Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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985 Ceramic Implantology with Sammy Noumbissi, DDS, MS : Dentistry Uncensored with Howard Farran

985 Ceramic Implantology with Sammy Noumbissi, DDS, MS : Dentistry Uncensored with Howard Farran

4/6/2018 4:15:29 PM   |   Comments: 0   |   Views: 219

985 Ceramic Implantology with Sammy Noumbissi, DDS, MS : Dentistry Uncensored with Howard Farran

Sammy Noumbissi obtained his Doctorate in Dental Surgery from Howard University in Washington DC. He was then selected to attend the prestigious Loma Linda University Graduate Program in Implant Dentistry. There he received three years of formal training in dental implantology which culminated with a certificate in Implant Dentistry and a Master of Science degree in Implant Surgery. He is a researcher, author and has published abstracts and articles on ceramic implants in peer reviewed dental journals. He lectures nationally and internationally and is the current and founding president of the International Academy of Ceramic Implantology which is an independent association and education provider exclusively focused on metal free and ceramic implantology. Dr. Noumbissi has been practicing and educating dentists on metal free implantology since 2009. His practice and the academy are both located in Silver Spring, Maryland USA.

VIDEO - DUwHF #985 - Sammy Noumbissi

AUDIO - DUwHF #985 - Sammy Noumbissi

Howard: It's just a huge honor for me today to be podcast interviewing Dr. Sammy Noumbissi, DDS, MS all the way from Silver Springs, Maryland, which is a suburb of Washington, D.C. He obtained his doctorate in dental surgery from Howard University in Washington, D.C. I don't know if you know that, but that school was named after me ninety-five years before I was born. How cool is that that they started that Howard University in 1867 and I wouldn't be born for ninety-five more years. 

He was then selected to attend the prestigious Loma Linda University graduate program in implant dentistry. There he received three years of formal training in dental implantology, which culminated with a certificate in implant dentistry and a Master's science degree in implant surgery. 

He’s a researcher, author and has published abstracts and articles on ceramic implants in peer reviewed dental journals. He lectures nationally and internationally and is a current and founding president of the International Academy of Ceramic Implantology, which is an independent association and education provider exclusively focused on metal free and ceramic implantology. Dr. Noumbissi has been practicing and educating dentists on metal free implantology since 2009. His practice and the academy are both located in Silver Springs, Maryland University. 

Well, thank you so much for coming on the show. 

Sammy: Thank you, Howard. Thanks for having me.

Howard: Oh, it's an honor. So gosh, the first implant was placed by Brånemark, I wonder what year that was. You know what year that was? Can you Google what year did Dr. Brånemark placed his first implant? And they pretty much all been titanium. So do you see ceramic implants as the next big thing in implantology?

Sammy: Yes, I do and for many reasons. Like you said, the grandfather of implants was Brånemark from when he started. He was in the mid-fifties, I can’t remember. Until today, titanium implants remain the dominant form of tooth replacement in implantology. However, over time now we've been finding that echnology has evolved and we find that not all patients and not all titanium alloys are created equal and therefore, we start to face challenges and we also start to face the public asking for better materials to be inserted in their body. 

Howard: I just Googled it. Leonard Linkow in the 1950s was one of the first to insert titanium and other metal implants into the bones of the jaw. Artificial teeth were then attached to this piece of metal. In 1965 Brånemark placed his first titanium implant to a human volunteer. So I wonder when the first ceramic implant was done. 

Sammy: Well, if you go back in the history of ceramic implants, we have the equivalent of Brånemark and Linkow’s ceramic implants which is Sami Sandhaus out of Switzerland and Sami Sandhaus started looking into ceramic implants, modern ceramic implants, I should say in the seventies. He even had a brand at the time, his own system which was made out of early type of ceramic and since then it's evolved. So ceramic implants are not new. I mean, totally just came up recently. They've been around; people studying them and placing them in the background and I want to say in the last fifteen, twenty years, we've really seen now a real resurgence and a development and advancement of ceramic materials for implantation. 

Howard: They say these ceramics are metal free but they’re made out of zirconium and technically isn’t zirconium a metal?

Sammy: Okay that's a very, very good question, Howard. Because I get that all the time and it's always brought up. Now, when you look at ceramic implants today, they're most made of three ceramics in majority: zirconia, alumina and yttria. 

Now, your question was about the zirconia part. There's one thing where people have to be very careful. Zirconia and zirconium are two different things. Zirconium, you’re right is the metal. If you look on the table of elements, you see that zirconium is right around titanium and other metals. However, zirconium is one of those metals like aluminum and yttrium that are called transitional metals. So these are metals that under certain type of treatment and processing can transition into a crystal phase and therefore, become ceramics. 

So zirconium alone is a metal, but now when you do oxidation of the zirconium, you have zirconium oxide which is called zirconia. You have aluminum oxide which is called alumina and the same thing for yttrium which is yttrium oxide and becomes yttria. So the idea that the ceramic implants, zirconia implants are another type of metal implant, it's a misperception. It's actually a ceramic which has the properties of all ceramics and divoid completely transform from a metal into a crystal. 

Howard: That is profound and very interesting. So why do you think there's a market for ceramic implants? Is it cosmetic? Is it allergies to metal? What do you think is the driving force? 

Sammy: I think the driving force at the moment is, believe it or not, the public, it's the patients. If you look around, there's a lot of health food markets, there's a lot of organic, there's a lot of wellness, there's a lot of well-being. So the mindset of our patients, the public of those we serve has evolved. So you find that patients are going out now requesting alternative therapies or requesting less invasive therapies. 

Now on the other side, on our side as professionals, those of us who have done a lot of implants for a long time have witnessed that some patients do not tolerate well those implants. They have sensitivities to those implants or allergies. We’re also finding out now it’s being pretty much documented better and better that a lot of issues with peri-implantitis has to do with titanium breaking down into bone and causing inflammation. And of course, as you mentioned, there’s also the aesthetic factor. I mean, white implants, you don't have greying or soft tissue and things like that. 

So it’s multi-dimensional, the aesthetics, the health demands of the public and the awareness now in our profession now that there are problems in some individuals, not all, with tolerating a metal implanted in the bone for long periods of time. 

Howard: Gordon Christensen said that and a lot of people thought he was crazy that there were metal allergies to titanium because the knee jerk reaction is that “No, it's not, it's completely tolerable.” But you agree with Gordon that some people have sensitivities to titanium?

Sammy: Absolutely. Gordon Christensen is absolutely right and I would go further and say that today with what we know and what's documented in the literature that titanium is bio-tolerated. Titanium is bio-tolerated compared to zirconia and what we know about the cornea at this point now. So it’s worked well. It's served orthopedics in dentistry and implantology very well, but now we know more. We are able to find out more what it can do or what it can’t do so potentially cause for any given patient and we have to pay attention to them. 

Howard: Zimmer is really the largest implant company, really in the world because they do hips and knees and spine disc and everything. They just put their dental implant division up for sale this week. I wonder why do you think they're getting out of the dental implant? 

Sammy: Well, if you look at Zimmer right now, they've always been titanium. And I think the titanium, I'm not an expert in the business, but being a keen observer of how implantology has evolved in the last twenty years, we have a plethora of implant companies. So in the United States, I think the last number I saw was a hundred and fifty or a hundred and thirty FDA approved titanium implants in the United States. 

So I think the market is crowded and now we can find pretty functional good implants for $80, $90 in the market and if you look at a Zimmer implant, it's a very good implant. I’ve used a lot of Zimmers for many years, they cost about $200, $300 and then you have the clones and so I think what has happened is for them and that's my opinion, the market has gotten crowded. It was always a little thing on the side for Zimmer. They're huge in a urology and orthopedics and all that. So I think it's just probably a business move as far as they're concerned. 

Howard: So what percent of the market today in 2018 the implants is ceramic and where do you see it in ten years? 

Sammy: Today we're looking at less than 1%; it's still a very niche market. As you're probably aware, the International Academy of Ceramic Implantology. We are also very small organization, we’ve existed for about seven years and the numbers are growing. That's fine. You find that the big players are getting to ceramic implants like Nobel and (unclear 10:04) and Straumann, of course. So that's a good thing. But now, it's still a very niche product. It’s gradually moving out of the holistic dentist niche into going slightly mainstream. 

Now you ask me where do I see it ten years from now? I don't think ceramic implants will come around and completely wipe off titanium implants or completely replace them. I just think that they're going to have their fair share on the market. The problem now we have with ceramic implants is the cost. It can be very expensive, especially based on which technology is used to make them. So ten years from now, I'll stick my neck out and say maybe it could be somewhere around 15, 20% of the implant market. 

Howard: Wow. So your website is IAOCI, the International Academy of Ceramic Implantology. I know what my homies are thinking and the first thing you're thinking is well, which ceramic implant do you prefer?

Sammy: Ceramic implants, I'm going to be a little long in my answer, but I’ll try to be very succinct anyway. Ceramic implants are made in two ways; it can be made either by milling or it can be made by injection molding. 

Now one, milling technology's expensive because you have to have drills and milling machines to grind blocks of zirconia. Whereas, injection molding, you can make a lot of implants in one shot and they come in two forms. They come in one-piece implants and in two-piece implants. Now there are the challenges that have come about on both ends. 

A one-piece implant is very challenging not only to place but also to restore because once we place the implant, we have the abutment connected to the implant and you have to send a patient out and trust that they will not disturb that implant prematurely. So that's a big challenge and then if you have angles or difficult areas, sometimes a straight implant one-piece is not the most appropriate implant to place. 

Then you go to the two-piece implants which are similar to what we know with titanium implants, but a challenge they have right now is to find a screw that's not metal. So for example, Straumann has come out with a two-piece in Europe, not in the US yet and it has a metal screw which a lot of purists either on the patient or the doctor don't like the idea of having a metal screw within ceramics and if you look at the biomechanics of the two materials, they're not very compatible so there's issues there. 

So there's only one implant right now in the market that has a carbon fiber screw and has enjoyed a lot of success because of that. But then again, the downside of that is that the screw has to be of a certain size and it takes a lot of restorative space. 

So to answer your question, Howard, very squarely what's my favorite ceramic implant or which one do I favor? Not really any because they’re all designed a little differently and they tend to be better applicable in certain situations versus others. What do I use the most? I like two-piece because again, it reminds me of the flexibility I had with titanium. One-piece are very good in premolar areas and things like that where things are a little more straight, where there's less stress, there's less chances of premature stress on the implant. So yes, it's very difficult to give you a square answer on that. 

Howard: One of the biggest problems that these kids have is they come out of dental school two hundred and fifty, three hundred and fifty thousand dollars in debt and they’ve never placed a single implant. I mean, it's so hard to go from zero to one. What would you tell some lady who’s twenty-five years old, she's a commuting to work right now and she's never placed a single implant? Guide her under journey. How should she start?

Sammy: You’re right, they come with lot of debt and very few can afford to go to residencies like I did for three years and just learn implants. 

Howard: How did you swing that?

Sammy: Well, at the time it wasn't as expensive as it is today. That was about fifteen years ago, but it was tough. It was tough. I had to like everybody, I'll be honest, it was challenging. Financially, it was. But then there was a passion in me to go and pursue that. 

Now mentoring a young dentist, the dentist coming out of dental school, twenty-five years old, three hundred and fifty, four hundred thousand dollars in debt. I say start by finding a mentor, start by hanging around a guy who is open-minded, who is willing to share, who can walk you through it. I even say that this is something I really, really advocate. Start restoring implants before you place implants because in implantology, the difference between the men and the boys, I'm not being sexist, but between the two is prosthetics. You can place implants all day long. If you can’t use them for prosthetics, you're not going anywhere with it. 

So I tell young people or beginners, find a mentor, try to restore them because when you restore them, you see the problems that can come from poor placement or poor planning. Then go into single cases. Simple single cases and simple doesn't mean anterior because a lot of people think a simple implant case is a number eight or number nine, that's not true. It's probably a premolar in a maxilla, that's the area of the mouth where things are very straight. You’re less likely to hit a nerve or perforate the sinus and things like that and then immediate placement is not a simple case either. A lot of people think, “Oh, the hole is there, I can just stuff the implant in there.” No. 

So also what they have at their disposal, which I didn't have just fifteen, twenty years ago. It's a lot of tools; there's cone-beam CTs, there’s 3D planning, the services that can help you plan. I didn't have that and I'm not in the business that very long. So find a mentor, start restoring them first, do simple cases and slowly grow. Also educate yourself, be open-minded. Read. You have to read, you have to look at articles, you have to go to courses. All these things come gradually and slowly. So that's my advice. 

Howard: I agree. Finding a mentor is just everything and that's why I love doing this podcast so they can, using the smartphone, to carry your voices while she’s on the treadmill. What percent of oral surgeons and periodontists, do you think are open-minded and think in hope, growth and abundancy versus living in fear and scarcity and she knocks on his door and he's thinking, “I want you to send your implants to me, I don't want to teach you how to do this. This is my business.” What percent of oral surgeons and periodontics do you think think in abundance? 

Sammy: I can't give you a number but it's probably very, very low, but what I can say is this. When I came out after my three arduous years of learning implantology, I had the same reflex. You tend to protect what you've earned, your hard-earned knowledge, but you know what I found out very quickly? The more you educate people on a certain aspect of things, the more they understand limitations and the more they understand what they're willing to do or able to do. 

So I found that my referrals went up when I explained and showed the process and some of these people will sit and say, “Dr. Sammy, I think I'm going to let you that do that” and once you educate these people to see what you see or how you see it, they see more. They might keep a few in their office, the singles and whatnot, but they will now learn how to identify the cases that fit what you need as a specialist or the expert. So the percentage I don’t really know a number, it’s probably below 5%. I don’t know.

Howard: Yeah, exactly and the orthodontist has the same problem. They're so scared of a general dentists doing Invisalign and what is the Invisalign doing now? They're bypassing the orthodontist; they’ve bought a controlling interest in SmileDirectClub and now they're going straight to the consumer in malls and here, the orthodontist thought the general dentist was the bad guy. And every orthodontist that I've seen in the last ten years who knew general dentists were going to do Invisalign and got behind it and start putting up study clubs in their office saying, “Hey dude, if you're going to do this Invisalign, I want to make sure you're doing it right.” Their practices exploded because the general dentists might start doing some Invisalign. 

What I've seen with orthodontics is general dentists saying it's a great idea, they don't realize an orthodontist is flipping a chair every fifteen minutes and they're scheduling an hour for an ortho-check or thirty minutes and they all get into it and then most of them get out of it and then who do they leave all their business to? That orthodontist who had a relationship and bought in abundance and same thing I've seen that over and over.  Endodontists, they let you come in and sit down and watch them do a root canal. They always have the biggest practices. Living in fear is just not an option.

I remember this metal allergy. I've seen this rodeo before thirty years ago. I mean back when, by the way, when I got out of dental school, a PFM was the cosmetic everything. I mean, that was cosmetic dentistry. But you saw it and like Irish, well Scottish kind of northern Scandinavian that some people would get a tattoo from the amalgam and Gordon thought it was because people like me were a little more acidic and were leaching the metals out from the PFM into the tissue and we know people are different. Like I'm Irish and Irish had the highest percent of celiac sprue. In fact, if you ever go to Ireland, every single grocery store has a celiac-free section. In the United States, it's very rare disease celiac sprue but in Ireland, it’s very common. 

So I could totally see that some people would have a metal allergy. Do you think Irish people are more susceptible to titanium or have you seen any demographic men, women, menopause, anything that’s more closely associated with metal allergy than not?

Sammy: It's very interesting the points that you made; you said a couple of very pertinent things. For example, there's been some studies out there that did some genetic. There's potentially genetic markers to people more likely to have implant failures. It's not well-studied yet, but there's a couple of papers I've seen around suggesting that genetically some people might be predisposed not to be very receptive to implants. 

Now talking about getting what Dr. Gordon Christensen told you about being acidic. Acidity runs with being inflammatory, in an inflammation state. So when you have that PFM or you have that implant, well, if you're acidic or if you have a certain amount of inflammation around an implant, you induce corrosion attack to that implant because of acidity and then that implant releases more metal ions in the peri-implant area and then you have the macrophages that come into TNF alpha and you have more information than you have osteolysis, you have peri-implantitis and then you have implant loss.

So I cannot prove it, but one thing is for sure and that will be a great study to verify, see where people who live, for example, in areas where there's enough sunlight, where they spend a lot of time outside and wear light shirts like yours instead of a suit and jacket like me, if they have a higher success rate. And why am I going there? Where am I going with this? We now know, it’s been known but we now accept more openly that a deficient vitamin D person like me who lives in Silver Spring and not in Florida or Arizona and a high cholesterol patient or somebody who has been taking antidepressants for a long time like serotonin uptake inhibitors and things like that, they tend to have a higher failure rate. 

So again, these are things that have not been deeply investigated or looked into. But I would agree with you that there is a very strong chance that there's certain people or certain demographics that are not just going to do well with certain materials.

Howard: That is very profound. Another thing that I see kind of bizarre, let's face it, people who need All-on-4, they usually weren't a vegan yoga instructor who rode her bicycle to work every day. I mean in Phoenix, these are people who drank a lot, smoked a lot, didn't brush their teeth a lot, more likely to have Mountain Dew than bottled water and then they've lost everything sometimes even from meth. And then some dentists will put this All-on-4, but it didn't change the behavior. You’ve still got your Uncle Eddie in a trailer park at Apache Junction and he's behavior isn’t changed and they're charging $25,000 an arch, which combined is fifty thousand, is that right? I'd love to find out what is the top selling $50,000 car in America. And then they come into my office and they’ve got an entire ham sandwich underneath these implants and we see that at five years, 20% have peri-implantitis that maybe at nine years up to 40 to 60% have peri-implantitis. In a decade, a lot of these cases are falling out. But then you see for these implants with like the Zest Anchors attachment, the ball and socket where when that denture is placed in there, it snaps into place. But then you can pop that out and rinse it off and clean it and it's half the price. 

I think so many of these All-on-4s for twenty-five thousand an arch, All-on-4 fix should have been All-on-4 removable and it would've been half the price. I mean, you could do All-on-4 upper and lower for twenty-five thousand where All-on-4 upper and lower is fifty thousand. What are your thoughts on that rant? 

Sammy: Well, you've touched upon a lot of good things. For example, you said the guy who purchases these All-on-4s, all his work is done without changing his or her behavior. Well, not only that, all of this is also the without checking his chemistry, his blood work and all kinds of other things. I think when you look at the old implant papers, the old implant reports, it used to be done in hospitals. Patients had blood work before the implant was placed. Our colleagues in orthopedics do that, they don't go and do a knee replacement without knowing what's the systemic status of the patients. We in implant dentistry, we just released a lot of implants and by and large, they're very successful. However, the more people get implants because before it used to be a very, if I may say, restricted elite group of people who could afford them but now implants have become affordable. I mean, you're talking about this fixed arches on four, I've seen places that do them for somewhere around under $20,000. 

So you’re finding that more people can afford it and more people are getting it. But once you broaden the pool of people that are receiving all these implants, now you're going down into people that have other issues. They can afford it, but they have health problems that are not solved. They are on antidepressants, they are low in vitamin D, they are high on cholesterol and low on vitamin C; all these things that affect bone healing. But most of us just go out there and do it and do it well and most of the time get a good result. 

Now, talking about the cleaning list of materials. It's also proven that zirconia compared to any type of metal, tends to stay a lot cleaner in the mouth. Zirconia accumulates very little plaque and if you have little plaque anywhere, you tend to have less bacteria. If you have less bacteria, there's less bacteria by-products, therefore less inflammation. 

So again, we circle back to the material. Titanium has done well for us, but what we need to understand is that the materials evolve. Now we’re having such things as flexible concrete; ceramics that can bend a little bit. Not as much as titanium yet, but they're getting better at enduring certain types of stress. So this myth about they’re all going to fracture all the time, fracture is a big—no, it's no longer true as it was in 1971 when Sandhaus started or in the eighties. It’s much better. You see? 

So I think we’re at a crossroads today. It's a yesterday or now dentistry. Everybody wants everything now, but we also have to, as professionals realize that we have new materials. They’re always going to evolve, they're going to get better and that we should always keep our minds open as to what is in our armamentarium to treat our patients. 

Howard: You should call that implant what you were talking about that they started out with an elite, more expensive group of people and now it's gone mainstream. It's going to be different. You should call that the Southwest Airlines Effect because when I started lecturing in 1990, only rich people flew on airplanes and it was like Pan Am and Eastern and Braniff and TWA and men were almost always in suits. I remember a connecting flight in Atlanta on Eastern Airlines and they didn't let one of the guys board the plane because basically, he looked tennis shoes and sweats. But now that Southwest Airlines made it so low cost and everyone has the freedom to afford to fly, you should call that the Southwest Airlines Effect on dental implants. So who do you keep referring to on these ceramic implants? What is his name? 

Sammy: Well, what I would argue would be called the grandfather of ceramic implants is Sami Sandhaus. S-A-M-I Sandhaus.

Howard: Sami?

Sammy: Sami like me, S-A-M-I. Sandhaus.

Howard: Sami Sandhaus.

Sammy: S-A-N-D-H-A-U-S. Yeah, he's in his nineties and still practicing and doing surgery in Switzerland. 

Howard: Is he your buddy? 

Sammy: Yes, he was our keynote speaker last year at our congress in Miami, ceramic implant congress and we gave him a lifetime award. He was so emotional because he lived to see an organization dedicated to honor him because he had always been somewhat of a pariah on the side trying all these ceramic implants and today, you find out there's a big changes in evolution. I mean, when you look at these big players; Nobel, Straumann and Camlog now having their lines of ceramic implants, it's good news. It's amazing they know they have enough money to know what's coming and to anticipate things. They have teams that are dedicated to that and when they make that switch, you know that we're going in the right direction. 

Howard: So that's the guy right there?

Sammy: That's correct. 

Howard: So why does he have a PR in front of his name? He's in a practice, everyone's a DR and he's a PR?

Sammy: He’s a professor. In Europe, they're very particular and they make sure that that's acknowledged and when you teach university, you get a PR.

Howard: And where does he live and teach? What country? 

Sammy: I think he’s in Basel, Switzerland.

Howard: Basel, Switzerland. So how's his English? 

Sammy: Very good. 

Howard: Well, then tell him to come on the show. That'd be great to have him follow you, two Sammy's back to back. That'd be romantic.

Sammy: I'll do that. I'll send some videos to Ryan of him that you can look and then I'll send him an email. I'll do that for you. 

Howard: Well, Gandhi said it that first they laugh at you and then they go violent on you and then they accept you and I keep telling these kids that go easy on these innovators because when I was in school, University of Missouri, Kansas City, the professors all openly threw the oral surgeon under a bus that was placing implants. I mean, it was Ramus Frames, it was subperiosteal. They called him the butcher. I mean, can you imagine going to a university where professors are calling other professors the butcher? And then out here and around the United States, a lot of these are early pioneers, the first time one of their big cases failed, the board would take their license away and I know that a dentist who was all that and a bag of chips and on top of the world and doing all these subs and Ramus Frames and really helping a lot of people, they took his license away and he basically bankrupted, moved into a trailer and drank himself to death and it was just so sad. 

So when dentists are throwing people under the bus, I tell them that almost all this stuff we have, came from these pioneers who were really, really treated unfairly. And now you see it, it's so funny how actions don't match their words. So many dentists where if you say alternative medicine or holistic, they just think you're a crackpot. Yet when that dentist finds out he has high blood pressure or high cholesterol, he doesn't go play big pharma with his MD. He changes his diet, he changes his behavior and I'm like, “Oh, what are you going all alternative medicine on me? What are you, a holistic quack?” And what's amazing is there's so many Americans who don't believe in big pharma, they don't want to be part of poly pharma and when dentists put holistic or alternative or natural on their website, it's huge marketing. But they feel like they don't want to do it because they don't want to be a whack job yet they are a whack job whenever it comes to them. 

34 Sammy: Yes. But you see, it goes back to what we were talking a little earlier at the beginning of our conversation that the public has changed. I think that again, the internet has been the game changer here. There's access to a lot of information, good and bad, but it's there and so what our patients, our clients, our patients who are our clients do, they go and read certain things and now your patient in Kansas or in Scottsdale or in Phoenix can read the writings of a guy in Australia or in New Zealand, there's no barrier. 

So now they come to you and say, “There's this guy in Australia that does this or there's this guy in Wisconsin or in Washington state. Can you do this for me?” So in the realm of ceramic implants, I see this every day. These patients who are even referred by their dentist to neurosurgeon or a periodontist to get implants and they say, “I went to this guy, I asked him about ceramic implants he dismissed it or she dismissed it. I went back on the internet, did my homework. I found you and I'm here.” 

So you find that even dentists refer their patients to their trusted and preferred surgeon and the patients make up their mind. I mean, I have been a couple of endodontist and orthodontist friends who say that their self-referrals have increased. So people just walk into the specialist's office and say, “I want you to do my root canal. I want you to do my ortho, I want you to do ceramic implants for me.” So the public is driving this and it's going to be that way for a long time. 

I always tell when I lecture, I tell doctors, I say, “Look at the number of whole foods supermarkets, the numbers of organic this and organic that and wellness this and wellness that.” Why are they there? Why are they flourishing? Because there's a change in consciousness. 

Howard: It goes back to the Southwest Airlines Effect because right now 1% of the population is the greatest generation, I think they're eighty-seven to ninety-five then there's 9% of the silent generation there, sixty-eight to eighty-five. Then you've got the boomers are 24% of the population, right now they're forty-nine to sixty-eight. But those three generations, they would go to the doctor, the doctor would say, “You need a knee transplant or a knee implant” or “a hip” or “you need this” and they'd say, “Well okay, you're the doctor.” 

But now we got generation X and millennials and generation Z and they don't care that you're a doctor, they're going to do a fifteen-minute Google search and Southwest Airlines has made it affordable to fly. And these dentists that are building their cases on their website that says, this is my work, these are cases I did myself and these guys are in Kansas City in Wichita and they're having patients jump on Southwest Airlines from three states away. Their mom would have just gone to the dentist because that's their family dentist in Parsons, Kansas, he's worked on their family for generations and the millennials are saying, “No, I'm not going to let her old man Cranston. I don't think he's on top of the game. I've been doing a Google search and there's a guy in Kansas City and I’ll just drive or fly there because flying is so low cost” and plus it doesn't matter if there is a metal allergy or not. If the patient believes it and they're the ones with the cash, that's what they're going to get. 

I mean, I have people all the time and the flag words don't even make sense like they say, “Well, is this material natural?” and I always say, “You mean natural like chlamydia or natural like a HIV? Natural like a hurricane or the black hole in the middle of the milky way that's eventually going to suck our entire solar system into it and spit it out.” But when they're saying natural, when they're saying alternative, they're the customer and if that's what they want, that's what they're going to get. And if you stand them down and say, “No, no, you're crazy. Here's all literature. You're safe. We're going to do it my way or the highway.” Well, they’ll go the highway and they'll even get on the Southwest Airlines highway and fly away with their money.

Sammy: Yeah, I know that's what happens and I can tell you even my friends and colleagues in Europe, they tell me how they receive so many US patients in their practices in Europe. And me in Washington, D.C., Silver Spring, Maryland, people fly from Florida, California a little less these days because there's a few more doctors on those coasts doing ceramic implants. But when I started ceramic implants in 2009, I mean it was an honor, but it was also difficult because you have these patients coming from all over the country and nobody willing to touch a follow-up with them and they cannot stay in your town two, three, four weeks for you to follow through. It was difficult so it's an honor to have people fly over to your office. That's great, but it's even better to see that wthe ith efforts that we're doing at the IAOCI and the cases that we post here and there on social media, on our website that more doctors are opening to this. That industry is now realizing this is something that the public wants, this is something that's going to make the doctors better. Let's get in and have it available to our customers and that's how you see the big players offering ceramic implants now

Howard: There's about five thousand periodontists, five thousand oral surgeons and twelve thousand orthodontists. That's the largest specialty. If you've cut orthodontists in half, each half would be larger than the second largest oral surgeons. But the periodontists, they voted on changing their name at the last meeting and it only failed by one vote. They wanted to add dental implants into their name and but I kind of look at the periodontists in 2018, there doesn't seem to be an agreed definition of peri-implantitis in treatment protocol. I mean, if you just Googled, well I mean it's really not black and white yet. What do you think is the protocol because peri-implantitis is a really big deal? 

I mean, I'm reading that at sixty months, 20% implants have peri-implantitis. That at nine years, depending on the study, 40 to 60% have implant implantitis. Again, that's why I think All-on-4 is going to cause a lot of problems. I think a lot of these people are paying $50,000 for All-on-4 and ten to fifteen years later that's going to be a failed case. But what is your protocol for peri-implantitis and there are some treatments that involve very expensive lasers that can cost seventy-five to a hundred and thirty-five thousand dollars like the Millennium. So what are your thoughts on peri-implantitis protocol? 

Sammy: Well, peri-implantitis this is the way I look at it. First, we have to start to learn to look at the cause of the problem and not only the symptoms. I think too often we have a symptom approach treatment where there's puss, there’s bone loss, we're going to clean and we're going to graft and we’re going to give you antibiotics and then things are going to be better. 

Now in the process of doing that, there’s other things that I find a little strange is that to clean an implant, there were protocols when I was in residency and a few years back that use certain acidic products. There were some products where you blast an implant with a Prophy Jet or whatever. Well, when you do that, let's stop and think what are you doing? You're inserting more particles of a material in the area that's already injured or you are, with acidity, inducing a corrosion attack on the very implant that you're trying to treat. So why is the peri-implantitis there? We now know it’s because the implant has released metal ions to the surrounding area. How does it do that? It does that in when it's under corrosion attack and then you're going to come and clean it with an acidic product?

So these are little things that we have to start to pause and look and say okay, let’s back to the root of the problem. What’s the causative agent? What’s the root of the problem? Then, how do we treat it? Do we treat it with chemicals, do we treat it with antibiotics, do we treat—how do we treat it? I'm not saying they're bad options, but what we use to treat the problem, is it always a solution or is it going to have a side effect that's worse than the problem itself? 

Now talking about peri-implantitis, how do you treat it? In my practice, when I see peri-implantitis with what we now know documented in the literature. One of the latest papers came out in November of 2017 by Dr. Diane Daubert out of University of Washington because my US colleagues always want to see a US study. Well, now we have one and a couple more because there's been studies on corrosion and peri-effect on peri-implant tissue for years, but they were coming from Brazil, they were coming from India, they were coming from other places and supposedly, they were not credible. 

University of Washington has released a study where there's a clear correlation between the release of metal ions and peri-implantitis. Now that we know that what do we do when we see peri-implantitis in th practice? Do we try to solve it the same way we used to? Do we have a new way to do it or do we just tell the patient, “Look, whatever we have today to solve this problem can worsen the problem or not even solve a problem at all”? So do we suggest that the implant be removed and replaced with a fresher titanium implant or be removed and replaced with a ceramic implant? 

So now these are decisions that we have to be able to make and these are options we have to be able to present, competently present to our patients because at the end of the day, they're going to be the ones having it in their body and they're the ones who are going to have to decide which way they want to go. Do we treat it? We've always treated it and give it another year or two. Do we try something different that's probably not proven and we might get another three years? Or do we just remove it and start over and maybe we can give them another ten, fifteen years with a ceramic implant? Who knows. So how do I treat it? Just like I said, I present the facts and the options to the patient and they make a decision. 

Howard: So specifically, I'm going to hold your feet to the fire because it's a big decision. The LANAP, the Laser-Assisted New Attachment Procedure, is a surgical therapy for the treatment in periodontitis, but these kids are young and seventy-five thousand lasers are big deal. That's what they need, though. They want to buy it. They want to get a CBC, it's a hundred grand. But what do you think of the investment of a seventy-five to a hundred and thirty-five thousand dollars Millennium laser for the treatment of periodontitis?

Sammy: So the LANAP, it's a procedure that, to tell you the truth, a few clinical cases I've seen presented here and there in the literature, amazing results. Now can this be replicated over and over and over and over and guarantee that what was recovered would last? I don't know because I myself am not a user of LANAP. However, I'm one of those guilty ones where I was barely out of residency, not even bought my first house and I went out and bought a cone beam because I needed it to do these implant cases. I would call myself an implantologist. Well hey, you have to have the tools. 

The LANAP from the limited information I've seen and I think there's no, that I'm aware of at least, longitudinal study over years showing a LANAP treated case can maintain its new attachment and new bone, whatever over five, ten, fifteen years. I don't think we are there yet. So I tell the young kids, I say, “Listen again, choose a mentor, a LANAP owner go in and see what he or she is doing with his LANAP.” Watch it for a little while before you jump in and buy this hundred and twenty-thousand-dollar device because I believe the protocols, I've been to a couple LANAP lectures once or twice over the years, but I think the investment in the technology has to warrant, not guarantee, but a certain type of stability to what you claim or the solution that you're trying to bring to the patient. 

Howard: Which cone beam did you go with? 

Sammy: I went with the PreXion from, at the time the company was called TeraRecon, but now they call it the PreXion 3D. I got my cone beam in 2007 when they were not even more than twenty cone beams in the country. I went with a PreXion, which at the time was really and still is, one of the top machines in terms of imaging quality and no exposure.

Howard: And who makes that? 

Sammy: PreXion.

Howard: I mean, what country? 

Sammy: Oh, it’s a Japanese machine. 

Howard: A Japanese machine. I thought that was so sad during world war two so many dentist refugees came to the United States from Germany and they wouldn't recognize your license and I always thought that was such a joke. I mean, Germany makes Mercedes-Benzes and Porsche and Volvo and this country makes Chevy and the Ford and Chrysler and their lab techs. I mean, the greatest lab techs in the world are from Germany. I mean, they go to school for five, six, seven years and then they come over here and they look at—Americans always think they're number one in everything. I think the only thing Americans are number one in is self-esteem, military, insurance, banking, finance, music, movies. But that's what I'm loving about the internet is now it's really shrinking the world’s two million dentists into the internet. 

I mean, gosh darn. I knew a guy, a friend of mine here in town, he learned how to place implants. He got Apple TV and he'd come home after work and he’d get his bowl of popcorn and a beer and he would just go to YouTube and search dental implant surgery and he’d watch YouTube videos. He said he watched YouTube videos an hour every night on YouTube, on his big screen TV and within a year he felt that he was an implantologist. I mean, that is amazing. I mean that he learned how to place implants on YouTube. 

Sammy: Yeah, that’s how the world has become small and that's where all associations have to learn to adapt. We at IAOCI, we have just put together an educational platform with videos where people would now go just to YouTube and watch videos, but they will go to a platform where they'll watch the video, they'll get some questions about what they watched, they’ll be tested, they’ll be able to see where they stand in terms of understanding the concept because it’s not just watching the video and going to try it tomorrow morning. It’s watching the video, taking a little test for it, getting some CE credits for it and learning. 

But you're right, it's amazing. Today, you can even take a course that guys in Australia doing surgery, live surgery and you’re sitting in your apartment or your house in Arizona or D.C. and you can learn like that. So the world, it's changed and it brings its challenges, but it also brings a lot of benefits. Things are happening very, very fast. When I started ceramic implants in 2009, I did not realize, everybody called me crazy. “Oh, you're going to cut out titanium? You’re not going to make money, you're going to struggle” and that hasn't been the case. The people, our patients, our clients, we hate to use that word but they are our clients, our patients are much more educated. They might not have degrees, but they have access to information, they can read, they can understand and they'll come in and challenge you. Literally.

Howard: You know the best marketing I think you should do for the IAOCI? A lot of people make an online CE course on Dentaltown. We put up four hundred and eleven courses and they're coming up on a million views. The millennials, they like the fact that it's an hour as opposed to an all-day and a lot of people really build their brand and after they see you for an hour, they know you, they know your name, you can talk about your course, everything about it. But I think it's a win-win situation. They get an hour of ADA, AGD approved education, you build your brand and talk about everything. 

Sammy: Yeah, let me work on that (unclear 51:22).

Howard: Yeah, because you already have all the content and in fact, you know what, I would do several. I mean, if you've got all the content, put several up, build your brand because the millennials are different. I'm fifty-five, I’ve got four kids, four grandkids, I'm almost dead and we grew up driving to bricks and mortar places and registering and all that stuff. These millennials, man, they love to watch this stuff. I talk to them all the time, they say they’ve watched every one of the online CE courses on an iPad in their bed. 

Sammy: Have you noticed how our attendance has dropped in a lot of meetings?

Howard: All the meetings.

Sammy: All the meetings, it’s unbelievable.

Howard: Yeah and they always say the same thing. They always say, “Why is that?” Because she's laying in bed with an iPad, leaned up against a pillow and if her phone rings or she's got to go to the bathroom or wants to go make a sandwich, she just puts it on pause. 

I think some of the biggest brands in the world—take someone like Carl Misch and Gordon Christensen. I mean, they basically lectured every weekend at a dog and pony show every weekend for forty years. Now there's guys that do an online CE course and their views are in the hundreds of thousands right out the gate. In fact, look at this. I started this podcast because of your town that you're next to, Washington, D.C. It was a year before the election and there's a quarter-million dentists on Dentaltown and sixty thousand downloads of the app. They're saying, “Howard, I have an hour commute to work and I can't listen to this toxic crap, Hillary and Bengasi and Russia and Putin and North Korea.” They said, “By the time I get to work I’m depressed, it’s too toxic. Will you make a podcast?” Because they were listening to podcasts on cooking, quilting, raising kids, hunting, everything. 

So we came out with that and it's so amazing. There's now sixty dental podcasts being uploaded on Dentaltown, but look at some of the views. This guy started a podcast, How to Open a Dental Office. Look at that. He has six hundred and eighty-six thousand views. How long did it take Carl Misch and Gordon Christensen to get six hundred and eighty-six thousand views? I mean, that takes decades. Now you can put a podcast or an online CE course and have a brand name in two hundred and twenty countries. 

Sammy: Spontaneously.

Howard: This technology is amazing. I can't believe we’re already at fifty-five minutes. What questions was I not smart enough to ask? 

Sammy: What can I say? Oh, maybe a little bit on the technical side of ceramic implants, if you want. Meaning how they're made, the surface treatment, do they also integrate, little things like that? What else can we talk about? 

Howard: So is it an osteointegration with the ceramic just like the titanium? I mean, is it pretty much the same? 

Sammy: It's similar, but it's not the same because if you look at all the titanium implants we have on the market now, they're coated. So if you look at most titanium implants that are HA-coated or that are whatever. What's HA? HA is a ceramic. 

So I always poke at my titanium friends, I say, “Hey, are you placing HA-coated implants or RBM or whatever one of those coatings?” You’re placing a metal implant that’s coated in a ceramic, right? So what you find is that the integration of a titanium implant versus a titanium-coated implant versus a ceramic implant is different. Because on the titanium implant we have an additive transformation of the surface or an additive enhancement of the implant surface. Whereas, a ceramic implant is subtractive and what does that mean? Again, on the titanium you're coating, you’re adding the surface, you're adding a layer and that layer is the interface between the bone and the implant.

So if you look at the histology, you will see that you have the bone, the HA and then the implant proper behind it. So sometimes those of us who have to remove implants because we didn't talk about this, but you have a lot of patients that are coming to offices asking for the titanium implants to be removed. It's happening. They say, “Since I got this, I have headaches.” “Since I got this, I have this, I have that. I want them out.” 

Now the ceramic implants rather, the way the surface is modified or enhanced is by subtraction and the subtraction is done in three ways. One is laser, which there is only one manufacturer that does that. The second one is by sandblasting which has fallen out of favor because they found that the sandblasting of zirconia can sometimes induce preliminary cracks and can make the implant weaker although, that argument is kind of going away now. But the most popular way of surface modification, surface enhancement for ceramic implants is acid etching, so everybody's using some form of acid etching. 

So what happens now when you place that implant in bone? When you place that implant in bone, the integration is more of a direct integration to the implant because the implant has little perforations but the roughness is on the implant itself, not in the coating sort of integration is into the implant. The bone loves that material, loves that surface, loves the anatomy or the shape of that surface that's given by the roughening process and grows into it. Whereas, on titanium-coated implant, it grows into the coating. So that's why if you've had to remove an implant for whatever reason, fractured or whatever, titanium implant, you always sometimes see the de-coating state in the bone and the implant came up. So that's the difference there. 

But when you look at the success rate of ceramic implants, it's the same. However, we're now finding in most ceramic implant conditions that the patient needs to be really well-optimized before you do these implants on them. I mean you’ve really got to make sure that the vitamin D is at a good level, the cholesterol, vitamin K, vitamin C because, this is a speculation at the moment, we think there's a little bit of a lag time in terms of the biological integration to take place compared to titanium-coated implant and if that lifetime takes a little too long, the ceramic implant tends to fail. Whereas the titanium-coated, I don't know if it’s because of the time we've had working with it, improving it. It does a lot, but that lag time can be longer and you can still have an implant that integrates. What happens ten years or five years later, that's a different story now. 

Howard: I had my blood work done and I'm not even kidding. I did that 23andMe and I'm 4.3% Neanderthal. Here I thought I was all Irish and I'm a part caveman. 

Sammy: You need to go back to your ancestors’ diet but that's another conversation. 

Howard: When I told my boys I was part caveman, they said they always knew. If you had to buy the CBCT over again. I mean, that's another really big decision. I mean, that's a six-figure decision. Are you happy with your PreXion? Would you buy it again today? 

Sammy: That machine yes, I'll buy it again today. They’ve had upgrade since. I mean, I've had mine eleven years now and their upgrades are very nice. I've also seen some other CBCT on the market that have made leaps and bounds. I mean, the last one I looked at was at a IAOCI meeting in Orlando and they had one from Biotech, it was amazing. I mean, the rendering, the quality of the software was mind-blowing. I bought a CBCT before I bought a house, but it was a good investment. 

Howard: I’m so old, my first CAT scan was actually a cat. I would just throw the cat on the patient's lap and she would smell the patient and tell me. You can't place an implant if you can't sell the case and I noticed that the people doing the most implants actually they're better salesmen. They have perfect sales and PreXion has that software where you can make 3D animated movies for a patient case acceptance. Do you like their software or are you using their animation to make movies? What are you doing to try to sell a case? Because you can't place it if you can't sell it.

Sammy: That's true. Personally, I don't use animation. I used animation many years ago. It was a company out of Canada, I think it was called (unclear 01:00:38) or whatever it was and it had a software that showed animation and maybe I wasn't patient enough, but I never really felt that I had an edge or I was able to close cases at a higher closer rate because I was able to show an animation. Now the animation has its pluses that you do less drawings and you do less scribbling and you can give them a good idea of what's happening now. I always believe that if you honest and candid with your patient, most of the time they'll tune into that being candid and honest and probably go forward.

Howard: Well, if you’re candid and honest, what the hell are you living in Washington, D.C. for? That is the biggest swamp.

Sammy: I'm stuck in the beltway. 

Howard: Oh my god, that's the biggest collection of lying thieves on earth. 

Sammy: But that's another thing I say, I tell especially the young dentists. I say, “I started out that way. I thought I could be the doctor for everybody. I could treat everybody. Not every patient is good for you and it might sound a little esoteric here, but they’re not.” 

At the end of the day, we are healers, we heal people and you're talking about ancestral diet, cavemen and all that. Back in those days, healers would look at some people and say, “I cannot help you.” They said, “Your energy is not good.” That's the kind of language they used to hold.  Now today we have cone beams, we have scanners, we have whatever, but sometimes you just have to use your judgment and say, “I'm not trained to handle this case” and put your ego out of the way just to understand that not every patient you're going to be able to treat, some you're going to have to let go. 

At the end of the day, all you want to be able to do is give your honest opinion, your expertise, your recommendations and let them decide. I'm not a hard sell guy; push, push, push just to sell. 

Howard: Yeah, they just hate sales. I mean, they hate it and they even tell you they hate it. It really bothers me because I just think if you really passionately love someone you're telling everyone about it, you know what I mean? It's like whenever you meet a person who's a vegan, I mean, they tell you within like one minute of meeting them. They can't talk to you for sixty seconds without letting you know that they're vegan. And when you look at people's how many diagnosed interproximal cavities are never filled and then the dentist is telling me he hates sales. I'm like, “Well, you're not a very good dentist if you can't convince Mom to remove her child's decay.” I mean, you say you don't like sales. Well, I don't think I like you as a dentist if you can’t convince them to remove their decay.

Sammy: The opportunity to not want to do it versus just not saying anything about it, it's one of these.

Howard: And they're crazy, too because I don't know what it's like in your area; I practice in Phoenix. About 25% of the people in Phoenix think fluoride is a communist plot. It's toxic, it's put in by dentists to soften teeth so they fall apart, need crowns and root canals, but you don't kick them out of your office. You tell them to just not use toothpaste. What's funny is they use this Uncle Tom’s all-natural toothpaste, which the rule of thumb on natural is there should be less than five ingredients and you should recognize all of them and you'd have to be a biochemist to list all the ingredients on this all-natural toothpaste that's owned by one of the largest toothpaste companies in the world. 

But yeah, if you don't have a chemistry of the patient or you think they don't trust you, I'd say most of my referrals are because they're crazy and Phoenix has a very high percentage of crazy people. But they do. It's a transient town like where I live, it didn't even exist thirty years ago. I mean, it's just sprawling suburbs. So when I grew up in Kansas, Wichita, pretty much everybody was born in Wichita and so was their mom, their dad and their cousin Eddie and it seemed to be a far more stable population. But you go to Phoenix and LA and Houston...

Sammy: Washington, too. Washington has a lot of transients. 

Howard: You know how you could always tell when a politician is lying in Washington, D.C.? Their lips are moving.

But hey Sammy, seriously. Thank you so much for accepting my invitation to come on here. Congratulations on the International Academy of Ceramic Implantology which is International Academy of Ceramic Implantology. I'd love to get an online course out of you for Dentaltown. I’d love that. I'm a firm believer watching this for thirty years. 

Last night, a couple of us dentists went out to dinner and we were reminiscing. One of my buddies across the street when they're thirty years passed away, Dr. David Rosner. We were reminiscing over the years. But I keep saying that the number one predictor if that that is going to be successful is if they take a hundred hours of CE every year. If you just keep exposing yourself to enough information, you're going to be motivated, you're going to fall in love with something. When dentists tell me that they’re burned out and they hate dentistry, what do they all have in common? They're not listening to people like you! No one's turning them on. No one's getting them excited and then they're going in there and they're trading time for money and they're burned out and the key to burnout is listening to people like you. I could listen to you for forty days and forty nights. 

Thank you so much on waking up on a Saturday and instead of sleeping in and playing golf, you came on the show to talk to my homies. I really, really appreciate it and I can't wait to see you again. 

Sammy: Yeah, thanks for having me. And thanks for all the support. I’ll be in touch with your back office and we'll put this stuff together. 

Howard: Well, I'm and then the guy in charge of online CE is Howard Goldstein, so he’s Hogo, I'm he’s hogo, but email me, Ryan, whatever but I'd really love to get an online course out of you on ceramics, especially being the founder of the International Academy of Ceramic Implantology.

Sammy: What would you like? You would like a lecture? A video? 

Howard: Everybody has a different. Some people just have a video of them giving a lecture. Some people do load up slides onto the internet and then call in and do a voice over. I’d say there's as many different. You just talk to Hogo. He's outside of Philadelphia, he's in Bethlehem, Pennsylvania.

Sammy: Oh, that’s not far from me.

Howard: Yeah, he moved there because he thought that's where Jesus was born and I keep telling him that I'm pretty sure it’s the wrong Bethlehem but anyway. Thank you so much for coming on the show. I hope the rest of your day is a rocking hot day. 

Sammy: Same to you.

Sammy: I am proud to announce that the IAOCI now has a members portal. This portal is going to have content necessary for anyone who wants to learn more about ceramic implants to be able to have access to the information necessary. This portal is going to be in an environment where you could come and have access to articles, videos, recorded webinars and earn education credits by either viewing recorded webinars, white papers, scientific articles, surgical videos, anything and everything about ceramic implants. I invite you to sign up and take a look at all the wonderful material we've put together for you and happy learning.

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