Dr. Dirk U. Duddeck DDS is Managing Director CleanImplant Foundation
Guest researcher at the Charité – University Medicine Berlin
Campus Benjamin Franklin - Department of Prosthodontics
Project Manager of the BDIZ EDI Quality and Research Committee
European Association of Dental Implantologists
Member of the BAIRD Implant Council - The British Academy of Implant & Restorative Dentistry
Member of the Academy of Osseointegration AO
Member of the European Academy of Osseointegration EAO
AUDIO-DUwHF #1097 Dirk U Duddeck, DDS
VIDEO-DUwHF #1097 Dirk U Duddeck, DDS
Howard: We are live in Las Vegas and I have the extreme honor to be podcast interviewing Dr. Dirk Duddeck, did I say your name right?
Dirk: Yeah absolutely
Howard: I did and you're from Berlin Germany?
Dirk: Yeah thank you for having me, I'm from Germany.
Howard: Oh well it's a such treat most of the dentists listening you here are from United States, Canada, Australia, New Zealand and so it's a big treat to have one of the biggest implant gurus from Germany this is a huge man in Vegas they have I think 1200 people here these are the elite implantology and you're speaking.
Dirk: I'm glad to yeah.
Howard: Yeah and to get that speaking gig on this stage I mean I guarantee at least a hundred implantology were begging to speak so congratulations.
Dirk: Thank you.
Howard: No I'm serious I mean that is just a huge.
Dirk: At least you have a story otherwise you wouldn't get any invitation.
Howard: So you're you're a DDS you graduate 83 to 85 University at Constance Bachelor of Science dental school University Berlin and Heidelberg Department 92 to 2015 Department for cranial maxillofacial and plastic surgery, University of Heidelberg internal disciplinary Department of oral surgery implantology, University of Cologne Germany and by the way I've been to Germany a dozen times cologne is my favorite.
Dirk: I understand
Howard: Oh my god so if you ever go to Germany with the Roman Empire 2,000 years ago its furthest out reach eastward was cologne and if you go to Cologne it still has a remnants of the Roman Empire wall around it but it's really neat because it's a mixture of German and Italian.
Howard: Cuisine but what I like the most about cologne is
Dirk: The Carnival season.
Howard: The Carnival season yeah what I like the most about cologne is when you get into too big of a city around the world you know you get lost myclone is small enough to worry when you're at the train or the subway they always understand that you're a tourist and they always even when they're this tall trying to help you trying to help you get on the train or are you low I had one little girl you said are you lost and I'm trying to find this street so I'll walk you there so I thought you should worry she why we like nine blocks I'm like gosh I mean it's just it's just a quaint town. So what are you why are you speaking here what are you speaking on what are you most passionate about an implant dentistry today?
Dirk: I try to cut a long story short I was actually asked to for a doctoral thesis ten more than ten years ago and the topic was the quality of dental implants with the look of a scanning electron microscope. So is there any differences in surface quality and the actually 11 years ago when I started the research and I had no clue at that day that I opened with this topic the box is pandora or I say Pandora's Box whatever. So I found something I couldn't understand as a young implantologist I said well implants should be clean as they are sterile and that I have to learn the Hetal on that sterile does not necessarily mean in clean and you can even sterilize particles that don't have to be in the body so the setup of this study I repeated it in the last 10 years at least four times so in the fourth study same setup same protocol and in comparison that is what concerns me most of all is the number of really contaminated implants implants with impurity is dramatically increasing instead of decreasing so you think if everything goes better and better an industry that the protocols the quality management everything should be in the right order but after 10 years and comparison more and more concerned and this brought me to the idea that it's not enough to lecture and to write articles there's dentists we have to do something and I always see the situation when a patient comes into my practice waiting room and she gets an appointment and then we have other small talk this week about the case and it was never being asked from any patient doctor can I have an implant from the company ABCD they always have a problem and they completely trust in my decision of what kind of implant system I will use for this case. So when we ask the colleagues on which data on which information is this decision based on they have very rare information about the real quality of the product, they read a lot of advertisement so the information is quite it's always good if you want to sell something a company loves to speak friendly for the product and it's hard to find neutral unbiased and analysis from scanning electron microscope and this is what I do know for at least more than 10 years and I've seen up to 250 different implants from more than 150 different manufacturers and there is no unfortunately no privilege for any country to produce an implant that let's say gives reason for concern or his room for improvement have to be very polite because sometimes getting true passionate about this problem. We are patient the trust they give us by the decision to enter our practice we owe them that we know and not just believe that a medical device and this and this topic steroid dental implant is first of all as clean as promised and as good as promised and what we see under the microscope is presumably beyond the imagination of the colleagues. So up to 25 to 30 percent of implants show impurities some minor and some really interesting particles in this scanner electron microscope we use a special technique I don't go too much into detail that we we detect the backscattered electrons that approach that produce an image not only about the topography but also about the elements on the on the under sample. So we see that something with less electrons like carbon or aluminum shows us some black spots and the titanium is light gray and if we see some metal particles and I could have seen nearly half of the periodic system there Jax teen iron nickel chromium they are quite shiny there they're bright. So I could identify there is something that is not the core material and then we go into the spot analysis and we could see the elemental composition of it. So as these particles not there's no information on the on the packaging I mean imagine if you if you buy a box of cereals let's say a chocolate bar and you can always see some information may contain traces of nuts and peanuts in case of some allergic patients, so we found I think we found more particles on some implants then simply we actually know nuts and peanuts but if we have something like tungsten like chromium nickel stainless steel particles organic contamination remnants of PTFE Teflon they should be clear it's simply like on any chocolate bar I mean why isn't implant less worse than a chocolate bar to warn patient and doctors and colleagues by using an implant if they have some I'd say room for improvement they should be so honest to say well we have some problems but no company will do so. So there is no privilege we found wonderful implants from Korea it's why we're here MegaGen is one of the finest I've seen so far in the microscope and the big companies say the bigger they are they usually they have a very good quality management so they have controlled about the production process they couldn't dare to have the problems we see in the and the midsize companies and we speak about at least there are numbers like 1,000 manufacturers worldwide including the tiny North Italian garage fabrication side and every Valley every one has it has an uncle is a CNC machines honestly the number might be about 400 implants with the...
Howard: 400 implant companies?
Dirk: Yeah I guess yeah.
Howard: but there's 400 just in Italy?
Dirk: Yeah I mean this sums up to a thousand but honestly there would be some at least there will be some companies with sharing the market 95%...
Howard: So why did it take off in Italy so big because they already had a big titanium industry?
Dirk: That's a good guess that's a good cause at least implantology in italy is quite famous because bella fukuda people don't dare to have some problems with their tooth if here's the same and in the UK missing choose is not that a social problem than in italy nobody would dare to show it, that's one thing.
Howard: Well if you buy any anything around the world like what are the tennis racket made out of the?
Dirk: Carbon, carbon fibers
Howard: Any with that material it's like though the whole industries in taiwan.
Dirk: I don't think Italy is the center of titanium.
Howard: because you know think it's amazing because there's like do you think there's one thousand different dental implant manufacturers in Italy?
Dirk: Yeah they're just sharing a very small portion of them all right we always concentrated...
Howard: So you said theirs 400 big ones?
Dirk: Yes it made a major one major one up nobody has the real number because they come and go every day we see so many.
Howard: but how many how many of them do you think are are so it's too big to be dirty?
Dirk: That's a good a good question I think there's a pattern if they have let's say the big five the big four.
Howard: and who are the big five in your mind?
Dirk: The blue, the green.
Howard: The blue, the green.
Dirk: Laurette we think about Straumann might be the market leader than we have nobel biocare.
Howard: So Straumann sells the most mainly through acuisions I mean they bought Biodent and
Dirk: Mudent in Brasilia.
Howard: Straumann nobel...
Dirk: Noble we have DENTSPLY with a straw and the acquisitions like MIS is a big one as part of Dentsply now.
Howard: and MIS make it simple out of Israel.
Dirk: Yeah exactly and I think Zimmer is number four but I don't have the exact number so.
Howard: and Zimmer is they put their dental implant division up for sale.
Dirk: It's not the only one I guess
Howard: That's for sale?
Dirk: Yeah yeah there's a lot of rumor and changes in the market so it's it's hard to my problem as a researcher is always to address people okay I can speak to so if a company is in this situation of acquisition you always lose your contact partners so this is a mess if you just have a have a nice guide would you speak to have some build up some trust and then everything changes every two to three years.
Howard: but would you say the those fiber clean pretty compared to the other 400 Straumann, Nobel Biocare dentsply, Astra, MIS, Zimmer, MegaGen?
Dirk: There's a pattern yeah I think they are too big to fail the reason is if we have these findings I can regular find and the scanning electron microscope on an implant that is on the market that says on the stock exchange a story about let's say a lack of quality management would have such a huge impact in their share so that they just care for the product they have to and they have the the power they have the money for it and because quality is nothing you get for granted use this is always a part of the price you pay for an implant and if you see I was sometimes asked what is the cheapest implant I found at the market do you have a good guess what is the cheap less $49 49...
Howard: Wow how cheap?
Dirk: It's about the one I found as 5445 Brazilian real that sums up to $15 $15
Howard: Are they made in Brazil?
Dirk: They are all packaged and external heck so you have the price range from let's say at least 15 or twelve dollars up to $400 and usually the quite expensive ones usually have the information that there is a good quality management they can't dare to have these problems in the manufacturing.
Howard: Well I want to stop you right there one of the the largest dental company in the world is really Danaher and they're spinning off their dental division the parent company is going to own the dental division but they're gonna separate it from their medical bills but yeah.
Dirk: Danaher bought Nobel right
Howard: Yeah they bought Nobel, that was my question so they bought Nobel which is their expensive premium and then they bought Implants Direct which is their their value play and you're talking to a bunch of dentists out there is it worth it to pay twice as much money for a Nobel than half the price or an implant derived how do how do you wrap your mind around Nobel. I mean you were talking earlier about you found an implant for 15 dollars and so how does the dentist draw the line between I want to do what's best for my patient so I buy the expense of Nobel can i buy the value implant direct can I buy a 15 dollar where does it mega gen fit in?
DIrk: Surely a threshold where you can't expect say if you pay with peanuts you can't expect you can only expect monkeys so if you pay too less if you pay too less and there's no you should you should not wonder that the implant has some less better quality or some impurities.
Howard: I'm typing that quote I've never heard that must be a German thing I've never heard of if you pay with peanuts... what did you say if you pay with peanuts...
Dirk: You get monkeys attract monkeys whatever.So this is a question I was after every lecture people ask me how less we can spend I mean in the end it's always if you choose a system I've made implants for our model at least about 20 years and if you choose a system it's it's not only its simply the implant surface the quality of an implant is probably a lot more. It starts with how to treat you how the time of deliver if in case you need any parts, is the doesn't need a week or does it need twenty eight twenty hours to have new parts so the complete that's the surface component you have you have the you have to be if you are fine with the system and you have good result in your practice sometimes it's easier to don't change running or winning system and to go to the cheapest implant I think the decision is always a problem. If you watch for example some of Iran Moscow on these cities on these exhibitions you could see the crowd coming to the booth of the companies and you can just listen to the question of these guys it's not only a Russian promised and it was a worldwide thing but it's dramatically how the concentrated the colleagues are on the price the first question is what is the price for an implant if I order fifty and a hundred thousand samples they the first question should be how good is the implant what is the evidence do we have clinical documentation over a long period so it's there and is it from the clinical point of view the good implant and not only from the price because in comparison to the complete price for the treatment an implant is just a tiny part so why make such a big deal about five or ten dollars more or less. I wonder why are some colleagues that buy a copycat and charge the real one there are some countries who do this is still a problem that is addressed to the EAO the European Association of integration.
Howard: Now your your website is www.cleanimplant.com and you run a non-profit you basically you're the managing director of the clean implant Foundation a nonprofit organization that conducts the largest periodical quality assessment implant dentistry and awards the globally accepted trusted quality mark for dental implants. I wish you would go on dental town it has 50 categories and one of implantology.
Howard: I wish you would go on there and post about this all the Americans could learn more about your deal but what are they gonna find if they go to cleanimplant.com?
Dirk: They will find the complete story how we started what is the problem who is supporting us protecting us. So what is the that is a system how we dare to decide what is a clean implant worth to be awarded with the quality mark. So I was I gave a lecture in San Diego a few years ago of the ICA Congress and after the lecture was crowded by more than this stood around me like too many people just pick up a room or after the lecture and they're just shouting names I just thought they were just asking for my business card at least they dropped names from the third Reichstag ... Dr. Duddeck can we still trust company blah blah blah so just by dropping names I thought about well these guys wanna don't care about the system they just go it's all about trust trusting a manufacturer after the lecture this trust was let's say they have more questions than answers and I thought about we have to find a, is not me who decides about what is a good or nice implant or green airplane we have to find a system and it's an as a non-biased a peer-reviewed analysis. So this is when we started the long journey of how can we produce data that are so delicate I mean we have I was we glad about the problems how to solve no this the strategies how to solve the problem of a contaminated implant ironically there's some nice tries even to the threat of legal action to zip our mouth.
Howard: How long is this video on your website?
Dirk: One minute and 30 seconds, actually there's a lot of nice images of these findings.
Howard: Yeah we can we insert that video right now...
Dirk: (Video) so standing in front of the German Reichstag our government is hosted I would like to talk about regulation we have in Europe a good system that proves the quality of medical devices notified body they sue the job and looking for the process quality of a manufacturing side of an implant. So the problem we have although we have all these authorities in the US it's fear in Europe is the CEO thirties in Brussels and notified bodies doing the job we have unfortunately a lot of implants that pass all these processes and they get a certificate in under the microscope we found so many contaminants from some implants that obviously we have no control the CleanImplant Foundation will have a global quality field and we will work for better quality that every implantologist all over the world will no now belief that his implant is clean.
Dirk: So we started actually with the question what is the clean implant and I had the data about 250 implants already at that date it was last year and I collected all the information and make a proposal so this ended and the consensus paper in a peer review was Thomas, Vanderburgh, Michael Norton, may be well known here Scott Gans and all the other guys our scientific advisory board so on this the decision for the threshold was not made by me I just made a proposal but we had six signatures under the consensus paper that defines what could be expected if you pay more than $15 for an implant and what there are these findings we should not never except on a sterile device that should last for a lifetime in the bone of our patients who trust us for the decision so coming to this point we well first of all we found how many particles would be still acceptable it's very hard to find an implant which is zero particles on it very very hard only a few companies can deliver these and we thought about up to 10 particles less than 50 micron we have a lot of implants in this range and then we have a huge bunch of implants that had even much more systematic contaminations, complete plugs because the complete shoulder is is full with something we can only measure that is organic contamination we don't have the information if it's either polyethylene or just a phone or whatever. So then we thought about how can we produce data on a level that we are not going to be sued for every decision I mean France is so delicate we speak about a billion-dollar market and there's this Institute from Germany who just goes there thumbs up thumbs down so how could they dare and it's we actually saw the reaction from the industry already friends like companies who have to produce find implants they love our job and the companies who have I say room for improvement they don't love us they can have other words for us but it's more pelagics room for improvement. So then we decided to have the complete set up and five steps and this is important we select five implants for the scanning electron microscope three implants always we order from the companies X factory and two randomly by colleagues on the same nearly the same batch plus minus three months so we can is that we don't compare apples and oranges but always influenced from the same type and approximately the same production period and all these five implants have to match the consensus paper decision what is the clean so we never accept like particles of copper chromium nickel tungsten any metal that is not the core material and no huge plaques no huge areas of organic contamination and the other thing is after we received the samples we it's ridiculous we had to invest another fifty thousand euro in it in a clean room environment for this 20 seconds of unpacking the implants and for the transfer and the scanning electron microscope vacuum because I received an email from the US company doctor Duddeck interesting and you thank you for the information of the findings how long does it take from unpacking the implant to your microscope it's saying in between the light we have time to spit on the implant or just pick it up from the ground and then put it in it. So to get rid of the accusation that there must be some there is something on the implant I invested in another fifty thousand in a cleanroom class five environment so the complete microscope now it's an it's an ax laminar flow area.
Howard: Where do you get that money if your a nonprofit?
Dirk: At least I'm all in my company I invested more than 250 thousand.
Howard: Of your own money?
Dirk: I'm all-in yeah let me just finish because it's so important that the colleagues understand that we are not just tumbling the dices we just have a very straight a process of the protocol of the analysis this is important because we have to defend all accurate accusation that Ioh Dr. Duddeck they pay you something in the other category that there's no chance so after collecting these five unpacking in a clean room environment we always have an a special image that takes about one hour we collecting up to 400 single as the M frames electronically stitched together to one huge M image that shows the complete implant at least in an angle of view of 120 degree what is just lying flat there and so we have no chance to cherry-pick nice areas you will always find even on the 15 euro implant from Brazil you will find a nice-looking area with zero particles but this is not the complete implant the bone will see. So we see always the complete implant this is number four and then we produce the decision paper as a recommendation and then it's then I'm out I two members of the santa-cratic ball again it's Thomas Erikson and a bird who would have drawn from from Belgium Louie cannula from Italy a family from Morocco internationally renowned dentists and professors with a reputation that give its we could speak about this guys the motivation of these guys two randomly selected in a peer review peer review process they decide this fits everything together and this is meets the criteria and then they award the implant with the trusted quality mark so this is a process we have to Double Trouble five times safe that this is an unbiased acquisition of data and otherwise I have always accusation is actually some nice and funny ridiculous brutal and aggressive reactions all the way up like for example one CEO I mean thinking that I'm our job is disturbing the business there's one thing writing me that it's obviously that I had different sources of light who to produce shadow in the image to have it a bad outcome I see I have to read it three times and I just checked the manual of the scanning electron microscope there is no light in the room there is no way to produce a shadow and another one is it CEO from Switzerland they are they're not idiots but they writing me so I have evidence and an email they're writing me stories like well it's obviously that you have melt ok the appeal is dirty we have some some points off of carbon it's obviously you melted the titanium with the electron beam of the microscope again I had to read it three times, this is totally stupid nonsense. I mean there's no no idea too too stupid to explain why these particles are on the implant it's simply a lack of quality management and again if it's 50 dollars if it's four hundred dollars we should expect that the implant is as good as technically possible and we see implants on the market date they can't produce an implant with 0-2 very minor contaminations of particles and this is the level we should erase the bar and and this is what to fulfill the promise of the patient who's sitting there with a problem trusting in my decision for implant system it should be a good implant as good as technically possible not just believing or just using choosing an implant because I get an extra iPad if I order 500 implants like in some countries still not in Europe not in the US but there's some strange decision making processes in the world but it's always first down to the one situation. If you work for 20 years in the university you always get the patient that lost trust and talk around the university area your the last address doctor Duddeck you and the university you're working in the private office of professor sorrow and you can cologne if you find a solution and they could see the disappointed complaining patient they lost not only trust in the dentist they actually lost trust in implantology because there was so many things went wrong and you see this human beings we not speak about statistical numbers we don't speak about tests and bigger dogs or guinea pigs if they say we have 95 percent success wonderful I see five complaining patients crying ladies wasting my time in my office I mean it is our job in university to speak with them but we see five people who have a loss of an implant and we have the technician complaining about the costs who pays for it what went wrong is it just always the you can't always blame the technician or blame the patient for not brushing the teeth or for a low standard dental hygiene you can't blame the industry of always it's always a mixture of factors that leads to a loss of bone and this is so important that in the end we have one tiny problem I know it's a tiny part of the chain of quality and success influence implants effects to exist this should not open a new problem as we are treating implants always say with even with patients with radiation before and the University all these cases the colleagues from the private practice they go with the patient say please treat this patient he has bleeding disease or whatever so you go always to the limit this is my universities are for and the last problem you ought to have is another additional let's say extra load of foreign bodies and to end the story about this foreign body thing is if people ask me how many particles are acceptable for the body I said well I asked the same questions to Thomas Erickson and he wrote a nice article about ending in the theory of the foreign body equilibrium this is the reason why the former Chancellor of Germany died years ago and he smoked about three packages of cigarettes it didn't die of lung cancer and you have another colleague of patient who smokes just two cigarettes a day and they get thing at a carcinoma. So there is an individual foreign body equilibrium in every patient there's a reason why when you make probably take a rusty nail and some patients can live with it if it's sterile. It's better you have a sterile implant and not a rusty nail but if you have the chance to produce an implant with zero to minor very minor particles you should have this implant and not deal with an extra problem and in the follow-up and this is interesting to understand because people telling me they always well is it really that dangerous my I never have a patient that died of an implant say yeah lucky you but they were complaining they lots of an implant is a drama for a patient it's a statistical number for scientists but if we see a foreign body whatever it is on the implant it's so important to understand that all the particles we will see in the video they lose probably contact due to the high friction forces in the moment of entering the implant so we always have a concentration of all these particles even if it's metal particles like bronze particles I found a copper chromium nickel some tungsten stainless steel particles on the dense cortical bone so there it starts a foreign body reaction as an answer for a foreign body this is you can read it in the first semester in the university the way biology is reacting to a foreign body and unfortunately and the follow-up of the foreign body reaction we always have an increase of osteoclast and osteoclast urge analyst that means the body is quite stupid to get is a super cleaning woman to get rid of the problem of let's say some particles at the cortical bone where you want to have the best a sealed with a bone at least don't want to have peri implantitis and the body helps to get rid of these particles by taking away the bones so osteoclast increase is like my cleaning ask my cleaning women to get rid of some red wine on the carpet okay doctor when you come home the red wine is gone and she takes a knife and just cuts it out I said what the ruined the carpet I mean ask removed for the red wine. So the body is working the same by getting rid of these particles soon macrophages they got they got help from osteoclast so then I speak about in my lecture about the domino theory it start with the contamination with the foreign body an avoidable foreign body by the way then we have the foreign body reaction we have then increase of osteoclasts we have let's say a loss of bone just one or two millimeters it's not even more but then we have a rough surface of the implant free to the sullivan to do ology and then we have bacteria and with bacteria we have infection we have a parent and leukocyte as we are probably a peri-implantitis and probably more loss of bone that ends in the end like dominoes stones one after the other ends and the loss of an implant and the crying complaining patients. So this is the story we have to speak about.
Howard: You notice that when some people wear fake jewelry they'll get a tattooing a green around their skin and some people won't and I've noticed in 30 years dark-skinned people Hispanics, American Indians, African Americans they don't get that but Northern Europeans English Scandinavia they'll get that green tattooing around there and some dentists are making that analogy that titanium implants aren't as inert as everybody thinks they are and they're starting to say that you should go to ceramic implants but it sounds like you might be saying that maybe it's not the titanium at all maybe it's that there's all these impurities that are supposed to be. So saying all that what does that make you think you you think there's gonna be a ceramic implants so that people don't have reactions to titanium or are you saying more that it's not the titanium it's that they're they're dirty with all these other things that you're talking about?
Dirk: They're very very rare cases if you look on the scientific evidence level who speaks about two reactions on titanium particles you will find them in the bone for sure up to the next one or two centimeters we right beneath the the insertion but we have the same topic with aluminum oxide remnants on blasting process don't it's my personal opinion it's not evidence based I don't think that any patients gets Alzheimer's disease because of there are some remnants of aluminum particles on the bone. I'm actually more concerned about because we know there's from the statistical point my asking banovic and my me up the days is aluminum remnant really a problem for just to pick up one thing and she said no we don't have any differences in hostintegration and we're moving in removal talk so the friction force you need to the force you need to unscrew an implant and the the level of bone to implant contact there's no not such not such a huge impact on aluminum oxide but we sure see some reactions on a higher load of organic particles but you mentioned one thing it's two two or two like colors we have in Germany we work also together with the front of an institute and they make a lot of research one is this in the in the turn it's a huge explained area in Geneva to test the tiny tiny tiny parts of the body and they made a research and we found first of all they identified the colors of two to this on metal every color and h2 is a metal tiny metal and the nanoparticles and they could find all these nanoparticles in the lymph nodes that patients were headed to to so the corresponding color they found the corresponding metal particles inside lymph nodes and not in one and many of them. If I see these particles like some interesting particles containing copper and tin I have to go to my chemistry books from lays on the school and what is copper and tin it's bronze and yes where the heck is bronze comes bronze on an implant it's going like an FBI analysis for better implants by the way and then we found out that the nozzle from the blasting is made of bronze so the different fabrication science or some bronze particles come to the implant at stick on the implant and this will have an impact nobody can tell me that this particle best case will be washed away but if it's part of the body it will be taken out by macrophages. The problem is by the way not that these particles are so small so small or so big the problem is if they are smaller than 8 micron so even I am interested in these small particles they can they are ready for macrophages they can take it up and then I the next question is where do they go I don't want to answer this question because I don't have no clue about this and it colleagues asking after lecture Dr. Duddeck how important is this and this and this say ok so coming down from a statistical scientific base question to let's say to ethic to medical ethics and then I just say well you have the choice let's say it's Sunday evening and you hear a loud noise some your son your mother your wife is just falling down the stairways and you see oh something happen she's crying a lot of noise and you go down there and you see well you sign your mother is losing his central incisor okay see what okay this is a no chance we need an immediate implementation it's sunday evening you give the call to your team and say Lisa we don't start at 9:00 we start at 7:00 in the morning first patient is my son my wife people I really care for and you have two systems in your in your stock one is the 15 euro system or even if it's system where you say well so cheap we've got a good price and the other one is one of the implants where you know from research and from the quality method is there is a fine implant what is the choice of the implant for your son for your mother for people you really care for and why not for every patient so coming if you have the chance to use a medical device was no question mark at least we are reducing question marks. I don't go too deep into the discussion how many particles off of stainless steel will have an impact it's avoidable it's that easy my message is so plain and simple industry is able to produce it and the dentist should pay a little more for this quality management but by forcing the industry to lower and lower prices you get what you paid for so there is a threshold I don't know between good guess $100 $50 there's a there's a price where you can't guarantee a quality mark that is good for a medical device that's all about it and you find the complete story on the website.
Howard: Yeah I love your quote from Winston Churchill on their website says criticism may not be agreeable but it is necessary it fulfills the same function as pain in the human body it calls attention to the development of an unhealthy state of things and if you go to your website the first picture on there what am what are we looking at there?
Dirk: This is a remnant off a huge remnant about more than 500 microns in the polished part of an of an implant and they're under shoulder and you see some black organic material and the tiny white particles I had to check this three times it's antimony and I have to check where this the heck as a antimony come I found no idea antimony you need something you can measure this gun shooting areas it's part of the the gunpowder and it's toxic. I mean there's a story from Berlin where they had Berlin police huge numbers of people who went ill and so they have a very high rate of people who do complaining and suddenly they found out that the air condition in the shooting area with the train it was was a defect so it comes down to the antimony level in there and their blood. So this is probably something that is not good I don't know what it is I don't know the reaction but again we found bronze we found copper chromium iron tungsten. So a lot of metals and I'm actually more concerned about this masses of organic contaminants and they work on an implant and whatever stage from production or handling these particles come to the implant they work like chewing on the pedestrian they collect all these let's little stones on the is issuing on a pedestrian you see some stones inside the chewing gum right and the same act the same as with some it works like glue on an implant it's hard to get rid of these particles during the the process of cleaning and you see all the stuff that is during this process.
Howard: So where do you live in Germany now?
Dirk: In Berlin.
Howard: You live in Berlin and were you able to fly it non-stop Berlin to Las Vegas?
Dirk: It was an 11 hour flight yeah
Howard: To Vegas?
Dirk: Good time to prepare my lecture.
Howard: It's always the greatest downtime. I remember the most brutal lecture I ever gave was in Cambodia and from the time I left the airport to got to the hotel was 36 hours and I took and I thank God I took three of my four boys with me because they got an appreciation for dad because they were just they were just dead zombies and like dad I don't know how you do this I'm like yeah how would you like to do it at my age.
Dirk: I just owe you one question you asked for Ciccone I'm ceramic implants it's important if ceramic implants they have a history of failures in the beginning in the early beginning and this is kind of lots of colleagues are blaming ceramic implants they're not as good as but they will be better every year we see an increase every big company is now if actually producing one, developing a new one or just buying a system so some mixtures and they are usually for patients that really care so much for their they have actually allergic history and it looks like a ceramic implant is the solution with zero reaction on the bodies we know it's nice to the gingiva and they work really fine but we have this is just because they are white they're not necessarily cleaner then you have a different process and the sintering process with very high temperature they burn away every organic material but then you have to package them you have to touch them and we still find a high number of ceramic implants with organic contaminants avoidable contamination, we found other ones with the zero so again here the same problem will you have to address the industry for the same care of quality management as we have people force the industry to have for titanium implants.
Howard: and then you also have the the market because like the scientists that I read say that um ninety percent of the people on a gluten-free diet have no scientific reason to be on a gluten free diet, and there's just a lot of dentists and a lot of patients who don't want metal.
Dirk: Exactly metal free implant.
Howard: That's what they believe that's the market and any chance we the reviews of your lecture are just amazing do you think there's any way you'd ever put that course on dentaltown?
Dirk: I promise I will.
Howard: You promise, oh my gosh any time you want to put online CE course on dentaltown.
DIrk: Would be my pleasure.
Howard: It was just an honor for you to fly 11 hours and I caught him here we're both lecturing at a MegaGen and to catch you here thank you so much for taking the time to come by and talk.
Dirk: Thanks for having me again, thank you so much.
Howard: Thank you very much.