On the Scene with Nobel Biocare at Chicago Midwinter 2009

Interviewees: Domenico Scala; David Kumamoto, DDS

During this year's Chicago Midwinter Meeting, hosted by the Chicago Dental Society (CDS), Inside Dentistry was given the exclusive opportunity to interview Dr. David Kumamoto, president of CDS, and Mr. Domenico Scala, CEO of Nobel Biocare. This interview, conducted by publisher Daniel Perkins, afforded the opportunity to talk with both of these recognized leaders on the impact of technology-driven change in both the profession and dental education.

Daniel Perkins (DP): Domenico, you have been with the company 18 months and you have a very strong financial background in the agra and pharma industries. Can you share with our readers what attracted you to Nobel Biocare?

Domenico Scala (DS): Nobel Biocare has a remarkable history and legacy and the number one position in its field. And it's quite an attractive field. I believe that even though the dental implant industry is about 25 years old, there is plenty of innovation to come. It's a young industry, a growing industry, a dynamic industry, so those are the features that attracted me to this field.

DP: Your educational background is in economics and corporate finance. How do you see the current economic conditions in which we find ourselves impacting the dental industry as a whole, and, more specifically, sales of implants and Nobel Biocare's operations?

DS: I am an educated economist, but a non-practicing one. There are a few industries that are good places to be in a less favorable economic environment, and healthcare is one of them. I think dentistry is one of them. We are not immune, of course, but we are resistant. Our business has seen a slowdown since last year, and growth is not comparable to what we have seen in previous years, but we remain financially solid and continue to bring innovation to the industry. The economy doesn't hold us back. We continue to be a reliable partner to our university partners. We continue to support them through these difficult times; we have not really scaled back. We are here for the long term.

DP: Dr. Kumamoto, we know that you are an educator, a faculty member, and very involved with the CDS. Do you practice dentistry as well?

David Kumamoto (DK) : Yes, I have a private general practice. Because of my duties with the dental society, I'm limited to about 2 days a week now, and I'm also at the university 2.5 days a week, so I'm almost full time even though I'm part time. At the university, I'm working with the students in the area of restorative dentistry: simple fillings, castings, and implants. Nobel Biocare has a generous grant at the University of Illinois—a $1 million implant grant. The University will put in two lower implants to make implant-supported prostheses for patients in need, so we're very happy to be partnered with Nobel Biocare.

DP: Dr. Kumamoto, you are involved in academia and private practice, and you are the president of one of the largest dental societies in the United States. What do you think that companies such as Nobel Biocare really bring to this market? How is it changing students' reactions to what is available to them today... and perhaps does it change how you teach?

DK: When I was a student, implants were very basic. We actually had what were called blade implants, and nobody in my curriculum worked with implants. Today it is a requirement for our undergraduate students to work on an implant case. Companies like Nobel Biocare help make it possible to be involved with the restoration of at least one implant case before they graduate. It's because of the industry's willingness to support the universities that this is possible.

DP: Do you think this is going to have a significant impact on patient care?

DK: I think that with these programs, with the schools requiring students to place implants, it will make the treatment of patients much easier. The dentists will be prepared to restore implants and place implants, and I think this will really improve patient care overall.

DP: Domenico, the Nobel Biocare name has a rich history going back to the Brånemark days. The company name is virtually synonymous with implants, at least in the US market. Can you tell us your vision for the company? Where is the emphasis?

DS: Nobel Biocare's legacy is really two innovations: Brånemark's discovery of osseointegration, and—what most people don't know—it's also CAD/CAM prosthetics, thanks to Mats Anderson, a Nobel Biocare employee who initially brought this innovation to the marketplace. Of course, our implant business is much bigger than our prosthetics business. But we are bringing very new technologies to the market this year with new software, new scanners, and other new products, and our ambition is to really become the partner of choice for both clinicians and laboratories when it comes to restoring teeth from root to crown.

DP: Dr. Kumamoto, with all of the advances in implants and new technologies, how important is patient education today? Do we need more patient education tools? Will they really help to transfer the information to patients? Lastly, do you think that direct-to-consumer advertising is appropriate for implants?

DK: I think that if you market to patients directly and they don't have a scientific background, you may confuse them. Some things are better explained in the dental office. The dentist can and should answer any questions and clear up any fears patients might have about implants. If patient education tools are put together properly patients can really understand what an implant is. In the past, patients were reluctant to have implants—they'd heard the horror stories—but over the years with better research and increasing success rates, placing an implant is now just as easy as putting in a simple filling.

DP: Domenico, as a follow-up to you, what is Nobel Biocare doing to help general practitioners communicate to patients what is available through implants?

DS: We are doing two things. We are doing substantial training and education of the clinical requirements to treatment for the dentists. But we also teach them how to provide options to the patient. I think that we need to listen to the patient, especially in times when economic conditions are less than favorable, and provide treatment options that can achieve similar functionality—perhaps less esthetically—but still at a favorable price. We are also trying to educate the dentists that there is not one solution, but various different treatment options at different price points. We are also bringing products to market that enable these treatment options. The third point is direct-to-consumer. I agree with Dr. Kumamoto. DTC, going over the dentist's head, is tricky because at the end of the day, the treatment decision maker is the dentist, not the patient, and not the company. I think we have to be very careful that what industry is doing in this area is very closely aligned with the dentists, who will have to cope with whatever industry is doing, because they are the ultimate decision makers for the treatment.

DP: Dr. Kumamoto, can you speak to generational changes in attitudes among students? How has the technology that's available to students today, and the availability of information through the Internet, changed things?

DK: It took me a long time to become confident with placing implants. Today, whenever students see an edentulous area, all they can think about is placing an implant—they are very confident that implants are the solution to many problems. They know it is a conservative treatment, and they are very confident that implants are easy to place. I think most students need a little more experience; I don't think most of them understand the possible complications with occlusion or other postoperative problems, but they all want to put implants in. I think sometimes just attending a lecture and seeing the before and after, they don't understand what goes on in between.

DP: Domenico, I recently was at the University of Pennsylvania and I spoke with a couple of implant clinicians, all faculty members, who told me that they are using almost exclusively—in 90% plus of their cases—Nobel Active implants. I found that surprising only because that implant is still relatively new. I was wondering if you could speak to some of the unique properties of the Nobel Active implant. What kind of acceptance rate are you seeing around the world?

DS: I would qualify Penn as an experienced user of implants. Therefore, I'm not surprised that Nobel Active has had such a high success rate there. We are positioning Nobel Active as an implant for the experienced user. We have many other implants that you can start with. Nobel Active can achieve very high initial stability in compromised bone situations. I think that's one, if not the key, advantage of Nobel Active. We introduced Nobel Active in a very controlled manner. We had an almost 10-month launch phase where we trained nearly 2,000 clinicians worldwide to make sure that when we launched we had gotten enough feedback from the clinicians on the product and let that feedback flow into our instructions for use. Since we launched the product in May 2008, the uptake has been incredibly positive—the fastest uptake ever of a Nobel Biocare product.

DP: Domenico, we've all seen numbers that indicate that the implant market is worth about $8 billion per year, worldwide, and the crown-and-bridge market is worth about $60 billion per year. How do those numbers impact planning for Nobel Biocare? You're involved in implants, but also in Procera and other new technologies. Do the realities of how the dollars are allocated in the marketplace and what "buckets" they fall into influence the development and strategic direction of the company?

DS: Absolutely. The biggest "bucket" is actually non-CAD/CAM crown-and-bridge. This is why the launch of new products, new scanners, and new software should make it as easy as possible, as intuitive as possible, for laboratory technicians—who perhaps in the past were not involved with CAD/CAM technologies—to use them as well. And we would also like to, over time, cover 60% to 70% of a laboratory's needs with our technologies. If we get there, then I think we are going to really be a partner of choice for the laboratory industry, and there's a big opportunity. But we're not going to do that on casted materials or porcelain-fused-to-metal.

DP: Nobel has completed several acquisitions over the past year. Particularly I'm interested in the acquisition of Biocad, a licensing deal with Optimed, and the acquisition of Medasin. Can you tell our readers a little bit about these companies, what products they have, what will it bring to Nobel Biocare, and what will it mean for our readers in the delivery of implant and related prosthetic care for their patients?

DS: Optimet is a subsidiary of the Ophir Optronics Group, an Israeli-based group involved in measurement technologies. Optimet has developed a conoscopic holography technology to measure surfaces, and we have the exclusive right to use this technology in the dental space. Our new scanner is going to come into the market with this technology and it will provide superior measurement capabilities that existing scanners cannot offer.

Biocad was founded by a laboratory technician based in Quebec, who developed software to make it simple for the technician to do CAD/CAM work. Over the last 10 months we continued to develop the software with him and decided to acquire the company. This software is the basis for our Nobel Procera software.

Medasin is the company that invented the NobelGuide. We agree with Dr. Kumamoto that guided surgery, guided implant treatment planning, is absolutely critical to success and we have acquired the company because it is our intention to have significant upgrades to the software later this year. Digital dentistry is a key driver for the dental profession. It is even leading other medical practices. I think dentistry has taken a huge leap and we are absolutely committed to delivering state-of-the-art digital capabilities to our clients.

DP: So you're really building a total digital solution for your customers—practices around the world and the laboratories that they work with.

DS: Digital dentistry is a key driver for the dental profession. I would even go so far as to say that in digital technology, dentistry is even leading other medical practices. I think dentistry has taken a huge leap and we are absolutely committed to delivering state-of-the-art digital capabilities to our clients.

DP: Dr. Kumamoto, hearing Domenico's answer, what's your opinion on companies like Nobel Biocare—either through R&D and organic development or acquisition and bringing in complementary product lines—providing an umbrella approach for practicing clinicians? Does it provide a real benefit to them?

DK: Two years ago I attended the Nobel Biocare conference in Las Vegas and it was a great experience for me to see how the products were manufactured. As an academician, it really cleared things up for me. It was important to see how the implants were manufactured, how the software should be used, and I could see that there could be some kind of standardization of care which would make treatment much easier for everyone. If the technology is compatible, I think patient care will improve for everyone.

DP: Dr. Kumamoto, in bringing information about products to market, what do you think—particularly for an area like implants—are best-marketing practices where general practitioners are concerned?

DK: I don't think that blanket marketing is the way to go. I think you need to have that personal relationship between the dentist and the patient, because again, my students think every implant will fit every patient, but as practitioners we know that every patient is an individual. So we have to carefully treatment plan. I think marketing is fine, but I think the practitioner and the patient have to understand the limitations of every implant that's put in.

DP: Domenico, it appears that implant companies, at least in the North American marketplace, have really pulled back in advertising to general practitioners. Is this a function of the current economic climate, or is there a shift in strategy?

DS: In Nobel Biocare's case, it has nothing to do with the economy. We have simply sharpened the way we are addressing the general practitioner. We have basically three offers for them. One, in terms of training education, focuses on treatment planning—which patients can receive which treatment? At what point in time does the general practitioner refer to a specialist? We need to have high treatment-planning capabilities.

The second module is the training for general practitioners who want to do simple surgical procedures. We have core training courses for them, and we have a more advanced course for people who want to do more complicated things. What we don't do is advocate a one-size-fits-all training approach. We're more sharpened. We have taken off a number of outside providers to make sure we maintain a high standard of training, and we have re-internalized a number of training courses.

DP: Traditionally, key drivers of acceptance of implants in the dental marketplace have been driven by education, research, and the ability to develop user-friendly and patient-friendly products and procedures. Driving consumer awareness has played a role. As things continue to change and grow, we go through economic cycles and we go through technology cycles. Do you think that those will remain the key drivers moving forward?

DK: As a practitioner, I think that because patients see print media and the Internet, they are more demanding today. The emphasis on cosmetics plays a big part, and I think that implant systems, particularly in the anterior regions, make implants very desirable for many patients. Finances right now aren't the best for everyone, but I think as things settle down the markets will come back and patients will be asking for implants more than they are today.

DS: Despite all of the progress we have seen in the United States, we should not forget that the United States has only one third of the penetration rate of implants compared to Western Europe. So the United States is not leading, it is lagging. Why? I think the acceptance and the training and education have been a hindrance. I think the entire industry and the universities are working on that and we are progressing. Yes, the economy will have its effect, but in the end the market is under penetrated, the demand is there, the demography is as favorable as it can get—the age bracket of 55 and older is the fastest-growing age bracket in the United States and it has the highest incidence of need. Therefore, the long-term prospects remain very positive.

DP: Domenico, for our readers particularly who are Nobel Biocare customers, are thinking of becoming Nobel Biocare customers, or are thinking of becoming involved in implants at least as far as treatment planning with other members of a team, what can Nobel Biocare do to help them and support them in making that commitment to get involved?

DS: We have plenty of programs where we can have dentists start with implant dentistry. We have programs on the clinical side but we also have them on the practice-building side, because we also support our dentists in the development of their practices by learning how to treatment plan and how to offer treatment options to their patients. We also have programs to teach the staff; a dentist is sometimes only as good as his or her staff. The bottom line is that we have a wide range of product and non-product offerings and so I really believe that Nobel Biocare can be the partner of choice for surgical and restorative dentists as well as for the laboratories.

DP: Innovation has always been one of the key characteristics of Nobel Biocare going back to the Brånemark days, and I think that one of the really innovative ways that Nobel Biocare has been helping to change education, acceptance rates of implants, and better understanding by the profession, students, and faculty is through your programs with various universities around the world. Can you give us an update on that network?

DS: We currently have 24 universities worldwide with whom we are partnering. Our single biggest partner in the United States is NYU, but beyond that we also work with and have relationships with many other schools, so it's not just limited to the 24. We will continue these partnerships, but we will not expand the number of partnerships at the pace we have over the last couple years, because I think that now we have reached a sizeable partnership level. However, there will be additions going forward regionally to complement the skill sets of the existing partnerships. We have had a very good experience in this area because it leads to changes in curricula, it leads to the privilege of dentists being exposed to implant dentistry while they are being educated, not after they are educated, and that is really the aim of the partnership program.

DP: Dr. Kumamoto, what do you think the impact of these school partnerships will be?

DK: I think students today are very fortunate to have an education that I didn't have when I was in school. For those of us who have been out for quite a while, we notice that implant courses at Midwinter and other meetings always draw big crowds, so we know that practitioners who weren't educated on implants in school want to know about them; they want to be able to place implants because they will be competing with the new graduates who do know about implants. Older dentists know that if they're not on top of things, patients will go to the new graduates who are tech-savvy.

DP: Domenico, how do you see the market growth of implants and new technologies in Europe and North America? How is Nobel Biocare introducing these products in economically developing nations such as India, China, and other parts of Asia? What are the unique challenges of expanding Nobel Biocare's reach in those and other countries?

DS: The bulk of our business is in Western Europe and the United States, and the United States remains our single biggest market. We are the market leader in all but two countries in the Western world. That's a remarkable position to have achieved. But we're also developing markets like China and India, and we are growing very fast. We are still at small absolute numbers, but the importance is to establish a premium market, which does not necessarily mean price, but quality care. We want to make sure that we bring the standard of care to these markets to the level we would like to see over the long term. We are heavily involved in training and education in China and India, and—together with the local associations and professionals—we are creating premium implant-based tooth restoration markets. There's no doubt that China and India will be sizeable markets. Japan is also a market where we're doing very well. The standards are very high but it's a market which nevertheless has been a little bit neglected over the last 5 to 10 years. We are seeing implant dentistry picking up a little bit there as well, so the market is very positive in the long term. Latin America—Brazil is the single biggest market—will also be a focus. Brazil alone has 180,000 dentists, so it's a very big market.

DP: I have one last question. Dr. Kumamoto, if you could have Nobel Biocare deliver anything to you, what would you want them to put in the pipeline that would really make your and your students' and your patients' lives better?

DK: I love technology. I know that some companies can computer-generate restorations for treatment planning already, but that's not really available to our students. Some of these technologies are costly and I'm afraid that a lot of dentists won't be able to afford it in the near future. But if we could have some lower-cost technologies, I'd be one of the first people to jump right in and use it.

DS: One of the visions we have is that we are going to integrate NobelGuide with Nobel Procera and build a complete oral rehabilitation system where you really have one platform for doing treatment planning—which I agree with Dr. Kumamoto is the critical step to go over the hump—but also to have digital platform which is really shared among the surgical, the restorative dentist, and the laboratory.

DP: Domenico and Dr. Kumamoto, on behalf of the readers of Inside Dentistry, I'd like to thank you both very much for your time. We see this as a very exciting time to be involved in implant dentistry, and we appreciate this opportunity to probe all of the possibilities this technology holds.

About the Interviewees

Domenico Scala
CEO
Nobel Biocare

David Kumamoto, DDS
Professor
University of Chicago, Illinois
School of Dentistry

President
Chicago Dental Society