Dentistry Uncensored with Howard Farran

How to perform dentistry faster, easier, higher in quality and lower in cost. Subscribe to the podcast: https://podcasts.apple.com/us/podcast/dentistry-uncensored-with-howard-farran/id916907356

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"Having technology for the sake of having it is pretty stupid. Having it when it's to your useful advantage is the key."

Howard Farran: It is an extreme honor today to be interviewing Scott Menaker. Did I say that right? 

Scott Menaker: That's correct, Howard. 

Howard Farran: I was telling you earlier that my last name Farran in Arabic actually means baker and your name is Russian and it means butcher. 

Scott Menaker: Yes. 

Howard Farran: We got a baker and a butcher, and now all we need left is a candlestick maker, so hopefully, one of the 5,000 dentists listening to this is the candlestick maker. You graduated at UNC in 1985. Was that when Michael Jordan was playing there?

Scott Menaker: I was fortunate enough to have caught him for a couple of years there, so it was a great thing. 

Howard Farran: Now, did you know he was going to be the great one when you were at UNC? 

Scott Menaker: I think everybody had an idea after that first year how great he was going to be. He was not the number one guy coming out of North Carolina. There was another guy in that team, a guard named Buzz Peterson who was like the top rated guy but Buzz went on to be a coach and Michael obviously went on to be the man. 

Howard Farran: Man, he was the man. You know why I love Michael Jordan the most? You know what romantic thing that I associate Michael Jordan with? This is a true story. People don't get it, I'm 52, unless you're a bald guy who is 52, but when I was losing my hair, senior year of high school and was bald, fresh year on college, people would always say, "Oh man, I'm so sorry you're losing ..." It was just like people would always treat you like you're going through this great tragedy, you know what I mean? I didn't really get it because when I lost my hair, I lost my blow dryer, my shampoo, my conditioner, my comb and it took me ... I mean, I just thought it was just like, "Man, keep it simple too," but it was just this great thing. 

It wasn't until Michael Jordan and the Chicago Bulls made it to the finals with my Phoenix Suns who had the other gorgeously handsome guy, Charles Barkley with the bald head, and the whole world or the whole America watched these seven games of these two bald guys with million dollar smiles, and I swear, it was the next day, bald was cool, and people stopped their comb overs and people who were half bald were shaving the whole thing, and people with as much hair as you were shaving their head. Michael Jordan and Charles Barkley made being bald a cool thing, and I thank them for that. Basically, one of the things that I wanted to get you on about is you're obviously, I mean you got your FAGD, you got your Fellowship in the Congress of Oral Implantology, you've been doing dentistry for 30 years, you're a great clinician, but you have always had a knack for all things digital in dentistry. Why is that? 

Scott Menaker: You know, when I started 30 years ago, we had one computer, it was a DOS system. Most people listening probably don't know what a DOS system was but it basically allowed you to type in information and it was a simple we knew who you were, we put your name, address and phone number and we knew how much money you owed us, and that was about it. As time has gone on, the technology has certainly changed and computers changed and I sit here today in my office, there's 2 dentists, we have 14 computers, we have two servers, we have two CEREC units, we have digital pan, 3D scans, digital X-rays for 15 ... What it's really done is it's changed and allowed us to really put our practice in a great place. 

We're offering the latest and the greatest ... Having technology for the sake of having it is pretty stupid. Having it when it's to your advantage and that it's useful is the key, and that's what we've been able to do. In the case of my CEREC unit, we're talking the digital world, I've been at it with the CEREC about 9 years now, it made doing crown and bridge fun. Instead of just prepping in and taking an impression and disappearing down the hall, I get to have a little bit of say in what happens and what my crowns look like and what things your shape like. It should really made things for me and made it fun. 

Howard Farran: How many CEREC systems do you think have been sold in the United States? There's a 120,000 general dentists, 30,000 specialists, of the 120,000, how many units do you think they have out? 

Scott Menaker: I think that the Patterson and Sirona are estimating, they're in that 13, 14% range, so you're talking 15,000 dentists, give or take, are using CEREC, some have been there for many, many years. I got there when it made sense to me, when you could get a 3D picture, instead of using dots and lines. The 3D, you could look at it and see that it was a tooth, it made sense to me. 

Howard Farran: Where do you think CAD/CAM is right now? Do you think in 10 more years, it'll go from 15,000 dentists having one to 30,000 or you think they ... Because you and I have been in dentistry 30 years. When these lasers come out, there's seem to be a glass ceiling, like they come out and maybe 5,000 would buy it and then that was it, so maybe same with air abrasion or same with certain things, so do you think that the 15,000, they'll stay in the buy one, bought one or do you think it's still growing and do you think in 10 years, it maybe 30,000 dentists?

Scott Menaker: I clearly think it's going to grow. Now it'll never certainly take over, but you've gotten the easy part, the people who are interested in technology and who get it, and I think it's allowed those of us that are using it to really use it to our advantage in terms of marketing and providing a great service to our patients. We're just down at the Hinman Dental Meeting in Atlanta in March, it used to be that the CEREC was the only one down there. Now if you walk through the exhibit hall, I won't say all the big players have got them and everybody's trying to do it. It's all free med service. Invisalign, ClearCorrect in the orthodontic field, Glidewell, the biggest lab in the country, everybody wants it in a digital setting because it's faster, easier, and more accurate, and I just think people have to get by the idea that the technology is scary and also get over the cost factor too because it certainly pays for itself.

Howard Farran: What I picked up on, the keyword that you said when you were explaining this to me is "Have fun" and that is ... I tell everybody that dentistry is a high stress job because I grew up, my dad had restaurants, and if you ever saw people coming in, getting ready to order a footlong chili cheese dog and onion rings and a chocolate shake, they were so dang happy, you could've hit them with a crowbar and they'd still have been smiling. You go to Disneyland and I swear to God, you can't make this up, I saw a kid jumping up and down, so excited when they were opening the doors to Disneyland that he actually needed to have his pants changed, and then you go into dentistry and people walk in there and just say "Oh my god, I don't have time for this, I hate coming here, I hate the dentist." 

Dentistry is a very stressful job, and if buying a laser or a CERA or anything makes you happy, if some toy makes you have fun, it's going to pay for itself tenfold because you've got to make dentistry fun, and if you hate endo, that's what endodontists are for. If you buy a 3D X-ray machine and you just think it's the coolest thing in the world, then you can't afford not to have one, and if you're afraid of your hygienist and you can't talk to her and every time she confronts you, you want to cough up a blood clot, you have to let her go. 

Scott Menaker: Absolutely. 

Howard Farran: You can't do things you don't like to do for money because if you trade things you don't like to do for money, you will always end in disease, depression, addiction, it's just not going to be pretty, and I can tell you have dentistry because you have dentistry enough to go get your FAGD. You loved it enough to get into implants, you loved it enough to get on technology. I'm going to go through all these with you because 5,000 kids just walked out of school and graduated in dental school 2 weeks ago, and for these 5,000 kids, why did you get your FAGD and would you recommend that to these graduates?

Scott Menaker: There's nothing like continuing your education. One of the things that I talked to young Dennis coming out and almost any of my patients that are coming and kids finishing school, I said "I'm going to give you the best advice you've ever heard in your life, and you need to listen to me," and so they looked at me like I'm going to give them a million dollars, and I look at them and I go "Remember this," I said. "You don't know crap," and they looked at me like "What?" I go "Okay, so here's the the idea. You've gone to school, dental school, law school, whatever it is, and you know how to do a task, you can do a filling, you can do a crown maybe, you might be able to do a root canal, but you've been given tasks and steps but you really have no idea how it all works." It all dawned on me years ago. 

I have an identical twin brother, so he's a CPA. We went different paths. He hated science, I didn't necessarily decide numbers were a great thing to look at everyday, although I do appreciate him in my office, but Steve was doing these audits and he's out doing these ... I'm in dental school and I'm seeing he's travelling and they've got him going all over these places and I said "It's so cool. You're doing all these great stuff," and he goes "I don't know what the hell I'm doing." 

He says "I sit down, they give me some work papers, I do my task, I give them to them, and then somebody takes them and does something with them, and then they give me another set," and it really dawned on me that he was just beginning his career, now he's running in a whole audit department, in a big piece of McGladrey, one of the largest accounting firms around, he's got a huge job with them, he understands the whole piece, and that was my advice to recent dental school grads and it ties into this FAGD thing, which is you got to keep learning. You got to keep looking and exploring, you got to be adding new things because if you keep doing things the same way you did it, I'm still sitting here with paper X-rays and maybe using hydrocolloid and rubber base, stuff that just doesn't exist anymore or shouldn't exist. 

You're learning and you're figuring out how you provide better service to each of your patients and how you enjoy what you're doing as you learn along the way, and that's what it's all about. You've got your masters in the AGD, and you get it for the same reason I'm sure. 

Howard Farran: Absolutely, and I look back, not only do I look back to the AGD as ... What I liked most about it was the structured curriculum because I did not want to take a lot of these, like I was like "Why should I take implants or ortho? I don't do those things," but I had to to get my FAGD and my MAGD, and then in having to take those, I was forced and not happy, and I complained and some older guy, I think I was about 25, and some 65 year old MAGD guy put his arm around me, said "Howard, just take the damn course. Just shut up, we know more than you do, you're a young kid," and so to knock out my MAGD or FAGD requirements and implants, what I signed up for, Carl Misch's 7 3 day weekend course and fell in love with implants, and that's where I want to go next with you because you got your FAGD and you got your Fellowship with the International Congress of Implantology. 

I like to look at macroeconomics from around the world. Instead of looking at the 150,000 dentists in SA, I like to compare the 2 million dentists around the world in almost 200 different countries, and here's something I don't understand about implants, here's what's I feel crazy. In a country like South Korea where they have 20,000 general dentists and 15,000 out of 20,000 place an implant themselves every month, and German dentists, they all place implants and they only use oral surgeons for the super big, complex cases like the All-on-4 or something that needed some [inaudible 00:12:29], and in Germany, in Europe, in Brazil, and everywhere you go but America. 

America has 120,000 general dentists, and 115,000 of them have never placed a single implant in their entire life, and the other thing I don't understand is that why is that, and number 2 is in Germany, an oral surgeon will place for every root form they place, because 96% of implants are placed one at a time to replace a single missing tooth, and when someone comes in fully edentulous, they'll use mini implants. They'll put 4 in the lower, 6 on the upper, and that denture snaps on there, and here at America, the oral surgeons don't even offer mini implants.

You send your patient with a denture to an oral surgeon and they got 1 treatment plan and it's a 50,000 Mercedes Benz or maybe you can have the Ferrari or maybe they'll do a modified Lamborghini, and then when you say "Well, this person's a hillbilly and they don't have any money and they don't have that kind of money. Can you offer a lower cost alternative and like minis?" They'll look at you like "Minis? I'm an oral surgeon. I'm a periodontist. I'm a prosthoodontist. I don't do yard cell work with mini implants." Why is America, which should be number 1 in everything, why are they just non existent on the map with mini implants, and why did the general dentist not place them, and you've got your Fellowship in implant.

Scott Menaker: It maybe a little bit of the scare factor of the unknown. Implants just got a bad rap early on and few people chose to do them and there wasn't a lot of training, or it was, initially, you went to a weekend meeting, you bought $8,000 worth of implants with really no clue and no training. You trained with Carl Misch, I did his prosthetics course probably 20 years ago and it really changed my whole outlook on a lot of things, but as you go along, you got to continue to move the needle forward and you just got to go get the training, and I think people get afraid and they're like "I don't want to this" or "I can't do it" and they just got to find the right people. I work with a terrific group of periodontist and oral surgeons who are certainly willing to help, they're willing to answer questions, but I think people got to just surround themselves with the right people to help encourage you along the way.

Howard Farran: Does your own oral surgeons, do they offer the $50,000 big 3 implant case? Do they also offer an alternative $5,000 with minis or is it just all or none?

Scott Menaker: Most of the time, I guess if it's going to be minis, I'll do it. It's just something I feel comfortable doing, and we all should. 

Howard Farran: What percent of general dentists in your estimation, forget my perception, your perception, what percent of general dentists, if grandma came in with an ill fitting denture, would do a rewind and then adjust it 5 times over the next year and if grandma's not happy and you're not happy and you cringe every time you see her name coming up your schedule and you're thinking "I only charge her 250 for a reline, now I've had to adjust it 10 times, but they didn't even offer a real solution like me." What percent of the general dentists would you say do not offer minis instead of a reline?

Scott Menaker: I'd say probably 95% of them won't, if not even more than that. Until there's more people that are willing to do more training to really understand how it works and the benefits, they just keep doing what they do. You keep using PFMs as your only alternative, you're not using zirconium and porcelain, it just goes across the board, and I think you have to be willing to change and see that there's something different and something better and get the training to go do it. 

Howard Farran: This woman, there are 5,000 people who are going to listen to this podcast and right now, there's this dentis and she's 30 years old and she's driving to work and she can think off her head 5 denture patients that she doesn't want to see in her schedule and she's never placed in a mini. Give her baby steps. How did she go from never ever placing a mini to the second floor where she got grandma in there and placed 4 on the lower and 6 on the upper and the patient lived happily ever after? How do you get from A to B?

Scott Menaker: I think you got to start obviously by getting some good education. I'm not a big fan of just taking a quick weekend course and really not understanding what am I doing so I can drill a hole to the gum tissue, and I've taken those courses. They can work but you drill a hole through the gum tissue, you do 1 or 2 drills, you put a screw in and you go. I think you really need to understand what it is you're drilling into and what you're doing and what are the real risk in complications and is that the real benefit. You got to understand forces and where you put them. The one thing that Carl Misch said to me, said in the course years ago that stuck with me and it's applied almost that I do as a dentist, he used the word "Stress", and you talk about it and are generalized, but he said, "You have to understand what stress is and where you're putting things." 

He said "You can put an implant anywhere you want but if you don't understand where the stress is being put on that, it won't survive," so I think you don't have to go out and take a year long continuum to go put many implants in, but I think you need to go spend a little bit of time really understanding what they do and what they need and it shouldn't take long, and as you're indicating, it can change your practice. It can change your patient's life-

Howard Farran: Okay, but be specific. She's 30 and you're 55 and have your Fellowship in Implants and FAGD, what training would you recommend to her to place minis? Do you have any names, numbers, websites? Where would you go?

Scott Menaker: I guess there's a lot of them out there, maybe it depends on your area. I chose to participate in a 9 month continuum that was a weekend long course, and you really got a full understanding of what's going on with implants.

Howard Farran: Was that at UNC?

Scott Menaker: It was actually a private group nearby that does great training. One would be talking to some of the implant companies. They're putting on some of those courses as well.

Howard Farran: What minis are you using?

Scott Menaker: I'm using some of the small ones from Biohorizons and Straumann.

Howard Farran: Biohorizon, that was Carl Misch's implant company, right?

Scott Menaker: It sure was. 

Howard Farran: Biohorizons and then Straumann, that's Switzerland?

Scott Menaker: Yes, it is. I think you'll have to answer that one.

Howard Farran: It starts with an S. It is in Europe.

Scott Menaker: It does. You've got 2 Ns on the ...

Howard Farran: Yeah, so talking to your rep would be good for some hands on courses.

Scott Menaker: Absolutely, because I think a lot of them are, at least certainly the ones that we've got in our area are very ... They're looking to help dentist get into the implants. Obviously good for their business and there's lots of training which we talked to, finding mentors, finding people, certainly looking through Dentaltown and other great resources out there, it can help guide you where to go, and don't settle for one. Take a couple of them and figure out which one works. 

Howard Farran: I agree. Back to technology, you and I have been out 30 years. Has technology been a game changer in your clinical dentistry with regards to implants? You've mentioned that you got a ICAD, do you think going from a 2D panel to a 3D ... Did you say ICAD is what you use?

Scott Menaker: I've got the Sirona XG3D.

Howard Farran: Is that the GALILEOS?

Scott Menaker: It's the smaller version of the GALILEOS.

Howard Farran: What's it called?

Scott Menaker: XG3D.

Howard Farran: XG3D. What does XG stand for?

Scott Menaker: I have no idea. 

Howard Farran: I did P90X, I still have no idea.

Scott Menaker: They got a name for it but I don't know. I originally have gotten the unit as a 2D digital pan that was upgradable, and I would probably say 10 months after I did that or less than 10 months, we went to the 3D. We now take it as our standard, so if somebody comes in and they're due on a 5 year basis, we typically will take a Panorex as a great scanning and screening film. We take a 3D scan and we then review it with the patient, and it's really been eye opening. For me, my patients really appreciate when that we're showing it to them, but they like this stuff and just for me to show them, "Hey listen, just taking this X-ray, I've just cut you in half and I'm now looking at your teeth from the side." Instead of just a 2D version of it, I can see almost anything that I want to see. 

I had a young girl in a couple of months ago had a dentigerous cyst up around number 16 that was literally up into her orbit. In the 3D scan, you could really see the magnitude of how large this thing was and where it went, and we were able to have that discussion with her folks, her mom said can it wait, she's going to be busy, and I said "No, she shouldn't," and her mom said they really appreciate it, so I got a whole different picture by using this technology that I would not have had just using a regular 2D, and my patients are looking for that. We've positioned ourselves as a very progressive practice and I think in today's competitive world, you need to be doing that, you need to be positioning your practice well. This is just another tool. We're providing our patients with a great information and we're offering it in something that they can appreciate. 

Howard Farran: You got on at '85, I got on at '87, in those 30 years, do you think Dentistry is more competitive today, 2015, than it was when we got out in '85?

Scott Menaker: Absolutely. 

Howard Farran: Explain. Because when we got out, there was Orthodontic Centers of America trading on the New York stock exchange, there was a dozen of these big DSMOs on NASDAQ, and what happened to all of them?

Scott Menaker: They're gone. 

Howard Farran: Yeah, and do you think the next round ... Then they all disappeared and then there was nothing for 10 years, now they're all back with a vengeance. Do you think it's round 2 of what we saw the first round and that managing dentists is like herding cats or do you think this time, they're here to stay and Heartland and Pacific Dental will turn out to be Walgreens and CBC.

Scott Menaker: I'm not sure they're going to get that big. I think some of the bigger, more successful ones will probably stick around. What they offer is they take any insurance plan known to mankind, they don't care about the fee, they figured out a system they think that works well, and obviously, at this point, it's working well for them. I don't know whether it works long term. In the short term, it does, but the PDO competition, when we got out, it was indemnity insurance. I remember IBM had a plan that paid ... My crown, I think it was $400 at that time, they paid $3500 a year, they paid 90% of the fee, it was golden in a way. If somebody needed treatment, they could get it, and in 4 years, dental insurance has gone backwards, it's disappeared, you have a $1,000 plan, a fee for my crown is $1200, you get a crown and a cleaning or 2 and you're done. 

Howard Farran: I'm going to play devil's advocate. When I go around the world, the bricks, the fast emerging markets, Brazil, Russia, India, China, they don't even know what dental insurance is. Have you ever tried to explain dental insurance to a Chinese dentist in Xinjiang, they say "Well if you're the one not brushing your teeth and drinking Pepsi and Coca Cola and have a cavity, why would your boss or your government pay for your cavity?" The look at you like ... Am I missing something? Then in the United States, half of Americans don't even have insurance, and then when you go the United Kingdom, when you and I got out of school, they had 19,000 dentists and they all participated in the government plan, and now 25 years later, about 5,000 if them said "Forget it," they just dropped out completely. Now it's down about 14,000 with the government, NIA system, and 5,000 are just going through for service.

I think all democracies, they only have 2 goals. We're going to try to give you everything for free and no one's going to have to work or pay taxes, so you're not going to pay taxes, you can have everything for free, so insurance is the same thing. They want to not brush, not floss, not take care of their teeth, give their children Mountain Dew instead of anything nutritious, and then when they need a whole mouthful of cavities, they want their boss or Obama to pay for the whole thing and they don't want to pay taxes. Do you think that the insurance thing is a cop out to blame it on insurance or do you think it's-

Scott Menaker: I think people have gotten trained via the medical world where the $25 copays takes care of everything, and that stuff is all changing. We positioned our practice not really participate in those plans. We take one, which is Delta Premier, it's a very tiny percentage of my practice, and the rest of it is I get full fee, so the PPOs are not effecting me but I've worked really hard in our practice to position ourselves so that we don't have to deal with that. 

Howard Farran: Okay, but this kid that just got out of school doesn't know what you mean when you say "Position yourself". What do you mean by "Position yourself"? 

Scott Menaker: Part of that is the level of service that we provide, the care we provide, the technology that we use, the investment in continuing to update what we're doing, going to training to offer them the latest in services that's out there, and part of that is ... I've got 30 years of developing that relationship with a lot of my patients. If a guy coming out of school start from scratch, he's got to start getting people in his door to start getting cash flow, and what they normally do, and it's fraught with danger, which is they sign up for every PPO thinking that's the answer. 

I met with a young guy the other day who said "Well, I'm not busy so I'm signing up for more." I go "If that's all you're doing, you're dead because you're going to be working at the mercy of ... You're going to be just a commodity," so as long as you're participating in the plan, people will come. When they stop, when you stop participating the plan, they're going to go away to the next guy, and there is certainly a group of people that are on that tact. I say that you go out to the people, as you said, the 50% that don't have dental insurance who value good service, who value good dental care, and are willing to pay a fair fee for great service. 

Howard Farran: The other thing that dental insurance is good for is someone says "Okay, if you want more of something, subsidize it. If you want less of something, tax it," so the employer of the government subsidized health care and they got this insurance benefit. Well it only covers $1,000 so if they need any type of comprehensive treatment, you can take the insurance, you can follow the plans, but you can upsell to a full amount to case dentistry if you have the skill set, if you have the confidence, if you can present the treatment-

Scott Menaker: That's exactly right. You've got to have the confidence to be able to do that and the skills. Just tell people what they need. You let them make a decision whether they're going to do it, you got to lay out the benefits of doing it, and also what's going to happen if they don't do it, but ultimately, at the end of the day ... I'm trying to ... I heard many years ago. I think it was a guy named Rick Kushner out of Colorado, and one of the things he said at a meeting was 90% of what we do in dentistry is selected. The only time they need us is when they've broken a front tooth or they're in pain. I think that number's probably about 98%. 

I saw people walking and this guy walk in my office yesterday. He's been having a toothache for 2 years and he goes "I figured it's finally time to do something," so people are not ... You have to create, you have to educate them, you have to help them understand the benefits of doing this and why you're the guy that do it, and they'll pay you. I got plenty of people who are willing to pay me my full fee for what we do and not have to take 30 or 40% to give it to the PPOs and the insurance companies. 

Howard Farran: What do you mean when you say how Touch Dentology is changing the rules of patient engagement?

Scott Menaker: One of the things I've always toyed with is how do I tell people, give them their education. What is it when they come in to get their teeth cleaned. What happens? Most of the time, people think as long as they don't have to come back and have a filling done, but then I don't have to come to see URI, you're good, they're great, they can go do whatever the heck they want to do for 6 months and they'll come back and in 6 months and repeat and keep going, and so I always looked at do I create a checklist or do I create something to give them, and that never seem to work, it was a lot of paper, and then you get something from the periodontist that says "I saw one of your patients. Mrs. Medicare was in, she got her teeth cleaned, there's a little pocket 14 and 15, and her plaque was ..." But they never do that to the patient, so the patient's kind of in the dark. 

About a year or so ago, I had a conversation with a long time patient of mine, very successful in the hospital world, and now in the app world, in the medical aspect, and we started talking and I said I got this idea of what I'm now calling "The oral fit score" which is a way to really evaluate somebody in a very quick, systematic way, give them recommendations, and then have a conversation with them, and that led me to getting an app, the first app that we built, which is the oral fit score which is enabling us to really have a conversation and it's really a great tool for my hygienist. 

I have 4 hygienist and they all speak a different language. One of them likes to talk about dentistry, one of them hates to talk about dentistry, she'll tell you anything and she'll probably even call you names, but she doesn't want to talk about dentistry, and by using the score now, she came to me a week afterwards and said "I'm now being accountable to my patient," so we're talking to our patients about are their gums bleeding, do they have plaque, do they have tartar, are they eating a lot of sugar, what is the health of their teeth? What's the oral cancer exam look like? We've created all of this in a very simple app that's done on an iPad that they then review with a patient. We get a copy, the patient gets a copy, and-

Howard Farran: What's the app called? If they go to their app store store right now.

Scott Menaker: You really can't get it because it's a subscription that they'd have to get with us that we'd have to build and customize. They can go to our website touchdentology.com and they can see that, and if they call us, we can certainly get them a lot more information.

Howard Farran: You built this. Is it an app or is it a mobile version of a website?

Scott Menaker: This is an actual app. This scoring is done, it's touch screen, you add your patient information, you evaluate them basically so that the hygienist is the main person doing this. They're not having to key in lots of information, they're just using touch screens and saying plaque is none, light, moderate, heavy. Bleeding, similar thing. Conditions of teeth, we're giving them the options of broken teeth, cracked fillings, missing teeth, abscesses, there's all kinds of things, as well as when you get into the treatment side, you can talk about what they need to come back for. You need to come back and have a tooth filled, you need to come back and have an implant, we've referred you to pa periodontist, all of that is displayed on this in a real quick thing, takes less than 5 minutes to do in terms of doing it and reviewing it with the hygienist. 

We got about 1500 of these done right now. The response from our patients has been tremendous. 

Howard Farran: You have 1500 patients?

Scott Menaker: Scores. We got 1500 scores that we've done with my 4 hygienist in probably the last 4 months. 

Howard Farran: Is this a new thing for you?

Scott Menaker: This is new. Absolutely new.

Howard Farran: How new?

Scott Menaker: We started using this in late January, early February, and just now, bringing it to the marketplace so that other dentists can take advantage of this.

Howard Farran: Now have any other dentists around you done this to?

Scott Menaker: We've got a few there who's starting to use as kind of a trial basis as well, and again, we're new to the world and just looking to help people understand how it works. The key for a dentist, I was talking with my wife the other day, the key here is as dentists, we're not the ones that are really using this tool. It's a tool for our staff. It's got all 4 of my hygienists speaking the same language. They're having to have conversations with patients that, you said earlier, if the hygienist is not doing what we want, we need to get rid of them, they now understand what I need them to do. The patient response has been tremendous. They love-

Howard Farran: Then the patient is going to download this app on their smartphone and then-

Scott Menaker: No. Once we go do the score, and the score is generated, they will sit there and have a conversation, literally holding the iPad in their hand, reviewing this with the patient, telling them what they see. I then come in to do my exam, they're then reviewing a lot of that information so that I can hone in on what they've been seeing and reinforce the value of what they've done, and then what happens is once that score is generated, the practice immediately gets a PDF of that that you can then download. We download that into our document cue, it goes into our patient record, and we now have that that we can compare. We then ask the patient, "Do you want us to print this or do you want us to email this to you?" I bought a printer, it's collecting dust. They all say "Email it to me." 

The neat thing is you hit the button, it goes swoosh, and then you hear the chime on their phone, and patients think it's the coolest thing because one, they can then go back and review that any time they want, they can then get that any time they want when they go the other app we built which is a mobile app for the practice, which is the kind of a version of ... It's somewhat of a mobile website but it's the next version of a mobile website. 

I think the coolest thing would be for my patients to all be sitting with my app on their phone because I look at it this way, they're mine. They're not trying to remember who I am or how to get in touch with me, they hit a button, they can file it under their health category or the could just have it sitting their and they got access to me, and part of what we're going to do is provide information to dentists, so if you've got a newsletter, we look at yours, you got a great newsletter of blogs and offers, all of that can be put on there, but if you don't have access to that information or don't have somebody who's savvy enough to be doing that and doing social media, we can now also help provide some of that, so it's really a marriage of the in office oral fit score app and the out of office mobile app.

It's just another branding and marketing opportunity. If you just want to get all the PPO guys of the world and that's your patient base and you're happy, you don't need me. You really don't, but if you're looking to position your practice to get the good patients who want to do the bigger cases and the smaller ones but who appreciate what we do, we need to provide them with information and show them that we're on the leading edge of what's going on, and that's what our apps will do.

Howard Farran: What's the next move for your company? Sell it to some other dentists?

Scott Menaker: That's exactly what we're getting ready to do. 

Howard Farran: How much you think is something like this is going to cost?

Scott Menaker: We're looking at probably a monthly fee of $300 a month, and that will cover full customization of the mobile app where we pretty much look like it is yours and not anybody else's. From colors and logos and information and bios and special offers and special information on things that you're doing, we'll take care of customizing that, and as well as the oral fit score app where you can do as many of those. We store it in the cloud for you, we provide all that kind of service. As I was trying to think about this, we pissed away dentists, we pissed away a lot of money during our careers buying the latest and greatest, we think this material is good. We get a journal article, here's something, we buy it, and then 10 years later, we look at our closet and it's full of stuff. 

This is something I think that is the simplest thing, easiest thing to use, and for $300 a month, it's a drop in the bucket of what we will spend and it will have a dynamic impact, and we've seen it in our practice, I think that just we'll see it as well that their patients will love what it provides. Their staff will like, especially their hygienist, the tool that it gives them, and it just continues to brand and position their practice in the marketplace in a different place. 

Howard Farran: I would say that the thing that dentists waste the most money on in their career hands down is their girlfriend and paying off their ex wife. I think it's funny when all these dentists complain about their $250,000 student loans and I'm like "Dude, your first divorce will cost you a million, okay?" 

Scott Menaker: You're absolutely right.

Howard Farran: Your student loan is the least of your problems. I also want to say that when you've collected a lot of this stuff, the free classified ads on Dentaltown, it's amazing. Probably over 1200 unique dentists go to that thing everyday, but it is amazing. If you do have a mortuary of old stuff you bought for thousands of dollars, you can unload that stuff on the free classifieds. I just want to say one thing and make a comment on you said about, when you work with the specialist, one that the periodontist was sending you back notes thing that the person had plaque or bleeding gums or whatever and the patient wasn't seeing this, I reverse that with my specialist. 

If I'm going to send my oral surgeon for a wisdom teeth, it's extremely important that when they schedule my appointment that my patient, they call our front desk and we email over the treatment plan because when the oral surgeon is going to go in there and only see 4 wisdom teeth then pop them out, that doesn't do anything for me, but if the oral surgeon goes in there and while you're numbing up, puts his hand you and says "By the way, you still got 6 cavities. We're just pulling the 4 wisdom teeth there, but you know I'm not going to fix those 6 cavities. 

You need 6 fillings and you need to get back there and see how we're going to have those 6 done because I've been an oral surgeon for 25 years and these 6 cavities are going to turn into 6 root canals, and right now, you just have 6 fillings and if you don't get that done, it's going to turn into 6 root canal, build up, and crowns, you don't have the money for that, so then you're going to be back here in my office getting 6 more teeth extracted," and that's why 31 million Americans don't have one tooth, and I can't tell you how many times those kids come back from the oral surgeon, they would say "Oh yeah, when I was there, he told me don't forget to come back here and see you to get that done." 

Same thing with periodontists. You send them to ask him gum disease and the worst ones, they just look at that little gum tissue and the best ones send them back for the treatment plan and say "In order to do this right, we're going to do all this stuff, but I don't like the margins on 2, number 3, and I don't like this and that," and so comprehensive care is working with specialists that can do both things. 

Scott Menaker: You know, Howard, you're right, and that's the group. We don't have to refer to just anybody. You got to pick a great group of people and the ones I've worked with, one periodontist for 30 years, he and I see things the same way. When I went to Carl Misch's course, came back and I said "Listen. If you place an implant for me, don't ever place it in the wrong place, put it in the right place so that I can restore it and it'll survive," and it just became a conversation that you've had in an iPad with a specialist to say "What are my expectations," and they certainly live up to that, so to the dentists that are getting started or not happy with their specialist, find the right ones and the good ones because there's plenty of them out there. 

Howard Farran: I want to ask you a question on that right there. Do you think that specialist should be using a surgical guide or do you think an oral surgeon or a periodontist places the implant in the wrong direction, instead of starting crown down and saying "Hey, this is where the crown needs to be. This is where the bone is. Can we connect it to ..." Are you using surgical guide or do you just set things down my surgeon, I'll just lay a full fit thickness flap and I can see the tooth in front of the tooth behind this, flip the difference, buccal, lingual, mesial, distal, and just free hand it or are you a surgical guide sort?

Scott Menaker: I'm using a guide but I'm also [inaudible 00:42:14]. 

Howard Farran: It just depends on the situation?

Scott Menaker: That's just what I've gotten used to and what works for me, and I know there's, again, lots of ways and you talked to some of the periodontists who've been doing implants for years, they would never think about using any kind of guide, and now they'll say you do it 100% of the time. Again, that's one of those things that I think you've got to develop a comfort level. You're placing them, what are you doing?

Howard Farran: How do you make your surgical guide? Do you make it yourself? Do you have a lab dude? Do you mail it out? I know the Sirona, you have CAD/CAM and GALILEOS, they mail out their own surgical guide, is that what you're doing?

Scott Menaker: I'm doing some of that and sometimes, depending on it, I'll have one made.

Howard Farran: If you have one made, who makes it?

Scott Menaker: There's a couple of implant companies, basic big labs and implant companies, Implant Innovations is one of them that I've used, and the others are sending it to Sirona as well for them to do it. 

Howard Farran: I also want to tell you about when you're talking about the mobile version or your app, I'm so old school. When I see my cellphone, to me, you know what I see, looking at that at 52 years old? I see my mom's refrigerator when I was a little kid, and my mom ran the entire household, me and my brother and 5 sisters, with magnets on the refrigerator, and she had a phone nailed down to the wall, and if she traded with you, whether it'd be the pharmacist, the school, the church, the orthodontist, all those magnets were on the refrigerator. 

That was her Rolodex, and now I see when these dental offices get an app on that smartphone, every time mom picks up that smart phone and is flashing through her apps, she's seeing your dental office, and she's seeing your dental office app without having you to pay money to have it on a billboard off the side of the road or printing paper and doing a direct mail piece that's coming to your mailbox or buying a full page ad in the Yellow Pages just in case she happens to flip through it. I think what you were talking about with those Touch Dentology, I don't care what the app did. The only thing the app did would just be visible on mom's smartphone, think of the mind share that would get, think of the impressions that would get over a 5 year period. Every time she's flipping through her app, she sees your dental office. Don't you think that's huge value?

Scott Menaker: Absolutely. If you think about it, we were looking at this to say most people, most patients, if they're healthy, they've been in your practice a while, they see you, they know who you are 2 hours a year. That's it. Other than that, they have no clue who you are, so the more time that we can get in front of them just reinforces one, that they're going to continue to come to you, but two, that they can refer others to you, they become loyal to you, they speak about it, and maybe more apt to move down the continuum in terms of something happens, they need more services, they're going to probably need more services, I want them to be mine, and it's just another opportunity to go from 2 hours to maybe 15 or 20 hours during the year that you're able to get in front of them, you're absolutely right. 

Howard Farran: You talked a lot about clinical dentistry, FAGD, implants, all that kind of stuff. What are the non clinical things that determine a dental office success?

Scott Menaker: It's one of the things that you speak a lot about in terms of your MBA courses, which is the business side. To me, the biggest thing I tell people is that numbers don't lie, people do. If you understand the numbers, they can work. 

Howard Farran: I love that.

Scott Menaker: I ended up buying out a partner many, many years ago, and as I was getting ready to buy, I almost got out of dentistry. I was so just unhappy with where I was at, but the partner that I was leaving, things that come up, he was leaving and my brother's accountant, his partner, senior partner went and talked to him and he said "Are the numbers good?" I said "Yeah, they're good," because I looked at the numbers that I had been given and he said "Are they good" and I said "Yeah," and so again, I said "Yes, they're good," and he looks at me again and he goes "Make sure the numbers are good," and I went and look at the numbers, I spent 4 or 5 hours really digging in the numbers, and the numbers weren't good. I found that it taught me a lesson and I spent a lot of time over my career, I enjoy the business side of things but I understand numbers. 

I track statistics. Not just for tracking them, but I want to know trends. Did we lose? Is our production down and why or are Panorexis, which typically may average 45 or so a month, if they drop down to 30, what's the reason? Are my hygienists getting lazy? It just allows me to be a better manager, and the only way that you can do that is if you understand your business, and so understanding the numbers, I taught that lesson very early on and it stuck with me, and I just encourage everybody, I don't care what field you're in, you got to understand what's going on because if not, the only time you recognize there's a problem is when you run out of money, and that's a bad place to be. 

Howard Farran: I know, I've talked about that in my new book, Uncomplicate Business. Over and over, you just manage people, time, and money, you make some and sell some, watch the numbers, and there's 2 things dentists don't look at: The money and they don't watch the numbers, and I want to ask you with your expertise, now that 5,000 kids just walked out of dental school last week, a lot of these kids listen to this iPod podcast aren't watching numbers, do you think it's a, with your expertise and 30 years in the business, do you think it's a personality trait that you and I just like business? Just like some people like sports, some people do not like to watch sports. Do you think you and I just like it or do you think if a dentist doesn't look at the numbers, they can learn to like or do you think just it is what it is or-

Scott Menaker: You can look at this one or two ways. Do you get on the dental practice or do you get on the business, and I think to all of them I'd say you own a business and if you own a business, you need to understand everything. You may not like it. I've got a partner that's been with me for 9 years. Trisha has no interest whatsoever or did not in terms of numbers. In this time period, she understands the numbers and she manages them well. She tracks her statistics, she looks at things, so I think you can teach somebody a lot of what's going on. Maybe not to the degree you and I may like, but enough that they could be very successful.

Howard Farran: Is she an associate or is she a partner.

Scott Menaker: She is a partner.

Howard Farran: She is a partner, but you had a earlier partnership that you didn't like and you had to buy that partner out, is that what you were saying?

Scott Menaker: He was going to move and was going to leave, I was very young into the dental world, and it was a pretty big practice. I basically bought him out and converted a 2 doctor practice to a 1 doctor practice for about 15 years.

Howard Farran: Are you married too?

Scott Menaker: I am. 

Howard Farran: I want you to talk about what's the difference between marrying a woman that you live with and have children with and all that versus marrying a dentist partner because every recommends getting married but the truth is half of them fail. Everybody recommends having a group practice and getting a partner and that's like getting married to a partner, but half of those fail and you had one that failed and now you have one that's 9 years successful. What pointers would you tell these 5,000 graduates who are there out applying for a job at some dentist office, and this dentist says to them, "Yeah, you know, I'll hire you and I'll pay X and blah, blah, and if it's all good after a year, then I'd like you to buy in and be a partner," and she just gas like "Oh my god, I want a job, I don't know if I would have married you and be a plutonic dental partner," talk about that difficult subject. 

Scott Menaker: Before Trisha became a partner, I added an associate, he went back, after 15 years of being on my own, I had an associate, he went back to school, I had another associate who I asked to leave, it just didn't work. Nice guy, we were just not on the same page, so it really became a matter of personality, of her understanding what was here, what my expectations were, what I really wanted from her, and so I think it's not a matter of, and in her case, this is what I would tell the 5,000. It's not about the money. Trisha was offered other opportunities that were going to pay her more, she felt like this was the right place, that I was going to teach her, I was going to nurture her abilities, and that we could make this thing work. 

When you get out of school, you want to be busy and you want to start making money because you've never made money before. You just got to make sure that it's not all about the money in the beginning because it'll be about the money at the end. Don't be short sighted. Find the right person who can mentor you and who really is interested in you, not a guy who's just going "I just need somebody who's breathing and who has a right hand and who can drill fillings and take out teeth." There's got to be something more than that. 

Howard Farran: Very good. Partnerships are tough because people are just so complex. Gosh, people are complex. They're more complex than what we'll even know. It's just amazing. If anything amazes me more and more each year is just how complex the human ... Every time you're reading research, like I was just reading some research lately that the scientists think that in schools, the kids are never going to retain anything until after 10 o'clock. They wake up, they're sleepy, they're not ... You know what I mean? Just amazing. They're saying that kids can't take in information longer than 15 minutes at a time, and if they're on caffeine, cut it in half to 7 and a half minutes. When you read the data about human beings, wow. 

I still think the most amazing thing that ever happened on earth is that a bunch of talking monkeys landed one on the moon and brought them back safely. To think that 7 billion talking monkeys, sitting in trees, eating bananas actually got Neil Armstrong to the moon and back is just like wow. People are just complex, and that could be the most expensive decision you ever made. You have a lover right now and you think she's great, a lot of dentists, the biggest financial disaster or biggest health problem they'll ever have is getting their finger cut in a wedding ring, and most of them is I know, the biggest disaster they've ever had in their dental office was marrying a partner or having a partnership, so whenever you're dealing with humans, it's crazy. 

Tell me, there's so many technological changes in our careers over the last 30 years. What do you think, and you keep talking about "To position yourself" which sounds like you position yourself away from insurance, away from that and to a high tech, high touch dental office. What technologies do you think a dental office needs today? You go to a dental convention, there's literally dozens of toys you can buy. What toys do you think dentists should have?

Scott Menaker: The first one obviously is a good practice management system that allows you to integrate everything into one place. The next one to me would be digital X-rays. 

Howard Farran: Stop back to the first one. What system are you talking about? What do you use?

Scott Menaker: I'm just talking about your practice management system. There's lots of good ones out there.

Howard Farran: Give names. What do you use?

Scott Menaker: We use PracticeWorks. The other big ones out there are Eaglesoft, Dentrix, they've all managed and they're now all owned by the bigger dental supply companies so that they can also start offering all of their other pieces. It used to be you got everything from different people, and now, you can literally ... You go to Patterson and get everything from your X-rays to your CEREC to your their X-ray system-

Howard Farran: But you called it a "Practice management system". 

Scott Menaker: Yes. 

Howard Farran: I think that is the biggest oxymoron term in the world because Dentrix from Shine and Eaglesoft from Patterson and PracticeWorks from, is that Carestream?

Scott Menaker: Yes, Carestream.

Howard Farran: They call it practice management software and the only thing it doesn't do is manage your practice. It doesn't do payroll, you can't pay your bills, in fact, when you buy Dentrix, it can't even generate a check to pay for Dentrix. You have to go buy other software, like Quicken, you have to buy other software just to buy their practice management system, and every time I hear those guys on their publicly traded stock of Patterson and Shine, and they're talking about all these numbers and their earnings and their price earnings, I just want to call it and yell, "Hey, I'm your customer. How come I can't get in to this data about my own damn dental office? Everything you talk about your company isn't even on your software." 

These dentists don't know they're over headed into the day, they don't know their payroll, the staff doesn't click on and click off on Dentrix or Eaglesoft or PracticeWorks after you use some payroll service or someone else. I still think I will go to my grave saying that the worst thing about every dental office is that these practice management systems never connected to an accounting software and no dentist out there knows their cost. You go stop any dentist in America who walks out of a room and say "Hey, you just did a MOD composite on number 3 and billed out $285. Did you make money or lose money?" They have no idea. "Oh, you just signed up for a PPO and they're going to give you this much for a filling. Do you know what your break even point is on a filling?" "No idea." "So why did you sign up for it?" "No idea."

That was brought to you by Patterson's, Dentrix, Eaglesoft, Shine, so anyway, I'm going to stop that rant there, but after a practice management software, what was the next thing you said? Digital X-rays. 

Scott Menaker: Digital X-rays, absolutely. 

Howard Farran: Why is that? Half the dentists listening to you are using film, and they're like "Come on, Scott. Film's cheap, it's low cost, it's made by Kodak. Why should I go buy, and I hear these sensors are like 8,000 bucks and if you drop them on the floor, they break." Why should they buy digital?

Scott Menaker: Obviously, we grew up in the ... Whether it was new digital and you took a small, little film, you held it up to the light, you maybe had a view box, this big, huge view box to put this tiny little X-ray to see what you could see. If you could see if there was a decay or there is an infection or something going on around that, and today, what digital X-rays did was, not the earlier versions, but certainly the later ones have allowed us to really become more diagnostic, you can change contrast, you can look at things, and you're looking at them on a monitor that just becomes much easier. Now for my end of things, it's 55 years old, reluctantly, I've been dragged down the street of I got to wear some kind of reading glass, so I can't hold up a film right here anymore and see it, I got to hold it at here, but the biggest change is being able to see things that I think I missed years ago.

I can manipulate it and I don't have to wait 5 or 10 minutes for it to come through it, and if it's not clear or she didn't get the angle right, I got to go retake it. You push the button, you walk back in. If you don't like it, the sensor's still in the mouth. Move it to a different place, take the picture. It's just changed and people appreciate the fact that it's less radiation, and then again, in their mind, they're making the decision about you, you're using something that's current, not something that they remember their dentist using 50 years ago.

Howard Farran: My biggest reason is its patient mastery. When we had a Kodak film, it was only 1 inch wide and we kept it in the chart, and that's doctor focused. Now with digital X-rays, you can print that thing out on a 8 by 10, get a red pen, draw all over it, and give it to the patient. Now they own their X-ray and knowledge, Henry Ford said it's not technology until it goes into the hands of the masses, and Kodak film was not technology because it stayed in our chart. Digital X-ray is technology because it goes home with the patient, so after practice management system, after digital X-rays, what else?

Scott Menaker: I think then you got to really start looking at one, you obviously have to be productive enough to look at, I'll call it "The CEREC system". I don't know if you want to put a lectured hand pieces in there, but they're certainly not air driven.

Howard Farran: Are you electric handpiece?

Scott Menaker: Absolutely.

Howard Farran: I want to ask you about that. How come when you go to Japan, they're all electric, and when you go to America, they're all air. How did 2 great countries go down such 2 separate roads on handpieces? 

Scott Menaker: Good question. 

Howard Farran: You've been in both. You've had air and now you're electric.

Scott Menaker: That was all there was. I went to electric when I just got fed up with my handpieces stopping. When I sit down, I like to step on the pedal and I like to go. Being faster, being less trauma, I'm not sitting there doing a 30 minute crown crap. I want to get in and do what I need to do, and electric has just been ... For me, it's a Godsend. 

Howard Farran: How long you've been on electric?

Scott Menaker: Probably 15 years. I started with KaVos, I know there's lots of good ones out there, but KaVo was a hit at the time and you could take a lot of things from me, you can't take my electric handpiece. 

Howard Farran: Yeah, and most dentists, the patient hates in a way ... You get rid of the noise, you get rid of all these blown turbines, but what's really cool about it is you have infinite torque. Push the burn to the tooth and have it stop. 

Scott Menaker: Yup, and that's what I was doing, and if you got a big office and everybody is opening up the compressor valves at one time, with an air driven, you won't be able to cut. You don't have that with electric, and if you want, certainly, you could turn your RPMs down, very simple to do.

Howard Farran: I'll tell you that it's so fun to go to different countries. I always think every time you hear an American badmouthing another country, about 110% of the time, they've never even been to that country. You know what I mean? I think the greatest education you can ever get is to get out of this country and go see other countries, and all the other countries chose electric and America chose the air driven, and it was a horribly bad decision, and we're still hanging on to it 100 years later for no good reason. 

Scott Menaker: I think at the end of the day, we have a tendency as dentists to be cheap about probably the important things and we'll waste money on the toy that just came out that maybe doesn't work, who knows without really understanding the purpose behind it.

Howard Farran: What other technology?

Scott Menaker: Obviously, CEREC to me has been a game changer for my practice and my patients. I don't have to make temporaries, my patients love the idea that within an hour and a half, they're in and out of my office and have a beautiful crown that fits as well, if not better than what I could send off to the lab and they don't have to wait 3 weeks to come back, so CEREC has been fun. From doing anteriors, posteriors, making in plane abutments, bridges, just getting ready to start doing some orthodontics with it with Invisalign and ClearCorrect now taking scan, everybody wants digital. Everything in this world is digital. Why are we being slow to embrace that one, and it's not about the money. I was telling the Patterson people for years, stop doing it on ROI, start talking about how it will impact the enjoyment that you'll get in your practice, and for me, that's been it.

I like designing crowns, I like showing patients as I'm doing it because it's fun, and they love the idea that I'm showing them what's going on and they understand it and they appreciate it, and then they don't mind paying me whatever I want to charge them.

Howard Farran: We are out of time and that is the perfect thing to end on is that your success is because you're having fun.

Scott Menaker: Absolutely.

Howard Farran: If you're not having fun, you got to start having fun. If that means buying a toy, if that means working on a different team, if you have fun, you'll like what you're doing, and if you like what you're doing, you'll get good at it and the money will naturally follow. On that note, thank you so much for spending your time with me, buddy.

Scott Menaker: Thank you, Howard.

Howard Farran: Thank you for all you do for dentistry.

Scott Menaker: Same to you.

Howard Farran: All right, buddy. Bye.

Scott Menaker: Bye now.