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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1147 Thomas J. Schoen DDS on Bread & Butter Dentistry, Oral Surgery, Periosurgery, LANAP & LAPAP : Dentistry Uncensored with Howard Farran

1147 Thomas J. Schoen DDS on Bread & Butter Dentistry, Oral Surgery, Periosurgery, LANAP & LAPAP : Dentistry Uncensored with Howard Farran

2/27/2019 1:42:52 PM   |   Comments: 0   |   Views: 201

Dr. Tom Schoen is a small town dentist in a surprisingly crowded market with 5 general dentists practicing in his town of 2500 people. Dr Schoen has added Orthodontics, surgical and molar endodontics, periosurgery, LANAP, LAPAP and Pinhole surgeries and places and restores implants, often using 3D guided surgery. He is a firm believer that risk factors should heavily weigh in on treatment selection, and uses tools like PreViser to assess risk. 

VIDEO - DUwHF #1147 - Thomas Schoen

AUDIO - DUwHF #1147 - Thomas Schoen

He and his wife Lynn are the parents of 5 sons, one who has Down Syndrome, and one daughter . Dr Schoen is a golf addict and also loves spending quality time with his special needs son. He is a moderator on Dentaltown and has served on the editorial board of DT magazine.

Howard: It is just a huge honor for me today to be podcast interviewing Dr. Tom Schoen. He attended st. John's University graduating cum laude and then went on to attend the Minnesota School of Dentistry he currently serves on the board of Dentaltown magazine. He's a small town dentist in a surprisingly crowded market with five general dentist practicing in his town a 2,500. Dr. Schoen is at an orthodontic surgical and molar, endodontics, pareo surgery, LANAP, LAPAP and pinhole surgeries and places and restores implants often using 3d guided surgery. He is a firm believer that risk factors should heavily weigh in on treatment selection and uses tools like pre visor to assess the risk. He his wife Lynn are the parents of five sons, one who has Down syndrome and one daughter. Dr. Schoen is a golf addict and also loves spending quality time with a special needs son he is a moderator on Dentaltown and has served on the editorial board a Dentaltown magazine. My gosh thank you so much for all you've done for dentistry for Dentaltown my god you got almost 13,000 posts on Dentaltown I'm just honored to have you on the show today how are you doing?

Tom: I am doing very good Howard thank you for having me on your program

Howard: and I didn't know until I went to podcast you that we both have a special needs sister and mine was born 13 months after me and she's been the joy of my entire life

Tom: Yes that my son is just so awesome and you know every time I ponder about life not going real well at all I spend a little time with him and I come out with a totally new outlook again, it's been fantastic.

Howard: and they also seem to never lose the ability to play you know what I mean.

Tom: Yes

Howard: I mean I think you know I always read these studies that you know little kids laugh 200 times a day in adults laugh two times a day or whatever it is and my gosh I credit all of my comedian abilities because it always made kaeleen laughs I mean she was my she was my only fan of all my jokes and it was funny because we're growing up if I said a joke at the dinner table and as an appropriate kaeleen would just laugh and laugh and laugh so that put downward pressures on mom and dad and my other you know sisters but she's the only one who's laughed at every single one of my jokes and it makes I just love comedy because they kaeleen but so you graduated in 1982, so the most fair question to ask you is these podcaster millenials and so many of them think well Tom you graduated in the good old days and my gosh I'm graduating this year next year 2020 with $400,000 of student loans and they're starting to wonder if it was a bad idea. What would you say to one of your children he just walked out of dental school of $400,000 in debt would you say God or would you say that was a really good idea?

Tom: Actually I have a son in dental school now that's gonna graduate in 2020 he worked for me for five years and he knew what it's like in the dental office he knew the business and you know he was kind of our triage person keeping things moving and he definitely thinks it's a really good idea. He's excited about getting to go to work and you know everybody thinks that back in 82 everything was wonderful but when I graduated from school I had about $80,000 in debt and then I went to a town and opened up a practice and took out a practice loan and the prime rate was 21 and a half percent. So for the first five years I didn't even keep up with the interest on paying back my loan and I bought a house in town for about thirty thousand and you know thirty thousand that house is now worth a hundred and thirty even though it's forty years older but if you take three times my debt it bought a house and if he takes that same house 40 years older multiplied by 3 you get to the 400,000 there so the debt level is pretty much on par with that and somehow I made it and got through all the interest rates and the in the payments and got back on level and it made it a great career and so I think if you get in the right situation and I think you know I did a lot of floundering the first few years you know and you're reliant on supply guys, you're reliant on you know what little you had in dental school to do business and then going to CE but which CE and why and the whole thing and I think these kids coming out of school they have so much better selection to what CE is good what CE is bad they go on these dental chat rooms they go into Dentaltown and you know and there's so much great CE right on Dentaltown. Howard it's amazing that you've got available for these young Millennials for an incredible price where they don't have to get out and travel and spend big money on hotels and all of that and you know and then they can come down to Dentaltown and make it an event and do their one big travel day and and it's they can learn so much more by being on that and you know what I my career took off and my learning took off, it was you know right around 2000, 2001 when I joined Dentaltown and it opened up my eyes to things that I never would have considered because it was there and other people were doing it and so if other people are doing it why can't I and it's just been very rewarding.

Howard: Well that's entry and we both have so much in common. I graduated 87, 87 thousand dollars in student loans so eighty seven thousand dollars in 1987 is a hundred 7,800 in today the inflation period from 87 to 2019 was 2.6 percent on average and I want to tell you I don't believe in that inflation number I think it's the Federal Reserve their main purpose is to control inflation but they obviously have been, I don't want to say conspiracy if they're either very transparent but they cook the books for instance like when we were little we had an apartment and we could jump up and touch the ceiling well now the ceilings are twice as tall so they stop measuring like apartments at square floor footage and start doing a volume deal. So they say well you're living in twice twice the size house and twice the size apartment the bottom line is when we got out of school when I got out of high school in 1980 the most rockin hot new cars rolling off the assembly line like a like a Trans Am was ten grand and now that Trans Am is 30 grand and in the same time period they've claimed almost no inflation well I'm sorry all the cars cost three times more but so a hundred and ninety seven thousand dollars in the student loans I didn't get a dime from my dad did you get it did your dad help you pay yours?

Tom: No that's why I had a nice pile of debt starting right out.

Howard: Yeah so I agree with the the CE, so many of the kids they're so into brand names like they want to go to these big Institute's and get these certificates and it all looks fancy nice but so many times I'll talk to these Millennials I'll say what you do and they say oh last week and I flew to this other city and I went to this three-day course and and blah blah blah and I said well how much was the total cost how much was the course the the hotel everything and they'll drop three or four grand I'll say we'll tell me I mean it must have been profound what'd you learn tell me what you learned for three or four grand because for three or four grand you could have taken 400 courses online, you know and and the the the uber from the airport to the course would have been less than what the course taught but we both believe do it faster easier higher quality lower cost and why don't you just take that hour course on your iPad. Shoot I got a friend of mine up the street from my office that learned how to place implants cuz every night he came home from work he got on YouTube and googled implants dental implant surgery and watch an hour of just random YouTube videos of people placing implants and he said after a year he felt like he'd seen every implant situation, every implant deal. I mean he just he learned the entire thing so but when they're coming out of school and you know they they haven't done Invisalign case, you know they've hardly done anything give them a stair-step.What do you think is the best return on investment what skill to learn first to next I mean would you start what you tell them to start?

Tom: I would say go with Tommy Murph and go down and take a lot of wisdom teeth out because it's an amazing of course they have and it's real-world extractions and if you get comfortable with that then all the other surgical procedures that you can add you're not going to be flinching about laying a flap or removing bone or doing things like that and you'll know where the anatomy is you'll be able to you know do that and if you've got you know four or five hundred extractions under your belt you know then placing an implant is like not difficult at all compared to all of that. All your skills all your hand skills add up so that you know if you're doing the right implant and doing the right selection and not doing the severe degree of difficulty you know your surgical skills will certainly be able to handle all of those things. So when my son gets out I'm gonna send them right down to Costa Rica or wherever they go and and and have a lot of patience and take out a lot of wisdom teeth.

Howard: The bottom line is I still think the best business model is bread-and-butter dentistry and that's getting people out of pain with extractions, molar root canals and then your fillings, crowns, cleanings and x-rays and exams but so many people come out of school and they say Dr. Schoen I don't like blood and guts, I like pretty stuff I want to just do bonding, bleaching, veneers and Invisalign what would you say to that business model?

Tom: The bread and butter is doing the restorations and getting people out of pain and treating them right and then being able to add those procedures as you go if I can count on my fingers the amount of eight veneer cases I've done in my career you know it's

Howard: and that's and that's like that eight is the exact number of cases that all the professional people who made a living speaking on veneers that's their total number of cases that they lecture on I mean I've seen these cosmetic dentists and it's like man you showed that veneer case 20 years ago it's just not real world it's fantasy I think they're telling people what they want to hear as opposed to you know being an adult is telling you the ugly truth that's why I call this dentistry uncensored and when people say well I don't like the extractions I like molar endo I say well I don't like your $400,000 of student loans so suck it up buttercup and start pulling teeth and Tom Murphy. Tom Murphy is a good idea and another great idea that I've seen so many times and I always did is they have all these low-income dental clinics in town they have Saint Vincent DePaul they have you know the cast they have all these deals and when I was in dental school I used to always work the breaks in the oral surgery department and you could do if you worked your spring break in the oral surgery department with Dr. Brett Ferguson and and Dr. Charlie white you you could pull 50 teeth in a week and so if you're out there practicing in Houston somewhere and you don't want to go to Costa Rica Tom Murphy's outstanding excellent course which everybody loves go find some charity place downtown and just work pain chair just do extractions because what's cool there is usually there's an older dentist there that can bail you out if you only if you get stuck until you get to a point in your life or you'll get stuck anymore.

Tom: Right and my son has been you know spent a lot hours already at the Good Samaritan clinic which is over in Rochester about an hour away and he was the one that all the surgeons wanted to work with because he knew what was going on in the extractions so and that's where he got interested and I really want to do more of this that they're doing at the clinic there. So not as much at my office but but at the Good Samaritan clinic he got his interest in in the surgery and I think it's a good thing. Molar endo compared to doing all the hand files and the in the condensing of multiple cone points and making everything 3 appointment endo you know we've got things like wave 1 and and these systems that it just makes it so much easier I'd to me it's a no-brainer, if you have a little bit of patience and an understanding of three dimensions molar endo is a very very profitable and smart thing to do. I couldn't imagine practicing without doing that.

Howard: So you'd recommend extractions they learn first and then you said molar endo?

Tom: Correct

Howard: and after molar endo what you say next learn oral surgery, learn and and what percent of oral surgery you think is wisdom teeth versus just routine extractions?

Tom: I do a lot of routine extractions but I have a lot of PPO and then some Medicaid that I take and so I get a lot of those things and you know taking out 28 teeth and putting in immediate dentures and you do it and you've got two hours invested, even at PPO prices that's very very profitable and so if you know how to do that, that's just money that you know if you send it out the door you lose a lot of it and you learn a whole lot. So I would you know make sure you do all your immediate dentures and and things like that too because the cost the profitability per hour is very good and it's a great service and if you the key is getting a good lab and being able to communicate know what you need and you know so if you feel that your dental education and fell short go and get some good education on making dentures and doing these things and there are a bunch of them out there.

Howard: So explain your name on Dentaltown where does Dr. Teak come from?

Tom: Okay I come from a family of antique dealers and so I'm an antique dealer actually my grandmother had 10,000 antique lamps in her house so the wheelin and dealin and in poker face and and purchasing these things helped a lot on keeping the, it was a side job that was like a recreation and back when money was tight and you were starting out I just bought stuff and sold it in a shop and there's nothing more fun than buying a piece of furniture for $50 and selling it for $800 so using your knowledge about that so that was an antique dealer for a long time now I've stuffed it in my time for golf and fishing and and spending more time with family but I had an antique shop and it was fun so you know I was an antique dealer when I came in with that label there. The fun thing it was next door to my office and they come into the office and say will you sell it for this you know you want 40 will you sell it for 35 and I said who's in the shop tending the shop well I just left it open and it's small town they think nothing of leaving a store with no one in it and leaving the person who was asking the question or a free rein of the shops and it worked and it was fine until the casinos came in nearby and the pawn shops started popping up and then all of a sudden we had a theft problem because people could pawn it off so you know that's about the time I started sliding out of it because it wasn't so it wasn't so profitable anymore and places like eBay and stuff took away the antique dealers. So there's not nearly as many and the Millennials don't collect anything they don't want anything old you know you know you try to give your kids stuff they don't want it, you know it's it's the type of thing that you know. So I spend my time golfing and fishing so.

Howard: wow you you were one of the first big clinical you know I was thinking you as a clinical dentist, you used to be really big in the the you posted the flex mousse impression, do you still do that?

Tom: I still do and I do it you know I've done it every almost every impression that's one or two teeth or bridge and doing it that way it's still posted on Dentaltown so people can get all that information but I really have been remiss I really should do some CE on that and placing quadrant resins because I placed 2,000 resins a year Howard I certainly know how to do class two resins in an efficient manner and I think you know that's part of if you have the work to do the bread-and-butter work if you can do it efficiently there's certainly profit in that too and I know everybody hates doing it but I just find it a challenge and I still find it fun when I get to go in and do a quadrant of Dentistry and walk in and do 3m OD's and two DO's and get it done in an hour and have good contacts and good contours and a very functional thing it's it's a great service and so you know I use all kinds of different matrix bands and stuff like that and the impression taking is a four-minute thing there's no syringe around the tooth you get rid of the voids it's kind of a take on the Dr. Whose's technique where you bite into it and then you add some more and bite back into it but the problem with that he had and is that you have to paint dye on it because the impression distorts because if it fits and then you add some more to it it's distorted. So the impression I do is like a putty wash close bite impression. The the mousse layer is still flexible and then you put the wash in and bite together and the mousse layer distorts but then it sets up in the distorted position so it doesn't want to rebound and to start the second impression the lining impression and so since it all sets up like a putty wash you can do a closed mouth impression there too so I'll get I'll talk to Hogo at the midwinter meeting about setting up some CE for that because I think a lot of the young people who aren't ready to pull the trigger on a $40,000 scanner can really take impressions and get things accurate and do things well and do it in four minute time span and get quality impressions so I think I should really post that for you.

Howard: Well you know Warren Buffett always says you know I would to Creighton University in Omaha and he came over and lectured at our school and that was before he was world famous and all that kind of stuff and he has said he has said for 30 years that at the elite level of the fortune 500 most CEOs spend the whole day trying to raise their overhead and he says you had a business you had profit dollars and he takes his profit dollars off the table and that's why he's become worth you know 80 some billion dollars but people are always looking for harder more expensive the longest distance between two points I mean I take a crown you know you take a Impregum impression and send it to the lab and he makes it for 99 dollars makes you BruxZir crown and immediately the dentist starts saying no I must buy a $40,000 scanner or $140,000 CAD CAM or and fly to Scottsdale for $3,000 weekend courses and take my staff and stay in resort it's like my gosh I thought we were concerned about your $400,000 of student loans and making some net income but for some reason you're just infatuated with how to raise your overhead and higher and higher. Do you agree with that or not really?

Tom: I think when it makes sense and you can lower your overhead with technology you should do it or if the technology does something that you see a need for that you can't do it any other way except having that technology then it makes sense but I have this magic crown in a box thing where I drop my flexing Blue Moose impression in a box and walk away and in a couple of weeks I open the box and there's a crown and it's just like magic and I hardly do anything to be involved with it and it comes out beautifully and I put it in the mouth and it fits and and the patients are happy and I'm happy and you know there are some good labs that you don't have to spend $700 for a molar a molar crown anymore and it's when you're doing the non cosmetic the the bread-and-butter stuff you don't have to have a lab that will produce a $700 crown. I mean it might be perfect or whatever but if you do them bread-and-butter dentistry and the majority or crowns our posterior from people breaking teeth apart then you know you can do it very efficiently you can spend less than an hour and you know Jim Glidewell will sell you a crown for under a hundred bucks you've got that opportunity I really think that that's really a smart thing to do and so...

Howard: and you know back in the day I was such a huge fan of Jim Glidewell because it seemed like well look like the first courses I'd go to I remember back then in 87 they'd always lecture about the A patient the B patient the C patient the D patient the E patient and then when they described them all I always sit there and think man my entire family pedigree from Wichita Kansas to Parsons Kansas we're all D and F patients and then this guy doesn't think there's business and it was only Jim Glidewell same thing with Airlines they were always catering to the business traveler in the fortune 500 and trying to have the girls wear high heels and serve these fancy meals and it was Southwest Airlines was I said no no we're gonna drive down cost until every American has the freedom to afford to fly and Jim Glidewell has really been the Southwest airline Herb Kelleher of Dentistry in that he's been obsessed with driving down cost and this country is big it's 325 million people and too many dental courses want to make dentistry for kings and queens but if you got $400,000 of student loans you're gonna go back to America you're gonna find out that the vast huge majority is middle-class and poor and it's you're gonna do more fillings than veneers you're gonna do more single unit crowns than veneers and you're gonna do a hundred all on nuns for everyone all on four but you go to these courses like when you go to Chicago Midwinter Meeting how many classes do you think they'll have on the $25,000 an arch all on four and how many classes will they have on just a denture for Grandma?

Tom: Well the denture for grandma program you can't find...

Howard: Right, right

Tom: It's difficult you know but they assume that you know all of these things and you know not every not every dental student gets out of their school ready to hit the road running. You know I had a very good school that I went to but I certainly wasn't ready to hit the road running and I mean I learned the hard way like you and I did when we started and finding our way but there's just so much basic work that if you can keep your chair full it can work and that's the thing that I see a lot of dentists don't want to don't want to take a PPO or Medicaid or anything because I can't make a profit on it and yet they'll sit there with 20 to 25% of their schedule empty and if you only use the PPO to fill that instead of losing the $300 an hour that it costs you to be there if you only produce 200 in there you only lose $100 so that empty chair if you can keep your chair full all the time and you can learn to be efficient with that and you pick up a few specialty things. I mean that I collect I've collected seven figures on average the last five years and it's in a small town on 160 days a year and the majority of stuff I do like I said the 2,000 resins a year a lot of dentures a lot of extractions and those kinds of things when done efficiently really adds up and can be very profitable.

Howard: So you're also a big into Proviser are you still big into that?

Tom: Yes, I had a problem with the going in to do a check and recommending that gee we really need to get some scaling and root planing done here you know there's some real problems because they had a few five millimeter pockets and then I go and then the next one that had five millimeter pockets I wasn't doing much at all and they thought I was being really inconsistent and there were problems with because you know all the things that they know about is that if it's five millimeter pocket you plug it into this hole and a five millimeter and it didn't have anything to do with except how deep that probe went and so with proviser I found here's the tool that I've been looking for that can explain to me you know, it validates what I was doing already there to do already and that's you know an 85 year old with two five millimeter pockets isn't gonna need massive scaling and root planing but if it's a 22 year old and he has two five millimeter pockets it's a lot worse because he's got to keep his teeth how long and if he already has five millimeter pockets we're having some problems and so that 22 year old is that a lot higher risk than that 85 year old with the same probes and the same bleeding and you know and then there's attachment was how far it's gone you know that adds to risk there are so many things that we're adding to risk and the hard part is trying to get, if you get your hygienist to believe in the treatment that you're recommending and it isn't just off at chart but it's individualized for every person the patient's even if they're poor and whatever realize that you're telling them the truth and they want to be healthy and if you say this is your path to health and you present that and providers been very good at we're able to put in the data and get recommendations of this is how aggressive you have to be or this is at risk or what the risk is and then give the patient the report it acts like a second opinion and the great thing about it now is it's free you can do it for anyone so if you're going is this surgical should I send it to the periodontist you know it'll show you're keeping this in the house too long if you're sending it to the periodontist or this person needs more treatment and this person you can easily handle it yourself. So it depends on the risk and after you use it for awhile you understand what causes risk and what doesn't but to a newer dentist they're treating under treating a lot of people and over treating a lot of people just by going with that and previser has models for okay this person is breaking a lot of teeth a crown is more important for him than a person who isn't breaking a lot of teeth and when you're doing it it's not only the tooth structure that's left it's the machine that it's the person that the tooth is in and how that tooth broke and all of those things are added up with risk factors and if you look at treat the high-risk patients and are can do lesser cost things with the lower risk patients and then you see that it works it it really does a lot for the patient believing because they pick up on body language and if you're saying you need a crown and you know it's the seventh one a day you've recommended and your assistant is squirming around in her chair going god he must need to go on vacation you know and he needs some more money that kind of thing it's really hard for patients to follow through but if they believe you and the whole staff has that body language or you leave the room and they asked you would you do it and they can convincingly say yeah absolutely you know he's very conservative on this and he really was trying to get you to healthy and this is your path to health and we really believe in it and we've seen it so many times. It's a lot easier to have them go out front and set up the treatment and that's what keeps you chair full and if your chair is full with good treatment then then the dollars come.

Howard: You know I made a post yesterday on Dentaltown and it didn't go over very well there was a story mark was told, from Australia, Mark was told he needed $1,200 dental fillings suspicious he did an experiment and he went to multiple dentists and one dentist said he had needed six fillings and the other guy said he didn't need any fillings and so one guy Fort McCoy he's got like 600 posts on Dentaltown said old news Howard this was Reader's Digest years ago and the bottom line is it's very old and consistent news that dentistry is so subjective that's why I never liked the DSO model because so much of the DSO depends on how a dentist's diagnosis and treatment plans and I mean the readers digest for young kids it was clear back in the day when before the internet Reader's Digest was on everybody's parents and grandparents nightstand and basically he took an FMX of his own teeth and study models and went to 30 different dentists and got 30 different treatment plans. What does that say what does that say to dentistry?

Tom: Well I mean and that's an issue with dentistry you know and we're trying to do evidence-based dentistry but the majority of Dentistry is not, if we sent in everything that we did and had it in a database where we could do things that's why I like provisers they follow people and if you did the scaling and root planing when you had this situation what happened and they followed him for 15 years and found out what worked and what didn't work and what was a failure and so you have a database for at least the periodontal treatment where it's legitimate and and if you follow it you're gonna be right more often than wrong. The number of treatments I mean I'm very conservative I'm putting crown on. I know my buddy Mark Malterud calls it minimally invasive dentistry but you know I look at it and say that if you're you do the lowest cost restoration with the highest chance of success and so if you have an undermined non-working cusp in proper occlusion and no cross bites and you don't have a BruxZir you on lay with composite and have it there 30 years from now. If it's a working cusp it's not going to be there 30 years from now so but if you put a crown on that the chances of it being there 30 years from now are actually less than if you place the composite on it and and so and the chances of having endo down the road are less and so but we don't have enough statistics in dentistry as to which is breaking why things are breaking down and what to do. So you know the dentist is left to learn by himself what is you know high risk and one is low risk and you have dentists like is it John Kois who really does his treatment planning around risk and so that you want to be more aggressive with high-risk patients and far less aggressive with lower risk and I don't think that the students coming out of school are taking into account how much risk makes a difference and I just think that if you can assess there certain things that are gonna work and not work from an engineering standpoint you can be a lot conservative and really have better mouths in the long run by treating them without cutting so much enamel away that seems to be so predominant in dentistry.

Howard: Another subject that I love your posts on we see eye to eye on this is that you know when you look at a dental office when you look at the overhead I mean you know the average overhead in the United States is over 90% of all dentists accept a fee schedule so that's a PPO when you and I got out of school we submitted our fees now they tell us the fees and so that reduction between our fee and the fee schedule is about on national average it's about 42%. The next would be Labor 8% hygiene 6% dental assistance 6% front office their's 20% labor lab should be five supplies before and what so labor so insurance cost insurance deduction or what do you call that from your fee to the, adjusted production. So adjusted production from I charge a thousand for a crown but I'm gonna take this PPO for seven hundred so that's three hundred dollars cost to your crown is just adjusted production for taking this insurance the next would be 20 percent labor and when I go into any dental office what's everybody standing around waiting for a chair I'm like what are you doing back here playing fortnight in your office why are you on Facebook well I'm waiting on a chair Shirley's got a dismiss the patient clean up the rooms and it's like why don't you have an extra chair and you always talk about the cost of an empty chair tell these people about the cost of an empty chair.

Tom: Well I mean you're paying everybody and if you're if I'm not at work in working there's something wrong and you know the cost of an empty chair is simply that you have running overhead no matter where it is. So it's like a restaurant with nobody to eat and you're only busy at dinner and then at supper and yet you're paying all these people to be around. If you have the chair full you're never going backwards and even if it's a break even if you have six hours of profitability and two hours of break even then you still have profit where if you have six hours of profitability and two hours of that you might only net four hours worth of work instead of six hours worth of work because it wipes out all the profit that you made in a couple of hours. So I figure every every empty chair I have every moment of an empty chair wipes out the profitability on the same amount of time. So if I'm full six hours and I have two hour gap I only worked for four hours that day for profit and I made half the profit that I put up. So if you keep the chair so you have to you know be able to accept these things not because they're so profitable you can't be stuck on well if I had somebody else I could make way more money it's that if you have nobody else you're making no money and you're going backwards and for these young people to understand that putting people putting butts in their chairs is the most important thing to do at the start of the practices if you can get butts in the chairs you're at least not going to go backwards and and that's where you learn and get your speed and I'm a firm believer that every four or five years you can learn a discipline like you know wisdom tooth extraction or orthodontics or one app which I do or pinhole which I do and add these to your thing then it adds more and more time to the profitable part and then you can cut back on the PPOs and you can cut back on those and keep enough around so you have a full chair and it's because as long as you have a full chair you know and just have more more and more profitable things and so without the PPO and then we it's just a reality of life that a lot of people have to do that if you are relying totally on what the PPO does and nonprofit it's just it's very difficult situation but you know I'm in a small town with five dentists in town and a lot of competition and a lot of PPO and I'm not able to be you know significantly more profitable than the average ada dentist now I wasn't the first five years of the first ten years. Now it took me ten years to get up to the level of the ad a dentist was as I added more and more profitable procedures that I could do the profit went with it and you know and and Dentaltown was a big part of saying that I could do this and do this well and so the orthodontics I do and the the periodontal procedures that I do are all added in from continuing education and getting connected with good people that I found through Dentaltown that these people are the people to learn from and it's just been a rewarding thing and if you can get the right CE, be efficient with your CE and Dentaltown exposes you is just so much and if you find a guy and and take a course and say I really want to learn from this guy you can be a mentor and those people who are coming and doing CE on Dentaltown they're the ones that are going to mentor the students that take their CE courses they're not going to just ignore them and that I find is really important to, is to have a mentor in in the different disciplines that you add on so if you're adding orthodontics and you want to do quick orthodontics and you take a Ric DePaul class or something like that, that Rick's gonna be there in your corner when you need him and those are the kind of things where the people through Dentaltown and through the CE that you have there those are the people you want to connect with and that's what's neat about Dentaltown.

Howard: and you know on like orthodontics we have fourteen online courses on Dentaltown most of them run one to two hours I think average runs two hours and there you know the cost to view is thirty-six bucks. I mean it's just amazing who you been should Rick DePaul we've had him on so he's amazing you need to tell him he needs to get him get a ortho course on Dentaltown I don't think he has a narco course on Dentaltown does he now he doesn't.

Tom: I don't know

Howard: I think the gold standard for me if you want to be taught by a board-certified orthodontist is Richard Lit with force and he's got a course on Dentaltown and but yeah so when you're talking about orthodontics are you talking about bread-and-butter orthodontics is it mostly adult orthodontics, is it interceptive phase one with pediatric or is it Invisalign. What would what are you doing in small town in rural America orthodontics what's your bread and butter ortho?

Tom: Yes all of those things Howard. The orthodontists in my area within a hundred miles there's no orthodontist that will do a Medicaid case and they're the medically necessary ortho cases. So I have about forty of those cases that I'm doing and but I have adults in Invisalign and of you know about eight of them right now I have I really like the idea of you know the eight nine year old interceptive correct all across bites don't correct the class two, do the things you can do to set them on the road to have a better airway and to grow more normally as they progress in their growth. So I do you know growth focused orthodontics for for the kids that I have in my practice so that you know the class 3s disappear, the constricted we give a lot of kids and work with the ENTs to get their tonsils and adenoids out and it makes a huge difference in their orthodontic prognosis and makes difficult things easy. So we're involved with I'm involved with all phases of that but I've had like six hundred hours of CE in orthodontics you know and I was back way when I was taking map because the University of Minnesota was so against letting us know I couldn't even tell you if a case needed orthodontics or not when I graduated from school because they kept it you know if you have any questions send them to us is what the question the thing is. Their are lots I'm I'm really for a general dentist being able to do orthodontics that's straightforward and easy and the same with placing implants. I mean you know analogy is if you've got to put a tenpenny nail in the end of the 4x4 you know versus putting it in a quarter of an inch dowel, do the ones that are the 4x4 and if you're a little off-center it'll still work and you won't run into problems. Well there's ortho cases that if you're taught what to look out for and what not to do you know the bus leaves at five o'clock be under it, those are the ones I refer quite often to the orthodontists is the ones that that I know when I when they get done with it if they're treating and non-surgically it's not going to be good either, so I might as well let them have the less than ideal result instead of me.

Howard: So that's it's interesting how you have third party payment Medicaid by the way for international listeners, it's so confusing senior citizens in America get Medicare that's over 65 that's a federal Washington DC program for all 50 states Medicaid you can't become an expert in Medicaid if you don't live in a state because it's different in all 50 states so there's just

Tom: Correct

Howard: Their's nothing I can summer and that's why to international viewers well if you're wondering why you know 20 countries have socialized medicine and their advanced countries they're like Canada and England and Germany and all that, well then why was Obamacare so controversial because Obamacare he rolled that out through Medicaid so it was different in all 50 states and the one thing I noticed in Arizona is every single person that complained about Obamacare was on Arizona Medicaid access and had zero idea that that's what it was. So his lack of business acumen and lack of business skills and marketing and communication was just so unbelievable and no one really knows why he chose to roll it out 50 different programs with Obamacare and 50 different states instead of just expanding on the national program if that's really what he want to do but I think it's very genius that you found a hole in the market that there's five dentists in your town and your town has a very small population of what's a population of your town?

Tom: 2,500

Howard: 2,500 people with five dentists yet you were able to find a third party payment Medicaid through Wisconsin and there's nobody providing ortho in a hundred miles.

Tom: Right in in Minnesota

Howard: In Minnesota I mean, well you're on the border of Wisconsin right?

Tom: Yes I'm on the corner of Wisconsin and we do draw from Wisconsin quite a bit so you have a bit so the two little towns across the river have dentist there too so.

Howard: Yeah it's amazing how when you talk to experts in real estate how humans have a big psychological barrier to cross interstates and rivers I mean like like if you're up against a river you might be drawing people from 20 miles away on your side of the river but on the other side of the river that all these people just a mile away and you'll hardly get any of those people to cross the river. I mean I'm talking in generalizations.

Tom: I'm in a very unique situation in that the hospital from the 1860's that was the hub for 20 miles on the other side of the river there were no hospitals except for that so everybody had to you know come and take the ferry and go across the river and get to that hospital if they needed any hospital because that's where the doctors were and so the area has been you know the people are just used to coming across the river. So I can count while my town is 2500 my drawing area the hospital drawing area is 10,000 people and we have seven dentists in that 10,000 area and I draw from outside that.

Howard: When you're talking about you know expanding a new specialty every five years, you talk about wisdom teeth extractions you talked about orthodontics you're doing Invisalign let's switch over to pareo surgery because I think in your in I mean you know I been doing this and if you have any years you've been practicing?

Tom: I've been practicing 38 years

Howard: Yeah and me 31 I think periodontal surgery has changed more than any other of the professions I mean it was all quadrant surgery and then they decided to start replacing all the quadrants or do with implants and then after ten years of that they started seeing that you know 30, 40 percent of these implants have peri-implantitis at five to nine years. So now I'm seeing the the swing back to do anything to save the tooth. Even my endodontists friends a lot of the endodontist says that you know apricot to me and rich fills dropped to zero, retreat started plummeting I'm talking to you know 15 years ago and every said you know it's a failed root canal some good old guy trying to do as good as he could but it obviously didn't work so let's treat that thing with titanium and now I'm you're into LANAP, LAPAP, four peri-implantitis penile surgeries start ranting on pareo, first of all did you buy the LANAP laser?

Tom: Yes I did

Howard: and what did that cost you?

Tom: It cost me a pretty penny you know, I mean it was a six-figure investment when you figure the time and the time away and the investment into what it was...

Howard: Are you good with that investment would you do it again today?

Tom: I would do it again in a heartbeat, one of the things that did was it gave me something that I couldn't do any other way and the University of Minnesota physically when I went to the ortho floor they physically picked me up and threw me in the elevator on the ground, actually happened because they said get out of here you don't belong here but I went to the periodontal thing and they said we got surgeries we can't keep up with the surgeries you want to do surgeries we'll teach you how to do surgeries and so I never scaled the tooth without laying a flat first when I was in at the University of Minnesota so I've been doing a lot of flap surgeries quadrant surgeries and that type of thing. So I was very I'm very familiar with the anatomy and all of the things that we're doing and and it was like do I start doing gbr and doing that. I was sending people for grafts and the periodontist are very conservative you know and I was doing things like Danny Melchor with the barrelling and the biological shaping and I wanted to add connective tissue and the periodontist weren't letting me and so it allowed me to do more of a pareo restorative have that in to keep it in-house and be able to do that and when the LANAP has been amazing just an amazing technology but I looked at how much work is it gonna get me it's like I do 70 crowns a year on teeth well having a CEREC type technology and investing that much when you're doing the crown the crown and the quarter a week is just not a good investment. I looked at my because I have been a retirement community I looked at my people want to keep teeth and that and I did the numbers and I said it's gonna pay for it in a year and I was wrong it paid for it in six months because I found out that the the main way reason people were pushing it off was they didn't want their gums cut off and LANAP allowed them to have it treated without the gums cut off at the same cost and I what I thought was a cost measure for them not getting the surgeries was simply that and the local periodontist said absolutely will never do lasers and ten years later they they're doing LANAP now as well but so it took him ten years to catch up what they're offering the same services I am now.

Howard: Yeah and I got a shout out to periodontist in my backyard Allen Honigman because I remember he started doing LANAP the first and it was more than ten years ago might have been 20 years ago means one of the earliest adopters and I was shocked at how people would talk behind his back he was that that was crazy and non-scientific and he's crazy crazy crazy and then 20 years later every damn periodontist has one so hello and you know you're you know you're an absolute entrepreneur or I'm I mean to he climbed up the pole everybody shot at him and then everybody joined them so kudos to him and but are you doing more LANAP for teeth or are you doing more of the the other one the LAPAP for implant. I mean do you see more peri-implantitis around implants or you see more natural periodontist around human teeth?

Tom: I do the I mark it for the one I don't see as much I because it's not as big of an issue with with the implants I've placed so I seem to have come on to you know being able to put bones underground and platform shifting and and conical connection implants have allowed me to not have a lot of peri-implantitis around the teeth because of the juncture between the abutment and the tooth leaking which is a lot of times the cause and you know going with crowns that aren't that you can cement at the proper level so that you can get the cement out if your cementing them or you put him in with screws. So I've been lucky about that I've treated half-a-dozen with that but if I were a surgeon that were a periodontist or a an oral surgeon who was placing a lot of implants I wouldn't want to practice without having that in my tool belt it's been very handy for the half-a-dozen ones that I've been able to treat and so but the majority of it is is doing LANAP and taking care of deep pockets and staying on top of things that way.

Howard: and how how often are you placing implants?

Tom: Couple a week.

Howard: Couple a week and is there any advice on that or you are you favored of one system or another I know these kids like specifics there's we're coming up on the Cologne meeting next March and Cologne Germany they have that meeting every two years it's the largest dental meeting in the world there'll be over a hundred thousand dentist there and rumor has it there's over 250 different implant companies scheduled to have a booth or a table and these kids come out of school four hundred thousand in debt, they've never placed an implant and they they want to know what system do you use?

Tom: I use the implant direct clone the nobel active it's called interactive that implant direct does but it's it's got a nice conical connection and I also use in parts where its a BruxZir and we need something really really solid I use KAT implants and it's kind of yes it's got a welded shaft and the the abutment is the female part rather than the male part and the implant is is a male and has a stem sticking up to it and then the abutment is a female and it's a great system it screws down and you get them it's a true Morse taper and really keeps things out and the junction at the implant you know there's no chance of it flowering or having anything there are no screws to hold it in so there's no cement to put the abutment on it's all just torqued in and it's it's a very interesting system and where you need strength it's a great system where you have short implants it's a great system.

Howard: So do you like Kat implants the most then?

Tom: You know it's, they're both easy to work with they're both nice systems and I use the Kat when I need more strength and I'm worried that anything could possibly break but the implant direct ones are good I know blue sky bio makes a nice one anything that's a conical implant what I've just did since I went to interactive I haven't had any failures so far. Not a not a failure in the last five years they're all taking, they're all staying, they're not losing bone and it's been very good and the Kat implants as well good so either I've improved my techniques but I really think it's the implants themselves that are better and the placement being below the bone really helps out a lot so I've been happy with those systems.

Howard: You've been so generous through their time but I saw one last question because we're out of time. A personal one that you don't have to answer you don't to get too into it but I'm your 61 how do you look at retirement you've had some health issues you've been transparent about it on Dentaltown how do you look at retirement at 61 how do you look at your health and does that factor in dental and how long you'll practice or what talk about that?

Tom: Well it all depends on my son and his girlfriend and and where he ends up. He plans he's promised me two years and then if it works out and he sees a future in the practice there he said then we can then we can talk but if after two years he said you know I'm not gonna work for you anymore if you want to work you'll have to work for me and I look I'm my best-case scenario would be I keep doing the the stuff that like ortho and LANAP and that and gradually mentor them in and do it a couple of days a week and have him be working full-time and try to build up the practice enough so that he can eventually get an associate in a few so desires or he can do the things or that it's sellable. One of the things that all of us dentists are looking at that are that are my age is that there are DSOs that if I was selling to somebody coming out of school and so my practice a DSO will offer me more money and you know it's well you have to look at how your patients are going to be treated and what you're going to bring to the patients that you've had a relationship for 30 40 years to do that. So hopefully I won't have to deal with the DSO and I'll be able to keep independent. I'm a smile source member because I strongly believe that staying independent is the way to go and so I've been able to you know make that work and that's been a very positive thing and so I'm trying to do that and hopefully my son will come in and I can just you know work as much as I want when I want and drift off into the sunset. I might be working evening hours again and might be doing all those things when I did when I started up and a few Saturdays and things like that but I absolutely love this profession. I think it's the greatest profession in the world and it's just treated me so well and I'm gonna be working for a while because my daughter is a sophomore in college my baby and so we have to help her out too to get on her feet as well as we did the other five boys so.

Howard: Oh yeah yeah kids are so expensive I had four and it's amazing how even though they're in their 20s, when kids come out of school I tell them for every two hundred and fifty thousand dollars you're in debt that's equivalent to having a child so you know there were seven kids in my family four kids in mine. I tell my kids if you only had two kids you'd have twice as much money a my oldest one already has four just like dad and I was babysitting my 5th grandkid yesterday for about six hours and first thing his dad was telling me is he wants to have another one and it's like yeah I mean I get it but they're are a luxury item but hey seriously man thank you so much for coming on the show today and being so transparent and honest and sharing all your wisdom these kids are commuting an hour to work or they're on the Stairmaster and I'm a huge fan of your 13,000 posts on Dentaltown and thank you for all that you've done for dentistry, for Dentaltown for always going to townie meetings or mean Hogo at is uh every year Chicago midwinter for his Scotch tasting contest but I just think you're the real deal and thank you so much for coming on the show today.

Tom: Thank You Howard I appreciate it. 

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