Howard: It is just a huge, huge honor for me today to be podcast interviewing Sina Ghertasi Oskouei all the way from Iran. He is a researcher, lecturer and executive at the Tabriz University of Medical Sciences. He obtained his Doctor of Dental Surgery Degree with honors in 2007 from Tabriz University of Medical Science. He has been involved with research in many areas of Dentistry. Dr. Ghertasi is executive editor of Journal of Dental Research, Dental Clinics, Dental Prospects and also the Journal of Periodontology and Implant Dentistry, the official publication of Iranian Association of Periodontology.
Since 2014 he has been the supervisor of the academic publications office of the Department of Vice Chancellor for Research and Technology at Tabriz University of Medical Sciences, where he oversees the activities of the University and scholarly publication. He also maintains a private dental practice with focus on implants and cosmetic dentistry in Tabriz Northwest Iran. I'm the big fan of your post on Dentaltown, I think you're an amazing man. Thank you so much for coming on the show today. How are you doing?
Sina: Thank you. I'm doing great thank you for inviting me.
Howard: Oh my gosh. When I saw your first post on Dentaltown, I looked you up and your resume is incredible. So you're on North West Iran by Azerbaijan?
Sina: Yes
Howard: So your Western borders is with Iraq, your North borders Turkmenistan, and Afghanistan, and Pakistan. My gosh, that… Iran borders a lot of amazing civilizations. Iraq, Azerbaijan, Turkmenistan, Afghanistan, Pakistan. How many people live in an Iran right now and how many dentists do they have?
Sina: Seventy-five million living in Iran and they're close to, I guess three thousand dentists right now maybe estimating to forty thousand because they are having many graduates as we speak every year.
Howard: So forty thousand dentists for seventy-five million people?
Sina: Yes, so I guess there's still need for dentists.
Howard: So let's say seventy-five million that'll be six zero’s divided by forty thousand equals, that's the same as the United States. A dentist's for every eighteen hundred and seventy-five people that is the exact same ratio as the United States. So you're talking to a dentist in every single country on earth right now. What do you think dentists around the world would like to know about dentistry in Iran? Like my first question, I always wonder is like, does Iran have water fluoridation? do Iranians… do they drink more water or more Coke or Pepsi? Tell us what the unique things about a dentistry in Iran.
Sina: Absolutely. I'd say it's quite similar to everywhere in the world. We have water fluoridation. Where for one thing, we have even over fluoridated waters in some parts of even our province in Azerbaijan. They have fluorosis. Actually people that are born there, they have fluorosis because it's over fluoridated in some places, but overall we have water fluoridation. People drink coke, they drink everything, water.
And yeah, about dentistry it's pretty much the same as everywhere in the world. We have systemal education is actually close to be here as close to the American education as opposed to European curriculum. But it's pretty much the same. We all have our association meetings every year. I think last year we had close to twenty-seven seminars remember… twenty-five seminars a year for dentists and different specialties. So we have a very actually strong community of dentists in Iraq.
Howard: Well you got to invite me to speak some day just so I could have a vacation to Tiran.
Sina: Yeah. Yeah. Absolutely, they will love to have you here. Speak about practice management and dealing with everything dentistry.
Howard: Well you're on several… you're on the journal of Perion-implant dentistry. When I go… I've lectured in all six continents a thousand times. And to me the people are the same, the diet is usually the same, blah, blah, blah, blah. But it seems to me the biggest impact on the difference of dentistry is how it's paid for, like when you go to Tokyo and Paris, and London the government only gives you $100 U.S. for a root canal. Whereas the United States if you're out of PPO, low-cost insurance they'll give you at least six hundred and if you're an endodontics you'll get a thousand or twelve hundred.
So you go to those countries and they seem to would rather just pull the tooth and do an implant because an implant is not covered on the government scheme so they'll charge $1500 U.S. So my first question is who pays for the dentistry in Iran? Is it government, is it private insurance or is it cash?
Sina: It's mostly cash to give you a short answer, but we have very limited governmental support they're trying to expand on it but it's mostly for pulling teeth and got some governmental clinics. But most of the time, there are some added value insurances for some companies. They pay may be up to $1000 a year. No, that… yeah, yeah, $1000 and up to 10,000 some very limited companies have their insurances for their employees but most of the time people paid cash. So that's cash.
Howard: Nice, it seems like back in… I was born in ‘62 and that's when the government started Medicare and the physicians thought it was a great idea to get in bed with the government to have them help pay for everything. But if you get in bed with anyone you're going to get screwed and now I think forty years later, I think that the… or fifty years later I think the physicians are wondering what it's like to be in bed with the government on every single issue, and the health care in America for Medicaid and Medicare and all that kind of stuff. So you're thirty-four years old, you're young enough to be my son. By the way, I got to tell you, when I first saw your name it always makes me sad. You know why?
Sina: Why?
Howard: Because your name is Sina, right?
Sina: Yeah.
Howard: And my… when I… so I gotta tell you my Sina Soraya's story and it's a sad story. So I graduated '87. I come to Phoenix, Arizona. And back then the biggest distributor was health Co. who sell all the equipment supplies. And they went out of the business. And I was in there buying a bunch of equipment for my first dental office and the branch manager said he felt sorry for that guy over there because he was a dentist from Case Western and he was for originally born in Tehran and his name was Sina Soraya and they said he is… his family could no longer fund him, and he was living in his car. And he was looking for a job but he didn't think he could find a job, because he was living in his car and hadn't had a shower or anything in a week.
So I went over there and talked to him, and I just got married. And so I started talking to this guy, he's really cool. And I said so you're living in your car? And he said, ‘yeah’. And I said, ‘well just come live with me. I mean you're living in a car just come live on my couch’. So I brought him home to my ex-wife. And she's like okay so you go to the store and you meet some guy from Iran, and the next thing I know he's living in the house. And he was just the greatest guy, the greatest dentist and his… and his best friend was Willie Acop who was from Azerbaijan.
But, gosh, darn, he got taken out by cancer. And it was it was so sad. I mean the guy, he was… his sisters are dentists. He was the most ambitious, smartest, classiest, greatest dentist I ever met. and my God, his life was taken too early. So whenever I see your name, Sina, I always think of my buddy Sina Soraya and Willie Acop who's still practicing in California.
But I got to ask you, you're thirty-four, I'm fifty-four. I'm old enough to be your dad.
Sina: Yeah.
Howard: What are you passionate about today? What makes you... I’ve been looking at your smile. What makes you excited about dentistry today?
Sina: Everything digital. But there is sad story to do that because we don't have the access that American dentists have to like digital dentistry. How they have their own Sirona machine in their offices. And how they do CAD/CAM, and they do guided implant dentistry and everything. That is… that is present here, people are practicing those practices but it is not widespread, but we cannot have that kind of dentistry that American dentists are providing to their fellow citizens.
So that is my passion, I want to be able to deliver world quality dentistry to Iranians. I want to be able to give them the smiles that they deserve, but I need more equipment. And I need affordable equipment so that I can actually charge patients for that. So it's not like we charge a 1500 for implants, it's not right for you to charge 2000 for laminated veneers or something. It is different we were charging very low rates because of the currency exchange rate.
When we import equipment from other countries, that becomes total issues for us. So that becomes something very… I mean prestigious and very luxury to have a CAD/CAM in the office, but I don't know for some in New York may be ordinary, for us it's a no-brainer. I want to be able to break that into my practice and I want to be able to do everything digital. That is a passionate about but i'm working out that.
Howard: Well it comes down to is it affordable. I mean, when you look at something like digital x-rays in the United States. I mean the adoption rate has been like eighty percent. When you look at practice management software versus a paper chart the adoption rate is like eighty percent, but when you look at CAD/CAM the adoption rate is only been fifteen percent and it's been out there for twenty-five years. So I think a lot of Americans think that paying $150,000 for a chairside milling machine versus taking an impression, and sending it to the lab who can make you a zirconium crown for my $99. I mean… I don't… I think the affordability issue is everything.
America is a big country but half the people in America have a very hard time paying for their dental bills and have no insurance. So affordability is everything. And if you don't keep one eye on the patient and one eye on cost, then your own patients don't have the freedom to afford to save their teeth. So do you really think chair side milling, digital and oral scanning of impressions? You really think that's what's necessary for the people of Iran? What percent of those seventy-five million Iranians are so rich they have no problem paying for dentistry? And what percent of the Iranians have a hard time paying for a root canal, or an implant, or a crown?
Sina: I can hardly speak about percentages because I don't have a ready number to tell you. But what I can say is that, yeah, a lot of Iranians are having trouble paying for their dentistry, for the dentistry of their children or for themselves. So yeah, many are experiencing poor oral health and that is something that we should work on… work on that. But we can't like do charity and do things right. We have to find a way to do, as you said, affordable dentistry so that everybody could access some sort of treatment.
Yeah, chairside is something that is… chairside CAD/CAM that is… that is… that it is big technology and that's very nice to have that in the office. But in the long run I think, well maybe people could buy into the idea that it is possible to have fast dentistry. It's possible to have, as you say, do Dentistry at the lower cost and do it more efficiently. That is a very cool and I'm looking forward, I'm looking for ways to make that happen but, as you said no… I don't… I don't insist… that it's not necessary. You could do without that too.
Howard: So how are the crown and bridge labs in Iran? Do you send your crown and bridge locally or do you send it out of the country? What is the… what is the status and quality of local crown and bridge laboratories?
Sina: I do work locally and in some instances I may send some zirconia to a lab in Tehran maybe, but they're most of them are locally. There are a lot of good dental labs here in Tabriz. So maybe there are around five hundred in Tabriz, maybe less. Maybe three, four, forty, four hundred dentists in Tabriz, but around the province there are many smaller cities and towns that send their work to the laboratories in Tabriz. So it is on the center over here Northwestern Iran. So yeah, I do it locally and sometimes nationally.
Howard: And what percent of the dentists in Tabriz have practice management software on computers as opposed to paper charts? Have digital x-rays as opposed to film? What's that look like?
Sina: There are… I don't have the exact percentage. I wish I had to tell you exactly but it's what's the picture looking like but there are digital x-rays here in Tabriz and there are many… they are using fosul plate or they're using like the products (inaudible 14:28), RVG and things… digital x-rays. And they are using a practice management software but that is something that I have very big comment on. Because package management software's in Iran. People or dentist are not integrating that into their practice and the products that is there are not supporting this kind of integration, because going digital is something big. And you could send out an SMS to your patients and invite them, and you call them over for their check ins or for their scheduled treatment and that is something huge. But here we do it like most of the time it's paper-based. There are practice management software but I doubt it is efficiently working.
Howard: And what I always wonder what… I only know one language. The joke is, ‘What do you call someone that speaks two languages? Bilingual’. ‘What do you call someone who only speaks one language? An American’. So first of all, how did you learn English? Because your mother tongue… what was your mother tongue? Farsi?
Sina: Azeri.
Howard: What is it?
Sina: Yeah, Azeri is what we speak in Tabriz, okay?
Howard: Okay, so your mother let your mother tongue is from Azerbaijan
Sina: Yeah, yeah but I do speak Farsi. In the school we were taught Farsi. We can write Farsi, and speak in Farsi fluently. And I took language classes when I was in school, in high school all the way to the University and then I took courses too when I had graduated in the university and so I'm a big fan of language, yeah.
Howard: So, what did you say your mother tongue was?
Sina: You could say Turkish or Azeri, both would work.
Howard: Turkish…
Sina: But I rather to be spoken in Turkey. No, it's not. It's kind of different but Turkish is spoken in Tabriz.
Howard: But what did you call your language?
Sina: Azeri.
Howard: Azeri?
Sina: Yeah.
Howard: Interesting. I cannot believe that you can be in Iran doing a podcast in English. I mean if someone told me I had to do a podcast in Farsi I mean, I would just start laughing. It's like I wouldn't even know… I live a hundred miles from the border of Mexico and I can barely speak ten words in Spanish. I think you're either born with that or you're not, I mean, you either have a talent for language.
I mean I’ve been to… I remember one time I went to Brazil with another dentist and after one week he was getting by in Portuguese in Brazil and I'm just like… I mean every time he asked someone how to say something, they told them, and he remembered it. And I was like God, I cannot believe your brain can do that, my brain cannot do that.
So when people are trying to impress the patient, a lot of people think they're going to impress them with chairside milling, or having a laser, having all this stuff. I still think that the most successful dentists are the ones that have personality, and can communicate with the patients. They could attract and keep long term staff, dental assistants, hygienists. I would bet on the chairside manner a thousand to one over the technology guru. How would you describe practice management in Tehran?
Sina: Practice management is a state, you have to connect to the patient. And I see many successful dentists out there, some are faculty members. They have their expertise and they don't have as many patients as some general dentists do. Has an office which runs eight a.m. to eleven p.m. and they have some lunch break in there. And like a couple of associates working there. There are a lot of technician three days of the week, there are some doing the hygiene work and that is something different.
People are the same all over the world if you can connect with the patients, if you can provide them with some kind of financial options, some kind of payment plan or something. Then you're a winner. You have many patients that could afford your treatment that you are offering to them. But I think it's the same… I don't see anything different from how it’s running all over the world. I don't know, what's your opinion on how can we improve that here.
Howard: Well, yeah. I think that… I mean take orthodontists in my backyard. There's two orthodontists, who are from Canada, who are just adorable, loving, amazing people and they connect with all the moms. And they just have these huge million-dollar practices, and then there's another orthodontists who are just perfect orthodontist who do better orthodontics. Their cases look like a mechanical engineer did them, but they don't have any personality. And they don't talk, and they don't connect, and they have these little bitty offices, and one of them was in my front room, crying. I mean he actually went bankrupt during the financial crisis of 2008. And he was so confused because he was so damn good, and it's like, ‘dude, if I take my car in to you, I don't know how to fix a car. I grew up with five sisters, I played with dolls until I was twelve. I never pulled a transmission. So if I take my car in to you, you have to make me trust you, and like you, and convince me that you can fix the car and it's selling the invisible’.
And I would… I tell these dental school deans that if you want kids to go to rural America, because they're always complaining that all the dental students go to the big cities like Tehran. And I said, ‘well, if you want kids to go back to these small farming communities then those are the kids you have to except from dental school’. If you got a hundred and forty-seven major towns where half of Americans live like in LA in New York and Chicago. Don't accept any kids that were born there. I mean if you need them to go back to small towns only accept small towns and if you want the dentist to be really good. Forget all the grades and did he get an A in calculus and physics? Is he warm? Is he charming? Is she adorable? Do you just like the person.
One minute into the interview. I mean you got one minute chairside to connect with this patient and if this patient thinks you're talking down to them, you're condescending. And what's tough about dentistry, there's so many touch points because in America by the time you have five thousand charts, four thousand of them are gone and have gone to another dentist. And when you ask why they leave, we'll it could have been the dentist it could have been the dental assistant, it could have been the hygienist.
It is oftentimes the person answering the phone… when you get right down to it, who's ever answering your phone is the most important person. And that person is also usually the one collecting the money. So that is probably the most single key position in dentistry. By the way, back to hygienist. What is the… you said you have forty thousand dentist. How many of those dentists have a dental hygienist in the cleanings versus the dentist doing their own cleanings?
Sina: Actually we don't have the dental hygienist as we have in the America. We don't have a registered thing as a dental hygienist. Dentist has to go all of the cleaning and things. We have something called something close to dental hygienist they were trained like the two years of training. They were sent to rural areas where they were from and they could do simple basic things. They could still even do the fillings, and extractions, and they could do dentures. But again, the government decided that they should come back to dental school, take another four years of additional training that become a DDS. So we don't have that kind. But you could… you could train someone to do the hygiene work in your office but they would still not be registered with the office. So that is under supervision, yeah, that is possible but they don't have like that our hygienists here.
Howard: Well one of my all-time heroes was Bob Berkeley and he also died too early, went down in a plane crash, but this guy was back in the 50’s. And all the dentists in America were so busy pulling teeth and making dentures, and he was trying to get them to start these dental hygienists to do cleanings and prevent the dentures. And he got so much push back because most of the dentists said, ‘I don't have time for any of this crap, because I'm booked out weeks in advance pulling everyone's teeth doing dentures’. And he went around in his airplane city to city to city saying, ‘come on, do you want your kids to lose all their teeth and have dentures? I know, you're busy. I know you're making a lot of money but is this what you want for your children your grandchildren your great-grandchildren?’
And like I say, he went down in a small aircraft. But maybe that will be your claim to fame. Maybe you'll be the father of modern hygienists in Iran. Have you ever thought about starting a hygiene school and getting the government to license dental hygienist?
Sina: Yeah, maybe, why not? I know a dentist in Mashhad, that is Northeastern Iran, he trains dental assistants and he does his publicity online. He attracts young girls and I haven't seen… they're mostly female I don't know because it's very female dominated area in Iran. We don't have as many male dental assistants and he trains those young or maybe middle aged females to work as dental assistants. So he works… he teaches them basic things to act as a dental assistant. But I am not sure if that… I think do we had started to.
We have a registered University degree for dental assistant as a dental nurse, actually, but I don't think there are as many guys out there. Maybe we could start dental hygienist but still that is a one of the most easily paid areas, the cleanings. So I don't know if dentists are going to give it a right to dental hygienists but what do you say is about time management and the practice management, what the doctor does and the hygienist does. That is something truly valuable. So, I think we should take that into account maybe we should start that. Yeah, it's maybe more important that digital dentistry.
Howard: The first… I'm lecturing in Sydney and Melbourne, Australia this month. This is on right now this is a July 8th and I think I'm down there the 28th in Melbourne and then in Sydney when I first lectured there in 1990 they had… almost no one had a hygienist. They were just really starting to roll it out, and it was a very big change. And now it's so funny going back there thirty years later, where all the busy practices have hygienist. And now they just think it's standard of care, it's always been that way. But these young dentists don't realize when I went down there thirty years ago, it was a brand new thing.
Like I guarantee you thirty years from now in Tehran, eighty percent of all the cleanings will be done by dental hygienists. I mean, it's just will. I mean, because that's what's so neat about… when you live in a country, you drink the purple kool-aid and you think it's all true. The best education on earth is going to other countries. And I've learned more about dentistry lecturing in fifty other countries because all the people are the same. So what causes any differences? And you see this blending towards the median or the mean in dentistry, so what's going on in twenty countries right now will be going on in fifty countries. I mean, you just you just see that trend.
Why do you think in Iran, just like around the world, why do you think the employees always tend to be women? Why do you think men aren't attracted to dental Assisting, dental hygienist, dental nurses? Why do you think the women always end up… no matter what country you're in dental offices always have ninety percent of their employees or ninety-five percent are women? Why do you think that is?
Sina: I'm not sure. Here in Iran women are… people are religious. So maybe they are Muslims most of the time and when they come they don't want to be close to someone who is not one of those… they're relatives. So, I think, maybe it is more delicate. It provides more of a delicate atmosphere in the office, maybe. Maybe people like to be tended… cared by some females than with males. I'm not sure but it's a service business.
So not everybody will want to work in a service business maybe they would go… males would go for harder work for macho some male work or man work. I think it's that, maybe. But I think… I tried guys in the office and he's actually a friend of mine. He worked for some time and then he left, and I think he didn't like the job. He maybe wanted the job to maybe pay him more, I don't know. He's now working at a travel agency. So I don't know, but with the office and a travel agency. I don't know, what's the difference but that's the way it is.
Howard: I think it's because women have a maternal instincts. I mean when you go out through the animal kingdom male lions, tigers, polar bears they are always eating their own children when they're hungry, and the women are never seen to do it. Like you go you go to the Serengeti and see a cheetah, a female cheetah, nursing her children until they all starve to death and die. And then the man will come by and see that they starve to death and died in eat all three of them.
I think dentistry has a lot of attraction to people with maternal instincts and I think that that's women. I mean women have maternal instincts the only reason men treats her children well, is because they're educated and learned it. I don't think it's a natural behavior. I think it's a female thing.
In some Muslim countries, women dentists will not… women will not go to a male dentist. At some countries women have to go to… will only go to a woman dentist and a woman dentist won't treat a man. Do you see that in the Middle East and around?
Sina: Yeah, I can relate to that. I have definitely seen that that's not that wide spread but it is. I have seen that because it happens, it's true.
Howard: But is that is that a factor in Iran? Like, okay I'll give you an example, when I got out of school most of the gynecologists were men but the women didn't want to go to a man gynecologist and now that profession has been completely taken over by women which make sense because if you've never had a baby or you never had menstruation problems you probably aren't empathetic or sympathetic or believe what I'm telling you and I'm starting to see the same trend; I'm predicting this trend in pediatric dentistry. I mean, when you go to the pediatric dental schools I mean you, I can't tell you how many dental schools I've been at where all six the pediatric residents were women. And I'm predicting that pediatric dentistry will go the same way to kind as gynecology because who's taking the kids to the dentist; it's not the dad. It's always the mom, my gosh, when a dad comes in and I'm trying to fill out the chart I'll say, "Yeah, your son, Sina. What is his birth date? I mean he never knows. It's like you don't even know your son's birthday -you ask the mom she just rattles it off the top of her head and I think the women are the ones taking their children to the dentist and if they had to pick between a boy pediatric dentist and a girl pediatric dentist. They're just blocking it. So what percent of the 40,000 dentists in Iran are women?
Sina: I can even hardly tell you that but I think it's 50/50 because there are a lot of young girls in a dental school and with regards to what you said about pediatric residents and pediatric dentists. Yeah, I see many girl, many female dentists going to the pediatric residency but to other residency too, because you see female like oral surgeons or maxillofacial surgeons but yeah, from the perspective of what it looks like; yeah, a surgeon could be a guide and the pediatric dentist could be a passionate, loving, caring female dentist but there is still some stigma that people do not believe and that female dentists may handle the situation. Maybe, maybe, but that's not true. That's changing. So, it's as you said. I think we may see many or we already seen from.. I know like many 10 or 12 pediatric dentist here in Tabriz. And I think it's 50/50 because in the war, in pediatric dentistry while here at Tabriz University Medical Science, I think, I know as much as they are half the faculty members. So, that is yeah, there are a lot of women in this business.
Howard: Speaking of pediatric dentistry, Shahid, sorry I can't pronounce right Shahid Beheshti University School of Dentistry in Iran plans to establish a tooth stem cell bank to save dental pulp cavity stem cells, that's a - is that taking off? is the Iranians are they starting to want to bank their extracted baby tooth for future stem cell use and cancer treatments or what have you?
Sina: That is happening with physicians I don't know exactly whether they're saving the babies what cord?
Howard: Umbilical cord
Sina: Yeah, exactly. They are banking that, they were started testing and experimenting and of doing all the clinical trials and things. And, yeah I heard that and there's people who are working on stem cells here in Tabriz too. So, I think that Beheshti University in Tehran, what you said and yeah, that is happening and from their perspective from their patients or people did you ask that? That people are banking their teeth, their children's teeth? Yeah, I think it takes over It is also the capital in Tehran and then it moves them to other cities like Tabriz. I'm sure it will.
Howard: So, there's not a dental hygienist. So all the 40,000 dentists in Iran are doing their own cleaning. What is the average size of a dental office in Iran? What percent of the dental offices are one chair versus 2 chairs, 3 chairs? what would you say is the median mean mode dental office?
Sina: Yeah, a couple years ago - more maybe 4 - 5 years ago, I came on dentaltown and asked if 80 meters that corresponds to maybe 400 - 500 of a square feet that is 80sqm. They said that's my current office it's very small kind of place but I know in America they have like offices like 200 maybe sometimes 400 sqm. They said "move on, that is a very small office" but that's the way it is. It's most of the time there are in medical buildings and you cannot afford to have very big dental offices, you know, and I see offices as we are having as many as maybe 8 or 10 dental chairs in America but I only can recall 1 or 2 orthodontists here in Tabriz who have like a 10 or 12 unit or 12 chair office. The rest is 2 or 3. I don't even know people who have 4 dental office maybe in a clinic where a lot of dentists work together, but in a normal dental office that would be around 100 sqm. That corresponds to maybe 600 square feet, I guess. That's how it was and I kinda don't... I don't know how it works because you say when you add s chair, you have an opportunity, you can work on that and I don't kinda get that. How that works? You have to have a big fan sign? You have to have a big number of patients and then you have to have many dental assistants who can sit there patients and the chair and they can make the chair ready for the next patient? But I don't know, I know time is money but it's still gonna - I cannot see how that will work here in Iran.
Howard: Well, how many chairs does the average dentists have in Iran? Are they mostly working on a 1 chair or 2 to..
Sina: Maybe 2 an average will be, I'm not sure about, I'm saying on top of my head but I think that will be 2, I have 3 but that is 2 I guess.
Howard: So, basically what the Americans don't realize is happening is that they
started these big - basically, the American average dental office is probably somewhere between 4 and 5 chairs but I'd say I put out 4.5. So they have 4 or 5 chairs because their current business model was created in… started in 1948 when the Longshoremen's Club started dental insurance and it was - so they had high volume because the insurance was delivering large numbers of workers to your office in a very high fees and now, you know, 50 years later; they still have this high volume but it's very low fees. And when you travel around the world; you see that the people who have 1 or 2 chairs, low volume high fees, they actually are doing about 1/3 the productivity but they're actually making more money than the average American dentists. Like in Singapore or Tokyo or places like that, so the Americans you know they grew up in America they drink the kool-aid, all the dental office are big and high-volume and they don't realize that business model was when high volume was from group insurance with high fees and now that group insurance is 40% lower, like right now, the insurance I take in Arizona, 30 years ago I got paid a $1000 for a crown and $1000 for root canal. Now I get paid from the same insurance company $600 for a crown $600 for a root canal but you still have all these employees and dental assistants and hygienist. So, it's really becoming a high volume low fee deal and then you'll go meet a dentist like my favorite and you know, dentist that has like you say 100sqm 600 foot office with one chair and they're only doing like you know $250,000 a year in dentistry and they're taking home $200,000 in cash and then the dentist across the street, is running around like a chicken with his head cut off and it's taking home $150. It's like man, you saw 3x as many patients and made $50,000 less dollars and have you seen 3x as many patients-America, the craziest thing about America, I mean and that's saying something because America is bat shit crazy, has more attorneys than physicians so, if you see 3x as many patients as I do you're probably gonna get sued or go to court or go to the board, I mean, so what - it's going to be a very painful transition for dentists to realize why are you paying your hygienist $40 to do a cleaning when the insurance is only paying you $45 for the cleaning. I mean do you not understand simple math? And I find these older dentists where they'll do the rocks like root canals and crowns and extraction in the morning then they'll go to lunch they'll come back and they'll just sit there out all afternoon just doing cleanings and again these people are only doing 250 to 300,000 a year and they're taking home 200,000 and then right next to them in the office some idiot running 4 or 5 chairs buying all these CAD-CAMS and lasers and CBCT's and all these stuff and their overhead is off the charts. So, high volume was great when you had high fee insurance but high-volume with low fee PPO is not working. And by the way, you were talking about a chair side milling, you're also talking about a guided surgery. I want to ask you about guided surgery because that seems to be the most, you know, you're an executive editor at general of Periodontology implant dentistry in America. Anyone I know that's placed 1000 to 20,000 implants they never use guided surgery and then every time you find some young kid they want to get a CBCT and all this stuff and then they all want to be a guided surgeon and on the older guys or look at them saying "Dude, you're a surgeon, lay a flap look at the bone with your eyeballs". So, what is your view on guided surgery for the placement of dental implants?
Sina: As you said, yeah, it's increasing the overhead that's a simple math but the added value. I'm not sure if all the hype and all the things that we get because we have to send them offshore to, you know, out of the country and there's the posting; that the currency exchange rate that's the same of it of something like Invisalign or something because we don't have the laboratory here in Iran. So the guided surgeries is the same on all those GPS guided implant placement systems and things, technology is good I see many good slides, many good presenters speak about know we have CBCT were combining that with facial scans that you know, CAD-CAM scasm we're now making these aesthetic over the surgical guys. It is a good thing, I haven't used one. I have I've seen people who use that I've seen them in congress and seminars people use that but I think yeah, maybe the surgeon's confidence is more important than just a surgical guy because you could go wrong even very wrong with a surgical guide if not used correctly. So, that comes down to the expertise and you know, looking on with your hands.
Howard: So, what percent of the 40,000 dentists in Iran could read English on Dentaltown? Are they became members of Dentaltown? how many could they read it? and number 2 question: Can you open up Dentaltown and google chrome and translate the whole page to Farsi or Azeri or in another language?
Sina: I'll answer your second question first. You could open Chrome and you could do a translation but the translation technology from English to Persian still gives you funny results. It's not that sophisticated because it's a different kind of - you put the word comes last in the sentence and that's a whole different story. It somehow has to do some sort of a human input so that the technology is not that developed and you ask the first question I thought that we know maybe a lot of dentists could read but I came in contact. I teach technical language in English to the students of history here in Tabriz University of Medical Sciences and you know, they are younger kids that access to better technology and better education. They have taken their English courses and the language courses. They can have a conversation, they can, you know, go online and chat with people in English but when it comes to reading something about their profession in English many are; feel a language barrier. I see many there are many faculty members and many robots, you know, speakers who, you know, read articles in English. They discuss everything I have seen them in chat groups of dentists, they are very confident. Some are in contacts, some Iranian residents or Iranian practitioners where chat is far and those chat - who are living in the US. They chat in Persian and they share stuff in English but I'm not sure if they will be easy logging on to Dentaltown or any other English website to get a regular information. Maybe, something like a product recommendation or product review some will go but they still need to go read them and then tell them back in Persian or in Azeri. So, that's the point. That's how it goes here.
Howard: It's funny, my best friend in China. My best dentist friend in China I asked, "Where did you learn such amazing English?" and when he was little his mommy always shows him the cartoons in English and he learned English as a little child watching cartoons. And then, that turned into Hollywood movies as he got older and he said he learned all of his English from cartoons to movies. So, have you ever been to the United States?
Sina: I haven't been no. I have been into Europe but not the United States.
Howard: When you go to a dental convention, nobody cares what country you're from it's all about dentistry and helping patients and all that then the government just get is so wrong, I don't know why that is. So what is the day like for you? What are the procedures that you do most of the time? Like in a week-long period, I mean, are you doing fillings, root canals, crowns, placing implants? What's your routine like? What’s your bread and butter dentistry?
Dr. Sina? Yeah, most of the time I'm doing the restorations. I do anterior endo and molar endo but most of the molar endos I refer them to an endodontist friend but if there's an emergency, I would do that, I'm quite easy with that but I prefer that because it kind of not interfering more and because you have to find out for root canal and sometimes you don't find it and the patient is, you know, you have to do a re-treatment. So, the -- most of the time I'm doing anterior endos and doing crown buildups and crowns and I do implants too. But that hasn't turned into my bread and butter dentistry implants but I do most of the time restorations, fillings. I do composite veneers also ceramics that I'm working more on that because I have to work with a good lab to give a good result doing anterior cosmetic work.
Howard: So, what's the status of the 40,000 dentists if there was a hundred fillings done on a molar. What percent would be amalgam, which lasts about 38 years and is half the price, versus a composite which usually lasts 6 1/2 years and is twice the price? What percent of the fillings and molars are done with amalgam versus direct composite?
Sina: Amalgam used to be used here more often than composites but it's changing. People are looking forward for cosmetic, more cosmetic options and I don't know whoever created this cosmetic revolution; because, yeah, as you say composite of the plastic material doesn't lasts as long as the amalgam does. But, I'm more on a 50/50 for basis myself but I think it's the same as in the U.S; but we don't have that kind of more composite buildups for a posterior and I see more Dentaltown posts. I myself use mostly amalgam as a core to that in the posteriors. But yeah, for non-endo TCR, I used composite most of the time but.
Howard: Well, it's so funny because the insurance companies have reduced their fees 40% over the last 30 years and so the dentists overhead has gone from about 50% to 65%. We have 20% of the dentist right now having 80% overhead and then you look at root canal failures and the number one cause of a root canal failure is it didn't have the final restoration and when the Endodontists do the root canal they have to basically they don't, they can't do the final build up because the dentists who referred them, they want the money so they're walking around the leaking temporary to a bunch of gutta-percha and sealer for a week two weeks a month and then you look at amalgam; amalgam corrodes so the seal is impenetrable and resin contracts so there's a gap and you would think I just wish every endodontist before you know, when they were done would do an amalgam build up and let that thing seal and corrode until they get back in. I think it could- In America in 5 years in 60 months, 10% of the root canals done by general dentists are already extracted and when endodontist do them it's 5%. The general dentists, their problem is they didn't get the final restoration on and the endodontists problem is they're treating way too many cracked teeth that should have been implants to begin with, but I am - but it's so weird the culture of America like I've been talking to you let's see how long have I been talking? I've been talking to you for 55 minutes and I have not seen one of your bicuspids or molars. I mean you're a handsome guy, you're good looking but I only see like right now look at that I just see your upper ten teeth, I don't see a single mandibular tooth. So, why in the hell would someone do a cosmetic billing on your molar when I'm a dentist and I've been staring at you for an hour and I haven't seen 1 of your lower teeth, not one and on your upper teeth I haven't seen any of your molars. So, why are you infatuated with doing some crappy plastic filling that shrinks and last 6 1/2 years. And you know what the dentist say? that is so batshit crazy there, they say "well, yeah the average white filling lasts 6 1/2 years but I'm special and mine are better and I'm the greatest dentist in all of Missouri and my white fillings, I've never had one fail" and it's like all right buddy. I mean, I guess if you say it enough times you'll believe it but when you look at insurance data of hundreds of millions of claims, you know, their white filling lasts 6 1/2 years, their silver filling last 38 years, 10% of their molar root canals are extracted in 5 years, 5% for endodontists and you go to any American dentist and say, "What percent of your root canals fail?" and 99% of all the dentists in America will say, "Well, knock on wood I've never had a root canal fail because I'm special, I'm so special my white fillings last longer than amalgams and my root canals never fail". So, I guess ignorance is bliss and you know it never works on a math exam but it always works on a philosophy or political science or religious exam that if you just if you just say it so, you just you just believe. But, yeah - but what is the attitude of the Iranian people about a silver filling containing mercury? I mean are you having a growing organic movement that mercury is bad and I don't want this in my children's teeth? and do they talk about it in the press? What is the current belief model of the mercury in a silver filling?
Sina: It's not like the U.S. Now, I know that in the U.S. it's been in the press 60 minute because it is spoken about it they've talked about that in the press and they're hype and there are groups that do that. No, it's like that in Iran, people are not afraid of amalgam or the mercury in it. So, we know when we are removing amalgam filling, the dentist is exposed to more mercury than the patient himself. So, no they're not. They're more concerned about the longevity of the restorations and they ask the dentist which one lasts longer but then again there are people who want the cosmetic but they're not that much I wouldn't say like more than 10% would go for a white everything in their mouth. But most of times people are like considering and weighing their cost benefits of the restorations that they're asking for something that lasts longer and most of the time that's why I do another bill on posterior teeth that could be crowned later or because we're reducing the cost and everything. So yeah, no, there's that's not like the height in the US now.
Howard: I wanna ask you a question about beauty and culture with Iranian women. In the United States women will decorate every part of their body with gold, their ears, nose rings, belly button, chains, wedding rings but when you try to put gold in their teeth in America they think you're crazy. Now I only have 7 restorations in my mouth and they're all gold cemented with zinc phosphate cement and a big shout-out to a Sam Dominic and Michael Glass for doing this amazing work on my mouth of the years but when you go to like Africa they have a billion people or you go to Asia like Cambodia or Indonesia, Cambodia, Vietnam women also decorates their body, their teeth with gold. So, when you go to Soweto, those those women think a gold bracelet and a gold molar like I have is beautiful. So, what is it with Iranian women? Do they do they decorate? Do they see a gold filling as a beautiful decoration like they do with earrings and necklaces? or do they say no you're pointing out that I once had a flaw and I don't want anybody to know that I once had a flaw that had to be repaired with gold.
Sina: Actually decades ago people had a gold teeth, gold front teeth like lateral in their denture ,you know, they put that in, they're dentures so that they could show off that they are rich. That was some sign of, you know, I don't if they were real, you know, gold filling abilities that was just in a dentures and that was, you know we had a - she's still there, a neighbor who, she wears her dentures and she has a gold tooth on. But that's changing, dentists are turning to placing white gold outlays and gold crown; not crown but outlays but no, no, people don't - that's kind of going back for them so they don't have gold. Maybe a fake, maybe a rock star maybe but not people, they won't go for a gold.
Howard: I think the rock stars are so funny because if you look at a picture of Steve Jobs and Mark Zuckerberg of Facebook and Warren Buffett you know 3 of the richest guys in America they have on a shirt and a pair of jeans and then you go to some rapper and they got all this gold bling and they got all this gold stuff and that - and it will be bankrupt in 5 years. It's so funny how - and that's one of the biggest problems young dentists have is they diagnose the pocketbook because everyone I know that has money they don't have a car payment, they don't wear a gold Rolex watches. If you have it, you don't show it and if you don't have it you fake it and then if you ran into it by luck because you're a famous athlete or rap or whatever well you didn't earn it the normal way so you don't understand money because you'd make it through business and that's why you'll lose every dime of it. And so, a lot of these kids that are you know your age will see some old man come in and they got 20-year-old pants and a 30-year-old car and you'll think, "This guy just wants to pull the tooth and do a denture" and you don't realize this man has more money in the bank than you do in debt and so it's very confusing, I mean, it's just so true everyone I know in Scott cell that has a Mercedes Benz is leasing it or making payments on it. Everyone I know has a Mercedes Benz in Phoenix or Chandler or Gilbert bought in cash, I mean so it's very very confusing when you look at their -
Sina: Yeah, here in Iran the laminates. The cosmetic treatment is on the hype ,you know, there are Instagram stars they used to be normal people now they have white teeth and they're after they have more than a million followers because of their - not white teeth because of their add ins but everybody, every star, every single movie star, their doing laminates like they do in the U.S. but many ordinary people are coming now for laminates and their - because they want to have teeth that look white and I don't know, it's teeth that look fake white and I have placed a couple of those because patient wanted but that's not my favorite. But I think the trend is still the same all over the world because we saw many European dentists do their natural teeth and they're now like, they're the guys like (59:48 unclear) . I was in Italy they're turning to more white teeth because I don't know, chalky teeth look better in the picture maybe.
Howard: So, last question. We've gone over an hour you're so adorable to spend an hour with me in my home I'd say. In Iran well like when you go to Africa and you ask any African dentist whether they be in Somalia, Ethiopia, Tanzania. You say, well you know there's 58 countries in Africa who are the thought leaders? where do you go for dental dimensions? they only go to two places, they go to Johannesburg, South Africa or they go to Egypt and those are the two big thought leaders. Nigeria is rising rapidly on the scene but in Iran, who are who do they who most real thing is the thought leaders? I mean, who are the leaders? Is it Germany? is a Japan? is it Italy? the United States? Who do they generally listen to the most and think as the thought leader in dentistry?
Sina: I would say it's very mixed and it's lived and it's really especially dependent but we have many speakers from Europe at the last event in dental association meeting which have occurred in May this year. There we had a lot of speakers from Portugal from Italy, Spain the UK and sometimes we have speakers from Japan we do have speakers from America too, Dr. Reza Shah who wrote, who has a textbook on Prost dentistry. He came here to Thira this year and even last year I was present in its lecture. So, we have a lot of, you know, people in Iran like to see, you know, many lectures, they want to hear every opinion but I'm not sure if a name which one or is the opinion leader. I'm not sure. I don't know.
Howard: It sounds like it's Europe though.
Sina: Yeah.
Howard: I mean, most all the country just mentioned were Europe. So, who's the American that went over there and spoke? Reza Shah. He's a senior author, he has textbook afterward released from I think, Iowa University. He has a textbook compressor, he's a prosthodontist. No, he's not a friend of mine.
Howard: Can you can you email me his name and a link to a textbook at Howard@dentaltown. com
Sina: Okay I will.
Howard: Yeah, I am. I actually was born in Kansas which is the North. It corners are really close to Iowa and I went to undergrad in Omaha Nebraska which borders Iowa with. I went to Iowa a lot because when I went to college in Nebraska you couldn't buy beer till you're 21 but in Iowa, you could buy it at 18, so, every Friday night we had to drive across the river into Iowa just so we could be drunken hooligans. But, hey, yeah send me his email that was interesting. But hey, I just want to tell you seriously I'm I'm a big fan of your post I think you're an amazing man, I love your energy, your karma, your youth, I mean, you're just a beautiful person and thank you. It's a 8:30 in the morning right now in Phoenix Arizona on a Saturday. What time is it in Iran?
Sina: It's 8:00 p.m. at 5 past 8 p. m. Saturday evening here in Iran, Tabriz.
Howard: Wow, so you're exactly on the other side of the world. I'm 8 a.m. and you're 8 p.m. so it's like that drilling a hole in my backyard, if I sorta hit a hole I could be at your house in just 8,000 miles of dirt
Sina: Yeah, exactly that would be awesome we'll have a tunnel that goes from my basement to yours.
Howard: I would love to speak in Tehran. I've lectured in 50 countries, I've never had the honor yet to speak in Iran I would do for free and it would just be an honor. That's just a great civilization the Persian Empire, I mean, that the history books are filled. So you we’re - so, Iran was the first what was actually a Genghis Khan. Well, what's your Genghis Khan? a thousand? What were your Genghis Khan? No, thousand A.D.
Sina: Genghis member, Genghis Khan? I don't' quite get you.
Howard: Genghis Khan, he was the Mongolian who conquered pretty much Genghis Khan born was the Great Khan and the founder of the Mongolian Empire which became the largest contiguous Empire in history after his death he came to power by uniting many of the nomadic tribes of Northeast but I am I really, yeah, he was 1162 the 1227 he was the first - he is the grandfather of what he call it? globalization? I mean, but before Genghis Khan everybody just lived in their own tribe and so he was the first great Conqueror but I loved reading the history books of at Genghis Khan, the Persian Empire, the other emphire. I mean, you have some of the richest history in the world in the Persian Empire.
Sina: Yeah, if you're looking for Mayan history Cyrus the Great he was the great Iranian King to a 2500 years ago and the death; or actually, the remaining are still in here in new Shiraz, central Iran we call that Persepolis as the monuments which are remaining from 2,500 years ago. So, yeah Iran has a really great civilization but that was sometimes invaded by its neighbors throughout the history. So we have a very mixed culture and we're working on that, you know,
I totally agree it's a great company and we have to not go along with each other better than we do so that we could be better country even.
Howard: Wow. Cyrus the Great also called Cyrus II born 590 B.C. conquered and founded basically Persia for the Near East, the agency eastward to the Indus River. He's also remembered in the cyrus legend first recorded by Xenophon, Greek soldier and author. I have not, I am so embarrassed, I have not read anything on this man. But now I'm going to have some reading to do because I think reading about cyrus the great, the king of Persia that will be an awesome book. I have to go to Amazon and see what the best book is on Cyrus the Great. But speaking of Cyrus the Great, I think you're Sina the great.
Sina: Thank you.
Howard: Also, I told you Sina Cyrus the Great.
Sina: Wow. That's an honor, thank you.
Howard: But seriously man, thank you so much for coming on the show. I'm sure Dentists from all around the world love to learn. It's so fun how dentists - I mean, I love travel the most because when I travel to a country I'm not going to a Hilton or a high end and taking a tour I'm going to take that by a local homie who lives there and I don't like staying in hotels I like staying in the house. I'll never forget the first I went to Poland I just went there to open up the refrigerator and see what is it like inside a polish refrigerator and it was 100% different than my refrigerator at home. I'll never forget it was all these trays of all these different sausages somewhere, like light color and brown colored and I just love the the anthropological adventure of the meeting dentist all around the world and I also love the fact that you know we all are the same but the little details like in every country, just a little detail like a toilet is different, a window is different. I mean, so they all needed a toilet in a window and to fix a cavity but they all did it slightly differently and I just love looking at the variances of how the human mind saw a different way to make a toilet, a window, a door, a filling, a root canal, a crown it is just so damn cool and I had so much fun talking to you. Thank you Sina the great for coming on my show today.
Dr.Sina: Thank you and we're looking forward to having you in Iran as a speaker, as a friend, as a dentist. I'll be very happy to show you around.
Howard: Well anytime you want me to speak, I will be there I will pay my own way I just can't wait to visit Iran.
Sina: Absolutely. Well, I can't wait to see you here.
Howard: All right, buddy, have a rockin' hot day.