Dentistry Uncensored with Howard Farran

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Howard:

Welcome. This is a huge treat. I'm in Singapore in Dr. Gerald Tan's office, who is the president of the Aesthetic Dentistry Society of Singapore. Thanks for letting me come into your office today.

Gerald Tan:

You are most welcome, Howard.

Howard:

You're with your friend who is your Guru, because that's his name, Guru. I think that's the most awesome name I've ever heard. You're name is Guru ... How do you pronounce your last name?

Guru:

Othayakumar.

Howard:

Say it again.

Guru:

Othayakumar.

Howard:

Othayakumar. You graduated 2003, so 13 years ago, and you graduated, what?

Guru:

Three years ago.

Howard:

Three years ago, and you graduated from Adelaide.

Guru:

That's right.

Howard:

Australia, which being in Singapore is about what? Fifteen hundred dentists?

Guru:

Yeah, around about that.

Howard:

I've already met probably a dozen that graduated from dental school in Australia. That seems to be very common if to graduate from Australia. Tell me, Gerald, how did you ... Congratulations on being the president of the Aesthetic Dentistry Society of Singapore. What is that like? What's the study of dentistry like in Singapore these days?

Gerald Tan:

I study dentistry as a growing trend. We see a lot of people wanting to get their teeth look more pretty, so they are actively searching the internet for good cosmetic dentists. I think that there is a growing market for it, and that's why I decided to take part and volunteer in the society, and then after a few years of volunteering, I got voted in to be the president, so it's been great so far.

Howard:

What is cosmetic dentistry mostly in Singapore? Is that invisiline, is that bleaching, is that veneers?

Gerald Tan:

Yeah, a bit of all the above. It depends on the case. Generally speaking, patients have a rough idea of what they want, but they have no idea of what is possible, what treatment that they possibly could get to achieve that result that they may want. They come in for a consult and an exam, and then we just recommend according to what we see and according to what they want.

Howard:

Do you do more ortho, do you do more veneers?

Gerald Tan:

Both, yeah.

Howard:

Ortho and veneers?

Gerald Tan:

Ortho, veneers, whitening, bondings, changing out old amalgams. Those are really common requests. [inaudible 00:02:56] closures, the whole range of different things. Not dissimilar to the aesthetic demands of an average American patient, for example. American patients just want it really bright and white, but Asian patients don't really want to overdo the whiteness of their teeth. They still prefer to have a tinge of yellow.

Howard:

Yeah, I've noticed since I've been here. I haven't really seen anybody with the B1 or the toilet bowl ...

Gerald Tan:

Extra bleach white? Yeah.

Howard:

Kitchen sink bleach white. I don't think I've seen anybody, really, with that shade. It seems like most countries are more into natural shades. America seems to be the queen of the toilet bowl.

Gerald Tan:

Yeah. B1's, extra bleach whites. Yeah.

Howard:

Yeah. Is your orthodontic tend to be more fixed bands and brackets or does it tend to be more removable clear liners?

Gerald Tan:

Both, yeah. It depends on, again, the patients' wishes and needs. We offer both fixed as well as clear aligners. Of course, the top brand here would be Invisalign.

Howard:

What do you personally like better to achieve your results?

Gerald Tan:

Fixed braces, yeah.

Howard:

Because why?

Gerald Tan:

Because we get better fine control over the tooth movement and I feel that it's not as finicky as the clear aligners. Sometimes it's not as predictable as the fixed arch wire kind of braces.

Howard:

What about patient complaints?

Gerald Tan:

Patient complaints, as long as you manage their expectations right from the get-go, it's not such a huge issue.

Howard:

With removable ...

Gerald Tan:

With ...

Howard:

I mean, with fixed bands and brackets the dentist is in control of the compliance. With clear aligners, the patient is in charge.

Gerald Tan:

Yes. Yes, of course.

Howard:

Do you find longer, treatment compliance, longer treatment times, treatment lengths when the patient is in control of being able to take the liners in and out?

Gerald Tan:

Well, anecdotally, yes, but I take a lot of time and effort to sit down with the patient before treatment to ensure that the patient understands that a certain amount of discipline is required, if they would so chose to have a clear aligner. If I feel that this patient is not going to be cooperative or this patient is unable to have that certain level of discipline, I would just say, "You know what? You're probably not suitable for this," because it's a huge headache if patients don't comply and then they don't understand and then they complain, "Why is this taking so long?" You know? The treatment planning stage and the informed consent stage is so very important in my office.

Howard:

I want you to talk more about the orthodontic needs in southeast Asia because America is about six percent Asian. It's about 15 percent African Americans, 15 percent Hispanic, the other half is European. Asians have a different mix of orthodontic treatments than, say, people from Europe. Would you agree?

Gerald Tan:

I would.

Howard:

What tips could you give Americans where you do more ortho on Asians? Is there any more tricks, lessons learned? Because you probably have done more Asian orthodontic cases than a 60-year-old orthodontist in America.

Gerald Tan:

Yeah, for sure. Generally, from my experience Asian patients are not as demanding and not as difficult as some of the Caucasian patients that I've seen. I really don't know why. When an Asian patient has made up their mind that they want ortho done, they usually set their mind to having the discipline to finish. I just can't explain it. Maybe it's just the culture here.

Howard:

That would be the psychological part.

Gerald Tan:

That's the psychological part.

Howard:

I mean the Asian bimaxillary protrusive, and you treat more ...

Gerald Tan:

Yeah, a little more bimax protrusion cases, a lot more class 2, [DF 00:07:29] 1 and 2 cases. Not so many class 3. Would you say you see a lot of class 3? Maybe once in a while, but more class 2 cases, yeah?

Guru:

We've got a lot of bimaxillary protrusion. I think if you compare it to the Australian population, I think I see more class 3's here and a lot of orthognatic surgery with ortho, I think, just from some of the national institution here.

Howard:

There's lot of orthognatic surgeries done in Singapore?

Guru:

Yeah, for ortho, I would say.

Howard:

For class 3's?

Guru:

Mm-hmm (affirmative).

Howard:

Are those usually treated successfully?

Gerald Tan:

I would say so, yeah.

Guru:

Yeah, I would say so. Yeah.

Gerald Tan:

Most of these cases are treated in the government hospitals, in the big hospitals. We hardly see big orthognatic cases done in private practice. They will go to a huge government hospital, and an oral surgeon working there wold take over the case together with the orthodontist.

Howard:

When your elite dental group and being president of the Aesthetic Academy, do you also do endo or pediatric dentistry? Do you do [inaudible 00:08:50] or do you just try to focus on cosmetics?

Gerald Tan:

Yeah, I focus on cosmetics. We have a teamwork approach in our office, so our associates, like Dr. Guru, would handle, for example, the endos. I've made a choice not to do any endos because I really dislike endos, so I pass all the endo cases to Dr. Guru, and Dr. Guru, maybe he dislikes surgery, so he passes all the surgery down to me. We have a teamwork kind of approach here.

Howard:

You're doing more surgeries?

Gerald Tan:

I do a lot of surgeries.

Howard:

For implant placement?

Gerald Tan:

Yeah, implant placement.

Howard:

What system are you placing?

Gerald Tan:

Megagen, Straumann [crosstalk 00:09:37]

Howard:

Why is that? Why Megagen? Straumann? You said Straumann, too? Straumann bought a chunk of Megagen, right?

Gerald Tan:

Mm-hmm (affirmative).

Howard:

Do you know how much?

Gerald Tan:

I don't know how much, but I know Megagen is partly owned by Straumann.

Howard:

Yeah. Why do you use Straumann and Megagen?

Gerald Tan:

Well, we have two different systems. We have two different systems, and we offer two different systems to our patients because we see a whole range of different patients, and some patients are a bit price sensitive, so they would ask if we have a cheaper implant system so that they simply don't have to pay so much. The Straumann system that we offer is the high end ones for patients who want the best, and then Megagen would be a cheaper alternative for patients who are a bit more price sensitive.

I like Straumann and Megagen because I'm comfortable dealing with it clinically. I've been for the courses, I know the suppliers, we have a great relationship, and the price is right, too, for my office.

Howard:

Have you ever been to Seoul, Korea to see the Megagen [crosstalk 00:10:48]

Gerald Tan:

I have, yes. I have.

Howard:

You have? Really? How far of a flight is that from Singapore?

Gerald Tan:

I travel with Tommy and Andy.

Howard:

Right. How far a flight is Seoul fro here?

Gerald Tan:

I forget. I think seven hours maybe.

Howard:

Okay. Long way. How was that?

Gerald Tan:

That was fun, yeah. That was fun.

Howard:

Fun times? I'm so excited the rest of my life when someone asks me, "Who is your Guru?" I'm going to say, "Guru." His name is Guru. Your mom named you after the Guru? After the  term?

Guru:

Well, my parents back in the day were pretty superstitious. I think with Indian people ... You can calculate with Indian numerology what name you should give and stuff like that.

Howard:

Seriously?

Guru:

Yeah, yeah, yeah. They ended up with Guru.

Howard:

I never even knew anybody was named Guru. Sorry, Ryan, I did not think of that when I named you.

Guru:

It's not an uncommon name in India, I don't think.

Howard:

It's not an uncommon name in India?

Guru:

Yeah, it's not uncommon. Yeah, there are a fair few people called Guru, I think.

Howard:

How do you divide it up, then? There's two of you working here. You do the surgeries, you do the cosmetics. You do endodontics?

Guru:

Yes. Obviously, he's patient based, and then I've got my patient base as well, and so obviously aesthetic stuff as well. I'll do it. [crosstalk 00:12:09]

Howard:

You kind of have separate patient bases or do you guys both work on the same patient or ...?

Guru:

We do sometimes, as in for surgical cases, like big surgical cases I'll refer to Dr. Gerald, and then for some of his endo cases, it will be mine, but then if it's aesthetic cases, he's got his own aesthetic cases. I've got my own aesthetic cases. We've got separate cases as well, but sometimes we do cross over when ...

Gerald Tan:

We help each other out.

Guru:

Yeah, we help each other out.

Gerald Tan:

Yeah, we help each other out. The patient feels good because patients can see that they've got several dentists looking after them, and patients appreciate that we have a joint consultation with myself and Guru in the room together with the patient, if patients feel that they're being cared for by two or three different other dentists. We also have visiting consultants, visiting specialists that come on an ad hoc basis. When we need them, they'll come.

We have a visiting prosthodontist. We have a visiting oral surgeon. We have a visiting anesthetist. In Singapore ...

Howard:

Anesthetist?

Gerald Tan:

Yes, anesthesiologist? Anesthetist.

Howard:

You put them to sleep?

Gerald Tan:

Mm-hmm (affirmative). We have a licence in our office for intravenous sedation. We do offer nitrous, but a lot of times, from my experience, this is anecdotally, for a big case, nitrous is simply just not enough. Patients would rather be put to sleep. We work with a very talented anesthetist. He comes in. He sets up a drip. The patient drifts off to sleep and I do my think. The anesthetist will sit and observe and watch the patient's vital signs as I'm doing the surgery, whatever I need to do, and when I'm done, the anesthetist will wake the patient up, and then he leaves. Great. I love this system. That's something that we offer, too, in our office.

Howard:

Is that [crosstalk 00:14:05] word of mouth referral practice builder, word gets out [crosstalk 00:14:10]

Gerald Tan:

Yeah, I would say so, yeah. I have identified that the main issue that people have in Singapore visiting the dentist is dental anxiety. I initially thought it was cost, but when I did a survey, the number one reason why people don't go to see the dentist here, from my experience, is anxiety, fear. Irrational fear of the dentist.

The second issue that people have is convenience. People don't go to see the dentist because it's inconvenient for them to see the dentist. Is the dental office near train station, for example. Is the dental office open in the evenings or at nights? Is the dental office open during the weekends? Because most people work from 9:00 a.m. to 6:00 p.m. and they're only free to see the dentist after 6:00 p.m. Most people take a bus or take a train, and it would be great if the dental office is right next to a train station. If the dental office is far off, they say, "Aw, it's just too inconvenient to see a dentist."

We're located at this area where it's really easy for patients to come by train or by bus, and for those patients who drive, we've got really good, ample car park space so they can just park their car and take the lift up. So convenience, dental anxiety top two, and the third one is price. "Too pricey to see the dentist."

Howard:

What percent of Singaporeans use care versus public transportation, train, bus?

Gerald Tan:

I have no idea, but if I were to make a guess, it would be 10 percent.

Howard:

Ten percent what?

Gerald Tan:

Of Singaporeans drive.

Howard:

Ninety percent take public transportation? Yeah, I've noticed that most people don't use a car. Correct?

Gerald Tan:

Mm-hmm (affirmative).

Howard:

Ninety percent?

Gerald Tan:

It's very, very expensive.

Howard:

Explain the car situation. You have to buy a license?

Gerald Tan:

You have to buy a license to buy a car.

Howard:

How much is a license, usually?

Gerald Tan:

It's a Certificate of Entitlement. That's what they call it. Certificate of Entitlement. It's a COE. That certificate entitles you the privilege to buy a car.

Howard:

How much is that?

Gerald Tan:

It ranges from 50 thousand to 100 thousand Singapore dollars just to get that certificate.

Howard:

Then when you buy a car, you can only keep it for ten years and then you've got to ...?

Gerald Tan:

Not quite. You can keep it for ten years, and then after ten years you've got to buy another certificate to extend that privilege of owning the car for another ten years.

Howard:

What was the logic behind ... Singapore's logic to have 90 percent of the public ...?

Gerald Tan:

Our transport minister thinks that because Singapore is such a small country, they want to control the vehicle population. They don't want to create a city like [Jakarta 00:17:09], like Bangkok where you've got too many cars and everyone's stuck in a jam all the time, so they thought it would be a brilliant idea to tax the people so only the rich people can drive.

Howard:

Singapore doesn't have natural resource, doesn't make it's own gas or oil, right? You have to import all the gas.

Gerald Tan:

Our natural resource is our people.

Howard:

Do you know many other dentists that are doing IV sedation? Is this ...

Gerald Tan:

I do.

Howard:

Is it very common? Out of 15 hundred dentists in Singapore, is this very common or ...?

Gerald Tan:

Well, you're sitting in the Orchard Road belt. This is the main central activity hub of all of Singapore. That's like the Rodeo Drive of Singapore. You're sitting in this stretch right now. All the top dentists are here. Most of the top dental offices in this belt, in this street, do offer that option of intravenous sedation. The further out you go to the smaller suburbs, you get smaller clinics and they don't offer that.

Howard:

I heard all the gurus were on this street.

Gerald Tan:

Yeah. That's right. Yeah.

Howard:

You said anxiety was the number one. Convenience was number two. What are your hours?

Gerald Tan:

We open our office at 8:30 in the morning until about 6:30 at night, in the evenings. Saturdays we open from 8:30 to about 1:30 p.m. We close on Sundays.

Howard:

How many hours do you work a week?

Gerald Tan:

Oh gosh. I work those hours. From ...

Howard:

How many is that?

Gerald Tan:

I forget. It's eight hours a day, so that's 40, maybe 45 hours a week.

Howard:

Is it 45?

Gerald Tan:

Forty-three? Five and a half, yes.

Howard:

Figure it out.

Guru:

That's about right.

Gerald Tan:

Forty-five, yeah.

Howard:

I find it very interesting in southeast Asia that most dentists work 45 to 52 hours a week.

Gerald Tan:

In the US it's 32, right?

Howard:

When you go the United States, I say, "Well, what is your big problem?" They go, "Well, I've got 350 thousand dollars of student loans and I bought a practice for 600 thousand and a house for 600 thousand and I'm 25 years old and I'm a million dollars in debt and I'm stressed out of my mind." I say, "Well, what are your hours?"

"Monday through Thursday, 8:00 to 4:00." It's like, "You don't even have a full-time job." Then when you say to the American, "Well, maybe one way you could make a lot more money is you could work like an Asian and instead of working 32 hours a week ...

Gerald Tan:

It's a culture here in Asia.

Howard:

... you could work 52 hours a week."

Gerald Tan:

We work really hard yeah.

Howard:

They immediately say, "Well, no. I want to work smarter, not harder." The last thing an American wants to hear, "Is you know what you ought to do? Why don't you just work five and a half days a week?" When I opened up my practice, I opened up in 1987. I opened up 7:00 to 7:00 Monday through Saturday and I did it for a decade, but I paid off all my bills. I saved up a million dollars. All that stuff like that, but it's just hard to get ... Why do you think every other dentist site ... Everybody I meet in Singapore works 45 to 52 hours a week and in America they work 32? Why do you think that is?

Gerald Tan:

I think it's part culture. In Asia all of us have this culture of being really hardworking. We just simply just do not want to lose out. We just want to work hard, like you said, clear our debts, and being men, I suppose, we have to upkeep that image of being the breadwinner for the family, and for us who are privileged enough to own a practice, like you and me, this is our baby. We get consumed by it. Naturally, we think about our practice day and night because we want to work in it and we want to build it up. We want to build a goodwill. I cannot imagine any practice owner not wanting to work hard to build up the practice.

Howard:

I want to ask another thing. Do you think it's an advantage or disadvantage that there's not insurance in Singapore, because you practice next to Australia and New Zealand, which is huge, a lot of dental insurance. Everybody knows that the United Kingdom, their NSH pays very, very low and America is, I think, last I read in American only three percent of dentists don't take insurance. Do you wish Singapore had dental insurance or are you glad ...

Gerald Tan:

We actually do. We actually do have dental insurance.

Howard:

It's not a big part of your ...

Gerald Tan:

It's not a big part, but we do. We do have dental insurance.

Howard:

Talk about dental insurance. What's dental insurance like in your practice in Singapore?

Gerald Tan:

Well, the individual Singaporean person is not able to buy individual dental insurance plans. However, if you are a business owner, you can purchase dental insurance plans for your entire company, for all your employees. Those companies who have employees that enjoy dental benefits by way of their bosses buying for them dental insurance plans, they can go to dentists in a approved list and get dental treatment done and paid for by the insurance companies.

Howard:

Is it very common, though?

Gerald Tan:

It's getting more and more common.

Howard:

What percent of your patients have dental insurance?

Gerald Tan:

Thirty?

Guru:

Thirty.

Howard:

You think 30 percent?

Gerald Tan:

Seventy percent private paying patients but 30 percent insurance.

Howard:

That's the highest percent that I've met so far. Most of the dentists I've met so far say that it's under five percent. Like ...

Gerald Tan:

In Singapore?

Howard:

Yeah. So far of the dentists that I've talked to. They say it's about five percent, but you're ...

Gerald Tan:

My office is quite new. I just created this office less than two years ago, so for new practices, it does make sense to work with insurance companies just to build up that patient flow, especially when we're in a mall, like this, we're in the seventh floor. We hardly get any walk-ins. Not like today's dental is a huge building all by itself. The visibility is high. Patients see your practice and they just walk in. We hardly have any walk-ins, so we really depend on tie-ups with insurance companies just to get that flow, that initial flow. Once we've built th goodwill, we start to taper off with the insurance.

Howard:

I like to talk about things that are different with your country versus others. Talk about your advertising roles in Singapore versus, say, Australia or the United States?

Gerald Tan:

The Singapore government, or more specifically the Ministry of Health here, has set out a set of very, very strict publicity guidelines. I'll just summarize these guidelines for you. We're not allowed to have before and after photos in any of our marketing material. We're not allowed to have celebrity endorsements in any of our marketing material. We're not allowed to have patient testimonials, whether it's a good testimonial or a good review or whether it's a bad review, all reviews are against the law.

Howard:

A patient can't leave a Google review?

Gerald Tan:

No. It's against the law.

Howard:

Google doesn't not allow reviews, then?

Gerald Tan:

Google allows patients to write the review, but the responsibility of the owness is on the practice owner or the dentist to ensure that patients don't put reviews up on Google.

Howard:

If one of your patients left and said, "I really like you," and put a nice review, then you would try to contact that patient to take it down?

Gerald Tan:

To take it down, absolutely right.

Howard:

Seriously?

Gerald Tan:

It's ridiculous. It's ridiculous.

Howard:

Wow. Now, on your private website can you put before and after pictures?

Gerald Tan:

No.

Howard:

No?

Gerald Tan:

No.

Howard:

In a way, that just means that you can't rely on external advertising. You have to do internal.

Gerald Tan:

Internal, yeah.

Howard:

Then what do you do to build a practice since you're not allowed to do external, direct mail, fliers and all that?

Gerald Tan:

We have patient referral programs. We have a robust system to thank our patients for referring to us. We're currently building on it to try and improve on it. Maybe you can give me some tips. We feel that building the office goodwill by way of word-of-mouth referrals is the strongest and best way because our business is built on trust.

Like you correctly said in your lecture yesterday, patients who get referred to us by existing happy patients tend to spend three times more than those patients that have seen us, got to know us through a magazine or for a website or fancy article somewhere in the papers or whatever, yeah. We get a lot of shoppers, dental shoppers. They see an advertisement and then they call and make an inquiry, but they're not so serious about making an appointment. Do you have experience with those kind of patients?

Howard:

Oh, all day long.

Gerald Tan:

Oh, I'm sure. Yeah. I've tried. I've tried and tested spending a huge amount of money on fancy advertisements and ...

Howard:

I thought you just said you can't really advertise.

Gerald Tan:

We can, but to a very limited to degree. We can have a fancy advertisement with a fancy tagline, but we cannot advertise promotions, like, for example, discounts. We cannot use [lodgitary 00:27:47] terms like, for example, I cannot say, "I'm the most gentle dentist in Singapore." I cannot say, "I'm the most famous celebrity dentist in Singapore." I cannot say, "I'm the cheapest dentist in Singapore," whereas in the US you can make such claims, right?

Celebrity Hollywood dentist. You can say whatever you want about yourself, but if you dare to make that claim, you better live up to that expectation, right? In Singapore, because our Ministry of Health wants to create a level playing field, they have all these restrictions. A level playing field between the smaller boutique offices like mine versus the big chains, but there's only one big chain. There's only one Aspen in Singapore.

Howard:

There's an Aspen Dental in Singapore?

Gerald Tan:

No, no, no. I'm just saying an Aspen equivalent.

Howard:

What is the name of at one?

Gerald Tan:

Q&M.

Howard:

Q&M, right.

Gerald Tan:

Yeah, Q&M.

Howard:

Then in Australia it would be 1300 Smiles and Pacific Dental?

Guru:

Yeah.

Howard:

Pacific Dental?

Guru:

Yeah.

Gerald Tan:

Aspen is what? One hundred and fifty practices now?

Howard:

In the United States?

Gerald Tan:

What is it? No? Aspen?

Howard:

Oh, Heartland has 15 hundred.

Gerald Tan:

Okay.

Howard:

Heartland has 15 hundred. I think Pacific Dental Services is Steven Thorne, I think it has 500 Comfort Dental [inaudible 00:29:05]

Gerald Tan:

I met those guys. I've met those guys a Marc Cooper's ...

Howard:

Yes.

Gerald Tan:

... course.

Howard:

That was in Scottsdale. My God, you should've came over my house.

Gerald Tan:

I should have.

Howard:

I was ten minutes away form there.

Gerald Tan:

All of those big boys? Yeah. They came to attend the seminar.

Howard:

I loved Marc Cooper more when I heard about your story because he won't let anybody in there unless you're [crosstalk 00:29:22]

Gerald Tan:

Actually, Marc is coming in April, so I will be hosting him in April.

Howard:

The only reason he let you in there is because you weren't an American and he probably thought it was not proper to tell someone from southeast Asia that "You can't attend my seminar." He probably just couldn't say no to you.

Gerald Tan:

Probably.

Howard:

If you lived in Phoenix, Arizona and you didn't have more than one office, he would've told you, "Absolutely no." He just took you under his wing. That makes me like Marc Cooper even more.

Gerald Tan:

You know him well, don't you?

Howard:

Sure. What about technology? Do you use any specific technologies in your office that you're fond of?

Gerald Tan:

Yeah. Well, technology, all our fancy, shiny toys are really, really expensive in Singapore.

Howard:

What fancy, shiny toys did you buy?

Gerald Tan:

Well, I just bought a CBCT and all the new dental chairs, and all the software is expensive. The x-ray software is and all the computer hardware is expensive. There's a huge capital startup cost ...

Howard:

What CBCT did you go with?

Gerald Tan:

Vatech.

Howard:

Vatech?

Gerald Tan:

Yeah.

Howard:

V-a-t-e-c-h? Out of ...

Gerald Tan:

V-a-t-e-c-h.

Howard:

South Korea?

Gerald Tan:

Mm-hmm (affirmative).

Howard:

There's a couple CBCTs out of Korea, isn't there or is it just mostly Vatech?

Gerald Tan:

There's a Samsung one as well.

Howard:

Is there a Samsung one?

Gerald Tan:

There is a Samsung one. Samsung is starting to diversify into medical imaging.

Howard:

Are they selling a unit now?

Gerald Tan:

Mm-hmm (affirmative).

Howard:

You looked at the Samsung and the Vatech and you went with Vatech?

Gerald Tan:

Mm-hmm (affirmative).

Howard:

Just intuitively you'd think Samsung would probably beat anybody because they're such a powerhouse.

Gerald Tan:

You'd be surprised. Samsung is pretty new to the medical imaging game.

Howard:

You like Vatech better.

Gerald Tan:

Yeah, because they've been around for a while now, and this customer service is very good. Anything wrong with my CBCT, I call the ...

Howard:

How much was your CBCT?

Gerald Tan:

A hundred thousand Singapore dollars.

Howard:

A hundred thousand Singapore. So ...

Gerald Tan:

How much does it cost in the US?

Howard:

What would that be in US dollars?

Gerald Tan:

Eighty?

Howard:

It would be 80 thousand US?

Gerald Tan:

Mm-hmm (affirmative).

Howard:

It'd be 100 thousand Singapore. Yeah. Yeah, a CBC ... Let me tell you this [inaudible 31:33]. Some people say that CBCTs are like Samsung smarphones or iPhone smartphones, that you wouldn't want to own your smartphone for 10, 20 years because every three or four years the technology is so much better you want the new one. Did that ...

Gerald Tan:

We have a trade-in program here.

Howard:

Oh, you have a trade-in program? Okay, explain that.

Gerald Tan:

Well, if there's a new model that gets released, we get to trade-in this CBCT for a secondhand value and then we just top off the difference and get a new machine.

Howard:

Is the trade-in value already calculated or ...?

Gerald Tan:

Well, no. It's not really ... According to the condition of the machine at that time.

Howard:

That's a nice solution because that's the number one concern I hear about CBCTs is price. It's 100 thousand bucks, and number two is "I don't want to own my iPhone for 20 years."

Gerald Tan:

Well, there's a secondhand market for CBCTs.

Howard:

Fantastic.

Gerald Tan:

Sometimes you get a small office down in the suburbs who want to buy a secondhand CBCT, so the suppliers will help to match ...

Howard:

You bought the CBCT pretty much only for implants or anything else?

Gerald Tan:

Implants, wisdom teeth. Yeah, mostly for implants and wisdom teeth. Mostly, primarily. Yeah. Then the odd cyst.

Howard:

Whenever you pull out all four wisdom teeth, do you ever tell the patient, "Hey, we pulled out all the four wisdom teeth. Do you want us to pull all the dumb ones out too?"

Gerald Tan:

No, we don't do that.

Howard:

Stupid joke. Stupid joke. Any other technologies? Are you into lasers or CAD/CAM or any of that?

Gerald Tan:

Yeah, I wish I could, Howard, but it's just too cost prohibitive for me right now as as new office. I wish I could have all those bright, shiny toys right from the get-go, from the beginning, but that's just too cost prohibitive.

Howard:

Do you think they're necessary?

Gerald Tan:

Personally, I don't think so because patients never ask.

Howard:

Right.

Gerald Tan:

Patient never ask. They don't really care. They never ask, "Is your dental chair the latest 2016 model? Is your handpiece the latest 2016 model?"

Howard:

I would say 80 percent of all the millionaire dentists that are my friends in the United States don't place implants, don't have CAD/CAM, don't have a laser, don't have a CBCT and don't even ...

Gerald Tan:

They're really good with people.

Howard:

... and don't even do molar endo.

Gerald Tan:

They're really good with people.

Howard:

Yeah, they just do fillings and grounds. I think the most money you'll ever make is with a high-speed handpiece.

Gerald Tan:

I understand that. In my office we really focus on building a culture of connecting with our patients. We're in the business of treating human beings. It just so happens that coincidentally a tooth is attached to you. We treat you as a human being. Fixing a tooth is a given.

Howard:

By the way, Ryan, I'm going to have to say on this podcast, these two dentists have the two best heads of hair in all of dentistry. I don't think I've ever seen this good of hair in dentistry. Have you, Ryan? Can you think of anyone we ... We've done 350 podcasts and you have the best hair of all.

I want to ask another difference that we hear sometimes. We always hear in American, which uses hardly any glass ionomer, that there's just so much more glass ionomer used in Australia and New Zealand. Do either of you use glass ionomer in your practice or it mostly resin?

Gerald Tan:

Mostly resin?

Guru:

Yes.

Howard:

You like glass ionomer.

Guru:

Yeah.

Howard:

You don't.

Gerald Tan:

I like resin.

Howard:

Talk about glass ionomer because most of your viewers, probalby 83 percent of the people listening are Americans and most of them never use glass ionomer. Talk about glass ionomer.

Guru:

Difference selective applications, I feel. With glass ionomer, it's not very strong, but I like to use it as a base.

Gerald Tan:

It's a very forgiving material.

Guru:

Yeah. I like to use it as base so I don't have to use as much composite to avoid the shrinkage and stuff like that If I have a very big cavity, I like to put glass ionomer, either Fuji, mine are Fuji II first, and the later with composite. There's less [curing 00:35:50] and stuff.

Howard:

Is Fuji made by GC?

Guru:

Yep.

Howard:

Did the just move their headquarters from Tokyo to Switzerland? Correct?

Gerald Tan:

I forget.

Guru:

I'm not aware.

Howard:

How come he uses glass ionomer and you don't?

Gerald Tan:

I'm a bondadontist, so if I see dentin, I'm going to bond it. It's just a different school of thought. There's no right or wrong. Sometimes ...

Howard:

Now, could this be because you graduate from Singapoe and ...

Gerald Tan:

It could be.

Howard:

... and he graduated from Australia?

Gerald Tan:

It could be. I go for a lot of courses in the US. If I see a huge cavity, I'm going to bond it and probably do an inlay. I'm going to try to indicate for an inlay or onlay. I'll bond it inaly or onlay. I don't really fiddle around with glass ionomer for huge cavities.

Howard:

Would you say you're glass ionomer is because you went to dental school is Australia?

Guru:

I think yeah. I think Australia is more GIC pro than overseas.

Gerald Tan:

Glass ionomer has a space. It has it's space.

Guru:

Yeah, I think ...

Howard:

It has it's place, just not in your hands. It has it's place, mainly in his hands.

Guru:

I think it depends on the case, though. If it's large enough for, as he said, like a ceramic inlay or onlay, it would be a ceramic inlay. I've got no hesitation. It just depends on what I'm seeing at that point in time.

Gerald Tan:

Yeah, but sometimes patients just don't want to have ... They cannot afford to have an inlay, patients are in a huge hurry, they've got to leave in ten minutes and say, "I've got to get this filling done. I only have ten minutes. Just do your best. Whatever you can in ten minutes. I've got to go." Just squish some Fuji IX in there and tell the patient that this will probably hold for a couple of years and then you've got to change it out to a more definitive restoration. It just depends on the case.

Howard:

I'm going to ask you ... The United States about, basically, 125 thousand full-time general dentists, 30 thousand full-time specialists, about 25 thousand part-time dentists. It's basically at about 175 thousand licensed dentists and almost twice that many, 400 thousand hygienists. I noticed Singapore just started their hygiene program their oral health therapist program in 2003. First graduating class is 2006. Do you guys use a hygienist to do cleanings or do you do the cleanings yourself and what is the state of hygienist and oral health therapist in Singapore?

Gerald Tan:

In the Rodeo Drive of Singapore, Orchard Road, where we are, patients are very spoiled. If we try to introduce a hygienist in the office, they would probably say, "Woah, woah, woah, woah. I want the doctor to do everything. I'm just not used to having a hygienist," unless, of course, the patient is from America where they're used to having a hygienist do the cleanings first and the oral hygiene instructions. I think in America the hygienist would take the PAs and the x-rays as well?

Howard:

Sure.

Gerald Tan:

Yeah?

Howard:

Yeah.

Gerald Tan:

Patients in this stretch of town, in the Rodeo Drive of Singapore, they say, "I would rather pay more to have the doctors see me from start to finish. I don't want to see the hygienist." From my experience, we try to have a hygienist in the office, but our patients just don't want to see the hygienist. They say, "Oh, I would rather not. I'd rather have Dr. Tan do the cleaning for me. I don't mind paying a little bit more for Dr. Tan to see it. I'd rather not have the hygienist."

The hygienist are disillusioned [inaudible 00:39:51], so they get very frustrated. I've interviewed a couple of hygienists and they say they go to fancy clinics in town and they want to see patients, but patients just refuse to see them. It takes a while, like Dr. [Wang Chu's 00:40:07] office. It took him a while to successfully integrate that hygienist in his office. It took him a long while. You can ask him over dinner later. In the beginning patients just didn't want to see the hygienist. He almost had to turn patients away and say, "Well, if you're not going to see the hygienist, I'm not going to see you either. Just go find another practice." That takes a lot of balls. Yeah, that takes a lot of guts.

Howard:

Do you like doing cleanings?

Gerald Tan:

I dislike doing cleanings.

Howard:

You dislike doing cleanings?

Gerald Tan:

Yeah, but you know what? In the future, if our appointment books are just overflowing with so many patients and we're just having business out of our ears, I may take that brave step of getting a hygienist in and making that decision, from now on, even for my old patients, my good old friends, even if they want to see me for a cleaning, I have to say, "I'm sorry. No, don't do cleanings anymore from today onwards." That takes a lot of guts. That would piss people off. That would piss patients off, especially your old friends who have been seeing you for many years. You've got probably your high school buddies who see your for cleanings. I don't know how to handle that transition. Maybe you could give some advice.

Howard:

I'm so old, all my friends are dead. What about you? Do you like doing cleanings?

Guru:

Yeah, I'm okay with cleanings. I like to talk to patients when you're cleaning, so I'm okay with it, but just going back on the point with the hygienist, like America versus Singapore, I think the role of the hygienist in America is much more expanded than what it would be in Singapore. Even nurses over there. The nurses, they can do ... I think they can do some amount of clinical work.

Gerald Tan:

They can take impressions, right?

Guru:

The nurses ... Can they cut cavities? Are they just hygienists?

Howard:

The United States is a very confusing market because it has 50 states and all those laws are made at the state level, so they very from A to Z.

Guru:

Yeah, yeah.

Howard:

Some states a dental assistant cannot do anything but suction. Other states they can literally place fillings.

Guru:

Yeah.

Howard:

In Kansas, the dentist would give a shot and drill the cavity, and then the assistant could come in and put in the matrix and put in the amalgam or composite and take impressions. Basically an expanded function duty assistant can do anything that's not irreversible.

Guru:

Yeah.

Howard:

The dentist just removes tooth structure, but in other states ... If you're talking about America, you have to name the state and every one of them is different. I want to name you another bias I've heard in Singapore, and I don't know if my sample size was big enough, but it seems like most people in Singapore, most dentists don't like to do molar endo. Ryan, have we met anybody that said, "I love molar endo"?

Gerald Tan:

Guru likes it.

Howard:

Yeah, I know, but that's why I'm bringing this up. I don't think ... Do you love molar endo or is it just tolerable?

Guru:

No, no. I really like it.

Howard:

Yeah, you're the first person I've met in Singapore that said they love molar endo or really like it. You say you hate it. I almost wish I could survey all 15 hundred Singapore dentists and compare that to everyone in America. Do many of your peers like it or do you kind of stand out alone in that field?

Guru:

I wouldn't say all of them like it, but it's not as if all of them hate it either. I guess maybe about ... A couple of my peers really do like it, but I can see why molar endo is not something that most people like because ...

Howard:

Why is that? Why do you think most people wouldn't like it?

Guru:

Time, complication rate. Yeah, I think it's just the return of investment.

Howard:

It's finicking around at things that you cannot see.

Guru:

Yeah.

Howard:

Could it possibly be a low reimbursement rate? How much money do you get for a crown? How much money do you get for molar endo?

Gerald Tan:

We get about a thousand to a thousand five for a crown.

Howard:

A thousand bucks?

Gerald Tan:

On average for a crown [crosstalk 00:44:17]

Howard:

What do you get for a molar endo?

Gerald Tan:

Anywhere from 800 to a thousand two.

Howard:

So it's about the same price.

Gerald Tan:

About the same.

Howard:

So it's not money.

Guru:

It could be the molar endo also takes longer to do.

Gerald Tan:

The prices that I just told you is on this Rodeo Drive belt. The further out you go, if you have a brave dentist in a suburb willing to do an endo for you, he may be willing to lower his fees to about maybe six, seven hundred for a molar endo. Maybe the satisfaction comes from getting the patient out of pain.

Guru:

Yeah. Yeah.

Gerald Tan:

Having an appreciative patient. Maybe that's the kick that you get out of it.

Howard:

What else should I talk about? What else are you guys passionate about?

Gerald Tan:

Well, I'm a practice owner now, so I just like to share with you how that ... For many years I've spent a lot of time, effort and money learning to be a really great dentist and being really technically good at what I do, but owning a dental office requires a completely different skill set. I'm enjoying learning that brand new skill set, but sometimes it's challenging. Sometimes it's frustrating.

We as dentists, we think that we're pretty intelligent, right? We got through dental school. We're not morons. We're not idiots. We're pretty intelligent people, but once you start an office you start to manage staff, you start to manage other doctors, you start to look at clinic operations, you start to look at front desk protocols, you start to look at stock and inventory, we start to look at finance metrics.

All those things, I can tell you, has been a huge, very steep learning curve for me. My life has changed since I made that brave step to open a practice. All my time, effort and money now is spent on learning how to be a good business owner and how to be a good leader, how to be good with people, how to be good with finance. Like you said, people, time and money, right? Yeah. That is something that I feel should be taught in all dental schools to prepare dentists for private practice ownership, but I don't think in any university it's taught at any level. Is it taught in the US?

Howard:

It's being taught a heck of a lot more now after the year 2000 than it was ...

Gerald Tan:

I know a lot of dentists in Singapore have started their own practice but failed, ended up in a lot of heavy debt. They didn't make money. They have to close the clinic and they had to work for many years as an associate to repay that debt, and they get so jaded at the end they just do not want to ...

Howard:

How many dentists do you know that did that in Singapore, that started their own and went bankrupt?

Gerald Tan:

At least six.

Howard:

You know at least six? Yeah, there's been a dozen in my town of Phoenix in just 2016, and we're not even in March yet. In fact, this seminar, this podcast doesn't even exist. We're in a leap year. We're in a time warp. This is February 29th, but ...

Gerald Tan:

Some of these are really close buddies of mine and it hits them right there. They say, "Oh my God. I'm not an idiot. I got straight A's in school, in dental school. I can't even operate a simple two [operatory 00:48:17] practice. I'm just overwhelmed with work." It was just going on and on and on about it, and because of that their relationship suffers with their wife.

Howard:

Sure.

Gerald Tan:

Oh my God. When I listen, I get a bit worried, too. I wish that I had learned a bit more about dental practice management as an undergraduate.

Howard:

Well, this is great for all the older listeners to my podcast that are all in their 40s and 50s. This is one of the reasons why corporate dentistry is taking off so well in the United States, because so many of these young dentists, they don't want to deal with that. They say, "You know what? I'd rather just work for somebody else 8:00 to 5:00 and at five o'clock go home to my spouse and my children ...

Gerald Tan:

Do whatever you want, right.

Howard:

... and my life. I don't want to be married with this ball and chain ...

Gerald Tan:

To the practice, yeah.

Howard:

... business. I just tell people, "Do what makes you happy. If you hate molar endo, don't do it. Don't do something you hate for money or it'll lead to depression, disease, alcoholism, eating pain pills," blah, blah, blah. Business, some people just love business. They just love that game. They love it so much that when they start running a dental office, they don't even want to do the dentistry anymore.

Rick [Workman 00:49:32] own 15 hundred offices. He hasn't treated a patient in 20 years. Rick [Kirschner 00:49:37] owns 350 Comfort Dentals. He hasn't seen a patient in 20 years. Stephen Thorne up at Pacific Dental Services owns 500 dental offices. He's not even a dentist. His dad's a dentist. Business is one of those things. It's like treating children. I would rather quit dentistry than be a pediatric dentist. Then the next guy just loves it.

Gerald Tan:

Do you think you can be good in both?

Howard:

Oh, absolutely. Absolutely.

Gerald Tan:

Be a good dentist and be a good business owner?

Howard:

Absolutely. I'll give you a thousand names of dentists who are A clinicians and A business people, but some of those ...

Gerald Tan:

It's tough, though, huh? It's tough.

Howard:

Well, it's like anything. It's a challenge, and at first ...

Gerald Tan:

It depends on your character and personality.

Howard:

Yeah, and a lot of times it depends on the spouse. The secret weapon to most of the small businesses in the United States whether it be a dairy farm, a wheat farm, machine shop ...

Gerald Tan:

A supportive spouse, right?

Howard:

Is that the dad's out there on a tractor and mom's at the kitchen table cranking out all the receipts and selling the wheat.

Gerald Tan:

Supporting, yeah.

Howard:

Yeah. A lot of really great businessmen have a consigliere, whether that be a spouse or a business partner or a business advisor or somebody, and that's what Dentaltown is for.

Gerald Tan:

Or a mentor, yeah.

Howard:

Yeah. Dentaltown has 210 thousand people and some of the greatest business minds in dentistry are on those business threads all day long. If you ever get to a fork in the road and say, "I wonder if I should do this or do that?" Success is very counter-intuitive. Most people are pride and they think, "Well, I'm a dentist. I'm smart. I should not have this problem." It's very counter-intuitive to get on Dentaltown and say, "Hey ..." How old are you?

Gerald Tan:

Thirty-eight.

Howard:

Thirty-eight, so you're a baby compared to ... I'm 53. It's very counter-intuitive for a 38-year-old to just get on Dentaltown and say, "Hey, you know what? I don't know what to do. Should I do this or do that?" Just the act of asking that question shows humility, shows humbleness and it's completely counter-intuitive, and then all the people who love business will just chime in and they can't wait because the one thing humans like to do the most ...

Gerald Tan:

Is help people.

Howard:

Is help other people. That's their number one drug in life. Humans love to help other people.

Gerald Tan:

I agree.

Howard:

If they see some little old lady that can't get across the street, everybody's opening the door for everybody, and on Dentaltown, when you're stuck and you post out there, these people, for free, for no money, they're not trying to sell you anything, they're just pouring their heart out.

Gerald Tan:

Business [crosstalk 00:52:10]

Howard:

Ask for help.

Gerald Tan:

... has been a very humbling experience.

Howard:

Yeah.

Gerald Tan:

Yeah, and I hope that we keep in touch, Howard, after you leave.

Howard:

Absolutely.

Gerald Tan:

I see you as my mentor, you know?

Howard:

Well, I'm mentor and he's my guru. We have a threesome going here. It's just a triangle. A nonstop triangle.

Gerald Tan:

Once in a while I may drop you a message and "What's up?" If I head down to Arizona we can ...

Howard:

Yeah. My e-mail is Howard@dentaltown.com. I answer 100 percent of all my e-mails.

Gerald Tan:

You can take me out to the south rim and we can go up and down.

Howard:

Yeah. Yeah, so if it was easy, it wouldn't be ... If anybody could get a gold medal, it wouldn't be worth it. Challenges are ...

Gerald Tan:

Right now at this early stage, building my practice, I still feel it's a baby. It's two years old.

Howard:

That is a baby.

Gerald Tan:

I really don't know what I'm capable of, Howard. I really don't know. It's easy to say I've got grand plans and a grand dream of having a chain of 100 clinics all over Singapore and maybe southeast Asia, but the question is how am I going to get there?

Howard:

Well, I'll tell you how people got to 100. It seems inconceivable. They start with one office and maybe it takes eight years to turn into a second. Then that time is cut in half and maybe four years it turns into a third. Then maybe in two years it turns into a fourth, and then one year it's a fifth, and then eight months it's a sixth. Sam Walton, the first 20 years of his life I think he only got open 18 Walmarts. Now he's dead. He's dead, six feet underground, and they open up 40 a month. A lot it is just ... Think of biology. One turns into two. In the same amount of time, two turns into four. In the same amount of time, four turns into eight.

Gerald Tan:

The first one is always the most difficult one.

Howard:

The hardest division ever in life is from one location to two. In fact, most investors in the United States ... Say you start with a franchise. No one will even talk to you when you have one. They want to see you cover a city like Phoenix with a dozen, and then they still won't talk to you. Then they want to see, "Well, what happens when you divide to the next adjacent cities like Los Angeles to the west or Vegas to the north or Utah straight up or Denver to the right or Albuquerque?" They want to see that first city go to two or three other cities and do well.

Then when they see your franchise has a dozen locations in one city and a dozen locations in adjacent cities, and then it starts to go to the third ring of cities, that's when the investors all pour in, and then they'll ride that wave from coast to coast. That might be a 20, 30-year wait whether it's talking Walmart or Home Depot or Costco.

Gerald Tan:

That's how you start to open up 40 clinics?

Howard:

Your hardest work will be trying to get your prototype down, and what you do is you stay here until you've perfected your entire prototype, and that may take four years, six years, eight years, ten years. It may be never. Then if you can ever then go to a second location, that'll be the hardest thing that ever happens. Then if that works, then it's just a matter of time and two turns into three, turns into four, turns into five.

Just stay healthy and happy. Just make sure you're enjoying the game, you're having fun, you're happy and healthy, but if it's causing you to go and drink vodka until you pass out and it makes you get the blues and it makes you not want to come to work and it causes burnout, then quit doing it. Don't do things you don't like to do for money. If it's a fun, challenging game, pony up, go for a ride, but if it's making you unhealthy, unhappy and sad ...

Gerald Tan:

It's not for everyone, huh?

Howard:

Oh, absolutely. Well, nothing is for everyone.

Gerald Tan:

Practice ownership is not for everyone.

Howard:

Nothing is for everyone. There's two million dentists on Earth and you couldn't even get them to agree that today is Monday. Everybody's different. Everyone's unique. Just stay healthy, stay happy, keep breathing. Now I think we should end this from the guru. I'm just a moron. We have the guru. You should have the final word since you're the guru.

Gerald Tan:

Final word, yeah.

Howard:

Final words from the guru. You seem very happy. You guys are both all smiling and young and full of energy. You guys look like you're having a lot of fun.

Guru:

Thankfully because I've got a good mentor, so I'm never ever in trouble because I've got Dr. Gerald here. Basically at this point in time in my career all I want to do is learn. I'm only three years out. That's why I joined this practice because Dr. Gerald, he's really good with aesthetics and very good at the surgery. I'm pretty happy here and what's happening here it's very ethical and I'm learning a lot, so I'm pretty happy.

Howard:

I really think that is the most attractive thing to dentistry. I think the most horrible job would be on an assembly line doing the same thing over and over or going in and sitting at a desk job where you're just data entry or sitting on a tractor. I watch those farmers sit on a tractor and just go back and forth down those wheat fields. You know what I mean? The monotony does not exist if you're a policeman, a fireman, a dentist, a doctor, working in emergency room.

Gerald Tan:

Very day is a different [crosstalk 00:58:08].

Howard:

Oh my God. There's never a dull day at dentistry. I can't ever remember going home at the end of dentistry and saying, "Well, that was a pretty routine, boring, dull day. Those were just a dozen boring patients.

Gerald Tan:

We get a lot of interesting people.

Howard:

Oh my God.

Guru:

Yes, that's true. Yeah.

Howard:

Sometimes the people are so easy and the tooth is so hard, and sometimes the tooth is so easy and the person is so hard. My God, you never know what's going to happen when you walk into an [operatory 00:58:36]. That's what I think I love the most about it. You never know what's coming.

Guru:

Exactly.

Howard:

It seems like you walk in that door and you blink one time and you look at the clock and it's 5:30 in the afternoon and you're like, "Wow."

Guru:

Yeah, that's why I like the molar endos.

Howard:

Yeah. Yeah, molar endo is ... To me, one of the reasons I love molar endo is the same thing about a great movie. I always gauge a movie only on criteria. If I look at my iPhone five times to see what time it is and I'm trying to guesstimate how much longer the movie is or whatever, it's a horrible movie. What I love about a movie is when you're watching a movie and all of a sudden the credits roll up and you look at your clock and you're like, "Wow. That was 100 minutes." That's the way I feel about molar endo. You're in there, you're like Stevie Wonder picking a lock. You're just in a trance and you finally finish and you stand up and you look at the clock and you go, "Oh my God. That was an hour and ten minutes just gone in a trance." That's just ...

Gerald Tan:

What's your favorite movie of all time?

Howard:

Oh my gosh. I'd say Amadeus was a great one. I would say Sound of Music was probably my favorite.

Gerald Tan:

Oh, Sound of Music, oh.

Howard:

I would say ... What was the ...?

Gerald Tan:

Julie Andrews?

Howard:

Yeah, Julie Andrews. What was the other? The musical? The Russian Jewish family? If I were a rich man ... Fiddler on The Roof. I think Fiddler on The Roof and Sound of Music, Amadeus.

Gerald Tan:

For me it's Godfather part one.

Howard:

That was a classic.

Guru:

I'm pretty lame. I like Lord of the Rings.

Gerald Tan:

Lord of the Rings?

Howard:

Lord of the Rings? You know I wasn't a big Lord of the Rings fan. I was a big Star Wars fan.

Guru:

Oh yeah, yeah, yeah.

Howard:

Didn't really like ...

Gerald Tan:

Did you look at my Star Wars [inaudible 01:00:15]

Howard:

It doesn't make sense because I don't really read science fiction, but I love Star Wars, but I didn't really like Lord of the Rings, but I actually was luxuring in Auckland and took a bus tour. It's on the southern island where they film, right? Auckland is on the north island and they were on the south island? Or did I get that mixed up?

Guru:

Maybe. [crosstalk 01:00:36] I though it was all over.

Howard:

Okay, but I went down there and, of course, according to the tour bus that's where it was. Yeah, but I swear to G, I think that's the prettiest place I've ever seen on Earth.

Guru:

New Zealand?

Howard:

New Zealand.

Guru:

Yes.

Howard:

The plants were ... They're just plants you don't see anywhere else. You don't see them in Africa, North America, South America, Europe. The vegetation, the beauty, you literally, literally thought you were on a different planet. It was really cool.

Guru:

Yeah. I've heard a lot of ...

Gerald Tan:

What are the practices like in New Zealand?

Howard:

I would say that southeast Asia is very common in the fact that Americans, the standard dental office would be four [operatories 01:01:20]. The dentist would work two, with two assistants, and there'd be one or two hygienists working two rooms and there'd be one or two girls up front.

Gerald Tan:

No associates?

Howard:

No associates. Then you go to southeast Asia, and I mean China, Hong Kong, Malaysia, Cambodia, Vietnam, Australia, it's usually a one-doctor, one-chair room, and there's one helper that's from the phone ... It's usually one-chair, one-room, one doctor and maybe someone helping answer the phone. That is the primary difference. In Singapore, if I go into an office and there's four chairs, there's four dentists. Four dentists work four chairs. In America, that four-chair dental office would have one dentist. Like I say, there's twice as many hygienists as dentists. In southeast Asia there's almost no utilization of a hygienist. The dentists do the cleanings.

Gerald Tan:

So four chairs, four dentists would generate more revenue, wouldn't it?

Howard:

Yeah, but your number one cost is labor, so the dentist is the most expensive laborer in a dental office.

Gerald Tan:

That's true.

Howard:

Yeah, I would say ... In fact, I remember the first time I went to Australia I told people that I had more than one chair. A guy stood up in my lecture. I think it was like 90 or 92 or 93, something like that, and he stood up and he pretended he was doing a molar root canal on two people at the same time. He couldn't fathom that I'm doing a molar endo here while they're cleaning up the old room, seating the next patient, and then I could take a break from molar endo and just numb up the patient and let it soak in for five minutes. They didn't see the logistics. They literally thought I was working on two people in two chairs at the same time.

Guru:

When was the last time you went?

Howard:

Oh, I go to Australia all the time. I just was down there six months ago.

Guru:

Oh.

Howard:

I'm talking about in the early 90s.

Guru:

Oh, okay. Yeah, yeah, yeah because I don't think [crosstalk 01:03:21]

Howard:

In fact, when I first went down there, there weren't any hygiene programs. Singapore didn't graduate their first hygienist until 2006. I think I was lecturing in Australia before they had any hygiene programs.

Guru:

Yeah, I think that was ... back in the day. Right. Yeah.

Howard:

I started lecturing in 1990. This is 2016. I'm 53. I've been lecturing 90 to 2000, 2010. I've been lecturing 26 years. Usually if I go to a country, I'm going back for the third, fourth, fifth time. Hey, we're out of time. We went over an hour. Thank you guys so much. It was very useful. I think the people that listen to the podcast will love it. Thank you very much, guys.

Gerald Tan:

You're welcome.

Guru:

Thank you.