Dentistry Uncensored with Howard Farran
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244 Your Dental Symphony with Tom Cockerell : Dentistry Uncensored with Howard Farran

244 Your Dental Symphony with Tom Cockerell : Dentistry Uncensored with Howard Farran

12/1/2015 2:00:00 AM   |   Comments: 0   |   Views: 682

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AUDIO - HSP #244 - Tom Cockerell

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VIDEO - HSP #244 - Tom Cockerell

Tom Cockerell shares what was missing in dental software, and why he started Dental Symphony.




Dr. Tom Cockerell, Jr., has practiced general dentistry for 36 years in Fort Worth, Texas. He is the son of a dentist (now 92) who practiced for sixty years in Texas. Tom’s solo practice focused on the special needs patient treated in the hospital operating room but now an anesthesiologist joins him in the office one full day per week. In addition to special needs patient care Tom has a traditional patient base offering modern services using digital impression scanning, same day crown milling system, CBCT imaging, implant placement, prosthetics, periodontics and endodontics. His practice has a risk based preventive program using tools available from the Dental Symphony software. 


Dr. Cockerell is the CEO of WorthWhile, Inc., the creator of Dental Symphony and the convener of the Clinical Team. His long term plans include transitioning away from full time practice to full time software management continuing to make Dental Symphony the leader in dental software innovation that helps meet the clinical needs of dentists. He is also an avid bass player of rock and roll and jazz. He’s married to Patti for 41 years. They have three children - Bree, Daron and Jameson. Educated at the University and graduate level, they all three work for Dental Symphony and are also musicians and performers.




pratice website -

dental software -


1616 Pennsylvania Avenue

Fort Worth, Texas 76104

office - 817 921 2600

cell - 817 846 4109

Howard: It is a huge honor today to be podcast interviewing Tom Cockerell who's a 2nd generation dentist in Texas. Fort Lauderdale?

Tom: Fort Worth.

Howard: Fort Worth, Texas.

Tom: Yes.

Howard: Fort Worth, Texas. Fort Lauderdale. Fort Lauderdale is Florida. Fort Worth, Texas. It's Fort Worth, Texas then Dallas. What's that city in between? Arlington?

Tom: Arlington.

Howard: That's where the Cowboys are? Beautiful stadium. Dr. Tom Cockerell has practiced general dentistry for 36 years in Fort Worth, Texas. He's the son of a dentist who'd now 92, who practiced for 60 years in Texas. What's his secret to living 92 years?

Tom: I think good genes and he stays active.

Howard: Good genes?

Tom: He lives a very full life.

Howard: The mercury amalgam didn't kill him? Do you realize when I was in dental school we still lined our crucibles with, what was that white insulating material that caused cancer?

Tom: Asbestos.

Howard: Asbestos. Did you do that? We lined our crucibles with 100% pure asbestos and then poured [inaudible 00:01:28] and then stuck it in the oven and heated it up till it was glowing read. We're sitting there taking out glowing red asbestos and quenching it in water.

Tom: The key is that we didn't hide it in the walls and in our floors where I guess it's even more toxic than burning right in front of us.

Howard: While it's glowing red hot. Tom's solo practice folks on the special needs patient treated in the hospital operating room. Now an anesthesiologist just joins him in the office one full day per week. In addition to special needs patient care, Tom has a traditional patient based offering, modern services using digital impression scanning, same day crown milling, CBCT imaging, implant placement, prosthetics, pario, endo. His practice has a risk based preventive program using tools enabled from the Dental Symphony software. Dr. Cockerell is the CEO of WorthWhile, Inc., the creator of Dental Symphony which is why I called you. I think it's always neat when some dentist starts a business. Forget the SB-500, forget all the publicly trading companies. Whenever I see a dentist start a company, you know there's got to be a big reason why, a lot of passion and that's why I wanted to talk to you today. What's going on? How did you go from to What brought all that about? 

Tom: It began several years ago when I moved my practice from being paper based to electronic records. I did that rather quickly, actually over a weekend.

Howard: What year was that?

Tom: Say 2000.

Howard: I did mine in '99. Was it for the Y2K?

Tom: No, actually I just wanted computers and online ops and just seemed like that was going to be a good thing. When I did that I was a little surprised at how my practice wasn't easier. Actually it seemed harder to try to find everything I needed to find on a computer. I just set in min0d emotions. I'm thinking about what I thought was missing and what could be better. Eventually I put together a clinical team and a business team to create some software that would fill in some of the gaps that I felt were missing. That's where it started. Now we have 5 modules that dentists can use alongside their practice management systems.

Howard: It's not designed to replace Dentrix or Eaglesoft or Softden or PracticeWorks, it's to augment them?

Tom: That's right. It's like Demandforce or Lighthouse 360. The business part of this Dental Symphony is to the clinical part. We dig deep into the actual clinical management of patients. 

Howard: That is very interesting. There's a lot of peripheral software to help with marketing, recall, notifications, all this. Is this the only one that really augments the clinical?

Tom: I don't know if it is or not. We don't see anyone doing what we're doing. If I can give an example of what we do, about the process.

Howard: Please.

Tom: One of our modules is called e-patient. That was one of the very first things that our team worked on. It was the process of bringing patients into the office. Then looking at their medical history and trying to provide ways to make it easy for dentists to evaluated the patients very quickly. That started with a medical history that was very thorough and required automated follow up questions for diseases that patients checked off that they had. We created that software to do that in an online way through a portal that's connected to the website. 

When the patients then register into the practice using the software, the dentist is then going to have an output that's very helpful to them to very, very quickly look for risks that might be important and also have attached to that record, drug descriptions, point of care support centers more specific to that patient that helps evaluate the patient very quickly. The dentists are going to feel very confident in managing that patient. That was the first thing we did was what we call a pre-clinical assessment, a whole array of services related just to that to help get the patients in and plugged up, ready to start working.

Howard: You must have to update that all the time. Is it updating all prescription drugs and all that too?

Tom: That's right, yes.

Howard: I can't even keep straight the antibiotic prophylactic coverage of a joint. How many times has that changed since I got out of school in '87?

Tom: A few times. It's funny [inaudible 00:06:34] there are just a few [inaudible 00:06:36] people with antibiotic coverage for heart issues and joints and maybe immuno compromised patients. It gets confusing. I find myself having to think, "Okay, now hat do I do here? Does this need antibiotics?" You're right, we do all that. We're going to, in the medical summary, record this created for every patient that registers. We're going to have at the top of that page, a list of alerts that are important for dentists and then a summary of the systematic review of the medical history to answer those kinds of questions. It is confusing. Why not have drug descriptions written out right there, available to the dentist, on the summary that the dentist gets? It makes it easier.

Howard: You said you have 5 portals?

Tom: We have 5 modules.

Howard: Five modules and the first module is health history?

Tom: That's right. It's a patient portal that brings the information into the practice. It is a medical history, dental history. You can also have any other forms that are a particular interest to the practice such as sleep apnea, TMJ, sedation, whatever the special interest is of the practice. That's our first module, at least the first one we're talking about. The other modules have to do with this spectrum of how a patient is worked up for care which is where we felt like existing software just wasn't very strong. The second module is a module that you can use for recording examinations, third module is what we consider a more friendly useful perio charting system which you can use alongside your system. The third is an automated treatment planning, engine that allows the dentists just to chart their findings and then in just a matter of seconds get a treatment plan based upon their office preferences or their personal preferences. This can be any [inaudible 00:08:47] surface based restorations.  

To a request for a full prosthetic implant case it will take that charting, in just a matter of seconds, create a whole treatment plan for you that includes all of the ADA codes and associated treatment for a particular choice. Then the last module is a module that is a form to document creation system that allows you to support your treatment plan with information that is important that the patients know and it's important that the practice provide for patients. It has to do with a lay report of the clinical findings, the recommendations, your alternative care. How long is the treatment going to take? What the prognosis is, what are the preventive requirements required to make the prognosis, consent forms, financial information. Just a real quick way to put that information into a form and then have generated a packet for the patient that covers all of those things.  

These were the kinds of services throughout these 5 modules that I just thought and my team just thought, "Provide a way to do a better job," because how many times do you go in and look at a car, as an example, and you don't even talk to anybody and you look at that car and then you walk out with a 15 or 20 dollar brochure about those cars. Yet a patient can go to a dental office and come out with a $500 or a $50,000 treatment plan and walk out with an invoice. That's just about it and maybe a brochure or something. There ought to be a better way to inform patients about what their problems are, what the solutions are, what are their responsibilities? It helps the patient make informed decisions, makes the dentist I think feel better just about the information that they're walking out with. We just didn't find a way to do that in existing systems so this is just a real quick way to do that.  

Howard: You think dentists who buy this will actually have more selling of dentistry? They'll have a higher close rate if they're walking out with more information and a brochure, they're more likely to schedule treatment, do you think?

Tom: That's a good question. I don't think anything replaces the personality of the dentist and the office staff and just the ability to help people understand their way to help them. Nothing is better than that. For one thing, we're required to provide this information. At least it depends upon what the state or regional laws are. We're required to provide a certain amount of information. Do I think that patients walking out with a nice brochure that provides everything is helpful? I do. I don't think you build your practice around that. You build your practice around the personality. There are some people I'm sure that get these brochures and think, "Man, I didn't want this. Just tell me how much it's going to cost." Then there are others that come in with them and they're rolled up and they're referring to them all the time. I hope that answers your question.

Howard: Let's take a detour on that. Your dad's a 92 year old dentist, you're 65, I'm 53. Most of our viewers, they're kids. They're all under 30. Pretty much all. Maybe I'll get 1 or 2 emails of someone over 30 and that's the only reason they send the email is to say, "Hey, I'm over 30 and I listen to your show." You said something very important. It's not the brochure that makes them accepted. You said nothing replaces the one on one talking as far as on presenting [inaudible 00:12:35]. What tips could you give 30 year olds and [unders 00:12:37] about why some dentists can present full mount dentistry or quadrant dentistry instead of just the patient pointing at one tooth and saying, "We'll just fix this one that's broke in a crown,"?

Tom: That's a good question. I'm thinking about just my own evolution as a clinician. There would be several ways of answering that question. One is, at some time, I got to a point where I just decided, "I'm the doctor, the patient's the patient. This is what you need. Let's get after it," as opposed to, "Let me tell you all the things wrong and what's going to happen and this is what I'm going to do for you." At some point I left that behind. You have to go back to it sometimes. It depends upon the patient. A good interpersonal relationship between a dentist and a patient is to understand where the patient is with that and what they need. That's the first thing is pay attention to what that patient is. 

Are they listening to you? Are they able to listen? What are the barriers to that? Is fear not letting them hear you? Are finances worrying them? There are lots of barriers that you've got to get past. That's the first thing is listening to the patient. The second thing is you know what your skills are. Whatever you're good at, sell it. Really, if you're good at it and you know it'll work and you've got enough time and practice then patients will understand. Patients will pick that up that you know what you're talking about and more likely to agree to treatment. That's a couple of things.

Howard: What do you think these young kids should get good at? You said you've got to understand the patient and where they're at. Is it fear? Is it money? Speaking of fear, you bring in a dental anesthesiologist. Is that a dentist who's an anesthesiologist or is a nurse an [inaudible 00:14:34]

Tom: It's a dentist.

Howard: It's a dentist? One day a week?

Tom: One full day a week.

Howard: Talk about that. How does that work? How do you keep someone busy one way a week just on dental anesthesia? Does he do the dentistry too or just anesthesia and then you do the dentistry?

Tom: He does the anesthesia. Excuse me. I do the dentistry. We draw from the region here around Fort Worth, Dallas, North Texas. Over the years enough people have learned what I'm doing and dentists know what I'm doing that they'll refer me patients. A lot of them are special needs. We'll schedule 4 or 5 patients in a day and that's about all we can do. It's not very hard to keep an anesthesiologist busy. It works real well for us. Did you want to know specifics around what that day's like?

Howard: Yeah and explain special needs. That's a broad term. What do you mean when you say special needs? Could special needs be just fear, "I will not let you give me a shot?" Is special needs more precise?

Tom: Could be. That is just, "I'm afraid and I just can't stand this and I need to be asleep and I have a lot of work that needs to be done." That's worth considering obvious sedation. Special needs to me is mostly about access and about safe access. That could be limited because of physical problems such as cerebral palsy or any issue that keeps a patient from holding open, holding still and allowing you to do the work. Special needs is access first. In terms of finding the patient pool it is mentally handicapped patients that don't understand what needs to be done and so IV sedation is a good safe way of managing. Indeed the severe phobic patient, having and IV sedation and then trying to accomplish as much as possible at one time is good. Certainly the mentally compromised patients where there's some instability in their health and some risk then the idea of having an anesthesiologist there with an airway ready and IV and competence, that's probably a fair description of that patient pool.

Howard: Do you think having a patient pool like this was part of your formation to make you go towards Dental Symphony?

Tom: I think so, yes. I thought about things that I needed to really help me assess this patient well and understand. If they're a risk for bleeding might be or a risk for a susceptibility to infection or just general stable, unstable disease, their ability to withstand treatment. As I thought about that it was pretty clear to me what I needed to know in order to feel safe. I started out in the hospital environment. I had to support my diagnosis and treatment plan with a good logic for why we would be in that setting. That then made us realize, who doesn't need to know that? 

Really, everybody needs to know that and it's really hard to know that. How can we make that easier for that dentist to, with no effort on their own part, just by registering a patient, having all that information available to them and a point of care center that would explain what the risks are for the diseases that the patient presents with. You're not going to get a book. You're going to have a center for that patient that is specific for them. My personal experiences was the original driving force for this.

Howard: How much does Dental Symphony cost? Is it a monthly subscription or is it a one time fee? 

Tom: It is a monthly subscription, $69 for a module and additional modules I think are $15 a piece for each of them. 

Howard: Sixty-nine for the first one then 15 for each one after?

Tom: That's right. I believe that's right.

Howard: For the whole kit and caboodle what's it?

Tom: I think it's $170 per month.

Howard: That seems very low and reasonable.

Tom: I think so. I think it's a fantastic deal.

Howard: How many users do you have?

Tom: We have around 50 users now around the country. We are poised for growth because of our relationships with, one being Dentrix as we've integrated into their G5, G6 program. We'll be getting in front of them soon and we have some other collaborations that are coming. This reminds me, Dentrix was interested in what we were doing, felt like an integration would give their users a good experience and Dentrix seemed to be the first to recognize and create a way to augment their programs or their software with other app like devices which we are. Some of the others are coming out. I've heard that Eaglesoft is going to have an API which is the way that software can communicate and integrate with desktop systems. I think it's pretty early in those types of relationships but it's true, Demandforce and some of the others have paved the way for that, for improving the general experiences of the dental offices with their practice management systems. We expect to have pretty rapid growth.

Howard: Explain why you think Demandforce has helped pave the way. Explain what Demandforce is in case some of these kids don't know what it is.

Tom: I don't actually use Demandforce. I use MOGO which is similar.

Howard: Wasn't Demandforce sold to Intuit who owns Quicken for a billion dollars?

Tom: I think it was only 400 million.

Howard: It was only 400 million. I was off by 600 million. I thought it was a billion dollar deal but anyway. What was Demandforce and what do you think it paved the way with Dentrix for companies like yours?

Tom: Demandforce provides services that are obviously not available to most practice management system users like surveys, like text reminders, patients, pulling their data regarding accounts receivable and analyzing that for more productive ways of managing that. Looking at one that's slipped my mind, managing their recall. They provide software optimization, search engine optimization, those types of services that apparently aren't available through the parent system. In order to do that they have to be able to pull information from the database of those systems. That's all in the administrative side and there are several companies that do that. Not to necessarily repeat myself but we are on the clinical side rather than the administrative side. I'm not sure if I'm answering your question, Howard.

Howard: Basically I was saying, how did Demandforce pave the way for your company. It was in trying to get these companies to open up their software a little bit. Obviously they know their software has many, many shortcomings. They've opened it up, you're saying, so Demandforce can help augment the data. Now you're coming along with Dental Symphony on the clinical side where you can enter and more augment the data.

Tom: I think another way of looking at that is from the dentist's point of view. When we first started, the very first question that we would talk to dentists about was, "Do you have internet in your office?" Half of the people would say, "No, we don't have that." Then if they said yes then the next question was, "Do you have high speed or do you have dial up?" Then for those who had high speed we were able to talk to. 

Howard: What year was that?

Tom: That was back in 2009. 

Howard: 2009. When we started Dentaltown in 1998, only 1% of the dental offices had internet. One percent. If I had to go back and do it all over again I would've started Dentaltown about 2003.

Tom: That's exactly right. We had to wait through the iteration.

Howard: Oh my god. The only reason they got the internet connection in '98, '99, because they'd go to a parent teacher conference and the teachers would convince them that Billy needed to go to the NASA jet proposing websites to do his homework on the planet Pluto or something. It was always for homework for the kids.

Tom: I thought you were going to say that they got the internet because they had to do insurance processing through the internet which is certainly true for dental offices. That drove a lot. Back to about Demandforce, once the dentists had their high speed internet in the office then somebody had to get through their minds, "I could use the internet for something that would be helpful for me in the business side of things. That just opened up their minds that we're not having to fight through the use of apps in the practice any more than an owner of an iPhone has to understand, "Why do I have to make phones better?" It's the same thing. We've had to work through that progression of thought.

Howard: How many users did you say you have, 50?

Tom: Customers.

Howard: Customers?

Tom: Yup. 

Howard: Go ahead.

Tom: I was going to say I have 66 years now on me. 

Howard: Sixty-six years?

Tom: That's how many years I had. 

Howard: That you're 66 years old?

Tom: Yeah.

Howard: You ought to get them to start a thread on Dentaltown where they just start some thread called Dental Symphony and try to get your users talking about why they like it. I think if they were having a discussion with themselves it could be very informative to you of what they're using, how that's working, feedback for you. How many programmers do you have on that?

Tom: Right now we have 2. We've had up to 8 at one time when we first were building the bulk of the system. We'd love to have some conversation on Dentaltown. It's very interesting. You were talking about what makes a dentist create a company? Then another question is, what makes you create a software as a service company? Then how does that work? The business model for software as a service company, it's full of good ideas like that. There are all kinds of growth hacking books written that we read that talk about having our customers help us with the advancement of the program. That's certainly a great idea to look forward to doing that. It'd be good feedback. 

Howard: It'd be good feedback for you and your 2 programmers and then it'd be great sales to marketing for other Townies to see their friends talking about it.

Tom: When I say programmers I'm talking the people that are actually banging out code. We have other people that talk to customers and do demonstrations and work on design and functionality. 

Howard: Programmers are very different because I'll be telling my programmers what I need on Dentaltown and sometimes they'll remind me. You walk in here and you say, "Let's just make a peanut butter and jelly sandwich." Your guy goes, "A computer doesn't work that way. You can pick up a slice of bread. We can put the peanut butter and jelly on side A or B." 

Tom: It's best just to give them a task and then close the door and don't go back in because the next thing you know, you're interrupting their thought. That's what I run into. Initial design of a software can be literally thousands of pages of sketching out use case scenarios. It's just a very interesting project.

Howard: Your dad's 92, you're 66. Did any of your kids follow to make it third generation? Any of them in dentistry?

Tom: Not a one. Not a one are the least bit interested in it.

Howard: What do you think was the major change from the way your dad saw the profession at 92, the way you saw it and what do you predict is going to be the next phase of dentistry?

Tom: I would start that answer by saying that about 5 or 6 years ago my dad went with me to an implant class, 6 weekends down at San Antonio. Actually he no longer has his license as of a year ago but he has stayed very active in the profession throughout most of that time. He had his own private practice for decades and then sold it. Then he would just create a practice in another part of town and work it for a few years, sell it, do that elsewhere and that was very interesting to him. Got involved in insurance programs that were new wave at that time. It's not that we're that much different. Nothing jumps out at me as so much difference between how he has done it and how I have done it. I think I'm a little bit old school. I don't have a real big office or a real big staff. I like to think that I stay current and offer modern services and things, some of which he wasn't able to avail himself of. 

Howard: Is his wife still alive? Ninety-two?

Tom: Yes, they're not married but my mother and dad are both alive at 92.

Howard: They're not married?

Tom: No.

Howard: They separated or divorced? That's very rare. The average white male in America lives to be 74. He's almost beat it by 20 years. What do you think the secret is? As we're talking there's a big article out in Newsweek talking about the most dangerous occupations to practice in and dentistry is listed. They're listing all these occupational hazards and here's your dad at 92 years old. Your dad probably was exposed to a lot more. Did he ever hand-wring the mercury amalgam?

Tom: Probably and practiced decades without gloves and masks.

Howard: I don't think these kids are even aware. Explain about what hand-wringing amalgam was back in the day.

Tom: Actually we did, that's right. After you mix it then you would take a little. That's right, that little white round pad and we wrung the mercury out, right?

Howard: Yeah, the excess mercury. When I opened up there was a guy just about to retire that had carpet in his operatories. After he passed away and the carpet was lifted up there were balls of mercury. My boys were running around the office kicking these balls.

Tom: How fun.

Howard: The mercury would hit the wall and bounce into 2 balls and come back. It was just crazy.

Tom: I will never forget when I first started practicing, a dental assistant mixed up the amalgam when I said "mix" because I'd grown up here and my dad would say "mix." I always wanted to be able to say, "mix." I expected to have the amalgam given to me in a amalgam -

Howard: Condenser.

Tom: She just handed me a bottle of amalgam in my hand and I just thought, "Well, I guess this will work." I just put it in and then condensed and [inaudible 00:32:05] but that was different. I don't know about mercury, what your point may be. I remember thinking one time, working in a laboratory in a hospital and taking a thermometer and spinning it down to get the mercury down at the bottom thinking, "That'd be a good way instead of shaking it," so I did that and took the thermometer out and put it in my mouth to take my temperature. Of course at the bottom of it, the mercury just flowed out into my mouth and I thought, "Oh my gosh, I'm fixing to die here." Just a story.

Howard: I think it's funny we all lived because like I say, we used to heat up the asbestos in the lab work. You would pull it out and it would be glowing red and then you would quench it and it'd explode in the cold water. You'd dig your gold crown out. God, things have changed. I agree with you. I went totally paper to digital in the year 2000. The Y2K thing was big. I didn't really think it was an issue but the team needed a deadline and I told them early 1999, year 2000, we were going to be paperless. I think the term paperless is the most hilarious term ever because you're never going to get rid of paper in a dental office. 

You'll still have people walking around. They're still printing out schedules for the break room or this or that. There's always paper. You're right, it's been a long journey from 2000 to 2015, being paperless. I look back and still think it's a hell of a lot more expensive. Anybody tells you that you're going to go paperless to save money they're literally insane. You can't replace a pegboard system and a bunch of pieces of paper and pens and pencils with a whole bunch of electronic equipment and say that it saves you money. Basically these were some of the problems that made you start Dental Symphony. 

Tom: That's right. That's right, I never will forget. I never will forget that first Monday morning when I sat down with a patient and the question was about a certain tooth and what we had done. Instead of holding a piece of paper in my hand, a manila chart and looking, while I'm also looking at the patient and maintaining that relationship, I had to turn away from that patient and look at a computer screen where I only had one screen for one thing. I had to scroll through trying to find out what I had done and realized eventually, I really can't find this out very easy. Not in a timely way. That was my first experience. 

Saying that, I don't think anyone would say that it's not better having all of this information electronic record because certainly it is. The future of that and the ability to use that big data let's say within a practice and then even outside of that, that's a good thing. We just need to have software that helps, that thinks through everything that dentists do which starts with, "How quickly can I start working on this patient?" Then, "How can I register my examination? How can I have perio charting that is not a beating because most people will tell you how much they hate perio charting and have it meaningful. Some sexy things like standardizing the preferences of the clinician for the kinds of restorations they want to do so that all I have to do is be a good diagnostician, chart the findings. 

Then, having a turn around and create a treatment plan, have software that will do that for me automatically. Then a way to communicate my findings, that's where we stay, just in that realm. We feel like we can be helpful to anyone using any practice management system depending upon what their particular needs are. Even though electronic records are not perfect, they're not going to go away and they keep getting better. There are some good systems out there.

Howard: Right now the American Dental Association meeting is going on and you're seeing all this talk on Dentaltown. I don't even know the specifics. Anyway, the dental anesthesiologists are always trying to be a specialty and they're upset now about some other regulation. Are you following that right now?

Tom: Not closely.

Howard: I want to go back to dental anesthesiology because it's hard to but you say, "What keeps Americans from going to the dentist?" Fear has got to be in the top 3. Money is probably number one. Would you say fear is number 2?

Tom: Yes.

Howard: Basically money is the answer, what's the question? Then fear. Do you do dental anesthesiology or did you used to do it? How did you get this dental anesthesiologist coming in? Talk more about that a little bit.

Tom: No I don't do it because my practice is geared for the referred patient and those patients are not easy. Dentists don't send easy patients over. They're the hard patients. I really felt like I needed to stay out on that end of the spectrum and not confuse myself on what my skills were and where did my attention need to be? I don't do it. I rely upon an anesthesiologist. As far as having one come every week, I'm not sure how easy that is for anyone.

Howard: Does he bring in his own equipment or do you have an operatory decked out with a pulsoxymetrie, all that stuff?

Tom: We do have one room that's a little bit larger that's prepared just for that. He does roll in a cart early that morning and pulls everything out. Indeed it is a pulsoxymetrie and EKG and other vital signs.

Howard: I think the issue is they're talking about they want dental anesthesia to start measuring the gas exhale, the level of CO2. 

Tom: Capnography, the major of the CO2 which is a really good tool because you can see the oxygen saturation just from the percent of hemoglobin in the body. You can see that easily. Sometimes it's important to be able to recognize that when the patient is breathing or not breathing more quickly then seeing the saturations drop. Sometimes if you have drapes over patients you may not see that. I have gotten accustomed to looking at that wave for a capnography. Do I think everybody who does sedation needs that? I just don't know. It seems like a really good tool for what we're doing though.

Howard: I understand why safety comes first because there's 2 million dentists on Earth. Every time one person has a tragic accident, we had one in Hawaii this year, it's just all over social media. You see it flying over Twitter, Facebook. Huffington Post never misses any story that has the word dentist in it. They're probably the largest online player. It's one of those deals. Look at Cecil the Lion. One dentist out of 2 million shoots a lion and all dentists are just tarred with this for 3 or 4 months. One dental anesthesiology accident and it's just all over social media for 3, 4 months. Maybe if that one extra tool prevents one extra case. 

t seems like on these dental anesthesiology cases, it seems like when it goes south the dentist wasn't even in the ballpark of doing anything right. That last case in Hawaii, when the paramedics got there, the patient was still sitting up in the chair and the head was leaned forward while she was running down the hall looking for another doctor. No one even got the patient on their back, looked for the airway. It seems like when something goes wrong, nothing even remotely went right. It's not like you're trying to fine tune what to do exactly perfect. It's like, "Man, this wasn't even in the ballpark." Would you agree with that or disagree?

Tom: I would agree that for those things to happen, someone hasn't paid attention. It's easy to pay attention. All you have to do is have the proper monitors and staff people assigned. We are all listening to that pulsoxymetrie. The tone, as it beeps, if it starts to go down we know that the saturation is dropping. We look for it to go up and we'll do some things like repositioning the head, opening the airway, pulling the tongue out, making sure there's nothing in the back of their mouth that might obliterate the air patches. You can have adverse events certainly. You can have adverse cardiac events or strokes and those type of situations that are life threatening and terrible. In terms of typical IV sedation with the drugs that most of the people use, if you pay attention you should be able to manage those situations outside of some kind of aberrant thing happening. 

If I may, one other thing about Dental Symphony that we haven't talked about that relates to this is, within the software, there is an emergency response system that is really helpful. I've actually used it a couple of times myself. That's on a computer in an operatory if there's even then you can initiate the emergency response. The system is that in every computer in the office, just by pressing the button and saying that there's an emergency, each computer in the office will have a popup that will say, "There is an emergency in this room and this is everybody's job." It will list that so that instead of yelling down the hall or whatever or hearing a bunch of rustling of activity, the whole office is made aware of that immediately. Then at the site where the emergency occurs you can triage what that issue is, chest pain, breathing problems, it could be whatever. Then it will give instructions on how to manage that. 

I think it's a real, real good tool for a dental office to use if for no other reason than just to practice so that you're good for handling most common emergencies. That's with every account and it definitely makes sense. If we're interested in helping pre-clinically assess that patient so they're treated carefully. Then of course we're going to have something there that helps you manage that patient if there's any kind of problem. They're very rare but they do happen.

Howard: You said module 3 was on perio charting?

Tom: That's right. 

Howard: If you have health history on module 1 and you have perio charting on 3 and you have all this clinical stuff, one of the differences between your father's generation and our generation was this oral health continuum. They're finding a lot of diseases associated with the bugs that are found in the mouth. Do you think that's bigger in dentistry? The oral health continuum where people are linking other diseases from periodontal disease?

Tom: You hear a lot about it. I remember when guys like you and I started although I'm older than you, there was a move away from what was called the systemic origin of disease. Systemic disease relating from the oral cavity let's say. The oral cavity seeding organs and creating disease. That was poo-pooed when I was in school that that didn't occur and this is not how you're going to be taught. It seems like a few years ago there seemed to be a resurgence of that. I remember the first time I heard someone say, "Well, respiratory disease related to oral pathogens, periodontitis and the C-reactive proteins increasing the amount of inflammation in vessels and related to cardio disease. There seems to be a resurgence of that. I've heard some people say the research on that is equivocal but I'm tending to think that it's probably leaning towards, there is more and more interest in infectious disease related to the systemic disease. 

You remember just a few weeks ago we had a big scare all over the internet about Alzheimer related to infections from dentistry. I looked at the evidence based in the ADA and didn't really see much on that. Though I certainly would be curious about that just in terms of keeping our information up to date on Dental Symphony on what we're telling people. I think there's probably certainly something to that. There are organizations now that speak just to that, oral systemic problems. In terms of my practice and my dad's practice, does that make us do anything differently? Probably not. I do tell people just like I'm sure you do that we want your periodontium to be healthy. Everybody does.  

The likelihood of problems associated with that elsewhere are going to go down if they're healthy. Keep it healthy. It reminds me of the whole idea, the emphasis. I read that the information about prophylactics for patients who have heart disease, it seems more emphasis now is on, "Make sure your patients are healthy. The oral infections need to be kept to a minimum and that's more important than any antibiotics you're going to give them." That tells me if that answers your question, to just to continue to move for that. I'm sure there are probably some listening this you're going to say, "Tom what's wrong with you? It's all over the place. Get on board with that." I'm not saying I'm not on board but I think it is a transition. 

Howard: The human condition is always going to be 20% that's going to take anything you give them and be an extremist. You see extremists in all sectors, religion, politics, you name it. When sleep apnea started coming out then of course there's always the few nut bags who thing it's going to cure everything from male pattern baldness to acne. There's extremists. I do think what's funny is what goes around comes around. You can find lots of dentists saying 100 years ago that they'd find someone very sickly and jaundice and rundown and they'd pull out all their teeth and get rid of all that puss and pyrea and then the person would heal up and look better and feel better just getting all that infection out of the mouth. 

It's funny, here is is 100 years later and no one wants the cure by having full body extraction of all their teeth and be a [denturalist 00:48:02]. It's funny how 100 years ago some of the leaders in our profession were noticing a great improvement in the overall health when they pulled out all of that sea of infection and pyrea and puss and got them all cleaned up.

Tom: Likely have handled lots and lots of toothaches and swollen jaws and things and I've never heard anybody say, "It hurts right here and nowhere else," or, "It hurts right here but I generally feel pretty good." They feel terrible. You clean up their mouth, get rid of infection then generally overall they're just going to be a healthier person.

Howard: You do a lot of things. You also have digital impression scanning, you have same day crown millings, CBCT, TMJ you place implant. You do all that and endo?

Tom: Yes.

Howard: Let's go through that. What is your oral digital impression scanning? What brand did you go with?

Tom: I have the True Def 3M.

Howard: 3M's True Def. How long ago did you get that? Are you glad you bought it? How's that working?

Tom: I've had it nearly 3 years. I love it. I love it.

Howard: How much did that cost?

Tom: It was 11,000.

Howard: Eleven thousand. Why did you buy it?

Tom: I found when I was having my restorations made digitally as most people are now I think, it just seemed like a real mismatched to have an analog impression making a digital restoration when I could have a digital run restoration, a digital impression that would match up to make the digital restoration. Plus the more I saw the digital representation of my impressions the more problems I had. I was seeing when I really was honest with myself and looking at impressions, I would have bowls, I would have bubbles.

Howard: On the computer screen monitor?

Tom: Yeah. 

Howard: From the True Def. I agree. You're talking about when you take a rubber impression like a polyvinyl siloxane or I like Impregum 3M. With your loops on you can't really see that margin. When you use the oral scanner and you see the prep 40 times larger on the screen you're like, "Oh my god," and you've got to go back in there and make it prettier.

Tom: Actually I didn't say clearly what my reason was is that I just felt like there were problems with the polyvinyl siloxane impressions. They just had little defects there that I had grown accustomed to overlooking. "The lab guy can fix that," or whatever. They can't fix them if they're digital. That's one reason. The other reason I went with digital impressions is because it did away with having to pour models, mail impressions, ask when they're coming back. It just took away one of the oldest headaches in dentistry.

Howard: What lab do you send your oral scanning impressions to?

Tom: Mostly Glidewell, not always. 

Howard: Don't they give you a discount when you send in a digital impression because now they don't have to pay a human to pour up a rubber impression in stone and pay a human to trim a dye? It cuts their costs. Don't they pass some of that savings to you?

Tom: I think it's $20 per crown less.

Howard: They give you $20 a crown less. That True Def is just $11,000 one time? There's no per cost of each time you scan or anything like that?

Tom: There is a data plan that's anywhere from 2 or 3 hundred dollars depending upon which one you get that provides software updates and also is for the process required in taking the scan and sending it to whatever lab it's going to go to.

Howard: You gave them 11,000 down then you had to buy a plan. How much does the plan cost each month?

Tom: I think mine is around $200 a month.

Howard: Two hundred dollars and is that unlimited oral scanning impressions to Glidewell or do they ding you again on each use?

Tom: No, it's unlimited scans which to me was critical. I really did not like the other models of where you can only scan 10 or 20. Man, I didn't want anybody telling me that. If I want to scan, I want to scan and I didn't want to think about how much more it's costing.

Howard: You pay them $200 a month. Then you don't have to buy any polyether Impregum or polyvinyl siloxane or alginate?   

Tom: There are times when I'll take impressions. There are times when scanning is not easy.

Howard: Why? Go over that. When would you want to go back to an analog impression?

Tom: Let's say that it's a sleep patient and I've got a lot of work that I need to impress and they're on the anesthesia clock and I want to wake them up. Then I'll take an impression and then we'll pour the impressions and scan the impression. That's easy to do and you can define your margins real easy with the [inaudible 00:53:26] or whatever. That's one time. The other is if the patient's awake and 3M does require powder so it means it needs to stay dry. Sometimes if it's way back in the mouth it's hard for them. It's not a panacea for everything. To tell you the truth, you need to have somebody in your office that is good at scanning, somebody who's really, really good at that.

Howard: Do yo do the scanning or do you have someone else do it?

Tom: Rarely do I do it. I have someone who does it who's really good at it.

Howard: I don't understand why these dentists, they'll get a CAD/CAM machine and now all of a sudden they've got to be a lab man but when they had the impression they never did any of their lab work. They didn't pour up their dyes in, trim their dyes, they didn't do one damn thing. Then they buy a [inaudible 00:54:14] and now they're a glorified lab tech. You have CAD/CAM too. Is that E4D or GALILEOS or Sirona? What did you buy?

Tom: I have the IOS systems, the 150.

Howard: The IOS out of Glidewell's?

Tom: That's right.

Howard: Right on. I think you're the first guy I podcast interviewed other than [Detolla 00:54:34] that has that. You bought the IOS CAD/CAM.

Tom: That's right.

Howard: How much was that?

Tom: Fifty-eight.

Howard: Wow. See, I thought you would've gone E4D because it was in Dallas and you're in Fort Worth. Where is Dallas?

Tom: Where is Dallas, Texas?

Howard: Yeah. Is that near here? Did you ever go and meet the E4D? Gary Severance and all those guys? They're right up the street from you.

Tom: No, I didn't. To tell you the truth, I was an easy sell for IOS because I was one of I think that that first [inaudible 00:55:10] in Texas way back when.

Howard: Way back, when was it?

Tom: Ninety-five maybe?

Howard: Ninety-five. Probably about me too.

Tom: I did 1,000 restorations or so with it and liked it but it was pretty hard back then. It was pretty labor intensive I thought for one thing. One thing that happened is after that, the materials got better, labs began to get the end labs there so I didn't do them. I had a bad taste in my mouth because of that. It was first generation, wasn't real easy but I was very interested in computers. A couple years ago I was at a meeting and saw the design software for the FastDesign which connects with the IOS. It made perfect sense to me. It seemed easy, it was exactly what I thought it should be at a use of library templates to make the crowns. 

I was more interested in the software than I was in the actual milling machine because I thought, that's like the car that if you like the music give me a good car with a great radio and I know the car will run. I wasn't real, real concerned over it. I probably should've been but I was quite fine with the IOS. It's a whole lot less expensive, I've done several hundred restorations with it and I'm very pleased.

Howard: They bought that. That was a company out of southern Cal, wasn't it? San Diego? Did you know the company there? Do you know the founder or anybody down there?

Tom: I didn't. I was embarrassingly unaware of anything about the company. I just liked the system.

Howard: The IOS, don't they have a scanner? Did you have to buy the 3M True Def also? Did you just like the 3M oral scanner better than the IOS?

Tom: I'm not aware of an IOS scanner. I like the True Def. It does have powder but from what I understand that does make more accuracy. I just like it. I wasn't offered a scanner with the IOS although the IOS to their credit is open and they want to work with any system.

Howard: CBCT, which one did you get?

Tom: Kodak 9000.

Howard: Carestream?

Tom: That's right.

Howard: That's what I got too. Why did you get that one?

Tom: I got it about 7 years ago and I got it because I wanted to place implants and I have just the heebie jeebies about doing that in the absence of a CBCT. I've not done a lot of implants. I've done not nearly as many as I would like. I've done about 100 but I'm going to start using the surgical guide with that. I got it so that I could do implants. Then I learned, "Wow, I am seeing all these periapical issues." It's helped me with periodontics, it helped me with especially diagnosis for tooth aches with 2-D x-rays that are clear and I take a 3-D and boom, you see a lesion. I got it for improved diagnosis.

Howard: What implant system did you go with?

Tom: Straumann.

Howard: ITI Straumann. That's Switzerland or Sweden? Switzerland, isn't it? Why did you go Straumann? That's one of the originals. When I got out of school in '87 that was already out there. It was Straumann, Grand Mark.

Tom: I went with it because that's what these oral surgeons were using. To me it was the mechanics of that. They were really good in coming in and getting me set up with the things that I needed and support. I think it's a good system. 

Howard: I have so many older oral surgeons and periodontists. Because it confused me when Danaher who had bought the low-cost Implants Direct turned around and then bought the very high-cost Nobel Biocare. That just didn't make sense to me. Why did they buy the high-cost Mercedes Benz and the low-cost Chevy? These oral surgeons and periodontist tell me, they go, "They don't want to be burned. They've been on these Nobel Biocares. They work, they know they work, they don't care about the extra cost of the implant. They're charging $50,000 for a full mouth deal and the last thing they want to do is worry about one of the implants or the interfaces or something. I think it's amazing how brand loyal the Nobel Biocare brand. Buddy, that's it. We just hit the hour mark. Tom, thank you so much for doing this with me on a Saturday. Thank you. Tell your dad I just love him to death. I think he's just cooler than cool that he's a dentist and made it to 92 years old.

Tom: I'll do that.

Howard: I think the best marketing you would do, if you got 50 dental offices using Dental Symphony, start a thread on Dentaltown called Dental Symphony Users and email that link to all the 50 users and say, "Hey, the more you talk about it, the more feedback you'll have but the more marketing you'll have because all these Townies will see their friends talking about it and that might be the best marketing you could do. That's why I called you to do this. I thought this would be good to let people know that there's other things that merge with your dental office software that's just not the business side but the clinical side. Thanks to you for sharing your story with me. I thought it was an interesting story and I hope you have a great weekend.

Tom: Howard, thank you. It is an honor getting to visit with you and I really appreciate that. You have a good weekend too.

Howard: All right. Are you going to watch the Cowboys play or are you going to get on your bass guitar and start jamming out?

Tom: Both.

Howard: Both? All right, have a good day, buddy. Bye-bye.

Tom: Take care, bye.

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