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"Germany is the country of engineers. We have solutions that are perfect, technically, but they are not simple to maintain."
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AUDIO - Jan Kielhorn - HSP #113
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VIDEO - Jan Kielhorn - HSP #113
What is the uniform precision that goes into the design of an aircraft? What is the system McDonald's follows that makes the same worst burger all over the world? Standard Operating Procedure is a powerful tool. Learn how to use it correctly.
· Studied dentistry at Ruperta-Carola-Universität, Heidelberg, Germany
· Specialization in oral surgery (privat practice Dr. Dr. Haessler, Oppenheim, Germany)
· oral surgeon
· Specialist for oral implantology (DGI, DGZI, BDO, BDZI)
· Specialist for paradontology (DGP)
· 1998-2005: dental assistant Implant-Education-Center (Dr. Dr. Haessler, Oppenheim, Germany)
· guest professorship University Ludhiana, Punjab, India (department oral implantology)
· Author of several scientific articles (DPB)
· 2005: Founding of Implant Competence Centers in Oehringen, Germany
· Specializations: 3D diagnosis, navigation, oral implantology, augmentation, CAD/CAM
Dr. Farran: It is a great honor and privilege to be interviewing today all the way from little old Phoenix, Arizona, 9 hours into the future. It's 10:30 AM here. It's 7:30 PM where you're at in Germany and I'm interviewing today one of the most exciting oral surgeons and implantologists that I've come across. Thank you so much for letting me interview you for an hour today. Welcome.
Dr. Kielhorn: Thank you. Welcome.
Dr. Farran: Your name is Jan Kielhorn. My dental assistant since day one for 28 years, her name is Jan so I'm very, very fond of the name. Your parents have retired and they lived half the year in Florida. You've been to the United States a lot of times and my podcast audience is ... Someone will download this in every country. We're getting about 5,000 downloads. After 75 podcasts, I already passed 100,000 downloads every country on earth. It's probably 80% Americans and a lot of Americans probably don't understand the little nuance differences between the dental industry in Germany versus the United States. I was wondering if you thought there were any ... What are the similarities and differences between dentistry in the United States versus Germany?
Dr. Kielhorn: The similarities are that we are solution-orientated in what we sell to the patient. That's a lot we learned from the United States. The marketing that we took over, of course, from you guys. Also, to offer a complete solution for the patient instead of a product selling. That's what we took over from that country, from the United States. That makes us similar now. It may be adopted to that.
Difference would be that we are more scientific-driven. I got the impression that in the United States, a lot is done to avoid legal issues. A lot of things are done because you have to do it as you should do it in order not to get sued. Some protocols orientate that and they stop developing because it's not approved yet and it hasn't been done often enough. It's not approved. Whilst in Germany, if you have scientific approach, that's all you need. We don't care if there are some legal issues we have to make. That makes us a little bit different, I guess.
Dr. Farran: From me visiting your great country several times ... You're in Stuttgart?
Dr. Kielhorn: Yes.
Dr. Farran: No offense. I don't want to sound strange or anything but my favorite city in Germany is actually Cologne.
Dr. Kielhorn: Okay.
Dr. Farran: I don't know why. I've been to all of them but Cologne ... I think it's the coolest city in Europe. It is just so cool. To people who've never been there, it was the farthest outreach of the Roman empire and when you go to Cologne, you can still see the old Roman walls around the city. Have you been to Cologne?
Dr. Kielhorn: Yes, of course.
Dr. Farran: Yeah. It's [inaudible 00:03:21] at all the best German food, you can get all the best Italian food and you can get German-Italian kind of ... You don't really know if it's Italian or German but it has a very strong Italian influence, wouldn't you say?
Dr. Kielhorn: Yes, there's a lot of Italians now, of course.
Dr. Farran: Which is amazing that the Roman empire fell 550 AD and 1,500 years later, they still have Italians living there. Very interesting. The biggest takeaway I take away from Germany is that when you go to American dental manufacturing companies, they have a huge marketing department and maybe 30 or 60 telemarketers and Americans just know how to sell. They could sell you more stuff that you'd never need and they could sell you everything you'd never want. There's nobody that has a white coat on, that's a PhD, that was trained in the science, has any idea what they're saying. They just sell. They're always in [inaudible 00:04:25].
Then, you go to Germany and they're so concentrated on making it just perfectly right whether you're at Ivoclar, Sirona or KaVo. The manufacturing places, they'll have departments with 30, 40 people in white coats that have PhDs. They just going to make it like a Porsche or a Mercedes. They're just going to make it perfect. Then, they'll spend any effort on science. It's almost like the Germans believe, "If you make this so good, it'll sell itself." The Americans say, "God, we'll sell anything. We'll sell you a crap sandwich because we'll give you two for one. It'll be 20% off and you'll get some steak knife if you buy it today." I always thought that the Germans could learn a lot from the Americans on how to sell more stuff and the Americans need to learn from the Germans that, "Why don't you just make it right the first time?"
My first introduction to German manufacturing was when they rolled out the Space Shuttle Columbia and that was 30 years ago. I was in high school and it had this big arrow on the outside pointing to the fuel tank. I'm looking at this like, "Okay, I've got my own car. There's no arrow pointing to the gas tank. I know where the gas goes. Why do these astronauts ... Aren't they supposed to be smart? Why do they need an arrow pointing to the fuel tank?" You don't get it and so you realize that the entire space program was created by Germans.
When you go into Germany, they're so attention to detail. You would look down at the floor, "Sirona". In America, you say, "Where's the bathroom?" You'd say, "Where's the lobby? Where's the front desk?" You're always asking. Germany, you'd look down the floor and the red line takes you to the boys' room, the blue line takes you to the girls' room, the yellow line takes you to the front office, above every light switch is a code and everything's a manual.
It were just so hilarious where you told me that you wanted to go into protocol. Germans, they were just born protocol. You should rename your country, "the land of protocol" because you are obsessed with surgical protocol, that you need to do things in a certain order. You need to do it in a right way and you need to do all these certain stuffs. That's just German. That's German manufacturing. That's just a totally cultural German thing. Would you agree with that?
Dr. Kielhorn: I see it a bit differently, I think. It's that the Germans try to make it perfectly because we are the country of engineers. We like to do it in nearing to the perfect [inaudible 00:07:07]. On the other side, that makes it very complicated. We have solutions that are perfectly technical but they are not simple solutions. They are not simple to maintain. They're not simple to do. They cannot be done by everybody. You can't [inaudible 00:07:24] of a broad majority of dentists. That is what we are not good at.
I said the standard operating procedure comes from airlines, from safety in air flying, from pilots. That is all done by the Americans. The team effort on making McDonald's burgers the same worst burger all over the world, that is an effort the Americans can do because they can have a protocol in a team approach and then we've followed through that. Then, they will entertain and they will have a solution for that, keep it safe and simple. We, Germans, like to overdo it, to make it so damn complicated that if something happens, there's a lot of money into it but there's no benefit for the patient.
Dr. Farran: What are your plug-in-place solution, patient-oriented protocols? What would you like to see more of?
Dr. Kielhorn: I would see a 3D diagnostic as a standard. Cone-beam should be a standard. It should be a standard in endodontics. It should be a standard before you pull a tooth out. "Are you not certain that you could" and before you place an implant. It should be prosthetically driven all the time. It should be crown-down because that is what we need. We just need a retention for the implant crown and we don't need anything else. That's all an implant does. In augmentation, it's even worse because augmentation is often an improvisation. A lot of people just give their best. They have experience over 20 years. They have a lot of things that went wrong. That's what they learned from and that makes them get better but they improvise. Also, there should be a standard operating procedure for every indication and a 3D diagnostics to know what you're doing.
Dr. Farran: I like what you first said, this 3D diagnostics. I hope the profession chose the name CBCT before everybody buys one and calls it that because no patient in the world is going to understand what a CBCT is. We went from a 2D radiograph to a 3D radiograph and just keep it 3D. The absolute board-certified oral and maxillofacial surgeons tell me that from the most technical point of view, what we use in dentistry isn't even truly a CBCT. That has started out that way and it's been modified, mesmerized and all of those stuff. I love it. Keep it simple, stupid. Keep it safe and simple is what you say. I haven't heard that one. I was hearing a KISS principle, keep it simple, stupid. You said keep it safe and simple. I like that better. 3D diagnostic is mandatory, crown down, augmentation. Is 3D more prevalent in Germany than in the United States? How's the conversion from 2D to 3D going in Germany?
Dr. Kielhorn: Very fast. A lot of even dentists not doing surgery use cone-beam or 3D diagnostics for periodontics, for example, in order to determine is there a tooth that can be relied on or has it to be taken out. Even to take [inaudible 00:10:34] is a severe decision. You should be very sure you do that. In order to tell patients, we like a scientific approach to tell the patient what happens to him. If you see a 3D picture, people understand what is actually happening in the jaw instead of telling stories. You show pictures. You show reality pictures but not bloody pictures. You show a 3D animation of a show of a show like scientific TV.
Dr. Farran: How many dentists are in Germany?
Dr. Kielhorn: Oh, God. Good question. I think 200,000. I don't know.
Dr. Farran: You don't know? How many people?
Dr. Kielhorn: I don't know.
Dr. Farran: Okay. Do you know the percentage of German dentists that ... Let me say this. In the United States, the CBCTs are mostly going into oral surgeons' office, periodontists' office. They're just now starting to go into endodontists' office. I don't know really very many people in general dentist family practice buying them unless they place implants. It mostly started off with oral surgeons and periodontists. In the United States, there's a 120,000 general dentists and 30,000 specialists. There's 10,000 orthodontists in the United States but there's only 17,000 orthodontists in the world.
The point I'm trying to make is that the way America has 9 specialties recognized by the ADA, 7 clinical, 2 nonclinical oral and maxillofacial radiology in public health, when you go to other great civilizations like Brazil, India, China and Africa, you don't see specialization. You see more just general dentists. I guess the question I was asking you was is Germany ... You're an oral surgeon. Is Germany like the United States where it's mostly the specialist doing implants or do you see more general dentists doing it?
Dr. Kielhorn: A lot. Nearly everybody does the implants here, not only specialists. Simple cases or mini implants, for example, 1.8 millimeter diameter transgingival placement put into an old denture and that is done by a lot of dentists. The simple cases are all done by the dentists and they refer for severe cases or even refer only for augmentation then place implants themselves.
Dr. Farran: What percent of the general dentists would you believe placed an implant in the last 12 months in Germany? What percent of general dentists placed an implant in the last year?
Dr. Kielhorn: At least 50%.
Dr. Farran: Fifty percent. In Korea, it's 75%. Fifteen thousand out of 20,000 Korean dentists placed an implant last month. In the United States, I kid you not, Jan, only 5% of the 120,000 general dentists have ever placed one implant in their entire life. That's the side effect of overspecialization. Everything's a trade-off. There's good and bad to everything but the 25,000 specialists have taken that over. I think that's going to change.
I think when I placed my first implant almost 30 years ago, you had a 2D x-ray. You didn't know what you had until you opened up the tissue. You thought you had an inch of bone and it turns out that by the time you smooth it down and had some width, you didn't ... It was crazy. Now, I think 3D makes it a lot easier just like in endo. Endo used to be very, very hard because we do the whole thing manually with our fingers. Then, they came out with automated 300 rpm NiTi and [inaudible 00:14:12] and instant digital x-ray.
I actually believed that it was a lot harder back in the day but I hear every generation thinks they had it harder than the next generation. I'm sure I'm just being a whining, old man like my dad and my grandpa before me. Would you say it's easier to place an implant in 2015 than it was 20 years ago?
Dr. Kielhorn: Yes, of course, because the systems are so much better. If you see them place an implant in the former times, we had underdetermined preparation which was more than today. We had to wrench it in, wrench it back, wrench it in not to overload it and you had to have a very good feeling for the bone in order not to have an necrosis or loss of bone. Today, the systems are so well-adopted to the burrs and to the full system but placing it all big and overloaded is very difficult.
If you limit a unit, it's machine-driven. Placement of implants can be machine-driven. You can limit your insertion talk to, for example, [inaudible 00:15:15] centimeters. That all makes it very safe for people not knowing how bone feels because they got figures and they've got burrs who do the work for them. Like NiTi instruments in endodontics, it becomes better, less fractures, more safety, better fit. A lot changed. A lot from design, surfaces and the healing made it easier to place it, of course.
Dr. Farran: I always try to do these podcasts. I'm always trying to guess what 5,000 questions are. Here's this dentist, driving to work for an hour, listening to this on their car speakers and I'm always trying to guess their questions. I bet the biggest question out there right now is you're over there in Germany. When Americans think of Germany, American dentists think of Germany, they're thinking of KaVo, Sirona, Ivoclar. I know Ivoclar is on Germany's Liechtenstein but Liechtenstein used to be Germany, right? There's a little province that they gave to the king. What is the story of Liechtenstein?
Dr. Kielhorn: Some sort of story, yeah.
Dr. Farran: Yeah. Some type of story when they decided- I guess when they were done with the king, they just gave them a little plot of land and then went on with it or something like that.
Dr. Kielhorn: Something like that.
Dr. Farran: Liechtenstein's pretty much Germany. Would you agree with that?
Dr. Kielhorn: Yeah.
Dr. Farran: Yeah. We think of those great companies. I know these American dentists are driving their car then. Jan, you bought a 3D x-ray. What brand did you go with? When you place implants, there were 275 companies that the last IDS mainly in Cologne selling implants, you're in the land of Sirona, KaVo, Ivoclar, Porsche, Mercedes, Audi. What did you go with? What 3D x-ray machine and what implants did you choose living in Germany?
Dr. Kielhorn: In general? Me, myself?
Dr. Farran: Yes.
Dr. Kielhorn: I'm using an Orange one which is Korean. The thing is it comes from Ewoo company and Ewoo is one of the biggest manufacturers of all computer tomograms worldwide.
Dr. Farran: Spell it.
Dr. Kielhorn: Ewoo is I think E-W-O-O.
Dr. Farran: E-W-W-O.
Dr. Kielhorn: Yeah. Orange is the company who imports it here, pins it and applies it to German standards. Then, we use it. Why we use it is in the beginning, there were two which you can really use. Sirona was technical [inaudible 00:17:45] but not up-to-date because it doesn't have a flat screen. Now, it has a flat screen. It doesn't have a multiple field of hue which is important because you want to have a little field of hue for an endo and you want to have huge one for an implant. That was impossible at that time. There was only the Morita which was, of course, the gold standard. It still is one of the gold standards, one of the best from the technical standpoint and from the quality. Morita still is the leading machine according to German opinion.
Dr. Farran: That's out of Japan.
Dr. Kielhorn: Yeah but it's so expensive. There's [inaudible 00:18:24] even specialists. Orange was the first one who had a machine that had a panorama x-ray and a cone-beam in one machine. Now, that opens it to a lot of dentists. When they launched that, they were selling like hell. A doctor, he couldn't have two machines. He couldn't have an i-CAT machine and a panorama. He didn't have the space for that. He didn't have the money to invest so he wanted one machine who could do everything. Now, the Orange Tree was one that could offer you a [inaudible 00:18:57], that could offer you a panorama and a cone-beam all in one machine and affordable. That's why suddenly, general dentists bought all cone-beams just because of Orange and Ewoo machines. They got better and better and they are price-for-value perfect machine, perfect to work with.
Dr. Farran: Is that E-W-W-O.com, www.ewwo.com?
Dr. Kielhorn: Yeah, Ewoo. I think it's the manufacturer for computer grams worldwide.
Dr. Farran: That's at Seoul, South Korea?
Dr. Kielhorn: Yeah.
Dr. Farran: The moment you said that, also at Seoul, South Korea is MegaGen. That's an implant company. What implant company did you go with?
Dr. Kielhorn: Of course, because we have referring dentists, I have to have a lot of systems. We work with Denstein. We work with MegaGen, of course, which is very innovative. I just love it, what they do. They are, I think, the company at the moment who has the most innovation in it, the most strived, the most young rebels. We call ourselves the young and wild, the implant hooligans. Just go for new solutions. Don't be so crusted and old-fashioned and wait for 10 years to get it proved that you're right.
MegaGen is doing that. They make love in doing that and they've got a lot of knowledge because they're placing 5,000 implants to just check a detail on the implant. Who can do that? Just because they've got all these clinics, they can raise clinical research very fast. Besides Denstein, we also use ... Like MegaGen, we would have some Straumann customers and we have, of course, mini implant systems like the MDI system which is sold by ESPE which is a mini implant 1.8 millimeter, one piece just for retention of total dentures.
Dr. Farran: Is Straumann Sweden?
Dr. Kielhorn: No, Swiss.
Dr. Farran: Swiss. Switzerland?
Dr. Kielhorn: Yeah.
Dr. Farran: Okay. Did you see the new MegaGen bone crusher where you throw an extracted tooth and it pulverizes it and you use that for your bone grafting material?
Dr. Kielhorn: Yes, I've seen that. I've seen that. I've got an English friend who does a lot of that but in Germany, nobody would use that because what we want to have is a gold standard. When we do augmentation, we want it to be what it was before. We want to restore it to the best it has been, not something like it, not something worse. Of course, if you put in teeth, it will add volume and stable volume for years.
The golden standard is you will have volume. If you have a socket preservation for pontic or if you want to have some [inaudible 00:21:42] contour, I would augment in with that because it will stay. It's the same over 20, 30, 40 years but if I want to place an implant in there, I want to have bone that is able to react to stress, that react to compression, that I can compress, that has vitality, that I can restore again after two or three implants. That I cannot do if I make it more and more less vital. If I put more Sirano or [inaudible 00:22:10] stuff in there like [inaudible 00:22:12] or whatever, if put more and more teeth in there which is enamel, it won't stay there. That's a problem we have. We want to have the biological copy.
Dr. Farran: What is the name of that grinder, tooth grinder? Do you know the name of it?
Dr. Kielhorn: No. No, I've just seen so much of it.
Dr. Farran: You have to admit. That was a hell of an idea, though. That was a hell of an innovation.
Dr. Kielhorn: I was really amazed by that.
Dr. Farran: You know what it made me think? Going all the way back and I don't remember this. It reminded me going all the way back to freshman year in dental school when they were talking about hydroxyapatite and the histology teacher showed us a slide of hydroxyapatite. Then, he showed us another slide and he said, "Do you see any difference?" We're looking at it. We're like, "No." He said, "The one on the left is a human hydroxyapatite and the one on the right is a sea coral." That hydroxyapatite goes all the way back, billions of years to sea coral and the ocean. When I saw that machine, I thought, "I wonder if someday we'll be throwing sea shells in that thing making hydroxyapatite."
Dr. Kielhorn: [inaudible 00:23:21], for example, is coral structure.
Dr. Farran: Which one?
Dr. Kielhorn: [inaudible 00:23:25]. [inaudible 00:23:26] company is a coral structure which we use very successfully in sinus lifting because people who don't want to have anything from animals or other human beings like AlloCrafts, they like to have ... Germans are very aware of other people might be infected, whatever. They think plants are the best you can have which is true but they [inaudible 00:23:46] way. We use a lot of [inaudible 00:23:49] and that is from coral structures. Hydroxyapatite tubes with a high microporosity that gets partially resorbed and replaced by bone. That is used but it has no enamel structures. It has no cement, no infections. The toothing is amazing but you couldn't do that in this country. That's [inaudible 00:24:07].
Dr. Farran: It's already out there. What percent of the implants do you think need bone grafting around there?
Dr. Kielhorn: In my clinics, it gets more and more because I get only referred the worst cases. All the standard cases are already done by the general practitioner. The cases where it's [inaudible 00:24:32] we place in [inaudible 00:24:32] finished into the bone, that is all done elsewhere. We get the severe cases so we have to do quite a lot of augmentation especially in aesthetic zones. If you do just the functional cases for old people having an [inaudible 00:24:47] of MegaGen implant, [inaudible 00:24:49] for example to sink the implant 2 millimeters below bone can avoid augmentation.
Angled implants, all-on-four, all-on-six concepts can avoid augmentation, of course, and they're very successful here and very popular at the moment, screw-retained. Many of us, we have a lot of tendencies to avoid augmentation if it's just a functional cases. Also, there are severe resorption cases and high aesthetic cases where we have to do augmentation. Young people, aesthetic line, low lip line, something like that.
Dr. Farran: I want you to weigh in on a huge debate in the United States. If we're having it here, maybe you're having it there, too. There's this debate going on that says ... What I'm trying to focus on is the 95% of a 120,000 general dentists have never placed a singular implant ever in their career and a lot of them are listening to Jan today. They're sitting there trying to build up the courage to place their first implant and this is what their first thing they're stumbling over. One group says, "We'll get a 3D x-ray machine so you know where everything is and then build a surgical guide that will just snap into place. Then, there'll be a little hole there to stop guide." You just can't mess it up. You'll just go straight in.
The other camp says that's like learning how to ride a bicycle on training wheels and you need to learn how to lay a full-thickness flap and you need to look at the bone. If you have a single tooth implant ... In America, 96% of the crowns are done one tooth at a time and 96% of the implants are placed one implant at a time. If you're just placing one implant and you've got a tooth in front of it and a tooth behind it and you're really supposed to be a doctor, you should be able to open a full-thickness flap, look at the bone. If you need a surgical guide, you're not right in the head and that if you keep using surgical guides, you're never going to be a surgeon. Jan, how does this person, listening to you right now, who's never placed an implant, "What am I supposed to do?"
Dr. Kielhorn: NobelGuide was a big discussion in Germany. NobelGuide was a disaster for Nobel Biocare in Germany because what happened is they claimed it and marked it like the Americans feared as being more simple, more efficient and everybody could use it. That was a disaster because the problem is also a cone-beam or a 3D diagnostics has a certain limitation and imprecision. Secondly, the template might not fit in the right position. The last thing is if you're going the fitting for the bone, you can't suture and you don't know how to fit tissue, you will not be able to keep that implant.
We say that navigation makes implantology more precise and prosthetical-orientated but it does make it easier at all because you overheed, you can lose the bone, you can still have a false position if you're not able to read it perfectly and nothing doing planning for you. We say it makes it more precise but not easier. Of course, you should be placing implants in a normal bone, [inaudible 00:28:05]. You should be able to do that. For example, they can start with mini implants for bone where nothing happens. When you lose a mini implant, there will be no damage, no damage of bone, nothing. Not a lot of cost that are lost for the patient.
That is what you can easily do to start with and every [inaudible 00:28:26] practitioner should do minor surgery. They should be able to extract the tooth. They have to suture that. If they break the tooth and you have a broken root, they have to know how to do a simple cut to open that. The minor dentist surgery in Germany, everybody can do that. Even root resections are done by general dentists here. As long as it's anterior teeth or whatever, they all do it. That can be easily done. Of course, they should learn the basics. That is very important, the basics of surgery. We train all endodontologists to first know about periodontics and then they go to implantology because without periodontics, you will never be a good surgeon in implantology. That's what we believe in Germany.
Dr. Farran: I want to ask you another question. Here, we're always compared to Canada, Australia, Germany in healthcare. We're talking about healthcare. We're told that the Americans have a 22% of all babies born with a cesarean section but when you go to nationalized healthcare systems in Europe, that number is only like 5%. A lot of people think that's because they're afraid of the lawyers. They don't want to have anything go wrong with the baby and then say, "It should've been a C-section." Some people say it's because the insurance pays $5,000 for a C-section and only $1,000 if it comes out normally.
My question to you is regarding wisdom teeth. Some people say that Americans pull out all the wisdom teeth and that probably 80% of them don't need to come out. We just look at forwards and say, "They're coming out and we get paid literally a thousand, a lot of money to remove each one. There's no lab bill. It's basically four carps of Septocaine, a little nitrous oxide. Easy money." Being a German oral surgeon, what is your protocol on removing wisdom teeth and do Germans remove the same amount or a less amount of third molars, wisdom teeth, than the Americans?
Dr. Kielhorn: I guess a little less because we had a change in rule. We have certain guidelines we have obey according to the law and those guidelines became very strict. In the beginning, we had, for example, wisdom tooth taken out in the mandible. If there were some in the maxilla because there was no antagonist, we had to extract them also. This is forbidden, for example. Also, if there's a tendency that they would have some space, you have to wait and leave them. You have to have a very strong indication to show that the tooth will be moved, there will be decay on the anterior adjacent tooth or there will be a cyst building up. Then, you can remove them but the indication is not as easy as it has been 5 to 10 years ago.
It gets trickier that people leave them as long as there's no problem because if you have a complication here according to the law and the patient had no problem, then you're in trouble. You did a treatment that worsens the situation of the patient without an indication. That's why people are more restricted taking them out. We only take them out if they really lie completely angled or misplaced, if they already show a cyst or a resorption of the adjacent tooth. [inaudible 00:31:52] when the orthodontist remeet them to be removed for his treatment. Besides that, we don't extract all of them. That is not the law anymore.
Dr. Farran: How many years have you been an oral surgeon?
Dr. Kielhorn: Twenty years now.
Dr. Farran: Okay. Try to give me a percent. Compared to yourself 20 years ago, what percent less wisdom teeth are you removing today in 2015 than you were in 2005?
Dr. Kielhorn: At least 30-40% because 10 or 15 years ago, we would have removed them all, even antagonist that are totally straight. Now, we don't do that. We just take them out when there's a severe problem and we have severe indication.
Dr. Farran: Okay. I want to go back to your patient-oriented protocols. What else would you like to say about protocols?
Dr. Kielhorn: What I like about protocols is augmentation. It's my main topic because in augmentation, there's no protocols. Everybody's doing trial and error using different brand frames. They like to use [inaudible 00:32:55] frame. Next week, they try another membrane or they use cow particles or other animals. Then, the use hydroxyapatite, treat calcium phosphate. They keep on mixing because they heard it's good or whatever. There's no reliability. They don't have a clear indication. Some people say they like splitting. Then, they do only splitting but it will not give you habit. Some like [inaudible 00:33:19], some like AlloCraft. I think there should be standard protocols like we had in implantology. That is what makes implantology so safe, that we came from trial and error to safe protocols.
In augmentation, there are no such protocols. That's what we're fighting for and we want to have methods that are not sensitive. That's why, for example, I love the [inaudible 00:33:39] technique. I grew up having the [inaudible 00:33:42] technique which is a bone block, a bone plate, a thin plate of 0.5 millimeters taken from the ramus, transplanted like a little biological container and filled that with [inaudible 00:33:54] bone chips. That is the highest standard. Two hundred percent, you will get that bone that you designed. We said, "Okay" but taking out that plate, preparing the plate with microsaw, that is all very sensitive methods. You have to do a lot of these cases and have a lot of failures to be very good at that.
We say, "Okay. That is the first reason because it's one of the most successful methods. How can we change that?" Then, we were coming to AlloCraft which is a big topic in the US. In Germany, AlloCraft was only used for orthopedic and trauma surgery, not in dentistry a lot while you have 60% of AlloCrafts in the US. We haven't been using that widely but it's still very safe here. We came to that. We were not full blocks but we made these plates 0.8 millimeters and used AlloCraft plates. Now, everybody has a little paper cutter and they can cut his plate to the size he wants and he just needs to be able to screw it on.
We made the training very simple so everybody could do that. As long as he can suture that and calibers of tissue, everybody now will be able to do a [inaudible 00:35:03] technique and whenever he need a piece of bone, he has one in his cupboard because he can store them for 5 years. That is the benefit. In the container, there's [inaudible 00:35:14] bone chips we collect with the scraper or also AlloCraft chips. If you use the bone scraper chips, then you will have inside the most valuable, the most natural and the outside will be the most stable least resorbing. You're actually copying exactly how natural bone looks like.
Dr. Farran: That is exciting. What is the chance all these listeners could ever be honored that you would put up an online CE course on this on Dentaltown? We're just coming up on 200,000 members. We've put up 317 courses and they have been viewed over half a million times. If you have a lecture presentation, all you have to do is load up the slides and then you could do a voice-over on the phone. Do you think we could ever talk you into a ... Everything you're saying, I would just love to visually see.
Dr. Kielhorn: I did only one course. It's already on Dentaltown now.
Dr. Farran: The online CE course?
Dr. Kielhorn: Yes. One's already there. The second is coming up. It's already in the pipeline. It will be transferred, I think, next week or the week after that.
Dr. Farran: You put up the evolution of bone augmentation May 2015.
Dr. Kielhorn: Yeah.
Dr. Farran: Okay.
Dr. Kielhorn: That's the first. The second one, coming up on that, even with the follow-on cases and more severe cases exactly on the topic. There will be a follow-up course.
Dr. Farran: Tell the listeners about your online course you put up. Everything you just said, you explain that. How long is your online course?
Dr. Kielhorn: I don't know. It's about roughly an hour.
Dr. Farran: Everything you just summarized and what you just said is explained with pictures and slides for an hour?
Dr. Kielhorn: Yes. [inaudible 00:36:52] see how we went through the development and the next CE course will then be the professional techniques: full arch, full maxilla restoration with bone marrow aspiration and even [inaudible 00:37:02].
Dr. Farran: Wow. Then, back to this individual who's never placed implants, you were speaking very fantastic the fact that .. You should already know how to extract a tooth. If you're extracting a tooth and the root tip broke, you should already know how to lay a flap and get that out. Another question they're always asking is they extract a tooth. What is the protocol of when that should be bone grafted versus just sutured up? When you extract a tooth, what percent of the time do you just leave the socket or do you actually bone graft?
Dr. Kielhorn: What I do is what I call socket sealing. I don't call it socket preservation. I call it socket sealing. I will immediately seal that socket. I will seal it by a connective tissue craft. I will seal it by collagen flexbone via [inaudible 00:37:53], whatever. I will use the extracted tooth, shorten it and place it into the [inaudible 00:37:59] to keep the volume and the soft tissue architecture or I will use, for example, an implant and immediate improvisation to support that because if you support the natural architecture, if you maintain it, you don't have to restore it. That is my [inaudible 00:38:15]. I seal the socket because if you have a sealed blood clot, you always will have bone.
The only way when a [inaudible 00:38:21] is something least resorbing or building bone like [inaudible 00:38:24] for over 6 months, I will only do that if I need that volume. For example, if you extract 4 teeth and you will only place two implants, then the rest of the [inaudible 00:38:35] should be stuffed with something that keeps the volume over 10 or 20 years. Then, I need something that is very stable and not very resorbing. That's what I would put in [inaudible 00:38:45] myself. Actually, I mostly seal the socket and do a delayed implantation if I don't need volume instead of filling it completely with something the body has to work on.
Dr. Farran: That is interesting. Explain what you always mean by the less-is-more concept.
Dr. Kielhorn: Less-is-more concept, that's something we adopted from the United States. We want to have things very, very simple. That means I want to have less parts, less surgery. I want to have less trauma, minor surgeries. I have the best of diagnostics because your treatment will be only as good as the diagnostics it's based on. 3D diagnostics is a must. You will do less because of better diagnostics. The more you know, the less you have to see. That's the first reason. Little flap, big surgeon. Big flap, little surgeon. [inaudible 00:39:32] around like it was 30 years ago.
Second thing is that if you will use protocols with one [inaudible 00:39:39] one time, you will still shift which scientifically is proven to get better results in order to have less surgery. There's often no sense in having opening surgery in functional cases. Their one [inaudible 00:39:52] one time was to retain provisionals is something very nice to use. You only have one surgical step. Reduce the steps. Also, when you have covered the implant, put a connective tissue craft or increase volume of the tissue.
A lot of people first treat the implant and then they find out they don't have enough soft tissue for aesthetics or papilla. They will do all these minor surgeries to get papilla [inaudible 00:40:15] or to get more volume while putting it there immediately will give you more than you need but you never have too much soft tissue. Taking away is easier than building it up. That is reducing the steps. This is a less-is-more protocol.
Dr. Farran: Also, I want to say. You mentioned many implants earlier. I want to tell you that the truth about many implants is in the United States, oral surgeons and periodontists, they just don't place many implants and it seems like probably the specialists almost never placed them. I don't think I have ever seen a specialist place so many implant. Even many implant dentists I know, they're the very few general dentist placing them. I feel like it's a taboo area. In Germany, do you place many implants?
Dr. Kielhorn: Yes but it was a taboo for me, too, because as an oral surgeon, a specialist, you say, "Oh, why should I do that?" I can't place an implant with huge augmentation into everybody but what we ignored is that we didn't even get the customers. Look how many people you have wearing total dentures. A lot of people will not be able to afford a full implant treatment. They will be not able to afford anything but they need more retention for their dentures. They would afford $6,000 [inaudible 00:41:35] instead of $15,000.
Now, if you have a 20-minutes operation, a 20-minute surgery with no bleeding, no swelling, when he gets these teeth immediately or in four weeks but he immediately have a [inaudible 00:41:51] for it, you earned more as a doctor on that and the other treatment where you had a lot of material. The patient pays less and has a good result and you will get all the total dentures be [inaudible 00:42:05] couldn't afford the $15,000. Just be a marketing expert like the Americans are. If they calculate, they would see what a huge group of customers they ignore. It's a customer-added service and that is a big, big word in the United States.
It has to be customer-edited. That is a customer and you do something, that's what you can service, only for them for a special crew. I ignored that group and now I place 500 mini implants a year. It's like going to the beach. It's like 20 minutes, nothing happens and those are the patients who love you most because no swelling, no pain, not a lot of cost and if you lose one, so what? Place a new one.
Dr. Farran: What mini implant system did you're using?
Dr. Kielhorn: We using the MDI and now, we're using from Dentaurum, a new one coming up because it's a bit more sophisticated from the insertion protocol. The MDI system is sold ESPE. ESPE sells Impregum and Permadyne, all this impression material. They had the MDI system and that's a very good-working system.
Dr. Farran: You're saying ESPER? E-S-P-E-R?
Dr. Kielhorn: E-S-P-E.
Dr. Farran: Oh, E-S-P-E, ESPE.
Dr. Kielhorn: Yeah.
Dr. Farran: You mean the 3M ESPE one?
Dr. Kielhorn: Yes!
Dr. Farran: Okay, yeah. I'm sorry. I always call it E-S-P-E. I never heard it ESPE. The German's call it ESPE?
Dr. Kielhorn: It's a German company, ESPE.
Dr. Farran: Right. 3M acquired that 10 years ago?
Dr. Kielhorn: Yeah.
Dr. Farran: You're using the 3M ESPE mini implant system. Now, you're doing 500 a year. Twenty years ago, how many were you placing a year? Twenty years ago?
Dr. Kielhorn: Zero, nothing.
Dr. Farran: Zero. That's why I smelled the revolution here because the oral surgeons have made a mountain out of a molehill for all implants. They've all got to be this big production and what you're saying is that mini implants are a simple solution for people with full dentures and don't have a lot of money. Is mini implants mainly for full upper lower dentures?
Dr. Kielhorn: No, only. I wouldn't use them as anything else because then you will get in trouble in those cases.
Dr. Farran: You don't use it for dentures.
Dr. Kielhorn: No, only for total dentures, yeah. Only for total dentures. It's only retention for dentures, nothing else.
Dr. Farran: The 3M ESPE mini implants are only for full dentures.
Dr. Kielhorn: They have also bigger ones but you must know that if you get below 3.0, we know we get fractures with implants because we get too much load on it and we know that even with 3.4. A good surgeon knows that he needs at least 3.5, 3.8 diameter to place a normal tooth load on that. The 3.0 implants were only developed in the market for lower incisors because we didn't have the space, nothing else. They have been misused and we had a lot of problems. Every system has these problems.
If you get below that, if you get those minis, that's not a [inaudible 00:45:12]. Those mini minis with 1.8 millimeters, they weren't so good because they have a ball attachment, they are very low and they only have a total denture. They never break in that aspect but if you put a tooth load [inaudible 00:45:23], then you will have a problem. Then, I wouldn't use those mini mini implants.
Dr. Farran: How many would you place? How many 3M ESPE mini implants would you place?
Dr. Kielhorn: Six in the maxilla and four in the mandible.
Dr. Farran: Four in the intermandible in front of the mental foramens. Then, where would you place the six on the maxilla?
Dr. Kielhorn: I would place them all also in the anterior.
Dr. Farran: All anterior to the sinuses?
Dr. Kielhorn: Yes and you can have an angulation of about 15 to 20 degrees.
Dr. Farran: Explain that again, the angularity.
Dr. Kielhorn: It's a one-piece implant but because of the ball attachment, it allows you to have a 15-degree angle on the implant and you will still be able to insert it in the denture.
Dr. Farran: I think of the fact that 31 million Americans wear total dentures and 95% of all the general dentists have never placed one in their life. Here's 3M in Minneapolis, St. Paul who merged with ESPE. Where was ESPE? Was that in Berlin?
Dr. Kielhorn: In [inaudible 00:46:30]. It's called [inaudible 00:46:32]. In [inaudible 00:46:34].
Dr. Farran: Okay. Also, the big Sirona company. Am I wrong? Back in the day when I was little, was Sirona part of Semens? Did Sirona used to be a branch of Semens?
Dr. Kielhorn: Yes.
Dr. Farran: Then they just what? They just spun it off individually?
Dr. Kielhorn: Yes.
Dr. Farran: That's what I thought. I thought that was Semens and then the next you knew, it was Sirona. Spend a couple more minutes on this. Right now, there's this dentist driving to work and these average American dentists, they've got about an hour of commute to work. They're listening to a podcast. They're listening to a very famous oral surgeon all the way from Germany. They've never placed a single implant yet they're always complaining about the little old lady that comes in with the denture adjustment and they're always adjusting it, realigning it or whatever. This dentist has never placed a mini implant in their life. Talk to that dentist. What should that dentist do?
Dr. Kielhorn: You can do a simple training course and the good thing about it, it's a self-cutting implant. The thing is you're just preparing 1 millimeter into the bone. You're just perforating the conical bone and then you just screw in the implant because it's a self-cutting implant. That's why you will not perforate the conical bone and you can't trim in the wrong direction. That makes it so safe, mini implants. One of the safest procedure they can use and perfectly [inaudible 00:47:56]. You can even do a prosthetic orientation template just to get them perfectly orientated in your denture. It's very simple to do. I think I should do a CE course on that on Dentaltown. I never thought this topic would be so ...
Dr. Farran: You know what? I love that. I can't give too much information because my mom is still alive. Not my mom but let me just say her three brothers, not one of them got out of high school in Parsons, Kansas with one tooth left in their head. I'm from the very middle heartland of the United States, Kansas, and back in the day, my parents and grandparents, the only thing a dentist did, you went there in where you're in pain and they pull the tooth.
There's 31 million people. That's just a huge number of people. That's about the entire population of California or Canada doesn't have a tooth in their head. These people are dental cripples. They're afraid to smile. They're afraid to laugh at a party because their denture will flop out and you're saying that 20 years ago, a mini implant was taboo. It's like, "What are you? You're just not a real surgeon if just you're doing that little dinky stuff." This is a real solution. It's a real help for the 31 million dental cripples and 3M ESPE could probably sell a thousand percent more.
They say the American implant industry would grow 700% if the American dentist would place implants at the same rate as the South Koreans. Right now, you're probably going to be listening to 5,000 Americans and I bet you of those 5,000, 4,950 of them could give you the names of 10 denture patients that are a huge pain in their butt yet they've never placed a single mini implant. Then, when you talk about mini implants in America, it's taboo. When I was in college, it was perfectly legal to drink beer and whiskey. That was all good but if you smoked Marijuana, you are a bad evil person and need to go to jail. As a man, I could marry a woman but if I married I man, I'd be thrown out of town.
That's the way mini implants were. They're taboo. They're still taboo in America today and the people that get into them, they're never oral surgeons, they're never periodontists and there are always people who think their only solution to a problem is this huge 20, 30, 40, $50,000 implant reconstruction case. The problem is when you got a country a size as America, there's just a lot of people that don't have very much money.
Dr. Kielhorn: Exactly.
Dr. Farran: There's a ton of people. What did Henry Ford say? He said he does not consider it technology until you can apply it to the masses. If you've got some great idea to make a car and the only person that could afford it is the king or a queen, he says that ... He wasn't even [inaudible 00:51:09]. He says, "Technology is when it applies to the masses." This country is built by Rockefeller who took the whole country from lighting candles to burning kerosene. J. P. Morgan and Edison took them all from kerosene to electricity. I think the mini implant market is as big as the root-form implant market. Would you say they're the same size or do you think one's bigger than the other?
Dr. Kielhorn: It will be a huge market. I think it will be a huge market. I think people underestimate how huge this market is because those are patients implant people never had on their minds. They've never been counted. They've never been regarded as an implant patient. Just get those numbers and if you would publish that statistics as marketing, everybody would be baffled. Also, it is an add-on for a good surgeon because those mini implants also use-
If I do a severe augmentation, for example, of full maxilla and restore the full jaw, how do I take out the load on that jaw during healing if I haven't done a bone-replacing implant? I will use five or six mini implants. I will use them just as a retention for a total denture, as improvisation because people pay a lot of money for that treatment and you give them a provisional that is of no value for them. If they have mini implants, they have a fixed one. Your bone will heal nicely. There will be no load on the bone. After the jaw will heal, they take out the mini implants very easily and place [inaudible 00:52:35] implants. Even for the good surgeon who does augmentation, that's a large add-on by mini implants.
Dr. Farran: I want to ask you a question because you're a lot closer to Sweden than I am. This year, Professor Brånemark passed away. Was he an influence as an oral surgeon, as an implantologist? Did he have an impact on your career?
Dr. Kielhorn: Yes, of course, because he made implantology. Of course, without him, we wouldn't have implants. He did because Brånemark and Nobel Biocare was a big topic. It's saluted because what happened to Brånemark was that Nobel Biocare stopped developing implants and was just selling implants from other companies. Over one night, with this lady which then left of course, nobody cared, launched 117 new products overnight and you had to [inaudible 00:53:28] whatever kind, a straight, a perfect implant. You didn't have one user who had enough experience in all those systems so they really destroyed them. Now, they've been bought by that huge company.
Dr. Farran: Danaher at Washington, D. C.
Dr. Kielhorn: Yeah. Therefore, they lost it. They lost it. They were famous for solution-selling, all-on-four, all-on-six or simply in practice. Those were real good solutions, Nobel Biocare. What they could do is they could have solutions. They were solution-selling. They were the best but then, they stopped. They bought [inaudible 00:54:11] implants. They never had an own design. They changed surface in design massively overnight. All your experience was gone because there's another new system. That's what's not good about Nobel and that's why it lost what old Brånemark built up actually.
Dr. Farran: What I'm hearing you say is when Professor Brånemark ran the company, you loved it and he invented the implant, he invented the space but when he sold it, the next generation weren't good stewards of it.
Dr. Kielhorn: In selling and marketing. That is why a lot of Germans think that is typical for the United States. When a United States company buys it, that's what happens. Only numbers, numbers, numbers, no scientific because scientific would cost money.
Dr. Farran: I would put it another way. I explain it to my children that when the founder has a baby cow, all the time is gone into raising this cow, growing it and just making this cow produce four gallons of milk a day. Then when you sell the cow, they stop feeding it and nurture it. They just milk it, all the milk they can get out of it before they die because if they buy the cow for a dollar and they can milk $4 out of it before it dies, they think that's a victory.
As the founder, you'd want that cow to grow up and turn into two cows, four cows and six cows but it seems like when you sell it, they're no longer interested in growing the cow. They're just interested in milking $3 or $4 for everyone they put into. I'm going to through a statement at you and I want to see how you respond to it. A lot of Americans say, "All on four, none on three." What does that mean to you? You start laughing. Is that a critique? What does that make you think when I say, "All on four but none on three?" Meaning, to the viewers, that when you do all-on-four, if one of those implants fail, you lost the whole case.
Dr. Kielhorn: Yes, but if you have a screw retained, if you have a cemented bridge ... We, Germans in [inaudible 00:56:14], we do a lot cemented bridges still, not only screw-retained because we trust our implants. If you do that, we have cases [inaudible 00:56:21] showing it works. If you have that, for example, and you lose an implant on the bridge, of course, you will lose the bridge. If you have a Nobel plate on cemented teeth and you lose one tooth, your bridge will be gone. Bridge on two teeth will be none on one tooth. That is the same decision. That is stupid because the screw-retained all-on-four is a very simple structure.
The good thing about it is, first of all, it's screw-retained. If something happens like peri-implantitis and you have a good recall system and that's what you need, you need to maintain the implants, not to place them and then forget about the patient. If you maintain the implants, you will see that there's a bonus. If there's a bonus or signs of peri-implantitis, you can treat it or you send it to a specialist to treat it. It's not lost. It's 15 millimeter of bone you have to lose before you will lose the implant.
Secondly, this whole structure is usually composite veneers. You actually have a wear-off, not a ceramic. You avoid [inaudible 00:57:20]. You avoid chipping. It's easily repairable. Actually, the composite veneers screw-retained structure is the longest lasting, a structure we offer, and we give 10 years guarantee on that.
Dr. Farran: Wow. You said you trust your implants. You know the biggest shocking thing that... My first experience with Germany that just stunned me and I just felt like, "Wow" like I landed on another planet was ... When you talk to an American and they're bad-mouthing socialism or whatever, it's always some hillbilly, uneducated hick who's never left the country but I always like to listen to world travelers like Marco Polo, people who go all around the world.
What I found the most romantic about Germany is that in America, the dentists are all selling stuff all day long. They're all trying to sell crowns. They're all trying to have these expensive practices but whenever a company starts talking about their product, they don't believe them. They don't trust them. I almost think it's because they look in the mirror, they don't trust themselves. You go to a dental convention in America and you always listen. The dental manufacturers are allowed to make sales on the conventions and their CEOs are never speakers. They're always like these dirty salesman that are selling stuff for money. You always go listen about those companies from an independent third party dentist who 99 times out of a 100 has no idea what he's talking about.
Then, I went to the IDS meeting and there were no lectures. I'm hanging out with all these German dentists and they want to meet the CEO of the company. They're asking the CEO and they're saying, "What about this? What about that?" It was just all love, trust and respect. The person selling the product wanted to meet you and the person using the product want to meet the owners. I was thinking, "Oh my God. If this was America, the dentist would think the guy selling is a lying whore that was just lying to sell money." If I wanted to know about his product, I would go listen to some speaker who doesn't even have a PhD in organic chemistry, doesn't know research and just pretends they know everything and they know just enough to be dangerous.
Then, when I started Dentaltown in 1999, the first 1,000 complaints I got were all the same. "Hey. This guy joined and he's not a dentist. He works for 3M, [inaudible 00:59:50], MegaGen." I said, "Yeah, it's Dentaltown. It's not dentist town." I said, "How can I be a dentist if I don't have drills and x-ray machines? Don't you think the guy selling the [inaudible 01:00:03] from Japans needs to know what we think about?" If all the dentists say they wished it was red and he's making a blue, doesn't he need to be in on the conversation?" I just really love the German culture.
The other thing is in an IDS meeting, the first thing the CEO would ask you is if you wanted a beer! You're right there and he just pours you a beer, makes you a drink. [You're sitting, you're having a beer. If they ever got in America, then they'd probably call the police if someone brought a beer to a dental convention. I don't know if they'd call the pope, the police or the military. Everyone would freak out. There'd be complaints everywhere. I just love Germany. I could actually move to Cologne and never come back.
I just want you to know this. Our hour's up. We're out of time but I just want to tell you, Jan, seriously. If you could make a course on that 3M ESPE mini implant, there's 31 million Americans who are dental cripples including my three uncles, that would just do so much good. If you could design a course for an American who's never placed in implant but your criteria - you should be able to pull a tooth. I don't know if that's a regular tooth, a wisdom tooth or a partial implant.
Dr. Kielhorn: Regular.
Dr. Farran: Just a regular tooth. The requirements would be you'd have to be able to extract it. By the way, to those dentists out there in America who say they don't like blood, why did you become a dentist? Shouldn't you have become an engineer, a plumber or an electrician? When you tell me you went to eight years of college to become a dentist and you don't want like blood, sorry dude but you either have a bad attitude or you're not right in the head because most people who don't want to deal with crap don't become a plumber. Could you imagine a plumber saying, "Yeah, but I don't do anything with poop in it."
Jan, I'm telling you. If you could make a course for an American dentist that's never placed a single mini implant ... By the way, it figures that I'd have to go all the way to Germany to find someone who could talk about a mini implant in America because that's like smoking pot in the '70s in America. It's taboo.
Dr. Kielhorn: They will be amazed if I do that course. Also, in Germany.
Dr. Farran: Even the Germans?
Dr. Kielhorn: Yeah. What is this lecture for bone augmentations if you're in surgery doing mini implants? I find it funny. That's no problem. You should be [inaudible 01:02:42]. I do that but also, I love people [inaudible 01:02:44] impress.
Dr. Farran: Yeah. I always think that dentists are dentist-focused instead of patient-focused. "Put your ego out the door." It's like if you want to go out and shoot an elephant, that's cool but if the problem is there's a mouse running around in your kitchen and your grandma's screaming, let's just get the mouse and forget about the 4,000 pound elephant in Africa.
Dr. Kielhorn: Customer-added service.
Dr. Farran: Very good. Jan, thank you so much for staying up all the way 9 hours ahead in Germany for doing this. On behalf of the 5,000 people that listened to this, thank you so much and gosh, darn, I cannot wait to see your mini implant course.
Dr. Kielhorn: You're welcome.
Dr. Farran: All right. Thank you very much.
Dr. Kielhorn: Thank you so much.
Dr. Farran: I hope to see you next time in Germany.
Dr. Kielhorn: Yes, please do.
Dr. Farran: You have the best beer in the world.
Dr. Kielhorn: Yes, I know.
Dr. Farran: It's not Budweiser.
Dr. Kielhorn: No.
Dr. Farran: Budweiser is not the best beer in the world. You haven't drank beer until you got the Germany. All right. See you. Have a good day.
Dr. Kielhorn: Bye. See you.