By Scott S. Smith and Sandra Wells
Dr. Sargon Lazarof’s career is one of the most extraordinary in modern dentistry. But because powerful people in the industry wanted to stop him, it has been the greatest story never told. In retrospect, he could be thankful for early adversity, because it prepared him to withstand the efforts to destroy his reputation.
Lazarof was born in 1960 to Assyrian parents who had moved from Kiev, then in the Soviet Union, to Iran. Three years later, his father died.
A quick student, Sargon was accelerated and had completed his first year in high school at 14 when his mother sent him to Los Angeles to stay with his aunt and improve his prospects. “It was a tough ride, going from being popular at a private school to not being able to speak English at Hollywood High,” he recalls.
But it was at a career day when he first thought about dentistry as a profession. Until then, his aptitude with taking apart gadgets had him expecting to become an electrical engineer. “The guy who talked about that said you could expect to start at $1,800 a month,” he says. “When the dentist told us it you could make $6,000 a month, that caught my attention.”
He called up some local dental offices and got permission to observe. He liked the fact that dentistry would involve a lot of science and working with his hands. He socked away a fair amount of money towards dental school by playing bass guitar and singing with a group that played international music for ethnic events at a time when there was little competition. Graduating at 16, he had to pay to get into L.A. City College because it would be a few years before he had a green card. Three years later, he entered the University of Southern California on a scholarship to earn his Bachelor’s degree.
REBEL WITH A CAUSE
“I never even considered any other dental school than USC,” Dr. Lazarof says. “I developed a project as part of my application. I hooked up a toothbrush to water and got the bristles turning with water spraying from the tip at a time when no one was using water picks or electric tooth brushes.” The interviewing dentist was very impressed, although Sargon could not afford to file a patent for the device. He entered the school in 1982.
The first year was difficult, he admits, because he was openly arrogant and outspoken about doing things better than other students and clashed with some professors by violating what he thought were pointless rules.
Once, he was expected to clean one quarter of the patient’s mouth and he vowed to finish the entire mouth in the time allotted. The instructor told him it was impossible. When she inspected his work, she claimed to find the upper right quadrant too rough and told him to do it over. When she returned, she pronounced it fine—but had spent the extra time explaining the situation to the Dean of clinical affairs Dr. Randy Gates. He had only pretended to have done more work on it. It was a revelation that was to be confirmed repeatedly: politics could trump actual performance. He got permission from Dr. Randy Gates to finish his 160 points for cleaning before everyone else by continuing to do an entire mouth in one sitting. And throughout dental school, he would go far beyond the requirements and won numerous awards, as a result.
But he still felt discriminated against by the clique of professors who catered to students who came from families where the father or mother was a dentist. When he kept getting Cs for wax- ups that he thought were perfect, he decided to test his theory by borrowing one from a student who had received an A for it and resubmitting it as his own. Sure enough, he got a C.
His rebelliousness even extended to his uniform: he wore it with the sleeves rolled up, which roiled some of the more tightly-wound students and professors. But as he overcame the skeptics with performance, he became so popular that the School of Dentistry Yearbook displayed his picture with his trademark “Sargon Look.” He graduated in 1986.
At the dental board exam, the real world intruded again. Before he even got started, an examiner asked him where he was from, at a time when there was continuing resentment over the fact that the Iranian government had taken Americans hostage in Tehran. He was told bluntly that he was not going to pass and a code number was put at the top of the sheet for the other examiners. Sure enough, he was failed, even though he knew he had done excellent work. Though he only had $128 in the bank, Lazarof went to a lawyer who was also a dentist and charged $6000 to a credit card to have him file a suit against the board. When the trial came, the judge announced that there would be no presentations: he had already made up his mind based on written submissions that the dental board could do whatever it wanted.
Afterwards, the board’s attorney, a friend of Lazarof’s lawyer, advised that he knew that there was some irregularity and suggested that if he would retake just one portion of the board exam, to avoid liability issues, the board would give him his license. The experience gave him an early taste of legal injustice. “It hardened me and I thought, ‘No matter how often someone knocks me down, I’m going to get up again,’” Dr. Lazarof remembers.
On his first day at a Lawndale clinic in 1987, the dentist who was co-owner with a silent partner told the new practitioner that he would have to produce $1,200 to earn his $150 a day salary. At the end of the day, the owner had done $1,250, while Dr. Lazarof had taken in $2,400 by selling patients on the idea that for a little more money, he would give them a lot more attention. A year later, he was contributing so much to the practice that he demanded to be made a partner. “Just hire another student, instead,” the silent partner told the other dentist.
Then fortune intervened. A dentist in Beverly Hills had retired and sold his patient list to another practice, while a new dentist had not been able to succeed at the same location. Dr. Lazarof took over the fully-equipped office for $35,000.
In his first year, he had started doing implants with Calcitek, but was dissatisfied with the results. Dr. Per-Ingvar Branemark was only teaching specialists his delayed-load method, but Dr. Lazarof attended a seminar on delayed-load for general practitioners that was given by Dr. Gerald Niznick. In the middle of the class, Dr. Lazarof found himself wondering why it was necessary to wait for the sockets of the removed teeth to heal and then the bone to grow around the implant before the patient could have full function. Why couldn’t an implant be designed to keep it from moving right from the start? And why couldn’t the entire procedure be finished in one sitting, rather then requiring the patient to return many times over four to six months? He raised his hand to ask, and then thought better of it before he was called on.
That night, he told his wife, Mona Lisa, about the idea before they went to bed, then woke up at 4 a.m. with an idea. He got up and drew a design for such a device. He showed his father-in-law, a mechanical engineer, who suggested some refinements.
A prototype could cost $1,000 per unit, so to be able to afford to have enough of the model implant to get enough experience using them, Dr. Lazarof approached Wade Prescott at Allied Swiss, which manufactured the majority of implants. After looking at it, Prescott declared, “I’d better help you, because if you’re right, I soon won’t be making many of the others.” He proposed to do all the prototypes at no cost.
Getting a bucket of jawbones from the USC anatomy lab because it was switching from cadavers to slides, Dr. Lazarof began practicing and tweaking the implant design. By 1990, he had perfected the “immediate-load implant” (a phrase he trademarked) and filed papers for a patent.
“I asked a friend to be my first live patient for this and he asked me, “What’s the worst that could happen?’” says Dr. Lazarof. “I told him, ‘The implant could fall out,’ and he responded, ‘Well, my teeth are already falling out, so go ahead.’”
Dr. Lazarof was so nervous about the results that he asked his friend to come in daily for a month to be checked. No problems developed and he did four more implants. When he realized his invention was going to work, he went running down Beverly Drive screaming. “Everyone thought I was crazy,” Dr. Lazarof laughs.
He was also naïve. “I thought I could just go to the dentist next door and tell him about this and he’d be eager to use my implant,” he says.
He felt isolated, but continued to attract patients looking for cutting-edge implants and in 1991 wrote an article about his product in Dentistry Today. A surgeon in Europe somehow saw it and called about his wife, a racecar driver who had been in an accident, smashing all her maxillary teeth. She was dissatisfied with the initial restoration efforts. Once Dr. Lazarof had looked at the x-rays, he invited her to come to his office. Over the next 12 days, he did six implants and a full mouth restoration.
Soon, royalty in Europe and the Middle East were seeking him out.
As word of his results spread, other dentists badmouthed him, he heard. Others tried to copy him, but were stopped by his attorney.
One day in 1995, Dr. Lazarof was given a message to call his former USC professor, Dr. Marwan Abou-Rass, chairman of the USC endodontics department. “My first reaction was concern, because whenever I was called into him, it seemed like I’d done something wrong,” he chuckles.
It turned out that a student in one of Dr. Abou-Rass’s classes had told him about Dr. Lazarof’s implant. Dr. Abou-Rass wanted to find out about it and came over to the Beverly Hills office. After training by Dr. Lazarof. Dr. Abou-Rass eventually placed 40 of the Sargon Dental Implant in his own practice.
In 1994, the implant had received approval from the FDA. In early 1996, Dr. Abou-Rass set up a meeting with Dean Howard Landesman of the USC School of Dentistry to discuss the possibility of using the implant in the School.
Once Landesman heard about the results that Dr. Abou Rass was reporting, he told them he thought this would revolutionize implant technology and said he wanted USC to have a close working relationship with Dr. Lazarof. Dr. Abou-Rass commented that the immediate-load implant could revive the reputation of the USC dental school to the status it held in the 1940s and 50s, as the best in the world. They agreed to put together a 5-year clinical study, which would give the new implant increased credibility, assuming the results came out positively.
But there was resistance by some of the faculty. USC had an agreement to exclusively use Nobel Biocare’s Branemark delayed-load system and it was strongly favored by Dr. Winston Chee, the head of implantology. Dean Landesman asked Dr. Lazarof to talk with Dr. Chee and explain the advantages of his device. The first time he called, Dr. Chee hung up on him.
By the end of 1996, the dean and Dr. Abou-Rass had persuaded Dr. Chee to be the chief investigator. He had said that if the Sargon implant was a poor product, he would be able to bury it. On the other hand, if it really did allow patients to receive implants in one visit and have immediate and full ability to chew, he would get the credit for being one of its earliest supporters.
Dr. Lazarof was nervous about having Dr. Chee in charge, because of his clear bias in favor of Branemark, but Dean Landesman and Dr. Abou-Rass assured him that they would be overseeing the study.
To tie the Sargon implant more tightly to USC, Dr. Lazarof and three associates were appointed clinical professors: Dr. Robert Garfield, who taught at UCLA, Dr. Sumiya Hobo, a Japanese implantologist who had authored over 40 books, and Dr. Young Hwan Jo, who was promoting the Sargon implant in Korea. Dr. Lazarof also began training dentists around the world in USCaccredited seminars, for which it received as much as a total of $40,000 in fees.
To provide funding for the clinical study, Dr. Lazarof agreed to pay $200,000 and made an additional $100,000 donation to the dental school. Researched commenced in February 1997. In the first year of the study, everyone, including Dr. Chee, was impressed. Forty immediateload implants were placed, primarily by Dr. Haseem Nowzari under supervision by Dr. Lazarof, with no failures. In fact, they were so good that USC abandoned its exclusive agreement with Nobel Biocare and began using the Sargon implant outside of the study.
Meantime, in 1997, sales of the Sargon implant reached $2.7 million, primarily to the U.S., Japan, Korea and Saudi Arabia. The Japanese had made a commitment to buy $5.0 million per year if the clinical study had positive results after one year. Dr. Lazarof and Dean Landesman began talking about having a donation of $10-$15 million made from sales to fund a Sargon Implant Institute at USC.
As early as mid-1996, Dr. Lazarof had planned to put on a seminar in Los Angeles to introduce dentists to his implant. Dean Landesman and Dr. Abou-Rass prevailed on him to cancel it and instead to sponsor a seminar in conjunction with USC, where the results of the first year of the clinical study would be announced. The First International USC Symposium was held in Monte Carlo April 24 and 25, 1998. There were 400 in the audience, 40 of them dentists and their spouses who had been flown there by Dr. Lazarof. He paid the entire $200,000 cost of the Symposium.
Dr. Chee’s report was glowing and he received congratulations for such an important study. There was a standing ovation for Dr. Lazarof. A book about the implant co-authored by Dr. Lazarof, Dr. Hobo, and Dr. Nowzari was distributed and the three busily autographed it. Nobel Biocare, Dr. Lazarof says, even approached him to propose buying him out. He refused, but over the next few months they discussed an agreement that Nobel Biocare would purchase at least $50 million in Sargon implants a year.
THE CAMPAIGN TO UNDERMINE
What Dr. Lazarof did not know, which was initially denied by USC and discovered by his attorneys, is that Nobel Biocare had given a $300,000, no-strings-attached “gift” to the USC School of Dentistry during the first year of the Sargon study, after Branemark was no longer being used on an exclusive basis.
And he did not know that Dr. Chee’s attitude had changed after his presentation. Dr. Lazarof believes that Dr. Chee gradually realized from the other lectures and the enthusiasm for the book that so many others we’re getting involved that he would no longer be the center of the limelight related to the new implant.
When Dr. Chee returned home, he wrote a memo about how to destroy the reputation of Dr. Lazarof and his implant and e-mailed it to himself to save it (later found by attorneys during the legal discovery process). What follows is documented by court records posted at HYPERLINK “http://www.sargonvsusc.com” www.sargonvsusc.com, as well as related legal paperwork (to simplify understanding of how the issues were ultimately resolved, read the Opinion of the Court of Appeal first).
The contract between Dr. Lazarof and USC required a detailed report of the clinical study after one year, but despite numerous requests from dentists and other universities, no report was issued at the appointed time. Dr. Chee made excuses for the delay, claiming to need more time to be sure of the results. By this time, Dean Landesman had left to become dean of the University of Colorado dental school and Dr. Abou-Rass had gone to Saudi Arabia to open a USC clinic there, so Dr. Lazarof had lost his protectors.
Later, Dr. Chee claimed that when the implants were used outside of the strict protocols of the clinical study, there was a high failure rate, indicating that they had no place in a dental practice. He and some of the other USC professors began telling this to dentists around the world, which was devastating to sales of the Sargon Dental Implant. Dr. Lazarof also began hearing that Branemark representatives were badmouthing his implant, based on what USC was saying. Dr. Lazarof demanded to see the patient records that the failure rate claim was based on and Dr. Chee refused to turn them over, despite a contractual obligation. Eventually, he was legally forced to do so and Dr. Lazarof discovered the truth of the matter.
In the outside patients, 19 implants had supposedly failed in seven patients. What had not been mentioned is that six of these patients had already had a 100 percent failure with Branemark implants and that the Sargon implants were used for these seemingly hopeless cases and still had 70 percent success. But by late 1998, when relations between USC and Dr. Lazarof were falling apart, Dr. Chee ordered the Sargon implants removed as “failures,” based on any excuse. For example, in one case, during placement, the surgeon had accidentally cut a root. When the patient returned, complaining about pain, Dr. Chee ordered both the tooth with the root problem and the Sargon implant next to it removed. The implant was in so firmly that the dentist broke his tools trying to get it out and the patient had to return another time to have this done. Both teeth were counted as failures of the Sargon implant. In one case, the removal of a Branemark implant was counted as a Sargon failure. In another, the implant was loaded into the sinus area, which is known to cause failure. In such ways, the supposed 70 percent failure figure for Sargon was reached.
FIRE BY TRIAL
Finally, under pressure, Dr. Chee issued a report on the Sargon study in January 1999, which was generally positive, but a year late, a delay that by itself had put a cloud over the new implant. Furthermore, it was only a bare-bones summary, providing few of the patient details the contract required.
In May, Dr. Lazarof filed suit against USC for breach of contract and in July USC countersued, claiming he was in breach and misused its trademark in conjunction with his training dentists at the USC-sanctioned seminars.
In July, USC was also forced to release the full patient records and Dr. Lazarof realized that some of the patients had been selected in violation of the protocols: some were outside the age guidelines, had insufficient bone quality, used drugs or alcohol, smoked or had diabetes. And there had been follow-up with only six of the 23 patients who had received the implants. Most seriously, a handwriting expert from Speckin Forensic Laboratories hired by Dr. Lazarof determined that entries where it was claimed that there had been coronial radiolucencies were additions to the records made long after the patients had been treated and after Dr. Chee began making such claims about the results of the study.
In December 1999, Dr. Lazarof formally terminated the study agreement with USC. When his attorneys discovered that the wife of the judge was on the Board of Directors for the Institute for Corporate Counsel of USC law school, they filed to have the judge taken off the case. Since the trial had not begun and there was no evidence of actual bias, the state Court of Appeal refused to have him removed.
But the bias soon appeared. After 10 months of settlement negotiations with USC failed, in November 2001, Dr. Lazarof’s attorneys wanted to amend the case with two new claims involving discoveries since the initial filing. One was the $300,000 gift from Nobel Biocare. The other was the alteration of patient records. The trial judge refused to allow the case to be amended, arguing that it was too late and prejudicial to USC, even though the trial would not begin until March 2003. He also dismissed one of Dr. Lazarof’s original charges that USC should be liable for lost profits if found guilty, arguing that any specific amount would have been unforeseeable. He also excluded some witnesses for the plaintiff.
When the trial finally got started, it lasted 10 days. Jurors deliberated only a few hours before giving Dr. Lazarof a 12-0 victory, awarding him $433,324, plus certain legal expenses. They also voted 12-0 against USC in its counter-suit. The Attorneys for Sargon Enterprises were Deborah Sirias and Dan Decarlo of Lewis Brisbois and Brisgard. Jay Bloom was also of counsel. “I was convinced that USC was grossly derelict in its obligations to ensure that a competent study be run,” commented one juror in a declaration posted at the legal web site. “”USC did not present any credible or legitimate defense to its numerous breaches. As for USC’s claim for breach…there was not any evidence presented which showed that [Sargon Enterprises] did anything wrong…[and] the evidence presented…demonstrated that USC consented to Sargon Enterprises’ use of its trademark and logo…”
Dr. Lazaroff had obviously won. But then the trial judge’s maneuvers became truly bizarre as he formalized the results. With tortured arguments, he shifted $51,000 of USC’s trial costs to Dr. Lazarof and apportioned his costs to some defendants who had been dismissed and therefore no recovery claim could be counted, he said. The net result was that this brought Dr. Lazarof’s total award to $499,156, just $1,843 below a settlement offer of $501,000, which USC had made in negotiations. The judge then stated that Dr. Lazarof’s primary litigation objective had to recover lost profits, a charge the judge had not allowed to go to trial. Hence, he ruled that USC had prevailed and ordered Dr. Lazarof to pay it $700,000 towards its legal expenses.
“I was devastated yet again,” says Dr. Lazarof. “After all these years of litigation hell, with the general counsel at USC bragging about how he was going to outlast me because of their deep pockets, to have the judgment of the unanimous jury verdicts reversed so that I was having to pay USC $300,000 more than they would pay me was just unbearable.”
But as he vowed when he fought back to get licensed, he went ahead with an appeal, even though most appeals are not successful, given the natural bias of the legal system to uphold lower court rulings.
The brief to the Court of Appeal for the Second Appellate District was written by Greines, Martin, Stein & Richland LLP, with Jens Koepke and Timothy Coats as lead counsel. USC’s attorneys responded.
On February 25, 2005, the court provided its opinion, completely reversing the trial judge. It named Dr. Lazarof the prevailing party, awarded him what, with interest is now around $800,000 (and nothing for USC’s costs), and allowed him to go back to court to argue for recovery of lost profits, fraud claims, and punitive damages. That trial will take place in November 2006. USC appealed to the state Supreme Court, arguing that if the appeal court’s rulings were allowed to stand, current and future clinical studies in all universities would be endangered out of fear of liability. It depicted USC as seriously threatened by the prospect of having to pay lost profits, even though it has an endowment that currently stands at $2.5 billion. The Supreme Court upheld the appeal court.
Dr. Lazarof says that as a proud alumnus of USC, he still believes it is a world-class university led by a visionary president, Dr. Steven Sample. But no institution is perfect and this seems to be largely a case of an overzealous staff attorney, which is not an uncommon situation in the business world, where CEOs rarely try to second-guess the lawyers.
Dr. Lazarof says that his experience with university research has made him aware of a big issue no one wants to talk about: that the dependence on corporate funding to conduct medical research can distort the focus away from what the priorities should be for the benefit of the public.
DEFINING IMMEDIATE LOAD
Dr. Lazarof continues to be passionate about the importance of immediate-load implants, beyond allowing patients full function after one visit. “When you don’t immediately insert an implant, the tissue dies and the bone is absorbed, so they have to be built up again,” he explains. “I think it’s periodontal mutilation.
” But he is concerned about other companies’ products claiming to be immediate-load and the seminars promoting them. “The problem is that these are recycling essentially the same screws that were used before delayed-load became popularized. They put pressure at the top where the hard bone has little blood supply and causes it to be absorbed.” When lecturers are asked about the discrepancy between clinical claims and the results in practice, he says they admit that the key to success is patient selection and then reveal that only 25 percent of applicants are accepted as qualifying. “When you do the math, you realize that dentists are back to the 10-15 percent success rate which they had when the old style immediate-load implants were abandoned for delayed-load in the 1980s,” Dr. Lazarof observes.
“It’s really an abuse of the term ‘immediate load’ when the patient is given a small, nonfunctional provisional restoration and told not to chew on it for four or six weeks and they can’t return to normal function for months,” Dr. Lazarof says. “We give patients an apple to eat right after we’re finished placing the implant.” The definition of an immediate load implant is when it can withstand full function and esthetics in single tooth replacement at the time of placement. When the average dentist is asked about immediate loading, he or she replies that all implants can be immediately loaded, but it is extremely risky. They simply are not aware, Dr. Lazarof comments, that the Sargon Implant is the only one that was specifically designed to expand and control its stability in bone for immediate loading with 96 percent success rate.
And it has a 15-year track record. He points out that every other implant has had its design or surface changed in the past few years.
A recent development in crown material and technique has improved what Dr. Lazarof could do previously. Working with a Japanese company called Kurare, he has developed a technique to use their material called estenia, which is 92 percent porcelain and 8 percent resin, and handles like composite. When he first meets a patient who wants an implant, a model is made right then of the tooth to be extracted and shade is selected and sent to the lab (Koga Laboratories in Culver City, the only one that has been trained to do this, has a branch in the Sargon Institute in Encino to do this, and they can send a technician with portable equipment to do this at other dentists’ practices). The lab makes a crown shell that is then fixated on the implant at the time of placement. When the patient returns for the implant, the final porcelain crown is delivered. In 120 cases in the 30 months to January 2006, there was only one failure.
Also allowing Dr. Lazarof to take care of patients in one sitting is advanced sterilization of the sockets, using the Co2 ultra-high-speed Deka Laser.
Another important development that is coming later this year will be when Sargon implants are made with similar prosthetic heads to other implants. This will allow the surgeon to place the Sargon implant with the type of restorative head that the restoring dentist is used to. Dr. Lazarof has learned that a lot of dentists who take training classes in implantology are afraid to do the surgery when back in their offices. At his Encino institute and at a Sargon Implant Institute in Payson, Utah, run by Dr. Dan Dansie, dentists are not only trained, they can bring in their patients and do the work under supervision until they are comfortable operating by themselves.
Implants are about to become a much bigger part of dentistry. When the deans of U.S. dental schools met at the American Dental Education Association Summit on Advanced Dental Education in 2004, they announced that implant placement education should be part of the curriculum for general dentistry. That is expected to take effect over a number of years and will clearly provide a major boost to implant sales, which are now at $2.5 billion a year. “It’s a great feeling when you have a teary-eye patient come in devastated by having lost or loosing a tooth and you are able to tell them you can help them return to normal function and look immediately,” Dr. Lazarof says. “I want every dentist who takes out a tooth to have the experience of being able to replace it right then.”
“The real tragedy thus far is that so many patients had to go under unnecessary treatments and costs because they weren’t given the opportunity to get the Sargon Implant,” concludes Dr. Lazarof. “The good news is that we are restarting the implant revolution and this time, it will sweep across the world.”
The Sargon Dental Institute