Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
How to perform dentistry faster, easier, higher in quality and lower in cost.
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1120 Round Four With Mike "The Man" DiTolla : Dentistry Uncensored with Howard Farran

1120 Round Four With Mike "The Man" DiTolla : Dentistry Uncensored with Howard Farran

12/31/2018 7:58:09 AM   |   Comments: 0   |   Views: 211

As a dentist who practices within the largest lab in the US, Dr. DiTolla has access to tens of thousands of doctor’s preps and impressions on a monthly basis. As a result, he has an intimate knowledge of the common habits of the dentists getting the best restorative results. As a self-proclaimed “average dentist”, he has developed techniques that provide exceptional restorative results with a very average set of hands. His mission is to share these techniques with dentists to help them improve their preps, impressions, and restorations. When dentists perform better restorative dentistry they are happier, more profitable, and most importantly, the patient receives excellent restorative dentistry.

VIDEO - DUwHF #1120 - Dr. Mike DiTolla


AUDIO - DUwHF #1120 - Dr. Mike DiTolla


Dr. DiTolla graduated from the University of the Pacific School of Dentistry in 1988. He was awarded his Fellowship in the Academy of General Dentistry in 1995.  He is a graduate of the Las Vegas Institute of Cosmetic Dentistry, and is also a clinical evaluator for CRA. From 2001 – 2006, he was an Instructor for PAC-Live’s Live Patient Hands-on Veneer Course. He is the director of clinical affairs at Dentsply Sirona and is well known as one of dentistry’s most entertaining and regaling speakers. With more than 20 years of experience, DiTolla has extensive experience with multiple CAD/CAM systems and technologies.


Referred to as one of dentistry’s most entertaining speakers, Dr. DiTolla’s blend of humor and entertainment keeps attendees awake and helps a day of education become much more pleasant. He uses live clinical video in his presentations to reinforce the learning and increase retention of the techniques. 

Howard: It's just a huge honor for me to bring back one of my idols, my role models, a friend of mine for decades he was the first podcast I ever did Mike "The Man" DiTolla, we brought him back at number 200 we brought him back at number 400 and today is gonna be gosh I don't know what number we're on. I guess I the last one we put up was eleven seventeen I was thinking you should have been on at six hundred eight hundred a thousand and you skipped all the way to 1118 so why so that our viewers want to know why did you skip six four and a thousand are those just not lucky numbers for you?

Mike: You know it's no it's no feng shui kind of thing where there's unlucky numbers that I didn't want to do it I just don't think I got an invitation for you I would never say no so I just have to think that for whatever reason I don't know it just didn't occur to who was ever organizing your podcast that I was supposed to be on these milestone even number you know oh yes but I would have done it.

Howard: Do you think since it's two bald beauties on here that this is a technically dental porn?

Mike: I think to be dental porn you have to show pictures of highly stylized anterior crowns with white halos and incisal edge translucency and the stuff that never happens in the real world that's dental porn.

Howard: Speaking of cosmetic you know you're out there in California where everything's cosmetic, I don't know I really don't know anybody who knows more about the macroeconomics of the dental lab business but I just read a post today the use of gold in dentistry remains significant today with annual consumption typically estimated to be approximately 70 tons worldwide the value based on the current gold spot price of today at 1244 would be 2 billion almost 3 billion dollars worth of gold a year. You and I when we got out of school I mean we've been out for three decades we never saw the death of the pfm the pfm was the new thing and and do you think there's still a place for gold every restoration of my mouth is gold.

Mike: Well I mean yeah there's still a place for gold most definitely but as you know big as those numbers sound the gold is less than 1% of what gets done of the restorations that Glidewell laboratory. So you know those numbers sound big although I wouldn't know the difference if you said 60 tonnes of gold six tonnes or gold or 600 tonnes it all sounds like a lot to me but it's less than its you know just barely 1% of the restorations being done today. So it's a dying art it's unfortunate because it's really conservative and the final nail in the coffin probably for cast gold is going to be solid zirconia just because it can't do everything gold does but it can do a lot of things gold does and now that it's getting to be more tooth colored not just kind of a snow white color that's probably the death nail for gold restorations except for relatives of dentists where you know dentists still want to place that restoration in their relatives mouths.

Howard: Now when you first came on the show you were the dental director Glidewell and we both idolized Jim, Jim Glidewell's amazing. I can't get him on the show though I've asked him like 10 times he doesn't even reply and then you went to a Sirona and then when you left Sirona about a week later they turned into Sirona Dentsply and now you're the vice president of clinical affairs and communication at AEGIS Dental network. So how's your journey going are you are you having fun where you're at now?

Mike: I am because they AEGIS has a real dedication to creating this video platform that we're currently working on so they don't three great magazines magazines like Compendium that you and I kind of grew up with they've got Inside Dentistry, Inside Dental Technology. So these are you know it's a big brand within the dental publishing business but Dan Perkins the CEO when we first start talking about this project he said you know look at all the magazines they're getting thinner as time goes on and granted there's still the main way that dentists learn things but you can see this whole burgeoning field of video, whether it's unboxing videos whether it's clinical videos online like the kind that we started you know 15 20 years ago at Glidewell and you can see that video is going to be the way that the younger generation of dentists that are coming in this is how they're gonna learn about products, this is how they're gonna learn about techniques. Live lectures aren't going anywhere they'll still go for the camaraderie of being around other dentists and getting to talk to them but it's pretty clear to us that video consumption of information learning about products and techniques and clinical strategies that video is going to be the future of the way that dentists consume this type of information.

Howard: You know I love Dan Perkins, I really do I met him several times because he doesn't think in fear and scarcity. Some of the other dental magazines like when I walk up to them, hey buddy what up you know you think we're the same I remember what I got on dental school I ran across the street all excited to meet the eight dentists of practice across the street and thinking they're gonna be your buddies just like dental school and these are gonna be all your future alcoholic substance abuse enablers and like half of them like slam the door. Like wait wait I don't need a dentist and then the other half are like come on in and you know go watch the ball game and 30 years later guess which four crushed it and guess which four you know died in fear and scarcity and you know. I remember Dan and I have dinner one time and we said to each other if you throw a great magazine for free at the dentist's office when he but you know what he's waiting for a hygiene check, he's gonna pick it up and read it. Neither of us have ever met a single dentist that only reads Compendium or Dentaltown or Inside Dentistry what was the third one you said they had? Compendium, Inside Dentistry and what?

Mike: Inside Dental Technology, it's really the only journal out there that is aimed at the teamwork between laboratory technicians and dentists themselves. So it's  when you look at the board members on for that magazine it's a combination of lab technicians and dentists and so it's the one that really stresses the teamwork and covers the topics that really kind of crossover between dentists and laboratory technicians and that was my world for you know 15 years at Glidewell ,so it's a world that I'm really fascinated by and and that's the things I wanted to mention today is that I wanted to run a concept by you I truly believe that we have a couple things in dentistry that are very random. The first one is the six-month cleaning recommendation you know nobody knows where that actually came from if it was from an Amos and Pepsodent ad on an Amos and Andy show or whatever it was and another totally random thing in clinical dentistry is the two-week time period to get a crown back from the laboratory. Their's no scientific basis for this it doesn't even take a lab you know two weeks to make a crown they're lying to you if they tell you it takes two weeks to make a crown and there's lots of problems that happen with these two week temporary crowns that we're leaving in. We're having to do way too many adjustments occlusal and to the proximal contacts when we go to seat these crowds and every dentist knows this that if you leave a temporary on for 6 weeks or 12 weeks instead of 2 weeks the chances of being able to seat the crown are kind of slim and none without taking a new impression and I'm here to tell you Howard the opposite is true as well we should be seating crowns after three days. Not after two weeks nothing good happens while the temporary crown is in place and the longer it's in place the more of an influence it can have over the permanent crown that's coming in place we need to be seating crowns after three days instead of two weeks. This is kind of what I want to dedicate you know the rest of my clinical career to is making this change in the laboratory industry because they Glidewell for the last eight years I was there I sat all my crowns after three days instead of two weeks and the adjustments almost disappear which is great for the crown's great for the patient there's a big problem we're leaving temporary crowns in way too long.

Howard: Yeah in the bacteria seeps in and that's a big part of the sensitivity.

Mike: Of course, yeah bacteria is seeping in because we're using a cement that's designed to fail you know we're putting a temporary cement in this plastic the margins on the plastic crown aren't all that good. Their's so many times where a well-meaning dental assistant who's trying to polish this temporary crown and get rid of any sharp edges on there will smooth it and smooth it but they'll accidentally take the crown 200, 300, 400 microns out of occlusion and then two weeks later the opposing tooth is super erupted and now the crown is 400 microns high and you're grinding on the Emacs or the or the ceramic material and so I want I've been shouting about this for a couple of years that we need to have a dental laboratory that reflects this and finally a couple friends of mine who actually used to work at Glidewell while I was there they started a laboratory where that's what they do is three-day crowns and so you send them the impression or the digital impression and you get the crown back in three days. So you can put it into the patient's mouth before the temporary crown has a chance to do all these you know awful things.

Howard: and who are these guys in what's the name of their lab?

Mike: The name of the lab is 38 Smiles.

Howard: Numeral 38 38 Smiles.

Mike: Yeah so if you go to like that's their website and it's three days crown, three day crowns now this is for posterior single unit crowns this isn't a problem in the anterior because we don't have such a critical contact between the temporary and the opposing tooth and the other thing that 38 Smiles is doing that I love is, Rella Christensen, a hero to both you and I has been railing against the glaze that we put on zirconia crowns. She hates it because unlike with PFM's where the glaze was a protective coating on the outside of the crown. The glaze actually wears opposing teeth more than the Bruxer or zirconia underneath it does and so if you didn't glaze the crowns it's actually better for the opposing tooth. The problem has been that if you don't glaze the zirconia crown it doesn't look very life like and so it's been difficult to get laboratories to try to polish zirconia crowns. It's harder to make them look good that way it's easier just to slap some glaze in it and run it up in the oven and send it to the dentist and so Keve and Cindy at 38 Smiles the other thing they've committed to doing is they polish all their zirconia crowns rather than glazing their crowns and this I told Rella, I lectured for Gordon a couple months ago and Rella was in the audience I said I have a surprise for you there's a finally a lab that has bought into the Rella story of polishing the crown's rather than glazing them and this really takes advantage of how smooth the surface of zirconia can be when it's well polished and as a result you know they're turning around crowns in three days and they're sending out brucks or crowns that have been polished instead of glazed. This is kind of state of the art and crown of bridge today.

Howard: Now let's back up a little Mike so you're saying 3 day crown but I want to first go back to a same day crown how significant is that. Now I am so old at fifty-six with what four or five I have five, four boys and five grandchildren. I had the CEREC 1 which I don't think today anybody would say was a good temporary making machine I mean I think I made a good temporary and then then I had CEREC 2 and then and now it's CEREC 3. How significant of the market is same-day dentistry with a CAD/CAM device whether it be CEREC 3 which is owned by Dentsply Sirona or Planmeca out of has a company in Dallas Fort Worth. Well how big of players are these guys?

Mike: Well obviously Dentsply Sirona is still the big one in that segment but altogether they probably have penetrated the market around fifteen percent give or take a percentage point each direction of dentists who have bought that, that spot all those systems over time including the ones that you did. So it's hard to say how many are still using it and so same-day dentistry that is kind of in my world the ideal way to do it to be able to put you know so if three days is better than two weeks there's no doubt that same day is better than three weeks but a lot of dentists aren't willing to invest the money in the technology and it's really not even the money it's the change that has to take place in their office for them to incorporate chairside CAD/CAM, you're now asking a dentist instead of you know prepping a crown in operatory one and then going to operatory to to prep another one to stick around and help make the crown and most dentists will tell you that they don't enjoy the process of making crowns they only made two back in dental school they don't want to be the lab tech they'd rather go prep another one. So for me three day crowns represents kind of the best case scenario for dentists who aren't willing to make the investment and take the leap and change their office to go to chairside CAD/CAM but not doing the two-week temporary crown that we've always been doing .You know Howard to think about this at Glidewell Laboratories we had to design the crown's 400 microns out of occlusion. So most dentists when they think about a crown being made in the laboratory they think about it being made in contact with the opposing to what we had to do at Glidewell and it's still being done is designed the crown 400 microns out of occlusion so that's a four tenths of a millimeter opening between the crown and the opposing tooth and even when we did that we had about 17% of the dentist saying that the occlusion was too high on the crown even though we were designing at 400 microns out of occlusion. This is when I began to learn that the temporary crown was a real problem because we're having to leave the occlusal contact completely open and there's still dentists saying they had to adjust the occlusion too much that's why three days is important because even if your assistant accidentally leaves the temporary crown out of occlusion by 200 microns it's got far less of an effect if you're seeding the crown up to three days versus eating it after 14 days.

Howard: and what kind of crown are you liking wouldn't someone sends it to a lab what what kind of crown do you like well before I say this, I know there's guys you want to talk about full mouth rehab and you know all on four but the truth is America will do a hundred all on none cases called the denture for everyone all on four at $25,000 an arch. I mean for every America that can buy 50 thousand I mean last night I was feeling really excited so I went to Village Inn for dinner and I thought I love that place because I'm the youngest person in that restaurant I mean if you think you're old just go eat a village in Mesa, Arizona and you will feel like a young kid he's just kind of high school but when I the most fun insurance date I've ever seen was the 32 teeth and then a dollar spike for the teeth treated and all it is a flat line with four monster spikes on the for six year molars. I mean that's the tooth most likely to get an MOD, a crown, a root canal, directed a single implant. So I'm not talking about all on fours in all this but just podcasters are young most of the podcasters are 30 and under in fact shoot me an email and tell me how old you are where you're from or leave a comment after at the bottom of the YouTube video where you from what country all that kind of stuff I'd love to seeing that stuff, but for these young Millennials that just got out of school and for the first four years they're mostly doing molar crowds first molar crowns. What would your go-to first molar crown?

Mike: Well when you look at and when you look at Glidewell, Glidewell is a great example. Glidewell works with dentists in all 50 states they work with an average of 45 thousand dentists a month forty-five thousand dentists a month order one thing from Glidewell. It's unbelievable and out of all that stuff coming into the laboratory eighty-two percent of it is single unit crowns that's coming into crown and bridge eighty-two percent and then another nine percent is two unicrown's. So ninety-one percent of what's coming in to Glidewell the biggest lab in the world are one and two unit crowns. So you're exactly right when you say that American dentistry by GPS not prosthodontist but by GPS is getting done one and two units at a time that's just the way it's always going to be and so for that first molar that you're talking about or even if it's the second molar I'm a full strength zirconia guy I'm a Bruxer specifically full strength zirconia and the reason why is Gordon and Rella well specifically Rella now has seven years of research on full strength Bruxer in that eMac study that she did with Bruxer are in emacs both materials are performing admirably but Bruxer is outperforming any tooth colored material that they've ever tested before. It's unbelievable it's really it's performing like a champ there's a bunch of new translucent zirconia is out there now that ours not performing as well and that's another story but if I'm doing a molar it's gonna be Bruxer full strength the original solid zirconia for the molars and when I go anterior for that it's going to be Emacs anywhere else. You could use Emacs on that first molar but that requires you to reduce more that requires you to bond the crown into place rather than cement it and the recommendations that I make because of my history of Glidewell I make recommendations for the average dentist out there I'm not making recommendations for the top 2% of dentists so for the average dentist out though I haven't met I have to go with Bruxer full strength original formula zirconia on molars and then you can use emacs press everywhere else because all the anterior teeth have about a third of the biting force that you see in the posterior tooth so i'm a max in the anterior and the Bruxer are on the posterior.

Howard: Did you know I'm in the top 1% dentists for body mass index

Mike: Yeah I saw that you I know that have been your goal for a while so congratulations.

Howard: So Bruxer though isn't that a name brand that you have to use isn't that Glidewell's Bruxer or where you say Bruxer sure like that lab you're talking about 38 Smiles. I mean can they do a Bruxer crown I thought that would say

Mike: Yes Glidewell sells Bruxer to about 210 outside laboratories who buy it from Glidewell and use it as well and the only reason I say Bruxer is not because I was a Glidewell for 15 years and not because I was on the team that launched it. It's the only zirconia that's been as tested as tested for seven years clinically in the sea art study or the track study I should say that Rella is doing now. I truly believe that other full-strength solid zirconias are going to perform as well but I just can't say it with the kind of confidence I can for Bruxer because it's been in Rella's study with zero failures on molars for over seven years with feather edge or slight chamfer margins it's really it's it's unbelievable it still blows me away what a great material that's ended up being.

Howard: and what will you cement that zirconia with?

Mike: Anything, anything you want could be RelyX Luting cement could be Ceramir you could go take a step up and do like Speed CEM Ivoclar Vivadent that it's so strong it doesn't care if you still had flecks in your office you could put pull that out of the refrigerator and use that you could use Durelon if you want to use that it's such a strong bond...

Howard: Please don't say Durelon I get an ulcer everytime you say that, you don't know how ancient I am when I got out of school at 87 the biggest wig out there I'm not gonna say his name cuz it'll come haunt them I'll just say he practices in Clearwater Florida and but the big deal at the time he got burnt to was dye poor cemented with Durelon. So when a beautiful woman came in and one of these gorgeous clowns crowns it was dye poor cemented with Durelon. Guess how many of those that I see leaded fractured and had to be replaced for free.

Mike: I'm gonna say a hundred and two percent what I think one of them exploded and broke the opposing tooth at the same time.

Howard: and then we and then we lived through tetric ceram and there was art glass. I mean are dentists still guinea pigs for new product development, I mean does it come out as somebody's idea and then just and the next thing you're doing it you're doing it fee-for-service crowns you're doing them on your mom and dad I mean how long did it take you to figure out tetric ceram was not a good idea or art glass?

Mike: Well we were doing art glass to metal at Glidewell and the art glass kept falling off and the manufacturer said it was our fault but what we knew it wasn't we were even putting additional mechanical retention onto the crowns that the company wasn't asking us to do and it was still falling apart when you soaked it in saliva. So the crowns worked really well and people with xerostomia that was the main indication was anybody run out of saliva these crowns would last until as long as they lasted but there they in a sense dentists kind of are guinea pigs when it comes to indirect restorations like that at times. You know people think that we invented Bruxer I mean we did come up with Bruxer but solid zirconia was already being used in Europe by zircons and we really just introduced it with a lot of marketing to the United States market and got really good at doing it but yeah I there's hardly a day where I don't fall to the ground and kiss it and say thank you because Bruxer has worked out so well that's why...

Howard: The point I was making for these young kids I mean if you're listed in this under 30 trust me I know when you're 30 years old you think you're smart enough to rule the world but when you're 40 well what percent of the stuff you believe now at 50 you look back on your thoughts at thirty and just think those are ridiculous and what I'm telling you guys is that when I was young I tried all the new stuff I tried the tetric ceram, Ivoclar, the art glass, the Durelon. I tried all these things and now when you're a grandpa you say let all those little kids who graduated last week from dental school why don't they try all that for five years and then get back to me I mean I just I don't want to be a guinea pig your patients no one being anything learn how to separate bleeding edge technology from leading us like they still come to my office and want me to switch my Emperor gum to an oral scanners like dude it's a $17 impression I send it up the street for a $90 Bruxer crown and now you want to meet it change out with a $17,000 scanner and then you want me to buy a $200 a month software agreement, hell that's $2,400 in fact $2,400 let me get out my trustworthy calculator $2,400 divided by $17 an impression hell I can take a hundred and forty one impressions just for the software group. So just separate bleeding edge from leading edge you want to be high-tech but you don't want to run your local family experimental dental workshop.

Mike: Right, well and if you love technology and you want to use it to show off to your patients there's nothing wrong with digital impressions but every crown that Gordon Christensen, Frank Speer, John Boyce, Bill straw, Bob Lowe, whoever your clinical mentors are 99.999% of their dentistry has been done amazingly with polyether and polyvinyl materials so they aren't broken but if you want to get into digital scanning because you think it's cool it does help with the three day turnaround if you want to get a crown back in three days it's much easier to do with the with the digital scan because you get rid of the whole day of shipping getting it out there and just your point of bleeding-edge this study that Rella is doing a track where Bruxer and E max are performing so well keep in mind that Emax is Ivoclar's third crack at lithium disilicate. You know the first time they did it it was called Empress Tube, and it was a lithium disilicate sub structure that had ceramic on it that didn't work and it was taken off the market the second time was called IPS eros it was a lithium disilicate with a different veneering ceramic that didn't work and was taken off the market and then they had their genius stroke which was to use it as a monolithic material with no porcelain on the outside and boom Emacs takes off and changes the world in 2007. So even an incredibly successful product like that had to go through a couple iterations to get where it is now that said you and I practiced in an era where we have so many all ceramic failures you didn't even mention Wol-Ceram, one we did it that failed spectacularly and all ceramics you used to come in all the time and a company would have an all ceramic and they come tell our pfm Department hey sorry man this is the end of PFM's and Rudy Ramirez our pfm manager would just laugh and go yeah I've heard that before because there was so many bad failed all ceramics one after another but all of a sudden starting with Emacs in 2007 then Bruxer in 2009 there's this new category of high-strength all ceramic materials but the market still tries to come out with weaker ones you know things that are weaker than Emacs and most of them are for CAD CAM machines but they try to get labs to buy into but Emacs has set the new bar for the lowest minimally acceptable crown, single unit crown material in my world. So the 30 year-old dentist today well they should be leery of certain things that come out probably the one area they don't have to be leery of believe it or not is all ceramic indirect restorations because right now that has gotten really good with the combination of lithium disilicate silica and solid zirconia but there's plenty of other areas where there's gonna be new products that don't do so well and so you know it's always been for us about five-year clinical results sometimes it's hard to kind of wait five years and see what those results are going to be but yeah it always moves you that's why subscribing to something like Gordon's newsletter to see our newsletter it's still a great way to get the most unbiased information you can get.

Howard: The CR newsletter, my god why do they let it what do they leave it called CRA I still have to convert that in my brain I like serum user oh yeah that's CRA. Hey so Mike would you call scanning digital scanning would you call it bleeding edge or leading edge right now if you're a 30 year old millennial you open up your office you know they grew up on technology I even know had Ross Nash and his wife Deborah Englehart telling me that they think the fact that the kids grew up just playing video games they actually have less dexterity less artistic ability. Ross thinks the generate the baby boomers just the way the erases kids learn more muscle memory and hand dexterity than someone who's only had their hands on a remote control but if you're 30 years old you grew up on a on a xbox is digital scanning bleeding edge leading edge what would you recommend?

Mike: To me bleeding edge means the price is going to be exorbitantly high and it may not work all the time because it's such new technology. Leading-edge would-be prices have already made that initial drop from when they were super expensive like we used to see with the $38,000 intraoral cameras when the first one came out and it needs to be reliable and work 99% of the time and commonplace you know would be or common edge whatever we want to call that one, is when it's in the hands of at least 50% of the doctor so I would say it's leading-edge they all work you know the six commercially available systems I've used them all at Glidewell we owned them all they all work, they've all got advantages. In fact the funny thing about it is they do most of those digital impression systems will do five or six things really well that nothing else can do the one thing they don't do very well is take impressions and and so when it comes to measuring how much you've reduced between the prep and the opposing teeth they're great at that they're great at letting you have remote connection with your laboratory technician where you can prep seven through ten scan it and let your technician see it while the patients still in the chair and ask them do you want me to prep any more around anything off for you there's all kinds of great things you can do with that but when you look at Gordon's criteria faster easier higher quality more affordable you got those four criteria if you hit all four you'll be a runaway success if you hit three of them you'll be a great success if you hit only two you're going to struggle and if you hit one you're dead in the water and is it faster than a conventional impression no it's not, it takes 25 seconds to squirt polyvinyl around a tooth and stick a double arts tray and ham bite together is it easier no you have to take better care of the tissue with digital impressions than you do with a standard impression technique, is it higher quality yes it is higher quality it's about a percent more accurate than the combination of polyvinyl siloxane and distone and is it more affordable, no it's less affordable. So currently in the state there and it only meets one of them they can't be it's a niche product it can't be a runaway success because it doesn't solve enough problems for dentists it actually creates a couple of problems without solving problems that dentists don't have is polyvinyl and poly ether are reliable they're easy everybody knows how to use them you don't have to be as you know as particulate with the gingiva and keeping it dry as you do when you're taking a digital impression so until there's until there's the technology that will see through tissue, see through saliva, see through blood and can honestly take a an impression of the opposing arch the prep and the bite in 27 seconds like a regular conventional double arch impression does then it's going to be stuck kind of in this niche mode. In fact they're not selling very well ,aligns really the only company selling them and it's because their tie in to their aligners but that brings me to my question I want to ask you Howard I feel like I get to ask you one question well while we're doing this and that is have you been seeing all the ads for smile direct Club on TV?

Howard: Yes

Mike: Now this is remember we you and I used to give praise to Denmat because they were taking out full-page ads on the back of People magazine for their luminaires and so even for dentists who didn't do luminaires. At least Denmat was spending this money with the direct consumer campaign to tell our patients what luminaires were and then they would come in and ask us do you do those and you'd say yes or well or you say oh we do something just like them but thank God Denmat was out there educating patients so at least they knew you know what a venir was but i don't think we've ever seen a direct-to-consumer push like we're seeing now with smile direct club it's unbelievable how often these ads are running and I want to get your take on what you think as you might imagine orthodontist are up in arms about this and there's 39 state dental boards that are suing Smile Direct Club but you're always an out-of-the-box thinker and you see the big picture better than anyone else I want to see what your thoughts on this because it kind of reminds me of you remember when we were doing all the bleaching in the office by making custom trays and then one day crest was gonna release white strips and dentistry just went nuts it was like oh my god how can they do that boycott crest you know every dentist wanted to boycott crest because they were gonna start selling whitening strips over the counter and now that that happened you know 20 years ago no one really thinks about that anymore and yeah there's some patients who do that but dentists still provide that bleaching in their office what are your thoughts on smile direct Club in this and this concept of going direct to consumers with orthodontics?

Howard: Well a couple things you mentioned that Gordon always says his four rules are faster, easier, high; faster, easier, higher technology, lowering costs, but an MBA school you know that that comes from the 5 and the 5 is miniaturization. I remember when you work for a Glidewell you didn't like a Glidewell's own intraoral scanner because it was too big remember it need to get small. So you know the first steam engine was so big it can only pump water out of a coal mine but as it got faster easier higher quality lower price and smaller eventually fit on a ship and shipping and then a train so these technology these scanners got a smaller but back to your deal basically there's 323 million Americans and only 5% have ever got ortho because the one thing the orthodontist, you know they've gotten faster they've gotten easier they've gotten higher tech but they never lowered their cost and smile and so when the average ortho price in America is $6,500 a case I mean this is America I mean there's a lot of dentists listening to this podcast right now that would have that do not want to cough up 6,500 bucks for anything. I mean they got student loans I got a house I got a pregnant spouse. So what's neat about Smiles Direct Club is they figured out a way to do it for twenty five hundred dollars. You go into a Smiles Direct Club there's four or five of them around here I'm trying to do a podcast with the CEO of the Align Technology with Invisalign Itero, Joe Hogan but you know the guy doesn't return my any of my emails or phone calls and because he probably thinks I'm gonna sit there and take the party line of the orthodontist and held in though the average dentist is making one hundred seventy four thousand a year and the average orthodontist is making over three hundred thousand year there's no one in the government, we have five dentist in the US Congress they've never been in president they've never been a Supreme Court than ever in the Senate but five of them are in the nice House of Representatives and if you talk to any of those guys there's not any sympathy for a bunch of doctors making $300,000 here but since they have figured out a way Smiles Direct Club, which should be an interesting IPO they you go in there someone who's not a doctor scans and then they send you at home 20 trays and it's 2,500 I mean if you cut that price as 6500 only 5% of Americans got ortho at 2500 you would have to think what percent lowering that price 6500 to 2500. No one knows but what percent more of America will have access to straighter teeth what would you guess? You think that'll pick up? I mean you know you GM they had a high price Cadillac they didn't sell very many the lower price Buick a lower price olds a lower price Pontiac and what do they sell the most of the lowest priced Chevy. So at five percent the Cadillac 6500 drop in that place to 2500 you're looking at it at it somewhere between a Pontiac and a Chevy, it's probably the Chevy. So how much more of America do you think will get access to a straighter teeth with clear aligners, what's your guess?

Mike: I don't know I don't know if it'd be 25% or what it would be

Howard: Yeah and definitely go double-digit right you know it'll definitely be double-digit so at the minimum you and I agree it's going to be another ten percent of America get straighter teeth and what I like about that is just a human psychology when people don't like their teeth they don't brush them, floss them, they don't go to the dentist and the my main takeaway when bleaching came out which was by omni gel out of Arkansas back in 87 was that my god you bleached some kids teeth and now he's looking at him are they whiter oh what's that black dot oh that's the cavity, now he's coming back in and he wants that, well you get him please so with humans they're either all in or they're all out you'd either own your own boat and jetski and go to the lake every weekend or you ain't been to the lake one time in ten years and I so I think a bunch of people starting to get their teeth straighter is gonna make them more but the orthodontist again they'll do anything. They want to market for new patients, they wonder if they want to do all these things but you know what they don't want to do is come down on the price of their ortho right and then that's why competition is right there at their door beating on it.

Mike: Well then you're probably going to really like my new idea called endo direct club and this is where we send the patient a handpiece and some endo files cuz I've been doing it for thirty years and I'm still not that good I figure they can do it just as well as I can but actually my issue with it is I'm just not a big fan of removable aligners you know you and I went to rick 'let's course Brock Rondo's course we both store do an ortho within a couple of years of getting out of dental school you and I both know that if you want to move a tooth, I mean actually move it - you bond a bracket to the front you put an archwire in and you put an elastic on and you move it and the difference between that and a removable aligner. So I've never liked removable aligners because all you can do is kind of tip teeth and you can't do the same complexity of cases and I never feel like I had the same control as with brackets and archwires and so the funny thing to me about patients doing it at home is it goes to show just how innocuous removable liners are and just how little they do like if you could actually move teeth around in a serious way like you can with brackets and archwires they would never let patients do this at home it just goes to show that it's not really doing all that much to me and it can't do much damage as a result of that. I'm still like I like Six Month Smiles I don't know if you had much experience I know Ryan Swain helped grow that business on Dentaltown and I still do some work with Six Month Smiles because to me they represent the best model of all where you have total control over moving the teeth you can do more things with it versus the removable aligner market and so with patients doing it at home I'm hoping there's a Denmat effect where you have a patient who sees and by the way the dentists who are providing Six Month Smiles typically do it about half the price of those the fee you quoted for the orthodontist because they're not moving posterior teeth they're simply doing anterior teeth to give that patient that better smile that they want they're not correcting posterior crossbite it's all being done through IPR 5% of their time there might be a lower anterior extraction or something like that. So I'm hoping the net effect as patients sit at home they see a smile direct Club ad they come to the dentist and ask about it during their cleaning and they say well we don't do something like that but we have a system we do in six months with tooth colored brackets tooth colored arch wires and clear elastics where we have more control and we can move things quicker and then we'll finish you in those kind of removable aligners and that'll be your retainer. So I still lead towards fixed appliances you know anterior focus without doing the whole mouth like you and I used to do so you're not working on kids in adolescence you're just working on adults just concerned about anterior teeth it's cosmetic related ortho that's where I really think most dentists should be getting involved and bringing this into their practice. How long was your ortho education a dental school? Was it 13 minutes like mine?

Howard: Yeah and it is all based on the craniofacial embryological development I mean just all this stuff that didn't apply but you're so right it's all peace likes. I mean if you're just doing adults you know you know when you're taking a pano supplement on a 12 year old and tried to predict where they're gonna be at 18 to 21 you got to be pretty damn smart but just mild crowding you know that you stay away from you know long faces opener bites class twos, class threes and you're right they're just the patients are sitting here at the mirror because what stuff about being it orthodontist that the the first 20 months of ortho is pretty easy. All the stresses in finishing the case gives up just the detailing so if you're dealing with patients with lowered expectations and you know that mild crowding anterior they're looking in the mirror and it got a lot better that's a faster easier case. I mean Smiles Direct Clubs only going 20 trays but a lot of orthodontists that when they're doing Invisalign to actually get a detailed finished close, they're doing more like 30 trays and the difference between 10 trays close works in a hand grenades and interior crowding you know hey I'm gonna go back to skinny though you're so genius you I mean when I talk about oral scanners you actually said there were six which means there's not five there's not seven you know.

Mike: No, their's a lot more than six, their's six main ones in the u.s. right.

Howard: but one of my biggest complaints of my podcast is he didn't say which one so you know she's 30 years old she's driving to work she wants to get an oral scanner but you did go she wants to know Mike DiTolla, if I was gonna buy a oral scanner which one, they want me to hold the feet to the fire they don't like to they don't like when people use generalizations they want alright well okay go through go through this top six scanners.

Mike: Well I'm gonna give you I'll give you a couple of them because it's kind of like, it's like asking what's, what's a better car a Porsche Panamera or Ford Focus it's like well it all depends what you're expecting out of this experience. In my opinion the two top scanners on the market easily I don't think there's an argument are DENTSPLY Sirona Omnicam and 3Shape’s Trios. These are two great scanners that and i might even give the nod to the Trio's. I think the trio is probably a better product I just don't think they have the kind of support that you get from DENTSPLY Sirona but both of these are over $40,000 but they allow you do the most things with them and integrate with different systems but you're going to pay for, you're gonna pay for that opportunity to be able to do that and so maybe you'll say well I don't have any aspirations of ever doing chair side cad/cam crowns and I'm definitely more value focused and certainly the most affordable way in is with 3m's True Definition but so that's the that's the one that you kind of referenced earlier when you said around $15,000 and you mentioned something about a data plan that's part of the reason why it's so cheap up front is that there is a two data plans actually depending on whether or not you're going to do implants and other stuff, that one happens to integrate with align technology so you can send ortho impressions over there but the downside to that one is it's the only one out of the six that still requires powdering and so for a lot of dentists they're just like no I'm not going to do it because it it needs powder. I actually respect for 3m for keeping the powder with it that shows how dedicated they are to getting the best result with it and even if you have an Omni camera or three shapes trios there's definitely times where you're scanning something and the scan just doesn't look great and it always helps to powder just a little dusting of powder gets rid of reflections from like gold crowns or other metal in the mouth there are almost every scan that you do could be improved in terms of accuracy with some powder, it's just that all the systems of god powder free because that's clearly what dentists want to do, they don't want to deal with the hassle of powder. So I respect 3M for sticking to their powder guns even when it's a super unpopular decision to make it just shows they're kind of committed to the quality of it. So that's the lowest entry price but you're gonna pay that data fee and then you've got the Plant Scan one you got the Care Stream one in there as well and Dental Wings has one and there's you know forty five other ones if you're going to go to the IDS meeting in Cologne, Germany and see those as well. The messages they all work they'll all do what you want them to do and really what you need to do is go to a big show and see how they feel in your hands see how intuitive it is see if you can actually take an impression without having to ask for a rep to demo it for you see if it's like an Apple computer where you can just kind of figure out your way through and on an iPhone by touching a few buttons, what feels comfortable in your hand and and why do you want to do it. You know what what's your reason for getting involved with this don't ever let a rep selling digital impressions tell you that you're not at the standard of care if you're still doing polyether of poly bono that is that's complete you know bull, that's just not true. The gold standard is still you know poly vinyl and if you have to go sub gingival poly ether because it's actually you know not nearly as hydrophobic as polyvinyl is and so those are what we've used for generations and they still work you can get a crown back quicker with digital impressions, you can share information with your technician, you can see how much you've reduced and if you've reduced enough for an Emacs crown or zirconia crown. So there's a lot of ancillary reasons to get involved with digital impressions but by no means feel guilty at all if you want to stick with poly beam or poly vinyl or poly ether you're not behind the curve you're not doing lesser dentistry that's just not true.

Howard: You know what I love most about 3m though...

Mike: What?

Howard: Oh you know don't you...

Mike: Uh no...

Howard: When I when I go visit my sister my sisters are the nunnery in Lake Elmo so when I fly to Lake Elmo to go visit my oldest sister Mary Kay I have to do four hours in one minute of business to make it tax deductible, so I fly into Minneapolis st. Paul I go talk to the R&D; department at 3m for four hours and one minute or I go to Patterson I remember what his peak for sale used to be the CEO oh my god he was so fun he would give me the whole four hours won that but back to the I you said itaro this young millennial wants to do a bunch of Invisalign can she use what do you think of the eye taro first single unit crown and bridge?

 Mike: Oh absolutely it's come a long way from their initial and that was the first commercially available system in the US and when I got that we used to call it the dust buster because it was about the same size shape and weight as a dust buster and you were shoving it into somebody's mouth and I remember telling the rep I said God the tip is so wide it's just like hard to get in a patient's mouth and he said yeah a lot of our doctors like how wide it is because it helped keep the tongue out of the way I'm like oh that's some real rep doublespeak there that's some bragging about why the tip is so wide but as times gone on it's gotten lighter it's much easier to handle as well they're definitely selling more scanners than anybody else so they've got this robust network they've always had the best models you know if you're not going to do things to model free and still have a model that ITarot models gorgeous but the whole industry is moving away from models because we really don't need them anymore if we're doing if we're going to be scanning it and the other thing about scanning is that just know that all your labs are using it. So even if you take a polyvinyl or a polyether impression your lab gonna pour it up in dental stone and scan it because they immediately want to get it into the digital environment because they've got all those 30-year old employees that you were talking about Howard that grew up playing xbox in Nintendo when you walk through Glidewell now the average age of somebody designing a crowd has gone down 15 or 20 years in fact there's not there's probably not even a ceramist in the Glidewell building anymore because we don't use any ceramics for the most part everything's a monolithic restoration. So the labs have totally bought into scanning they've proved that it's a technology that works if you want to get it in your office just get the one get the one you like the way the interface looks and how it feels in your hand because if you don't like how it looks and feels and don't want to use it every day you're not going to use it it almost comes down to which one do you think looks the coolest and it's gonna turn you on about using it.

Mike: Well Mike but I'm gonna hold your feet to the fire because this is Dentistry Uncensored and there's a real dilemma out there you know you mentioned on I think you and I both agree that probably the best oral scanner is the 3shaped Trios but they're in a huge lawsuit with Align Technology because the Align Technology is spread wants to support ITarot so some of these scanners are going to be open-source working with each other if you wanted to do Invisalign would you just say you should use the ITarot because that's the big dog line technology or do you think 3Shape will make enough connections with other clear aligners you just do and Invisalign will be the brand name the patient will ask for Invisalign but you say yeah I got a scanner it's 3Shape and I'll do another clear aligner what would you know what would you how would you address that specific concern?

Mike: If you want to do a lot of Invisalign cases I have two suggestions one is take a Six Month Smiles course so you can see what it's like to really move teeth with arch wires and brackets because you should don't just know how to move teeth with the aligners, it's just totally different you and I went through it the real way I mean we were working on kids and adolescents and we were we saw everything ortho had to offer so by the time you get to aligners the principles of orthodontic movement are well cemented in your head but if you want to do a bunch of Invisalign cases yeah get the ITarot, I don't know why you wouldn't it's kind of like, it's kind of like when people used to want to use iTunes on a PC or use on iTunes with a phone that wasn't an Apple phone if you love somebody's environment stick with their hardware and their software. So in this case if you're a big Invisalign provider you want to go digital then absolutely go with the I Tarot because you can still do crown and bridge with it when you start doing that but it's a great pipeline into that Invisalign. So yes there are times and frankly if you want to do chair side restoration perhaps at some point I have to vote for my old employer DENTSPLY Sirona and the CEREC system. I think they have the most robust start to finish system if you're gonna be using that scanner with the mill you'd like the scanner in the mill to be made by the same people and have them make the software so you don't have issues between oh no that's a mill problem no that's a scanner problem.

Howard: So you've mentioned 6 Months Smiles a couple time that on the website it's actually the numeral 6, so it's numeral  She's never heard of 6 Month Smiles like why do you specifically mention that one what are your thoughts on 6 Month Smiles?

Mike: Well I just it goes back to the early Dentaltown days you know and when you and I were doing these big comprehensive remember those ortho classes we were doing out in Phoenix there were four or five four-day weekends. I mean it was really a lot of depth and we did it with Ric and then we did it with Brock Rondo and got into it then you would do cases and come back for follow-up once and so you got all of this knowledge and for me it was almost it was kind of too much ortho I kind of almost felt like a specialist at times because we were doing functional appliances for kids and doing all this other stuff and for some of the people who took the class with us they really loved it but my passion was more about straightening front teeth that's what I wanted to give patients smiles and so when I started seeing patients and hygiene this happens all the time where you see somebody who's had you know they're stable they don't have a lot of caries but their lower anterior teeth are crooked and they they say why are these teeth getting crookeder and you say well all teeth want to move downward and forwards and did you have ortho, yes I did where are your retainers I haven't worn them in 20 years and it's like well back in those days they you know they didn't do permanent retention from 22 to 27 but that would have been nice but I found that most of the cases I was doing was on adults who wanted to straighten their own teeth and it was just anterior changes to give them a good smile we would combine that with bleaching almost all the time or sometimes with minimal prep or no prep veneers and so I kind of evolved over to 6 Month Smiles because it was very easy for me to talk to other dentists about doing it. Like if you remember Howard when you and I started doing this remember we replace all the brackets by hand on the teeth we had the bracket measuring tool from the incisal edge and you try to line it up with a long axis and get it all right and you could always move the bracket later 6 Months Smiles is all based on indirect bracketing. So it's kind of like having a surgical guide for placing an implant so you send the patients models to 6 Months Smiles, they bond the brackets onto the model then do a suck down over it sent it back to the dentist so now you just edge the tooth you know R instant bonding agent on cement on the bracket seat the stent down light caramel peel it off and clean up the extra cement. So it's the lab that's actually putting it together they have a product called confidex which is a team of orthodontists that diagnoses your case and tells you what to do appointment by appointment. It's great hand-holding for dentists who got zero or almost zero orthodontic education in school but want to get involved with this and the reason it bothers me Howard is that I personally did too many cases as veneer cases that could have been adult ortho cases and we see these cases coming into Glidewell as well and people say you know no prep veneers well no prep veneers are very conservative compared to prep veneers but what's even more conservative than no prep veneers is adult limited adult orthodontics to just the anterior teeth, where we're creating some space with IP are having tooth colored brackets and archwires on for six months and straightening things out and bleaching them and that's truly conservative because even with no prep veneers the patient's kind of married to this restorative result they have to be done every ten or fifteen years. So you and I took these comprehensive ortho classes and I didn't love doing that what I ended up loved doing was aesthetically focused anterior limited orthodontics on adults and that was that was Ryan Swain 6 Month Smiles story and so that's kind of how I fell into it and got involved with it and I still talked to Dennis now who not only don't have any orthodontic training but instead of doing 25 crowns to graduate like we did back in 1988 they're doing six crowns and graduating from school because there's less patients and in less time and so they're coming out without a lot of clinical confidence and it's fine you can always learn to do algine and it's kind of a line kind of everything is done for you not a lie but just removable appliances in general but if you really want to understand how to move teeth I think that 6 Month Smiles right now is teaching GPS a great way to be able to move around and for me it's just as much aesthetic dentistry as veneers are you are. You really in my in my opinion can't call yourself an aesthetic dentist unless you know how to remove enamel and bondo veneer and know how to move a tooth so that you don't have to remove enamel if the case doesn't warrant it.

Howard: because when you and I got to school, your dad's a dentist when we got out of school back then when people had a bunch of crowding to do the veneer cases they had a root canal teeth, they didn't blink twice of doing all these root canals all this stuff and when you go back to those cases that we saw in the 80s we kind of thought man if you can't do ortho and unravel those teeth and stop having to do root canals on rotated you know peg laterals and all of that. I mean so yeah I don't think you can call yourself a cosmetic dentist if you can do ortho along with bleaching bonding veneers all that kind of stuff. Who's the CEO of 6 Months Smiles. who owns that now after I sold it?

Mike: It's a Perry Lowe, you might remember Perry he was the CEO at Axis Dental, The Bird Company before they were acquired by  KaVo Kerr and so Perry was at  KaVo Kerr for a while after  KaVo Kerr  bought Axis and then he went over to to 6 Month Smiles and so they just provide this great service for dentists they like I said that confidex is digital treatment planning for the GP so it's that kind of hand-holding like having a surgical guide for an implant and then with the indirect bracketing basically they're showing you exactly where to put it on, it it goes into place on the teeth right whether it's coming on the model so they've taken a lot of the difficulty out of it and again as we both learned in ortho you've got to get your team involved Howard because it's 99% of the work is being done by the team that's why if you ever want to get jealous you know you mentioned the orthodontist making at least twice as much as the average GP go to their office and watch the assistants do all the work. In fact you used to talk about ortho and your lectures you say look at what you guys will do molar endo but you won't do ortho you said look at what's involved in ortho it's like paper clips it's glue it's rubber bands you used to say you can buy the stuff at Office Depot I don't even know why you need to be a doctor to do ortho, and so you used to say that it would make orthodontist angry but now patients are doing their own orthodontics at home so you are proven to be true Howard when you said I don't even know why you need to be an orthodontist to do ortho you don't patients are doing it at home.

Howard: I can't believe Perry Lowe is the CEO out of Dallas he's been the owner that thing is he the owner I'm his CEO is he the owner he's been there for years I see.

Mike: Yeah he's been there for years yeah I used to CEO

Howard: Who owns it?

Mike: I believe there's some private equity money there a Ryan when Ryan got when Ryan Swain got out he sold it to a private equity company and they brought Perry on to run it.

Howard: Okay gosh darn, I'm almost running out of time with you I only got a few more minutes is there anything you wanted to talk about that I didn't bring up?

Mike: No I just wanted to I wanted to get the message out that two-week temporary crowds suck! It's just not it's not our best easiest way to do dentistry and so prop still like I said They're also very aggressive on their pricing because there's a small lab you know they do Bruxer like I said for with the Glidewell material, they do it for like $79 a unit, they do Emacs for $99 a unit so they...

Howard:and to get that in three days you'd really need to scan it?

Mike: It's gonna add it it's gonna make it four days if you send it overnight to them so yeah but mostly what they get it so I've been pretty impressed most of what they're getting is digital files from dentists. So dentists preps a crown scans it and they have it you know there's somebody sitting at a computer wait for him to come in five minutes later they're designing it and then they can be you know milling or since he max two hours later.

Howard: So what percent of their business is coming in via scan

Mike: Oh they're much higher than the average laboratory I would say just because of their connections and the dentist they know and and me talking about them I would say that 65 percent of what they're getting is digital scans.

Howard: 65%

Mike: Yeah

Howard: and what do you think the whole US market is on scans?

Mike: I don't know, I just know for Glidewell that it's around 18 to 20 percent

Howard: That's still high man that is still high and and the ITarot would work if you are doing Invisalign and if not than 3Shape and others. I'm gonna just get some fatherly advice cuz you and I now have you have three children and I have four you got any grandchildren yet no thankfully I mean what do I mean it let me to send them a book on how to kind of come on my for have turned into five how have turned into a donut I'm nada.

Mike: I've done live demos for them nothing seems to help I don't know if that's part of the problem. Well none of em are married so that's why I say thank God I don't have any grandkids yet.

Howard: Well hey but I just want you to end on some paternal advice if you're talking to one of your kids walk handouts go man they say this they say Howard, you don't know what you're talking about you and Mike graduated thirty years ago your dad probably graduated what would you know when your dad graduated?

Mike:Yeah 64

Howard: 64

Mike: Yep 1864 no 1964

Howard: 1964 and you graduated in 88

Mike: 88

Howard: and I was in 87 and now they're coming out in 2018 so you were 88 to eighteen thirty years your dad was thirty years before you I still laugh every time I'm number what time I first met you, you told me you wanted to be a dentist because your dad didn't work August. You said you didn't care about every other variable known to man you like dude if you're a dentist you don't have to work August it was historic.

Mike: It's beyond that he took us to Hawaii for the entire month of August so we went to Kauai for the, he just shut the door we went for the entire month. I didn't know if he was a dentist or a mid-level drug dealer I didn't know what he did but I knew I wanted to do that because none of my friends had the hole spent a whole month in Hawaii that's literally why I became a dentist.

Howard: Oh I know but they're saying they're saying that your dad have graduated in the golden years when I got out of school in 87 hell I would send my bill to Delta and they would just pay you know 50% on a crown whatever my fee was they paid 50% of the crown 80% the filling now Delta send you the damn fee and they're coming out of school four hundred thousand dollars in student loans because these dental schools now cost $100,000 a year including I'm in Arizona it only has two private schools A.T. Still in Mesa, Midwestern in Glendale. They're a hundred thousand those here they're coming out four hundred thousand dollars in student loans and she's listing right now and she's like Mike forget all this technical stuff I don't care about the difference between Bruxer and an Empress and Empress 2. How do I pay my student loans back that's the question how do I pay back four hundred grand in student loans what would you tell her right now?

Mike: To go practice for two years at Pacific Dental and to go get some experience and see what a really well run fee-for-service practice looks like in fact if you excel within Pacific you can be five years out of school and own you know three or four practices if you're a real rock star and you're killing it and you're really into it. There are still dentists coming out today who are doing fantastic there's still dentists coming out today who are struggling and those dentists who aren't happy with it either. I got lucky I chose this profession for really superficial reasons and fell in love with it after the fact you know I didn't I wasn't in love with dentistry because of teeth or enamel rods or anything it was because of the vacation benefits basically and fell in love with it. So I would choose it all over again but I think there's a unique opportunity with the rise of corporate dentistry to go practice somewhere. If you graduate from school and you're building on six crowns that's that's silly I didn't know anything and I had done 25 I can only imagine after six what you miss feel I talked to a guy from the University of Pittsburgh I said how many endo procedures did you do and he said three and I said and you graduated, he said yeah. I said that's not very many he said I know I really wish I would have got the chance to do a molar I was like you graduated from a US dental school without doing molar endo he said well I did one on an extracted tooth well it turns out it's a lot more difficult with it's still attached to the alveolus and the patient that's where the degree of difficulty really goes up compared to doing one in your hand. So if I was graduating today without a lot of clinical experience and confused about how I was going to pay these off I would go spend some time in Pacific. That's my favorite corporate dental out of all the ones I've seen that's my favorite corporate dental entity and see what they're doing every one of them CEREC unit in it, so you'll get to do some same-day Emacs restorations and see how that goes without having to invest in it yourself you can find out if you love the technology or don't like it or or middling. They've got a great ability to compensate dentists all Pacific dental wants you to do Howard, is treatment plan a crown and a half worth of treatment planning a day. So that's fifteen hundred dollars a day if a crowns a thousand dollars and all they want you to produce is a crown and a half worth of production. So they have low you'll be well compensated at Pacific Dental if you can just treatment plant fifteen hundred dollars a day and produce fifteen hundred dollars a day and they have a hard time finding associates fresh out of dental school who will do who are able to do that and that's not a lot you know as we as we know that's not a lot of production that's not a lot of diagnosis either and so our students are coming out less trained and more in debt and so I'm thankful that the corporate dental is around to help them get the rest of the training that they should have got in dental school and then be able to move on from there. So that would be my advice to my kids or any other young dentist is go these aren't the corporate don't remember how bad corporate dental chains were when you and I got at it out of school you know now Pacific actually is up to six hundred offices and they've got a CEREC unit in every office that's unbelievable to me that kind of commitment to technology and patient service they do seventy five percent of their Emax crowns same day that's amazing.

Howard: and he was on the show he was on Stephen Thorn the CEO 613,episode 613. If you want to see who you'd be working for. His dad was a dentist and he basically thought why else I go to school eight years to be a dentist I'll just hire one, amazing man and just a good guy.

Mike: His dad and my dad with the dental school together and

Howard: At UMP?

Mike: At U at university of Pacific and I just grew up thinking that the way to become independently wealthy was to you know become a dentist. Steve much smarter realized the way to become independently wealthy was to have six hundred, over six hundred dental offices.

Howard: and the other thing I say you know what how did you determined you know your altitude I mean I know people that are working at Heartland or Aspen and here they have the management systems to manage 600 offices and most the dentists I know can't manage their own office and it's like well in the two years there did you tell me about the systems, they can't even tell you the insurance code for a crown or a pro fee and I'm like well didn't you Wine and Dine your office manager didn't you get your regional director and become her best friend. I mean my god one year is one of these places just if you just got the leftovers on how they manage 600 and take that to your own office you'd be a light your head. Hey Mike I am out of time we both have to go love you to death thanks for coming on for the fourth time I really had Gordon Christian on three times and he's the god of Dentistry. So you must be the god of the universe thank you so much for coming on the show today and talking to my homies.

Mike: Thanks pal let's do it again soon. 


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