implants, we started off in the 70s and the 60s with commercially pure grade one titanium but none of the implants today are that. We look at the manufacturers, most of them are grade four titanium which has more levels of impurities. It's not really titanium that people might be allergic to it's the impurities. It's nickel, it's aluminum, it's the other stuff that's in it.
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Howard:
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Base metals.
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Dan:
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Base metals, correct. Then we have into these grade four or grade five titanium we connect abutments that are 'titanium' as well but it's a different grade of titanium. You got more impurities now. Now you got the grade 23 ELI titanium. You got other things that create that galvanism too. You have corrosion, you have interactions of more stuff in the mouth then you have screws that are a different grade of titanium because you need those screws to be stronger because we're getting fractures. You're creating three different types of titanium in one complex under the gums with bacteria, with saliva, with salts, with acids, something is going to give.
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We're not thinking about it in that way, we're just thinking titanium is the only thing that integrates that's the only thing we can use.
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Howard:
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There's a whole other universe, see I love the ... What was that movie back with ... What was that movie? Was it ... Where at the end of they just had the universe and it all got down that the universe was in a pool ball. Men in Black. Did you ever see the closing scene in Men in Black where they back out? Basically it's an entire ... the whole earth to the solar system to the universe ends up being a pool ball for these aliens shooting pool on a table. How many times have you taken apart an implant and you take out that [inaudible 00:26:52] and unscrew that screw and you can just smell it. Have you ever seen and smell that smell?
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Dan:
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You can smell in the reception room when you take it out.
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Howard:
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I know. If you could just smell it God only knows, there's probably a whole universe down there.
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Dan:
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Everybody smells it but nobody does anything about it. We think it's healthy. That's what surprises me about us in general is that we see the problems. Again, I go back to Carl Misch when he said you don't ask questions. You see things, people tell you things but you don't ask the questions and this is what I'm starting to ask is what are we doing about these things that we're seeing? We're seeing the peri-implantitis, we're seeing the screws breaking, we're seeing the bacteria. We're seeing all these things but the companies are trying to figure out ways of mitigating those complications, mitigating the risks but us dentists out there were just popping in titanium one after the other telling our patients this is going to last forever.
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This is the permanent solution which is really not because we're seeing what? 25/30% peri-implantitis rates, fracture rates of 1 to 3% per year of screws. We're seeing a lot of complications but we're not changing anything that we're doing. Here we have something that maybe doesn't correct every problem but corrects a lot of these problems and a material that looks amazing and patients want.
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Howard:
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You think there's less peri-implantitis around ceramic implants?
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Dan:
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Absolutely.
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Howard:
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Absolutely, and how much less? If you had to quantify it.
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Dan:
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You know what honestly I have not ... I've seen a few instances of bone loss and deeper pocketing around perio patients like given up on brushing and [inaudible 00:28:41] around the ceramic implants but all in all I'm almost seeing a reduction to nothing. With the ceramic we have a material that does not harbor bacteria. Titanium bacteria gets attracted to it. Zirconia is not the same and we have a one-piece design so there's no bacteria that's trapped in an interface below the gum. We know that even with the stromal tissue level implants had a better tissue reaction than anything that's bone level. Once we put an implant at bone level and we bury it so deep to make it look better we have bacteria sitting underneath the gums and brewing in there.
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Then you got the metal allergies and sensitivities tacked onto it. I think just from a material and from a design standpoint we're in a much better position with the ceramics into the future. Seeing what's going to happen in the mouth and a dirty mouth and a mouth that doesn't get brushed and a mouth full of bacteria. I think if I was a betting man I would bet on ceramics 10 times out of 10 rather than betting on a titanium implant.
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Howard:
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You mentioned the Carl Misch podcast a couple of times. I want to ask you the most controversial email I got regarding a podcast. There seems to be a big schism among implantologists to place implants in smokers or not. In Phoenix the reality is who are the people most likely to need implants? People that not exactly ... they weren't exactly hygienists if you know what I mean so they're probably more likely to smoke and not brush and not floss. It's their behaviors led to them needing those implants. Like Carl's brother Craig won't place an implant in you if you're a smoker, Carl will. What's the story with you?
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Dan:
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I try to get them on a hiatus from smoking if I can.
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Howard:
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A hiatus meaning a temporary ...
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Dan:
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A temporary stop at least while the implant is healing or at least at the beginning so the wound healing around the implant site is improved. We really see research out of Europe and the numbers out of Europe where they get same success rates as we do in North America as far as smoking goes. Smoking is not the ultimate mode of failure but having said that in my practice where we're placing all ceramic implants the patients that are coming and requesting it ... and there's a lot of patients coming in and asking for these types of implants. They are more health conscious in general so they're not the smoking type. When we do encounter the smokers I don't have an issue placing it as long as we get an understanding that this increases the chances of failure.
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Smoking does to some degree increase the likelihood of problems and if they can buy into that we're not as litigious as in the US.
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Howard:
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Is there still significantly more smoking going on in Europe? Obviously yes in Asia but is Europe still ... do they still smoke more?
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Dan:
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I think you walk around in Italy or France there's smoking all over the place. Everybody is learning about what happens when you smoke and the consequences so I'm sure there's a reduction but in terms of sheer numbers I'm sure there's more smokers in Europe than ...
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Howard:
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Because if Straumann has been working on this for 10 years in Europe they're out of what? What is Straumann out of? Switzerland?
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Dan:
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Yeah.
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Howard:
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I'm sure they got data on that too. Are you agnostic towards CBCTs or do you like a brand there? I'm trying to think of what is the outlier of CBC that you went to? You probably picked one out of Korea or Japan that I haven't heard of.
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Dan:
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No, I like the Planmeca.
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Howard:
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You're a Planmeca fan. You got their CAD/CAM. You just like Helsinki, Finland and so ...
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Dan:
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I like Helsinki, Finland but I like the products. I think the products are very well thought out and most of them are open architecture. They're well designed.
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Howard:
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What's the brand name of their CBCT?
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Dan:
|
It's ProMax.
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Howard:
|
ProMax. You want to know my whole theory on Planmeca? I swear to God this is my theory and I'm sticking to it. When you go to Scandinavia it is so cold for 10 months out of the year with almost no sunlight that the adapted mechanism for the dentist in those countries those people just work. When it's minus 30 outside and you only got four hours of sunlight they just work. I think their environment just breeds workers. I remember when I was at Creighton so many times I wanted to be a bad student and we'd say, "Forget it let's just go outside." It's in Omaha, Nebraska and you look outside and it's freezing and drizzle and dark and gloomy and you think, "Oh well I might as well just go back to my room and study."
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Now I'm down here in Phoenix in Arizona State University I don't know how those kids study. Every day is a gorgeous day who would want to sit inside your dorm room and study? They'd have to be an idiot. I think the whole world ought to move to Antarctica and all you do is just stay inside and work all day.
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Dan:
|
You should move to Toronto we're like this the whole nine months out of the year. This will be a perfect working environment.
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Howard:
|
You like the CBCT from ProMax from Planmeca. What about Digital Smile Design software, implant planning software? Does that all come with the ProMax or you ...
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Dan:
|
No, I use for my Digital Smile Design and again you had Dr. Christian Coachman on the podcast as well not too long ago and I use a piece of software that follows his protocol very well and it's called Smile Designer Pro. It's a very intuitive, very smart application compatible with pretty much all platforms if you're a Mac user, an iPad user. You can use it pretty much on anything. I think Android too and it's a great tool and it's got a 3D module to it so you can actually take your smile design and move it into the Planmeca design anterior teeth based on the smile design. A really, really nice application. Most importantly you get to show the patients what they're going to look like if they choose to go on with the treatment with various simulation options.
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Howard:
|
Talk about your online CE course which thank you so much for doing that. You put up a course Ceramic Dental Implants in Everyday Practice which not only can you see on your PC but you can see on your iPhone, your Samsung, your Droid. Thank you so much. Talk about that course.
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Dan:
|
The course is up there and it talks about ceramic implants. It summarizes a lot of the points, a lot of the evidence of why I chose to pursue placing ceramic implants rather than titanium. It talks about the strength, it talks about the osseointegration of ceramics, it talks about the design of the CeraRoot implants, indications, contraindications of the material. It really summarizes a lot of that in there and this leads obviously to ... I do courses about ceramic implants. We certify doctors on placement of these ceramic implants here in Toronto. It's a great gig where you have people to gauge how much interest they have in pursuing this technology.
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Then we have doctors coming in from all over North America and we train them here. Invariably everybody that attends the course then starts to place it because once you see the value that this brings to the patients and to the practice, because this is a unique offering. Everybody's doing titanium nowadays and to be able to offer a patient choice ... and you know choice is a great selling tool for treatment because we don't want to tell a patient, "This is the only thing that you can do." Giving patients a choice is a very powerful tool to be able to do more implants in practice.
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Howard:
|
Basically last year 2015 was the first year the 150,000 general dentists ... Well the United Stated has 211,000 dentists. Humans are alive with the dental degree. It's probably about 125,000 general dentists full-time, [inaudible 00:37:42] or more, probably 150,000 that just saw a patient last year and about 35,000 specialists. The oral surgeons and the periodontist last year 2015 placed less than the general dentist. We are now in game changing territory. The point I'm trying to make is that probably four out of five dentists listening to this podcast right now have never placed a single implant. Dan we've got to walk up a stairway and it's going to be a long stairway to get to where a guy like you is.
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|
This dental student they've been out of school five years they've never placed one. What's the first step? Your members of the International Congress for Implantology they've got a fellowship at the Academy of General Dentistry, The International Academy of Dental Facial Esthetics, fellow of the American Academy of Implant Dentistry. Go up five steps to the ladder from I've never placed one to I've just placed one.
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Dan:
|
First thing I would do is take Carl Misch's continuum. That's the first thing I would do and then you've got to really go in there and learn about treatment planning. You've got to know when to use an implant, how to plan for it, how to know if you got enough bone for one. You've got to go through these steps before anything. I think Carl has done this like nobody else in our profession. You've gone through his continuum as well and you know how invaluable that is.
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Howard:
|
Don't be the dumb guy in class who's asking questions where you knew the lecture today was over chapter one and you're asking, "What is that word? How do you spell it?" Everybody else in the class read the chapter. Carl Misch's book, read the damn book before you show up there. That book might take you a month to read and if you read his whole damn book and then you go take his class you're just going to get such a better learning experience.
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Dan:
|
Absolutely.
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Howard:
|
I'd rather be hearing it for the second time when I go hear him or at least know what he's going to think from A to Z before you walk in there [inaudible 00:39:53]. It just makes so much more sense and it's street smart. Street smart people learn with books and YouTube and Dentaltown and crazy people have to fly across the country to learn one little thing on eclusion. You know what I mean?
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Dan:
|
That's true.
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Howard:
|
Read the book and go to Carl Misch's course. Walk up more steps.
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Dan:
|
Then it really is about experience, it's about doing. You've got to start doing the surgeries. You've got to start with the simple cases and build up. Then once you have that foundation of treatment planning and you know how to graft and you know the basics choosing an implant system or choosing a material becomes easy, right? Because ...
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Howard:
|
I'm going to back you up. You said pick a simple case. I'm assuming you're talking about a incisor number eight on a supermodel with a high lip line who models for a living?
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Dan:
|
With a ceramic implant absolutely.
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Howard:
|
What are simple cases?
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Dan:
|
A simple case for me would be an upper premolar with abundant bone. You just took out the tooth, you did a quick socket preservation, three/four months later you have an upper premolar or a molar ...
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Howard:
|
Explain why that's simple. Why is that a simple case?
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Dan:
|
It's a simple case because most likely you're far away from the sinus so you're not nervous about that. You have no anatomical structures in the way. You're not worried about the mandibular nerve. The aesthetic demands on a premolar are usually less than they are in the front of the mouth so if you place that implant a little bit deeper, a little bit shallower there's prosthetic ways of correcting things. It's a comfort level that I think once you place the first few implants on premolars on the maxilla, even molars on the maxilla where there's abundant bone you ease into it. You learn about the quality of bone, you learn about how to feel the drilling part. Then placing the implant is really like drilling a screw in drywall.
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|
|
It really is not ... a monkey could do it. A monkey could place an implant. It's all about the planning, it's all about preparing the site for the implant. Maximizing soft tissue profiles. These are the things that are really important. Just performing the surgery becomes really just like drilling a hole. It's simpler, I think it's much easier to place an implant than to do and MOD composite, right? There's more skill involved in doing an MOD composite than there is in placing an implant straight.
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Howard:
|
Okay, so we read Carl Misch's book, then we went to Carl Misch's course and then we have treatment plan upper bicuspids. What's the fourth step?
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Dan:
|
Well the fourth step is once [inaudible 00:42:50] to do it but then like I said it's selecting what type of implants you want to be placing. You've got to start becoming familiar with a system.
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Howard:
|
What system are you going with? What is your bread and butter ceramic implant? CeraRoot?
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Dan:
|
It's CeraRoot, correct. That's the ceramic implant of choice.
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Howard:
|
Where are they out of?
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Dan:
|
Spain. Out of Barcelona.
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Howard:
|
Spain, Barcelona. God dang that's beautiful. Have you been there?
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Dan:
|
It's a beautiful place. It's ...
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Howard:
|
It's just beautiful. There's only a few places you go lecturing and you think, "Why the hell am I going back home?" Spain is just one of those places. Barcelona is ... and Madrid. Barcelona nicer than Madrid because it's more Mediterranean.
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Dan:
|
I agree. It's the nicest city in Europe probably just all around.
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Howard:
|
Those people just don't know what stress is. That is the most laid back society. Can I tell you my Barcelona story?
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Dan:
|
Mh-hmm (Affirmative)
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Howard:
|
I was talking to these dentists, I said ... they were talking about the hours and I said, "Well what are your hours?" They go, "What do mean?" I go, "Your hours. I mean when do you work?" They go, "I go in there in the morning." I go, "I know morning but like what time? 6 o'clock, 7 o'clock, 8 o'clock? What time is your first patient?" They're just like, "Oh you Americans." He goes, "I just wake up, I have breakfast, I read the paper, I have my coffee and then I walk to work and that's when I see my first patient. I'm not an American. I don't have a watch. I don't know what exact time it is." I'm just like, "Wow! That is a different planet."
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Dan:
|
Then 2 o'clock rolls around and they take siesta and then they go back to the office at 5:00 and work a couple of more hours and go out for dinner.
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Howard:
|
Yeah, and then you go to civilizations like Japan and Korea and America and everything is [inaudible 00:44:34] and people are running 40 red lights because they don't want to be three minutes late to work and you're just like, "Wow!" You're going to go with CeraRoot.
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Dan:
|
Yeah, and then learning everything you can about that system. You need to know everything about the implants you're placing not just that this is the cheapest implant around or this implant it got because so and so uses it and that's the implant of the day. You really need to study. If you're choosing titanium which a lot of people are choosing you really need to know what kind of titanium these implants are, what are they good for? What are they not good for? You can't use the same implant for everything unless you're really good at what you do. There's a lot of learning that happens as you're starting to use these implants to learn the particular systems. Then it's really practice, practice, practice. You've got to do the surgeries.
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|
|
You've got to get 20/30/50 implants under your belt to really, really get the hang of it. It's like everything else we did in dental school. We did the ... What is it, 50/100 composite surfaces before we really knew what bonding was all about. You've got to start to learn everything really slowly through your hands.
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Howard:
|
I had to do 50 extractions and 75 amalgams, 15 units of root canal and 15 units of denture. That was a dental degree in '87.
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|
Dan:
|
It was less for us at U of T at the University of Toronto we had less than that.
|
|
Howard:
|
My favorite deal was whenever it was on a spring break vacation whenever I always stayed and got a pay for it job in the pain clinic and you could pull your entire extraction requirement every time there was a school shut down for a week. Every time there was a spring break or a week off or whatever you could do your ... it was just amazing. I loved [inaudible 00:46:32] the most. That's my next question. She's sitting there driving she's like, "Dan I like bleaching, bonding, veneers, I'm a cosmetic dentist. I don't know if I'm in the blood and guts." What would you say to that woman?
|
|
Dan:
|
Everybody chooses their comfort level. I think that implants today are bread and butter. It's basic dentistry nowadays. There are plenty of teeth coming in that are non-restorable, that are failed and those cracked, fractured. Implant dentistry today is not something that's only reserved for the few. You wouldn't say the same thing about, "Oh I only do DLs and ML resonance but I'm not going to prep a crown." You're a dentist, that's what you're doing and we need to get trained at these things. These are basic. I consider these not the advance cases but the basic case, everybody should be doing them.
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|
Howard:
|
Well I think that the most shocking thing you're saying is that if I pulled all the dentists, all right? I looked at all the data in Dentaltown there's four million posts and I thought I built a word diagram on implants probably the biggest word in that deal next to the word implant would be peri-implantitis. That's the biggest monster and you're saying that you think this really is a massive reduction in peri-implantitis. I've had a 100 email requests to do guests on peri-implantitis, treating peri-implantitis. Do you think LANAP, the laser is good for peri-implant? That's like the top question and that's the most shocking part of your presentation.
|
|
Dan:
|
The whole profession, the implant manufacturers everybody is focused on this because it's been a problem or a long time. If you think where implant industry started from it started from full arch Branemark back in the 70s it was all based on full arch restoration. There were no teeth, bacteria load was reduced, they were restoring smooth machined implants with screwed in restorations and they had incredible success with it. Then we took those same principles that we used for the fully edentulous and we tried to apply them to the partially edentulous where we have way more problems, right? We're putting implants between teeth, we're losing bone, we're losing tissue, we're using rough implants now which have surfaces that attract more bacteria.
|
|
|
These manufacturers are chasing their tails trying to figure out ways of reducing these complications and everybody is talking about how to reduce these complications. We see beautiful cases with titanium implants. I'm not saying that you can't get beautiful healthy cases but look how much work these guys are putting into these cases, conditioning soft tissue to get the margin's profiles, thickening tissue, multiple soft tissue surgeries. The list goes on as to what you need to put into a case to make it look like something you see on the podium. Whereas I can do very similar things with a ceramic implant very simply because it's all built into the implant.
|
|
|
When you say easier I can make a central incisor or a lateral incisor look as good or better than the top titanium guys very, very easily, right? With a very easy prosthetic protocol restoring it very simply. I think everybody should be doing it.
|
|
Howard:
|
That is truly amazing, truly amazing stuff. Any other things you want to talk about? What else has got you passionate in dentistry?
|
|
Dan:
|
We got some courses running. We run the Centre of Excellence and Implant Dentistry here in Toronto.
|
|
Howard:
|
You spelled center wrong, you spelled it C-E-N-T-R-E, don't you Canadians know how to spell, it's C-E-N-T-E-R.
|
|
Dan:
|
In Canada it's R-E.
|
|
Howard:
|
When you say centre, C-E-N-T-R-E, is that French?
|
|
Dan:
|
I think it comes from the French, it surprises me too but this is how we spell it.
|
|
Howard:
|
Yeah, center is definitely ... also aesthetic is spelled differently around the world and you guys still say composite wrong you say composite.
|
|
Dan:
|
Tomato, tomato [crosstalk 00:51:04], right?
|
|
Howard:
|
Talk about The Centre of Excellence in Implant Dentistry which is www.ceimplantdentistry.com.
|
|
Dan:
|
My focus there has been to try and bring European style dentistry to North America and we started a couple of years ago and I started off with a training for the ceramic implants with Dr. Oliva from Barcelona and now it's evolved.
|
|
Howard:
|
What's his name? Dr. Aliva?
|
|
Dan:
|
Oliva O-L-I-V-A.
|
|
Howard:
|
O-L-I-V-A. What's his first name?
|
|
Dan:
|
There's two brothers. One of them is Josep, J-O-S-E-P and he is a trained periodontist and his brother Xavi, X-A-V-I and he ...
|
|
Howard:
|
Really? That's how you spell it? X-A-V-I?
|
|
Dan:
|
Yeah.
|
|
Howard:
|
How cool is that?
|
|
Dan:
|
It's the short form for Xavier.
|
|
Howard:
|
Oh okay.
|
|
Dan:
|
He actually now is in Santa Monica and he runs the US operations of CeraRoot, Santa Monica, California. They're the two inventors of the system.
|
|
Howard:
|
What year was that?
|
|
Dan:
|
When did they invent the system?
|
|
Howard:
|
Yeah.
|
|
Dan:
|
In the early 2000s so at about ... Clinical literature we have about 10 years of data about the CeraRoot implants. We ran courses for the CeraRoot certification and we also bring guys like I brought in a guy from the Ukraine, Nazariy Mykhaylyuk and he did a course about ...
|
|
Howard:
|
Naz.
|
|
Dan:
|
Naz year.
|
|
Howard:
|
I just podcast interviewed him. We were both lecturing in Johannesburg and so a funny story. I start doing a podcast with him and the only place we could find was a room by the bar and we're podcasting him and one by one friends are walking by. This one interview with Naz for the first half hour by the time it's over we've got an orthodontist from Portugal, we got Naz from the Ukraine, we got a cosmetic dentist from Cape Town and a prosthodontist from Greece. It was the most fun podcast I ever did. Oh my God. It finished at 2 o'clock in the morning and the only reason we stopped is because Ryan said, "Dude we only got three more minutes of tape so wrap it up in three minutes." Naz is so amazing.
|
|
Dan:
|
He's an amazing guy. He was here in October where we did a two day course, it went over really, really well. Everybody loved it. The guys is at this young age. You look at me and you think I'm young this guy has accomplished so much in the few years that he's been out there. Unbelievable.
|
|
Howard:
|
You did Behnam Shakibaie how do you say that name?
|
|
Dan:
|
Behnam Shakibaie.
|
|
Howard:
|
Shakibaie, we did a podcast with him to. Amazing man.
|
|
Dan:
|
Yeah, I just watched that and he's here in May, early May ... Middle of May doing a course about the microscope sinus lift so we're very excited about that. Another guy that you probably had on your podcast Dr. Ziv Simon.
|
|
Howard:
|
Ziv.
|
|
Dan:
|
He's coming to Toronto June 10th and 11th, I'm doing a course for guided surgery and soft tissue enhancement and we're really looking forward to that. That's going to be one amazing ...
|
|
Howard:
|
All of you guys are class act, you're all geniuses but more important than all that you're just really good guys who love to share.
|
|
Dan:
|
Yeah.
|
|
Howard:
|
That just speaks so highly of our profession of dentistry, there's just so many good guys. These kids don't know that when you're young and out of school you could walk into any old man's dentist across the street. He ain't your competitor. He's going to open the door and he's going to do anything for you. You know what I mean?
|
|
Dan:
|
That's true.
|
|
Howard:
|
Dentistry is very cool. Your CE implant dentistry is it more like a curriculum? Is it more like one, two, three four or is it one program? Talk about the menu.
|
|
Dan:
|
The menu really is a hodgepodge of topics so just whatever we feel passionate about and we’re hot about we create a yearly menu of courses if you have it. Aesthetic dentistry things like what Naz does but with a really high emphasis on implant dentistry.
|
|
Howard:
|
Okay but I’m driving to work now and I’m thinking, "Okay I don’t know about all that Dan I just want to get from … I’ve never placed one I just want to be able to place one. I just want to go from zero to one." What course would you take at the ceimplantdentistry.com website?
|
|
Dan:
|
I wouldn’t start there if … Our courses are really for those that have had some experience with implants. I wouldn’t start with me as much as I want to say, "Come and take everything on my menu." I would say you really got to start with the basics. I think so many people are doing like the Misch Institute. There’re so many institutes that are doing this so well Mike Pikos is doing an excellent job, there’s a lot of great education out there for the basic stuff I don’t need to do it.
|
|
Howard:
|
Are you friends with Pikos Mike?
|
|
Dan:
|
Yeah, I now Mike.
|
|
Howard:
|
I talked to him, I did a podcast with him a year ago in New York. If he's a friend email him and say, “Come back on and talk about his zero to one, his implant training for none to one review that course.” That would be a good follow up to yours, have yours come out there you just said that the next one be Pikos saying, “How do you go from zero to one?” Because I’m a firm believer that it’s like on my morning run the hardest step is the first one out the door and then the last mile home is just a gimmie. You know what I mean?
|
|
Dan:
|
Yeah, no it is. It’s a very difficult thing to do.
|
|
Howard:
|
Can you ask Pikos that?
|
|
Dan:
|
Sorry?
|
|
Howard:
|
Can you ask Mike that?
|
|
Dan:
|
Yeah, yeah I’ll be in touch with him, I’ll get him to connect with you, absolutely.
|
|
Howard:
|
Yeah that would be a great follow-up piece. Then what else has got you passionate?
|
|
Dan:
|
Family, family is always my get away from work, right? That’s passion but dentistry in general has got me really hodged up. I mean the ceramic side of it is being one of the few guys in the world. You look at how many dentists are really out there and being one of the few is an amazing place to be in. It’s humbling to be doing what I’m doing. When I look at the future how things are changing year to year since I started doing this there’s amazing opportunities out there.
|
|
Howard:
|
Did Shakibaie and Naz convince you to go to the microscope side of the world?
|
|
Dan:
|
Absolutely.
|
|
Howard:
|
Well then so you got a microscope?
|
|
Dan:
|
Oh yeah I do all my …
|
|
Howard:
|
You did not mention that you only got a minute for … or a couple of minutes left, tell us about your adventures into microscopy.
|
|
Dan:
|
I use a Zeiss Pico and I’ve been …
|
|
Howard:
|
You use a what?
|
|
Dan:
|
Zeiss Pico scope
|
|
Howard:
|
P-I-K-O?
|
|
Dan:
|
P-I-C-O.
|
|
Howard:
|
P-I-C-O.
|
|
Dan:
|
Yeah, and I’ve been using that for nearly all my surgeries. I do everything under the scope now and I can honestly say these two guys and the MicroVision Group have been instrumental at bringing the scopes into general practice but it’s an indispensable tool at this point. Once you see what you haven’t seen before you can’t work without seeing it again. It’s unbelievable the amount of detail and unbelievable how humbling it is when you see your old work under the scope and you realize what kind of crap you do without magnification. Yeah it’s a complete practice changer, is it ... of all the tools in the practice we look at things, what's the ROI on things?
|
|
|
Does a microscope have any return on our investments? I don’t know. I don’t think I make more because of the scope but I think that the scope makes me do what I do so much better.
|
|
Howard:
|
Okay, on the MicroVision Group there’s a www.congress.microvison.group, there's a Dubai MicroVision Group. Is there just a www.microvisiongroup or is it just MicroVision Group?
|
|
Dan:
|
I think MicroVision Group I think they have their site I know that their congress in Dubai April 7th and 8th which probably just passed. They should have their site and they’re always on Facebook. All the members are always posting their cases and their amazing transformations on Facebook.
|
|
Howard:
|
Did Naz and Shakibaie lecture at that MicroVision in Dubai?
|
|
Dan:
|
Yes, yeah.
|
|
Howard:
|
Yeah the easiest way to increase your quality go from naked eye to loops. The reason oral scanners … Every lab will tell you the average case is a 5% remake but if they go to oral scanning it’s not even a half of the percent because when you oral scan and you see your impression on the screen 40 by … A big old screen you’re just like, "Wow!" I think magnification ended on us. They drop a scope and they looked in their finished canal right before they obturate and they’re like, “Wow there’s a missed canal or God look at all the crud in that one canal or …” Just seeing in such the easiest way to increase quality.
|
|
Dan:
|
Absolutely, and I think without magnification we’re really working blind.
|
|
Howard:
|
That’s why I did not let Stevie Wonder place my implant.
|
|
Dan:
|
That’s a good … unless it was guided, if it was guided that would be different.
|
|
Howard:
|
Well hey Dan I think the world of you dude. I really am your biggest fan. Thanks so much for putting an online CE course. I just applaud the way your amazing mind works and you’re just going where they ain’t. Everybody is in titanium you’re in ceramic, everybody is going Dentsply Sirona you’re in E4D. I’m just pretty sure that in your mind if it doesn’t make sense to you, you just don’t go there. You do not follow the crowd.
|
|
Dan:
|
Absolutely, absolutely.
|
|
Howard:
|
It must make it difficult for your wife to manage you. Did she have to get an electric shock probe or something since you’re not used to following people?
|
|
Dan:
|
I’m so much different at home I'm more [inaudible 01:02:11]. I kind of sit back and relax. Howard it was great chatting with you this was an amazing experience thank you for inviting me.
|
|
Howard:
|
I’ve been telling everybody this I told Straumann this, I told CeraRoot this, I told everybody, “You know there’s great books for learning implants like Carl Misch's book." There’s great one onesie courses like an hour on implant here, an hour on implant here but still nobody has come out with a 25 to 50 hour A to Z implant curriculum from diagnosing to single root to just from an A to Z. If I owned CeraRoot, if I owned Straumann, if I own Nowak I'd create the first online university Dentaltown. I'd put it up tomorrow and we got 210,000 members because these kids are sitting there on their iPhone and they’re taking this online CE on the Dentaltown app but they’re throwing it on their Apple TV.
|
|
|
They’re sitting there at home in their favorite chair with surround sound and that’s … You just got to make it faster, easier, better, cheaper and if those CeraRoot brothers and you if you put that up there and just said, “Look I’m going to take you from not even knowing how to …" and the CBCT. I’m like, “God how do you read that?" It’d take five hours to explain that. I still when I look at my CBCTs at least once a month me and my two associates have no idea what we’re looking at. We’re always sending these files to [inaudible 01:03:42] saying, "What the hell is that?” Tell Josep and Xavi and yourself that you know I think it’s going to be the most profound marketing because guys like Branemark and Misch they spent their whole life going from convention to convention to convention, their whole life.
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Now you can reach that big of an audience in an hour on the internet. There are two million dentist, there’s only a billion people in North and South America. There’s more than a billion just in Africa, there’s a billion too just India, there’s a billion three just in China, there’s seven billion 300 million people with two million dentist and to just knock out a category killer. How many hours do you think it would take to explain implants A to z? You think you could do it in five 10, 20, 30, 50 how long do you think it’d take?
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Dan:
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We could do it in 50 to 70 hours. I think that breaking it down into manageable chunks just like the continuums over a weekend. Let’s do it, let’s do Dentaltown …
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Howard:
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Do it.
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Dan:
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We’re going to put it together, I am open to that.
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Howard:
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I’ll tell you what once you’ve watched the online CE on your big screen TV with surround sound with a beer in your hand and a bowl of popcorn you never want to go to the damn Dental Convention again. You know what I mean? It also depends on the beer, none of that Canadian stuff. We’re talking about real Budweiser from America.
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Dan:
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Okay, no Molson?
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Howard:
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Okay, Dan thank you again for giving an hour of your life and for all that you do for dentistry and for Dentaltown and you’re just an amazing man. Thank you so much.
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Dan:
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Thank you Howard. Thank you.
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