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VIDEO - DUwHF #885 - Amos Yahav
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AUDIO - DUwHF #885 - Amos Yahav
Dr. Amos Yahav D.M.D
- Graduated from the Carol Davila University of Medicine in Bucharest Romania in 1992
- In 1993, established a private clinic, limited to implants, oral rehabilitation, and
aesthetic dentistry in Netanya, Israel
- Highly experienced in the field of implant dentistry and oral rehabilitation
- Serves as a guest and keynote speaker at international conferences and professional
workshops worldwide and has spoken on 4 continents
Dr. Yahav is a serial entrepreneur whose practical way of thinking combined with creativity have enabled him to develop a variety of efficient professional tools, accessories, and materials for implants and the surgical field, including the invention of "Biphasic calcium sulfate" (BondBone®/ 3D Bond™ And Bond Apatite®/ 4 matrix ™) He also serves as an advisor for international companies in this very progressive field.
Dr. Yahav is currently the CEO of Augma Biomaterials
www.augmabio.com
Howard: It is a huge honor for me today to be podcast interviewing Doctor Amos Yahav all the way from Israel. It is 8:00 a.m. in the morning on Friday before the Labor Day weekend, and it's 6:00 p.m. in Israel. Thank you for having your Friday night out the being talked with my homies on this podcast. Doctor Amos Yahav graduated from Carol Davila University of Medicine in Bucharest Romania in 1992. In 1993 he established a private clinic limited to implants, oral rehabilitation, and aesthetic dentistry in Netanya, Israel.
Highly experienced in the field of implant dentistry and oral rehabilitation, serves as a guest and keynote speaker at international conferences and professional workshops worldwide, and has spoken on four continents. Doctor Yahav is a serial entrepreneur whose practical way of thinking, combined with creativity, have enabled him to develop a variety of efficient professional tools, accessories, and materials for implants and the surgical field. Including the invention of biphasic calcium sulfate known as Bond bone, 3D Bond and Bond Apatite, 4 matrix. He also serves as an adviser for international companies in this very progressive field. Doctor Yahav is currently the CEO of Augma Biomaterials and I asked him if he'd come on the show because I'm a big fan of his YouTube videos.
I love your YouTube videos, and before we start talking dentistry I've got to ask you a couple of questions. You were born in Romania. I love the music in your YouTube videos. Is that Romanian music?
Amos: No, no, no, I was born in Israel. I was born and raised in Israel. Actually I did my faculty in Romania and the music, I just love music, that's how you hear those music.
Howard: Who is that music? You should put the author of the music in your YouTube notes.
Amos: Yeah, I hope that I don't have infringement when I use such beautiful music.
Howard: You know what confuses me the most about Romania? Is I grew up in Catholic school, grammar school, high school, college, and my two older sisters became Catholic nuns. I was always taught that Mother Teresa was born in Romania. But I was actually lecturing and scope to Skopje, Macedonia and I was edumacated that she was born in Macedonia. So why did I think she was born in Romania? I was taught that by nuns.
Amos: I don't know what is the truth because sometimes everybody wants to take the credit for himself. So I don't know what is the story about that.
Howard: Yeah, I thought that was very interesting. So I'm very excited to get you on because you're such a legend in implant dentistry and bone grafting. I mean when people start to decide they want to place implants, they don't realize that they're going to have to learn a whole other skill eventually, about bone grafting. What made you start Augma Biomaterials, which on the website is A-U-G-M-A-B-I-O dot com. So agama for augmentation and bio biology I guess augmabio.com.
Amos: Actually, Augma started about fifteen years before we before we open the company. It started by startup company which I started in my basement in order to find a ultimate solution for bone grafting, because as you said in order to perform a good augmentation procedure you need to have a lot of skills, a lot of knowledge, and it's time consuming, and of course it's not so easy especially for those who start. So I wanted to find something that can do it completely different, something that we turn a very complex procedure into a very simple one. That would be more accessible more of GP clinicians that can perform because ideally one thing that our patient deserves the ultimate solution. The most efficient solution, a easy one that would be less painful, less swallowing, and would be much more easier for the clinician that also have a lot of times when they perform surgery, so that's why it started everything.
Howard: Well on DentalTown there's a quarter of a million dentists, but when we came out with the app sixty thousand dentists downloaded, and they were mostly born after 1980. So you're talking to a lot of millennials today, you're talking to a lot of kids. I'm very surprised, I keep telling dentists shoot me an email howard@dentaltown.com and tell me who you are, why you listen to the show, and I'm surprised at how many of them are in dental school, it's at least a quarter and it seems like the rest are all under age thirty. So when you talk about bone grafting, would you go back to the basics of bone grafting? There's a lot of different types of bone grafts, there’s autograft, allograft, Xenograft, Alloplast, there’s ceramic. What type of bone grafting are you doing? Why are you doing that as opposed to the other types of bone grafting?
Amos: Indeed as you say there are many many groups and families of bone grafting. But all of them are more of the same from their presence they come as gramuls, maximum is putty to improve the handling, some is blocks which required a very high skillfulness. We are the first company in the world that invent and introduce bone graft cement for the dental field. Now probably you will ask me what's so special about cement? Cement actually changed the construction field since the concrete have been founded, and it changed orthopedic field since 1982, when it was introduced to the orthopedic field.
However in our field we are still working, for my opinion, in a very primitive way and were cumbersome one. So I knew that unless we will find something that will not be a metal product, something that would be completely different. At least ten steps ahead that will establish a evolution in our field, nothing will be changed. So every company tried to do a little bit better at least, but still it's gramuls, it's like wire membrane, it's like wire to stabilize, and also the surgical protocols are more of the same, you need to have a binary closure tension free. When you do it tension free you release too much the flap, it's much more pain to the patient, much more swallow and it require high skill.
The other things is for example if we're talking about a general practitioner who wants to do socket grafting. So for him, in order to reflect the flap and to do advancement flap in order to close it, it’s very difficult unless you can provide him something that he doesn’t need to reflect the flap, he can eject the material into the site, and then he can protect it by a simple collegian sponge and a soft tissue will proliferate above it. So that was the idea about finding something that will be completely different from what we have today. So it took me about fifteen years to discover biphasic calcium sulfate in order to provide us, a clinician, the bone graft cement and we are the first one that have a suitable cement for the dental field. A cement that can set also in the presence of blood and saliva and instantly, that's what's so special about it. Of course it took time to create protocols in order to understand how to work with cement.
Howard: Your videos, I don't want to underscore surgical talent but it sure makes it look easier and faster. I mean it seems like, again not to be rude, but it seems like your technique is a lot easier and requires less surgical skill than many other techniques.
Amos: Indeed. Actually due to the special tool that we have it the bone cement. Try to figure out if you try to make even a complex augmentation, it will take you fifteen, twenty, twenty-five minutes just to stabilize your graft and to place the membrane in less than a minute. When I say in less than a minute nobody believes that it can be true, so everybody's looking is the catch. Something must be wrong here, but it's not. It's like having a horse and having a car, they behave differently, I just give you the right tool that will enable you to perform the procedure very easily. Now I use the most ancient material that was used, because I needed to find something that would be very safe with a long history.
But I find that it has some drawbacks, and that's why it took me fifteen years to overcome its drawbacks to enable it to set in the presence of blood and saliva, to build a protocol when to work it by itself, and when to work with it as a composite graft. That's why we have two products for that and try to think that now, in less than a minute, you can place or stabilize your implants, or you can replace or stabilize your graft. In three months you can place or stabilize your implant and you don't need a membrane which is additional cost, time consuming and require a high skill. So everything can be done, but you need to remember the flap shouldn't be tension free, it should be with a moderate tension you less cut the flap, you less release it and you just need to stabilize it. If you do it perfectly you’re going to have a great result.
Howard: I notice in all your videos that you have a microscope in the video, do you routinely do all your bone graftings through a microscope? Do you need a microscope? What are your thoughts on microscopes?
Amos: No, I think not in every one of them, just some of them, but it depends on the case. It depends on the case. When I want to use it I do it, but not always, of course most of the cases you don't need a microscope.
Howard: I want to go through some more details. A lot of the kids want to know, they pull a tooth and it was abscessed, say it had a filling, root canal periapical abscess. What are your thoughts about bone grafting when the site is infected? What is your protocol when you're pulling an abscess tooth?
Amos: So it's according to my experience when you have a chronic inflammation or something like that, that is not the issue you need to just read to correct the granulation issue, clean it with a sterile saline and it should be a sterile saline not a bag that we used last week or something like that. I know that some doctors are not changing the bags, but there is no chlorine inside so definitely it get contaminated after three hours. So always we need to use a new saline, however, if the defect is an acute abscess definitely I don't know nothing. The only thing that I gave, I give antibiotic, I leave it to heal a little bit and then I perform my grafting. So that's my philosophy about that.
Howard: Then there's a lot of people that wonder, say the patient is not ready for an implant and they're extracting a tooth. Is this a good protocol for your bone grafting cement? Do you recommend bone grafting cement in an extraction socket site if they're going to get an implant, maybe next year or the year after?
Amos: Yeah. First I think that if you can have a good primary stability for your implant, you can do it (inaudible 11:38) this is absolutely not a contraindication, you can do it and you will have a great results. But if you decided not to do in the same time, you don't need to wait one year you can do it in three months because the material is replacing the patient’s own bone, and that's the most advantage. What's the problem with the existing solution? There are three main problems, first they integrate, second they require a membrane, and third they are unstable. So now there are those who we will say is integration a throwback?
Yes indeed, integration is something great when you have an implant, but not when you have a bone graft. When you have a bone graft you would like to have the patient’s own bone back. If you have a good quality of bone graft and it's integrated within the bone, so then you might have some functional continuity and it's true. But eighty percent of the grafted site is not the patient’s own bone, and by the way it's the same also with allograft. Also allograft you will histology you will never find austosite within the particle of the allograft, because they do not transform into the patient’s own bone. Here the mechanism of action is completely different, when you place this type of cement immediately stuff there be of the solution is never integration, a release of tons of ions of culture. We start in a biological process to precipitate into a calcium phosphate, hydroxyapatite lattice work of the bone and the presence of calcium ion encourage the differentiation of the ploto potential stem cells into osteoblast, so it's completely different. That's why three months are enough you don't need to wait one year.
Howard: They’re commuting to work right now, so what I do is I retweet my guests last Twitter because they’re driving and they shouldn't be texting or anything. Your Twitter is @augmabio A-U-G-M-A bio and you have eight YouTube videos listed on there and they're all just super fantastic. I just retweeted your last one to my twenty thousand Twitter followers and when you get to work you've got to watch us on YouTube, it's amazing. His website is agamabio.com. So a lot of these kids, I know what they're thinking, they're thinking we just had six thousand Americans graduate from dental school three months ago, and we had another six thousand started freshman year at dental school this month, but they all graduate from dental school and they say ‘Amos, my school didn't teach me one implant. We didn’t do one implant you're talking about all this fancy stuff. How do I go from knowing nothing and never place that implant to learning how to place an implant?’ What would you tell the kids?
Amos: Well first you definitely right, I think a kid that finish school the first thing that you need to know, what you learned in school is the basics. The real study is the life, you need to go to as many conferences as you can to see many clinicians, many good clinicians to try to find mentors. But don't just rely on these mentors, because there are many many ways that things can be done. There was no one who has the monopoly for the knowledge, not everyone and not me definitely. So in order to enlarge knowledge that's the only way, there are very good courses I think today, we are very much exposed. It's not like in my day that you were not exposed to anything, there were not so many places, the only thing was conference.
So I think he can acquire a lot of knowledge just by watching YouTube videos, by going to conferences, by trying to find some mentors and learn from them and never take things as it’s from the Bible, because everybody has his own philosophy of work, own way of working. By the way sometimes there are those who can be a very high school qualified clinicians, but they are in their comfort zone, they are very afraid to adapt and you and your techniques or something like that. But what I think that everything has changed, now we are not so conservative as we have been. We are much more open to understand new techniques because the life is going so fast, so that's how it goes.
Howard: How many dental schools are in Israel?
Amos: As far as I know there are two dental schools, we are a small country. We are smaller than Jersey.
Howard: Smaller than New Jersey. How many people live in Israel? You said there's two dental schools.
Amos: Yeah, about eight million people live in Israel.
Howard: By the way I have to tell you that I've sent my mother to Rome, she's Catholic, went to see Rome, and I’ve sent her to Paris, and I’ve sent her to London. She wanted to go to her friend, so I sent her and her friends to Israel for ten days and they went to all these museum sites, and it was absolutely the single greatest vacation in her entire life. Ryan, we’ve got to send her back, she's seventy eight and ever since I sent her there she just wants to go back, I think that was the happiest ten days. I need to send her back with my two nun sisters, because oh my god they’d just love that. They loved it so much, so thanks for all the hospitality over there and your tourism department. She just absolutely loved it.
I don't know if it's this way in Israel, but definitely in America, so much of the implant training is tied to a manufacture it's so much manufacture driven. So a lot of the kids are looking at all these courses available, and they feel like they almost have to pick which implant system they're going to use before they start taking training, because most of the training is with or tied to an implant. So do implant systems matter? How many implants does Israel produce? MIS is out of Israel isn't it?
Amos: Indeed, MIS is one of them and is quite the leader in our field. There are many implant companies in Israel, actually I even don't know how much we have in Israel.
Howard: Did Straumann buy one of the companies in Israel?
Amos: It's not the strongest one by the way, we have Straumann but I think it's related to price. I think they are very good implants but I think it's related to the price, because we can have very good the implants which are manufactured in Israel, and with a much lower price and still they are very very good. So I think you're right because what happened is that without the companies, without the manufacturers, I am sure that we will not be in this stage where we do so many implants. Definitely the manufacturer is pushing, now I think there is a strong bonding and connection between the academic and the manufacturer, because both of them must work synergic because if not, there will be no progress because those who put the money on research at least most of them are the manufacturers.
So for a young kid who just started it's not so easy to decide which kind of implant to use, so definitely we should use based on what we heard from our friends and colleagues. When you get an experience then definitely you try a few things and then you decide which is the best one for you, because you should consider few things, first is the safety of the patients, and the performance of the implant, and the other things is the procedure itself, it must be as easy as possible and still with a good result. So it's not so easy, I remember in my days, at least at the beginning, I try about thirty types of implants until I get the conclusion which one I like to work the most and I can tell you a few of them was great. So (inaudible 19:41) there are some that are great, some which I would never use, but that's how it goes.
Howard: I know they all want to know which one do you use though. After trying thirty which one did you end up using.
Amos: Well I prefer not to place names in this, let me let me be politically correct.
Howard: This is dentistry uncensored, we've never been politically correct, but I understand. To the kids out there that's called channel conflict, so if you're selling bone grafting you don't want to make all the different implant people upset with you. So it's called a channel conflict. So you have two products will you explain the difference between BondBone, 3D Bon and Bon Appetit, 4 matrix.
Amos: Okay.
Howard: Are those your two main products?
Amos: Actually we have two main products. One is the 3D Bond, which is manufacture under the private label (inaudible 20:41) company, and the other is Bond Appetite which is manufacture under private label to MIS implants. So the difference between them that the treating bones is a pure biphasic calcium sulfate and their bond apatit is a combination of two thirds of biphasic calcium sulfate together with HA particle in a controlled particle site distribution. So now what's the difference between them? If you have a socket preservation case, you need a short term space maintainer, you need something that you will place there and will replace simultaneously with the patient’s own bone.
Therefore you can use the blue box, the 3D Bond. However, remember this is a short term space maintainer, if you’re going to use it in a larger defect, it will dissolve too fast and you will have nothing. Everything will dissolve even before the bone has the ability to form. So the other product is the Bond Apatite, as I mentioned earlier Bond Apatite is a mixture between biphasic calcium sulphate, which has the ability to transform simultaneously into the patient’s own bone and to encourage the bone formation, actually it's a bioactive material, and we have a stupid space maintainer which is HA particles. But we take a stupid material and we make it play smart. Why? We play with the particle size, we have particle size up to ninety micron to one millimeter and they have different shapes and different size.
Why did we do it? In order that for one point of view, it will reserve the three dimensional space, and in the other point of view they will dissolve as well, because we know that hydroxyapatite is not supposed to dissolve. I will never use hydroxyapatite by itself, I think it's the worst material to be used, but in this combination it's made a miracle. Why? From four to ten weeks all the biphasic calcium sulphate is replaced by the new osteoids, the newly formed bone and the other particles of the HA particles, small and medium size, are dissolved from three to six months. The bigger particles, which are less than ten percent, might last longer. So actually after three months you have three times more vital bone than any of the existing material in the market, and of course in six months we have about eighty percent and ninety percent of the patient’s own bone in your grafted site. That's what's so special about it, so we need to remember that 3D Bond is for socket grafting from precentral until the second premolar, and the Bond Apatite is for all other cases. It can be used in all different types of cases bigger, smaller, everything.
Howard: It's an easier surgical skill to do a socket grafting but it starts getting crazy, tough, when you start doing a sinus lift, and in your videos you talk about a crustal approach, and you talk about a lateral approach. Talk about sinus lifts to someone who's never done a sinus lift and is thinking about maybe doing their first sinus lift. What should they be thinking about?
Amos: Well, first thing in sinus lift it's a little bit different, because if we talk about socket and things indeed your surgical skill does not need to be high. However, in sinus lift first things you need to acquire a surgical skill, because no matter what type of area you are using them. If you don't know how to do the surgery perfect, and if you don't know how to open the window for example, or to do a Crestal approach and not to tear the membrane then your can in big trouble.
The other thing that you should know when you do sinus lift is try to understand how to confront complication when you have, because you can have for example ten cases or one hundred cases that goes nicely but when there is a complication you need to have experience. So that's what I suggest, first acquire a surgical skill, go to some courses, learn how to open it. No, the bone graft is the last thing which is important, it’s the last thing that is important. First is the surgical skill, this is something that if you have no skill I suggest that you don’t touch it even.
Howard: We lost a lot of implant legends last year, Misch, Branemark, Linka. Were any of those your mentors? Do you have any thoughts on any of those pioneers?
Amos: Well I can tell you one thing, any of those were my mentors and not one of them, because I don't believe in one way. I believe that from each one of them I can take something and that's what I did. So because what is relevant for today it’s not necessarily relevant for tomorrow, and sometimes you can find it very (inaudible 25:35) leaders which do the same thing thirty years, or forty years in the same way and not so open for a new technique. So I think, yes we have a lot to learn from them, a lot, but there is no one way. So that's why I think I should adopt some of them, there is no one mento for me. That is me.
Howard: Wow. Your YouTube videos are so great you have so much great content. I wish you'd make a online CE course for DentalTown. We've made four hundred courses and they've been viewed almost a million times, because old guys like us read textbooks and go to conventions, and the millennials, they watch it on their iPhone and then they can get Apple TV. So they throw that video up on their Apple TV and take these implant courses while they're sitting at their home in their lazy boy probably drinking a beer or a glass of wine. Do you think you'd ever make us a bone grafting continued education course?
Amos: First I think we should be grateful to you and we should appreciate what you do, because actually what you do is a some kind of life university, real one that we can see different approaches online and this is amazing what you do. So definitely it would be my pleasure, and of course privilege to do it with DentalTown and I think that I would do something that will go not about just my product, because I don't think that this is the issue here. I think I should talk about the bone biology, what happens when you place a bone graft, any types of bone graft.
How does it work? How is the augmentation? What are the key successful tips in order to have a predictable augmentation one gains by the others as less and less cumbersome in order to do so. So please just let me know and I will do it for DentalTown, and thank you for giving me this opportunity I think it would be great. It's really great for those who want to understand what is augmentation and (inaudible 27:47) experience in augmentation and want to enlarge their knowledge.
Howard: This is dentistry uncensored because we like to talk about everything that everyone argues about, I don't like to talk about anything that everyone agrees on. One of the problems with these kids that come out of school. Their instructor gave them a list of patients that are not ideal candidates for implants, and smoking is one of them. You don't do this and smokers. The problem is in America most of the people who lose their teeth and need implants, they're not Vegans, they’re not yoga instructors, are not marathon runners.
They're usually smoke and drink, and crazy Americans. So what would you tell this young lady who's twenty-five, and she's got some guy that needs an implant but he smokes a pack of Marlboro Red every day, and probably drinks six pack every night before he goes to bed. Does that disqualify him?
Amos: Yeah, I can tell you how I see it. First, you’re absolutely right, If we don't treat the very old person which are not candidates, we will not treat those the smoke, we will not treat this, so actually we prevent many of them from having a quality of life. I think it's something that should be placed on the balance, because don't forget that when you give an implant to somebody instead of an removable denture, you actually improve their life and it doesn't say, from my experience, that everybody who smokes is a failure. Definitely not. It's also like those with diabetes. Yes indeed, some of them have difficulty of feeling, we need to consider it, we need to to make a judgement to see how much do they smoke smoke.
But I cannot exclude all of those, at least those patients I don't do, because I don't think it's realistic in our work, and definitely don't forget that when when the implant succeeds for that person, you change his life he's very happy, he can eat, and he can feel much younger. I remember one day that one of my patients, an old one, said to me ‘when I lose my hair I feel so old as when I lose my teeth’. So that is the way of thinking, when you lose your teeth and your quality of life is so poor, definitely you should think what we give him and we should put it in balance, is smoking compared to the quality of life we can provide him.
Howard: Another question a lot of the kids are asking, immediate load versus some people bury the implant for three months, then go back on a second stage, then load. But the patient always wants immediate load and the older guys, like us, we are better at being the dog and the patient the tail. But a lot of these young kids, the older grandpa, makes them do things that makes them get out of their comfort zone. It seems like when I was little every time I had a bad idea about this tooth, the patient was talking me into something that I knew was a bad idea, and I was so young and dumb I’d do it anyway. So how should she get her mind wrapped around an immediate load implant placement versus a two stage?
Amos: Well I think first, if you can have good primary stability. If you can have good primary stability, and you have a good type of bone, actually from my experience I can do immediate loading immediately, and I can place my provisional on that. But it depends on your experience, how much experience do you have in order to judge, to make the right judgment when you use this and went to using it not with immediate loading. It also depends on the bone quality and the stability of the implants, of course if your stability is jeopardize I wouldn't dare even to make an immediate loading.
But if you have a good primary stability and the torque is sufficient, I would not be afraid to do immediate loading especially when I have a full arch which I can have cross arch stabilisation, which helps the implants to be in place and to be stable. So I think it's depend a lot on the experience about when to judge how to do it, and we say good judgment comes from a lot of experience, and a lot of experience comes from bad judgment. So I don't think that those who will have this experience would not have some failures down the road, there must be. It’s part of our training.
Howard: Same question. What should she be thinking about extracting and then placing an immediate implant versus extracting and letting it heal up for three months.
Amos: Well of course it depends again, if you can have a good primary stability of the implant you can extract, if you can drill to the implant, and you can stabilize it, and you feel the implant can stabilize, it's a very good way to do it. By the way the big advantage by using cement, is that you don't need to condense that cement between the boning of the socket and the implant, when you do so sometimes you might move the implant. Here the only thing that you need to do is to eject it about, press it firmly for three seconds with a dry gas, place a collagen sponge or collatape, and then soft tissue will grow about it. So definitely both options are good.
Howard: Another controversy, I'm trying my hardest to get you in trouble. When we did a podcast interview with Carl Misch before he passed away, and one of the most controversial things he said was that he thought the drawing of the blood, and the spinning of the platelets, and the PRF, he thought it was all nonsense, that there is no research and he said no to at all. What is your thoughts about drawing blood? What if you're talking to some young girl and she sees a course on PRF and she's thinking ‘do I really want to ask the patient if I can draw blood? Carl said no. What is your thoughts on that?
Amos: Well I can tell you something. Even if you want to complicate me, but I will tell you what I think about it. When you’re working with gramuls that does not transform into bone. You try to do everything in order to improve the quality of the bone, and the quality of healing that you have there. So it's like you can use different types of material in order to improve it, and of course you can use blasting in order to improve it, I don't know what will work better. But when you take the material that we placed into the patient’s Bond bone, and has the ability to use their bone and to encourage bone formation, you don't need nothing.
So (inaudible 35:52) hard to figure out when you take for example the biphasic calcium sulphate which replacing (inaudible 34:57) abrasion bond bone. I remember one day I was in the ICOI conference and I gave a small lecture to a study lab, and I showed them the cases and then they went to the main podium and they saw some cases where you use bond bone morphogenetic proteins, where use other techniques. In the end they come to say ‘well I don't know why should I spend so much money, and do it so complicated when you’re material is so simple, and can do it by that’. So I think this is the way, there is no need with my material to use it. There is nothing wrong about using it, but with my material you definitely don't need to do it because you’re going to have the patient’s own bone in three months. So that's what I’m thinking about that.
Howard: How many patients like to have their blood drawn? They don't. I mean I don't want anybody to draw my blood.
Amus: Nobody likes it. Nobody likes it. But some patients are relying on us and what we say they except. I have nothing against it but I don't think that with my product you need it. You absolutely don't need it because you’re going to have a great result without it, so it's up to you. It's up to you, sometimes we do things like fashions or something like that, but I don't have anything against it but with my product you definitely don't need it, because the biphasic calcium sulfate is bringing the patient's own bone quickly and simultaneously. By the way we don't want to accelerate the healing, because when you accelerate the healing you might end up with something which might be dangerous to patients.
We just want not to disturb the healing when you place gramuls, any types, you disturb the healing, you disturb the blood supply, you'll disturb everything there. So actually the healing gets much longer, and it takes time, and at the end of the day you don't have the patient’s own bone. The biphasic calcium sulfate turns into the patient’s on bone, and encourage the bone formation and does not interfere with the healing. So from my point of view there is no need to use nothing.
Howard: So if my homies went to your website augmabio.com. A-U-G-M-Abio.com. What are they going to find on your website?
Amos: Well on my website I think they're going to find a few interesting things. First is the explanation about what we are, what we stand for, what is our mission, what is our vision, where we want to take ourselves, what is our commitment to the dental community, because I think that for me is as a clinician I have a commitment. It's not just manufacturing something, I have a commitment to do things that will be much more easy and predictable to our clinicians, and to the patient because in the end of the day what we do is for our patient, and not just for ourselves.
But this is a win win situation. Another thing that you can find there, you can find some videos, some literature, some explanations, some tips how to use it, frequently asked questions. I think it’s worse to go visit our website and to see all of those things, and of course we are always open for questions from our visitors, because I think a part of our commitment is to educate our customers, and everybody. So we are always open to give answers and that's what they can find on our website.
Howard: So would you consider yourself a general dentist or a specialist like an oral surgeon or periodontist.
Amos: Yeah. My training was as a general dentist. However, I think I placed in my life more than twelve thousand implants, something like that. I have a lot of experience, that’s what I did from day one. So what they did in my clinic was only implants and augmentation procedures, so I don't have a title but I have enough experience.
Howard: Well I want to ask you about that, because I'm in the United States, you’re in Israel. When I lecture around the world implant is very different, like in Korea three out of four general dentists placed an implant last month. You come to the United States and three out of four general dentist did not place an implant last month. Why do you think some countries like Korea, Germany, Brazil, the general dentist three out of four routinely place implants, and then America it's not so much. What do you think about that? Do you think it's changing?
Amos: First I'm sure that it’s going to change, I have no doubt that it’s going to change. In Israel for example there are so many clinicians, general practitioner who have huge experience in implants, some less of course like with everything. But I think it's going to change because this is the power of the market, if you want to or if you don't want to, the implant companies are pushing more and more to have more GP’s in their portfolio, and I think that's what will be in the US. Now maybe it's a kind of mentality, there are countries that needs less are doing implants. But this is the force of the market, I'm sure with more and more will acquire knowledge and will place implants.
Howard: Let's talk about one of the most controversial things, and that is there's a lot of research showing that after five years in just sixty months, that twenty percent of the implants placed in America have peri implantitis. It is my view that it's hard to even have a consensus on what the protocol is for peri implantitis, some are treating it with lasers, some are opening up. So what is your view on peri implantitis? It scares a lot of people, these kids to place their first implant and Grandpa who lost a tooth from periodontal disease, because what's going to happen in five years if now the implant has periodontal disease, and no one really agrees on what the protocol to treat periodontal disease around an implant peri implantitis.
Amos: Well thank you for the question. I think it's the most controversial question and the most difficult to answer, because there are no protocols to treat peri implantitis. There are many suggested protocols but there is no one protocol that can be predictable. So I say peri implantitis can succeed, and I have some beautiful cases that I could make a show off with them, but it's definitely not predictable. So what do we say with our product, even so that I have some beautiful cases, and some don't do peri implantitis cases. Why? It's not predictable. If you want to fail, fail with my (inaudible 41:55). Peri implantitis is a very complex situation.
Why? First you need to clean the implant, and cleaning the implant, cleaning the inner parts of it, the porosity. It's almost impossible, antibiotic cannot work there because antibiotics need blood vessels in order to carry in the contamination things are very dangerous to the bone near around it. Lazer and this cannot go inside those pore, so sometimes it works sometimes not. By the way sometimes there is a mechanical grinding just to try to clean the pores of the implants, and the other things which is very very complicated is the defect morphology, which most of them are involved with also vertical parts that need to be stabilized. So we are thinking about looking for and trying to develop a product that will be suitable for that.
By the way it's not one product, we need find two kinds of products. One product that will clean the surface and will not toxify the surrounding tissue, and the other is a bone graft which we preserve in three dimensional structure and build the bone (inaudible 43:13). So it's very complicated, we don't have a solution, now for those that ask me what about those things? Should I place an implant or shouldn't because of the peri implantitis? Well I can tell you something, each one of us have a chance of an accident one day, it doesn't say that we are not going into the streets. So that's that's my philosophy about it.
Howard: How many dentists are in Israel?
Amos: I think we have something about ten thousand or fourteen thousand dentists, I think so. I think so, I'm not sure.
Howard: Say there's fourteen thousand. What percent of them do you think have ever place a dental implant?
Amos: My estimation, I don't think that there is any research that says exactly the number. By my estimation it's about twenty-five percent of clinician will do implants and augmentation procedure. That's my estimation about it.
Howard: So that is…
Amos: Fifty percent.
Howard: So what would you guess it is for the United States?
Amos: I believe that you have something about ten to twelve percent not more than this, because you have about one hundred and fifty thousand clinicians or one hundred eighty thousand clinicians.
Howard: There's two hundred and eleven thousand Americans who have a license to practice dentistry, a hundred and fifty thousand are general dentists thirty-two hours a week or more, and thirty thousand are specialist thirty-two hours a week or more. The number one specialty is orthodontics at like ten thousand eight hundred and then you cut that in half and you have five thousand oral surgeons, five thousand periodontists. That's another question I want to ask you, endodontists now are starting to think maybe when root canals failed, and they're thinking it's maybe because of a fracture and it's non-restorable. They're thinking of extracting the tooth and getting it implants.Are you seeing that trend in Israel and around the world?
Amos: Yes, of course. I can tell you something also for implant surgery, the main income can come from implant surgery. So that's what I call the market force, when the main income comes from that. It does not take so long in order to learn the basics of it. I can see endodontics because they can do other surgery, they do a vasectomy, they do other surgeries so, I don't see why they wouldn't use it. Why they wouldn’t place an implant, because sometimes a good implant is much more predictable that wrong done endodontic case, or redone orthodontic case. So I think many of them will be engaged with this. I don’t doubt.
Howard: So on Dentaltown there’s a quarter of a million dentists who have posted five and a half million times. So we have a search function, and I just did a search for Bond Appatite and you have some raving fans on here. I just posted on to them that I'm podcast interviewing you right now. But anyway, he was saying that when he read your advertisements, and watch your YouTube videos, he didn't believe it because he said it sounded too good to be true.
Amos: That's good.
Howard: He actually tried it and he said he'll never go back to granulating bone, and he'll never go back to other stuff. He said it's one of those rare things that if it sounds too good to be true, it's not true. But he thinks you're true.
Amos: Well that is our main challenge, because it looks to good to be true. Sometimes people say ‘what is behind it? How can we be so easy when we have learned to do it in other complicated ways?’ That's true. But we need to remember, a clinician who wants to start working with cement needs to make two decisions, the same decision that he took when he got his driving license. First I want because I understand the benefits, and second I'm not waiting after my second lesson, because there’s a small learning curve and you should change completely gramule your state of mind, and start learning the protocols about how using a cement. When you do it I can assure you you can never go back, because there is no reason to go back.
Howard: So I want to ask another question, we both agree there's not really a scientific predictable protocol for treating peri implantitis. What would you say to a young dentist? America has a lot of people who want everything natural, and they don't like GMO foods, and they're really unnatural, and when they're getting an implant they say ‘no I don't want any metal in my mouth, I want these all natural porcelain zirconium implants, because I want to be metal free’. She claims she has metal allergies, and I don't really know how I as a practitioner can really determine if Amos truly does have a metal allergy. So how does she deal with that diagnosis? Can she prove that Amos has mental allergies and should have a porcelain zirconium implant? What should she think?
Amos: Well I tell you something. If a patient will come to me and say I have a metal allergy, I don't want metal. I will never replace him with metal, because in his head he will have the allergy.
Howard: Right.
Amos: No matter what you do. You fight with the (inaudible 48:43) because of the tooth. I would never do something because don't forget we don't treat just teeth, we treat the patient. The patient is an integral part, it’s his mind, it’s his thoughts, his beliefs. So it's like trying to give somebody who doesn’t eat meat, try to give him meat, you shouldn’t do so. Even if you think that you are very professional in this, I think we should consider the patients needs. That's as far as the patient beliefs, the patient philosophies, we should respect it because if not everything that would happen is because of us, we don't want to be there. Now with the zirconia implant, telling you the truth I don't have experience so I don't have any opinion about that.
Howard: But yeah, you're right. You're not going to change people's minds, if they believe they have a mental allergy you just need to start thinking about something else. I also want to ask you something about shaming, Homosapien is a tribal animal, I was reading some very interesting research. We all know that we all obey the four hundred pound gorilla, that's our social integrity, but they also always pick on the bully, they always pick on the little monkey, and they did some research where they took out that baby primate and put it in another group, and they just found another group to beat up on.
So it's like that parallel is four hundred pound to bullying the guy, and they're completely lined up on a pole. A lot of times now when dentist on Dentaltown do a three in a bridge, a lot of people are shaming them saying ‘well why did you file down to virgin teeth?’ Well the flipside of that is if you talk to a ENT or a Rhinologist they're saying ‘well why did you blow up my sinus? Why did you pack all that stuff in the sinus, and bone graft? You had two teeth, and they use religious terms they say things like ‘well you filed down to virgin teeth’. I mean how can a tooth be a virgin? We have no documentation of teeth having sex.
So do you think that the three in a bridge is bad, and that you should be bullied and shamed for filing down two virgin teeth to do a bridge, and you should have placed half a dead cow in an implant, and membranes and all this and a sinus left, because we've seen the three in a bridge drop replaced about eighty percent by an implant. I'm asking you a biased question because you're from the God of odontology, you worship teeth but do you have any ear nose and throat friends in Israel? Do you have any friends that don't like you in the sinus? A lot of people think that's why the all on four took off so fast, is because the one thing the all on four did is it avoided sinus lifts.
Amos: Well I can tell you one thing, I did many sinus lifts in my life and it's a very good approach, and when you have a complication it's not so pleasant. No matter that you have experience or not, it's not so pleasant. But I would not excluded from my alimentum. We have an alimentum. Sometimes by the way I did bridges, sometimes I did maryland bridges, sometimes I did just implants. So I think it's a matter that everybody decides what the treatment modality is, first by his experience of course, because when you have a lot of experience and confidence in what you do, we can convince the patient to do it the way that you believe that would work.
Secondly I think those things should be given to the patients as a treatment modality, also to try to share with him to see what he would like to have, because sometimes a patient does not want to have a sinus lift, I don't want to have surgery, I prefer to shape two teeth and to make a bridge, it will be much more easy for me or it's would be less expensive for me. So I think there is no one way to do things, I think all of those are treatment modality and tools in alimentum, and we should decide based on this and based on our experience, because if my experience that when I'm doing something most of it fails, I would not suggest at this to the patient. But if I believe that most of it will work and I see that the patient’s condition is as well. I don't find any reason why not to suggest it to him.
Howard: I can’t believe we already went on an hour, but I still have a couple more controversial questions. Can I ask you some overtime questions?
Amos: Yes please.
Howard: Okay, two more huge controversies. One is to screw the implant in or cement? You have people on both sides, some just like to cement the prosthesis on the implant, some insist that the cement is toxic and as a big factor in peri implantitis and they should all be screw retained. You've placed twelve thousand implants. What is the percentage of your implants that you cemented the restoration versus made it screw retained?
Amos: Most of them.
Howard: Most of them what?
Amos: Was cemented. Most of them was cemented. You should master the technique to know how to clean the cement, and I can tell you why I cemented them, because what's happened is that if you have some screws that are released due to the masticatory force, or due to the imbalance of the occlusion. It shows you that there is something wrong here, so then you can go inside and do selective grinding and try to do it better. The problem is that until you distinguish it all of the other implant ever overloading, because it doesn't say that in a moment that the screw is starting to move. The patient comes to me, he can come one year later and already there. Instead of sitting on four implants it stays on 3, or on two, or on 1, sometimes.
So I believe one thing, when I cement it, when I believe in it, I cement it. There is no reason from my point of view, there is no reason why not to cement it because when it’s stable maximum with the time you come to check, you know that all the load even that maybe's was not so balanced, it's on four and not one second you check it. I mean I call the patient after a month and I do a selective grinding, check that all of my occlusion is perfectly fit, that's how I’m doing. So I'm not a fan of the screw in, I don't say that there is no way to do it by screw in, but I'm not a fan because of this reason.
Howard: I want to ask you a couple of public health questions because a lot of our viewers are all around the world and they all have different public health deals. Does Israel believe and utilize water fluoridation?
Amos: Yes.
Howard: Are your major cities fluoridated?
Amos: Yes, yes.
Howard: In America twenty-five percent of Americans think it's a communist plot, that it's toxic, it's really controversial in America. About seventy percent of the nineteen thousand and eighty towns are fluoridated, thirty percent still aren’t. Is it controversial in Israel or not really?
Amos: It's controversial. In the past it was, I don't know if it’s still. The Jews are not so involved with this but definitely it's controversial of course.
Howard: The same question about amalgam a lot of dentists in America believe that amalgam is a toxic material, and they always say things like several countries have banned it, which I'm having a hard time finding any of these countries that have banned it. Of your approximately twelve to fourteen dentists in Israel, what percent of them would you think still use amalgam?
Amos: Well I think it's a guess. I think it's very few, most of those that I know don't use amalgam, but they don't seem that they don't use amalgam just for that reason. I think they don't use amalgam because now we have very good options working with composite, don't forget that we learned so much about composite and the composite of today are amazing much higher quality than it was thirty years ago. So if you know how to do a great bonding and use a composite it's a great material to work with and it looks nice. So why should we work with amalgam? Still there are those who work with amalgams, but I don’t think that they’re a large quantity of the doctors. I don't have the right numbers about it.
Howard: Well one of the things I'm so passionate about amalgam is, I've been in many countries around the world where the dentist is working by themselves, and they don't have good suctioned or isolation. If you don't have good suctioned, isolation, rubber dams, you have to use amalgam.
Amos: Definitely. Definitely, one hundred percent I agree with you because a composite, if you don't work because you're talking about bonding and if there there something that interferes with your bonding, you will have the worst results. So definitely I completely agree with you, amalgam is a great product that served us for many many years. I’ve never heard that somebody died from amalgam, even if it has mercury but the mercury bound, it’s not a released mercury. Indeed if you want to have a good obturation and you don't have the right combination how to isolate your teeth you should use an amalgam. Definitely. Definitely, I agree with you.
Howard: Yeah.
Amos: The perspective of somebody who have experience in this field, definitely.
Howard: Yeah. Final question. Thank you so much for spending the hour with me. My final question is you’ve been in dentistry for twenty-five years, if your daughter just graduated from dental school today, and you were called in to give the graduation speech. What advice would you give her, because she's saying when you and I got out of school we didn't have three hundred and fifty thousand dollars of student loans. Now there's corporate dentistry, and sometimes she’s second guessing your decision saying ‘yeah, maybe it was a good idea to be a dentist when Amos and Howard got out of school. But what advice would you give her today?
Amos: Well first get out of your loans. Yes. How to do it? Get experience, learn, master the techniques that you learn, and then if you're good you will have a patience that we believe in you. Then of course I think that we can earn quite nice amount from having a dentist. But be passionate about what you do, because if you don't like what you do just go and look for another profession, because this profession is not easy. If you don't like it, if you don't have a passion for the profession. It's a very very stressful profession and very hard work as well. So first is to find that she has the passion for what she doing, to specialize in the thing that she's doing the best, and then I think she will be bold in that. That's what I'm thinking. That's what I suggest to her.
Howard: Also if she wants to get better at implantology, and she wants to join some of these associations of implantology. Do you have a favorite? Is there one that you recommend that she join?
Amos: Again I don't believe in one, I believe in many as many as you can is good because different techniques, different knowledge, different aspects of seeing things. I think that's the only one that can enrich you the most. So I don't believe in one.
Howard: Well I'm already regretting this podcast, because you just reminded me I’ve got to call and said my mother and two sisters back to Israel. So you just cost me a very large amount of money today. But I know I'll make their day, Ryan, if we call mom and sis and tell them we're going to send them back to Israel.
Amos: We have a great country, we have a great people here, and it's very concentrated. It’s so small but everything is within it. So for me the first time to come to the States it was like a shock. Everything is huge and the Israelis everything is tiny, you know many people’s names but now I'm getting used to the States. I think it's a great country and I enjoy every moment that I'm there. I'm going to give some lectures in the States, we’re going to give some educations about the bone cement because we want to spread the word that there is another and better techniques to do today. So definitely you are welcome as well to come visit us in Israel, and I’m going to be very soon in the States.
Howard: Well I look forward to your bone cementing online course on Dentaltown, I think they’re going to love it and if you want to find the easiest way to find his YouTube videos, just go to his Twitter @augmabio or what should they search on YouTube?
Amos: On YouTube Augma Biomaterials. Augma Biomaterials and then you can find some videos, some videos are with explanation how to do, and what are the tips how to do it perfectly, and we decided now to launch much more videos because we see that there is a great demand for that, and I'm so glad that now we are growing exponentially and we will provide much more videos, and much more education stuff to our customers.
Howard: Yeah. So I just typed in YouTube Augma Biomaterials. He has twenty-nine videos and a lot of these have sixteen hundred views, thirteen hundred views. I mean they're very very popular. That's how I found out about you. By the way what I recommend you do, is I recommend that you go to Dentaltown and go under implantology, and say I just podcast with Howard and he wanted me to post these videos, because what you could do on that YouTube video when you hit share there is a link, but if you type in bad it'll pick up the whole code and then on Dentaltown you could post all twenty-nine of your videos where it throws up the YouTube video.
So when they click that it goes right to YouTube, you'll still get your counts and views on YouTube, but I think you should post them all on Dentaltown because it would be the best free marketing you can do. You've already done the work, you've already done the content, but man a lot of these people will embed their YouTube video on Dentaltown and explode their views, and I think my forefinger tests whenever I see something as. Is it faster? Is it easier? Is it higher quality? Is it lower costs?
Again when I saw your YouTube video I thought it was too good to be true. So thank you for all that you've done for dentistry. Thank you so much on a Friday night, you should be out dancing and drinking and you're here talking to a bunch of dentists. So thank you so much for spending your Friday night with my homies.
Amos: Thank you very much for having me on your show. Thank you it's always a great pleasure and honor for me. Thank you very much.
Howard: I will see you in Israel with my sisters.
Amos: You promise. Keep your promise.
Howard: I promise.
Amos: Okay, don't forget I have a good memory.
Howard: All right well I have to go to dinner.