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Howard:
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It is a huge honor today. I just got done lecturing all day in Singapore and Dr. Jonathan EE was there today. Jonathan, when I think of Singapore, I only think of you because you have, what is it, 3,663 posts on DentalTown.
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Jonathan:
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About there if I haven't posted in the last minute.
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Howard:
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Thank you so much for sharing 3,663 posts on DentalTown. I just feel like I know you. I feel like you're a brother, a cousin, a nephew or whatever. I'm sure a lot of Townies, after reading your posts, are so happy to meet you because on your avatar it's a picture of you with your loops on and your mask. When I met you today, I couldn't have picked you out of a police lineup.
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Jonathan:
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Oh yeah, that's my superhero identity, see. I'm shy.
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Howard:
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Are you shy? You don't seem like you'd be shy at all. You got out of dental school in 2007. When did you become a Townie?
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Jonathan:
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That was, I think it was actually 2010. I was looking at my profile just now, 2010.
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Howard:
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Three years out of school.
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Jonathan:
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Three years out of school.
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Howard:
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What has DentalTown meant to you? what do you think of DentalTown?
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Jonathan:
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DentalTown, I would actually credit most of my professional development with DentalTown if I really look at it. The way that it works in Singapore is that we graduate with a government bond, so when we do our school we do school for four years and the government subsidizes that and we have to work for another four years for the government.
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It was at that point, I was about three years in, happened to be randomly surfing about dental stuff and then, oh, DentalTown. I joined it and then it opened up a lot of different viewpoints, a lot of different ways to do things, a lot of different ways to look at things. Just by reading bit by bit and seeing what everybody else was doing, it starts to give you new ways to do things, new ways to look at things, new ways to do things better.
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Howard:
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When you're on DentalTown, you're over here in southeast Asia, you're in Singapore, I noticed a lot of dentists that I met here, usually they went to dental school either in Singapore or Australia. Is that a fair reflection?
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Jonathan:
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Yeah, it's a pretty fair reflection because our faculty here is pretty small. They've been expanding it from my time. My time, we took in 34 people and now it's about 60. They're intending to expand it to about 80 in the next couple of years.
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Howard:
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The dental school graduating class?
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Jonathan:
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Yeah. Of course, with only 30-plus people coming out in my time, there were people who couldn't get in, so they would go over to Australia and they'll do the time over there and then they come back.
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Howard:
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When you're on DentalTown, does the flavor, to you, seem like it's more international or does the flavor feel like it's more just Americans?
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Jonathan:
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I don't know. It's like a roast chicken with barbecue sauce on it. Dentistry is the roast chicken. No matter how you roast the chicken, it's still going to be a roast chicken, but the sauce that you put on it gives a little subtle flavor. It still has those American roots but there are so many international clinicians, some of them from places like the UK. Some of them from Iran. Some of them from South America. They put different spins on it too, but at the end of the day, it's still teeth.
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There are going to be some things with local context on it, like insurance, billing codes, the way that you approach advertising. The teeth itself, that's pretty international.
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Howard:
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I think a lot of American dentists would be highly jealous of you because if I asked Americans to list the top five things they hate the most, I think dealing with insurance companies would make the top three, probably, of every dentist who voted. You don't have dental insurance in Singapore.
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Jonathan:
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It's very much less. The way that it usually works over here is that maybe the company wills say, "Okay, every employee get $150 a year, and you guys can spend it on dental, whatever way you want. You just show us the receipts."
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It's less of a situation whereby they're saying, "Okay, we have to buy a plan with this company and then this company's going to give us this much, but then the dentist has to be signed up with the company separately and then they have to do it according to a certain fee schedule."
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There's a lot less of the layers of administration to go through.
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Howard:
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I am not aware, really, of dental insurance being a factor in the countries of China, Philippines, Taiwan, Hong Kong, Malaysia, Cambodia, Vietnam, Indonesia, Singapore. Is that true?
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Jonathan:
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I would say yeah, pretty much. In fact, a lot of the times, when they're bringing in insurance forms, it's either they are expatriate or they're working for a multinational corporation.
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Howard:
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Dental insurance is a factor in Australia and Japan, but not really anywhere else in southeast Asia.
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Jonathan:
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Very little.
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Howard:
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Or Asia in general. Would you say southeast Asia or just Asia?
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Jonathan:
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Possibly Asia, although I don't have a good look into the China region.
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Howard:
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I'm not aware of any insurance in China. The reason I bring that up is I believe so many Americans believe that they have to participate in these plans. They have to be insurance driven. Would you tell them, "Dude, there's 2 million dentists around the world, and only 200,000 of them deal with this stuff." They don't deal with this in Brazil, Asia, Latin America. It's just a non-issue.
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you have to just get people to pay out of pocket for your services and I think that's a great mental exercise for all the dentists in the UK and Germany and Australia and New Zealand and Canada and America that just believe that it's all insurance-driven.
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Jonathan:
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That definitely is an issue. I see so many dentists on DentalTown grappling with that because the public has been led to feel that way about it. I can't remember who it was, it's just such a thing that everybody says, you never get tire insurance, but you need to change your tires every so often. You never get gas insurance, but you get dental insurance on something that you're going to need for frequent and periodic regular care.
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Howard:
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Yeah, it is a very bizarre. Sitting here in southeast Asia, between China, Japan, Australia, America, all these countries, you probably are a great referee point to see variances. I noticed one variance on clinical dentistry, like Australians buy more glass ionomer than Americans do.
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Jonathan:
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That's because they practically invented the stuff.
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Howard:
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Talk about that. Why is that? I like to go to the variances and that's a huge variance. What's the story behind that?
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Jonathan:
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I think it's probably because that's the way that they're educated. They're practically brought up in the stuff because there's a clinician, Mount. I forget his first name, but he did basically developed glass ionomers and he's an Australian.
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Howard:
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What was his name?
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Jonathan:
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Mount. M-O-U-N-T.
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Howard:
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M-O-U-N-T.
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Jonathan:
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Yeah, Mount.
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Howard:
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Is it Mount Kosciuszko?
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Jonathan:
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No, that's a surname. Not Rushmore but, yeah. He basically developed a lot of the glass ionomer technology and he had a lot of clinical experience with it. He loves the stuff. Because he teaches, all the schools are influenced by it. It's just like, if you flip it around and you look at America, the knowledge base on composites is a lot stronger than glass ionomer.
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I still get people asking, "Should you bond before you put in a fuji?" The answer is no.
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Howard:
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Talk about that. Explain that. If you get that question, go over the question. Explain it in detail because if it's a frequent question a lot of podcast listeners might have it too.
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Jonathan:
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Okay, guys. Glass ionomer, it's a hydrogel. It works by an acid-base reaction. You take the liquid, polyalconoic acid, and you mix it with the fluoral elemental silicon glass. These two combine together and they form a jelly substance.
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The beauty of the glass ionomer is that when it is brought in contact with a tooth structure, it starts to take the metal ions out of the tooth, starts to take the calcium out and mixes it with the filling itself. That's the power of the bond. If you go and put a bonding agent in there before you lay down the glass ionomer, it's passive. It doesn't form that layer of ion exchange and you might as well have put an amalgam in it. It's about the same.
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Howard:
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Wow, you're very knowledgeable on that.
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Jonathan:
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I had good teachers.
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Howard:
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Do you use glass ionomer?
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Jonathan:
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Yes, I do. It's got it's places. It's got places where it works better. It's got places where it doesn't work so well. Of course, if you're putting it in a cavity where it's not loaded, it's going to do beautifully.
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Howard:
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What do you mean not loaded?
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Jonathan:
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Perhaps an upper-eight occlusal, or the buckle of an upper occlusal where you're not going to have an occlusal load on it, but the area that I find at this present point in time that's not doing so well would be the class twos. Those areas there, because of the marginal ridges, they take all the stresses.
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I have personally been finding on the cases that I see in my clinic that they come back, maybe, in about three-years time. The marginal ridge is chipped and then you start to get food impaction. The second problem is because this stuff works by acid-based reaction. If you got that food in there and all the bacteria in there, and they're creating an acid environment, it makes the glass ionomer start to wash out faster.
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From what I've seen from the products in Singapore, class two's no good. However, GC has come come out with the Equia. I haven't had a chance to play with that yet. They're saying it's strong enough to run in the class twos, and I'm also seeing Activa comining out. It looks promising as well.
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I am not entirely familiar on the chemistry but it looks like it's going to be an RMGIC on steroids.
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Howard:
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Are they going to call it the Arnold Schwarzenegger since it's on steroids?
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Jonathan:
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Pretty much.
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Howard:
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What about other restoration? Is gold very common? I have seven restorations in my mouth. They're all gold inlays and onlays, because I'm old school. I believe gold last the longest. Is gold a factor in Singapore?
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Jonathan:
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There are people still doing gold. I used to offer it but because my clinic is more aimed at a slightly more budget patient base. I've actually switched to a non-precious metal alloy. It's not as pretty. It's not burnishable, which I dearly miss, but it's tough as heck.
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I can give the patient a long-lasting, durable restoration. If it's for an upper molar, they're never going to see it. I put one in my mother. No one's seen it. No one's said anything nasty.
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Howard:
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How old are you?
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Jonathan:
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I'm 34 in a couple months.
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Howard:
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34 and you got out in 2007.what has got you excited. You've been doing this almost a decade now and you're in your youthful prime, energy. What's got you excited about dentistry? What are you looking forward to doing in the next decade?
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Jonathan:
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All of it, man. There's always going to be advances. There's always going to be things that work out. There's always going to be things that you thought would work out, didn't work out. That's just part of the challenge. You get to see things like the developments in implant technology, start to develop new materials for crowns.
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The other day, I got this news over Facebook, that suddenly Serona's just gone and done something crazy and they've invented a way to process, meaning from start to finish, the lab end of a zirconia single crown in slightly less than an hour. Which means that now, ever for a slow guy like me, if I bought the stuff I might be able to make a zirconia crown for a patient using the CEREC system and have them out the door in two hours.
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Just within the space of a few years, we've gone from five hour centering times into something that can do this, that's big.
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Howard:
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Do you have a CEREC machine?
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Jonathan:
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I have access to a CEREC machine.
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Howard:
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What does that mean?
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Jonathan:
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Basically, for me I work in two locations. I work a little clinic in the suburbs four days a week, and then two days a week I work in a bigger clinic. It's another clinic in the chain that I work in and they have a CEREC machine on the weekend.
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Howard:
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Have you been playing with it?
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Jonathan:
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Bluecam.
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Howard:
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You've been playing with it?
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Jonathan:
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Yep.
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Howard:
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Do you like it?
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Jonathan:
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I have a love-hate relationship with powder.
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Howard:
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Yeah? What other things. Are you thinking about implants?
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Jonathan:
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Implants? I'm not thinking about them. I'm doing them.
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Howard:
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Tell us about that part of your journey.
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Jonathan:
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That's also part of a journey linked to DentalTown. It's just interesting how all these people from various different diverse backgrounds influence you. My big influence in DentalTown is a dentist by the name of Bill Shaffer.
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Howard:
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Oh, from London.
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Jonathan:
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Yes, Bill.
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Howard:
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Oh, I love Bill.
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Jonathan:
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Yeah, mentally I have him pegged as Bi-con Bill because he was this guy who came on in DentalTown and he was showing off all these implants and it was like, "Hey, where's the other half of the implant? Has it just been chopped off or something?"
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They were 6mm long and everyone was saying, "He's crazy. It's never going to work."
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He said, "But it does and here's all the recalls." He would show case after case after case.
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Howard:
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They still don't believe it.
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Jonathan:
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They're swinging around. That's the beauty of DentalTown, you see, because they have a community consensus. They, as a whole, by just every so often locking horns on a case, they'll come to an agreement. This pretty much generally works. I did see a shift in the consensus from, "Oh you need and implant like 20mm long. You've got to anchor it in the base of the brain."
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Bill started showing off all these 6mm, 6mm, 6mm, and he's also not an extremist in the sense that he'll do shorties when he needs them. He'll do long-ies when he needs them. He just showed them, these are the cases where you can do them and they're going to work, and these are cases where you may not want to choose them. You don't need to do it the way that I do it, but you can look at how I do it and if you want to give it a shot, why not? I saw the consensus shift.
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He was a big influence. He got me onto Bicon implants pretty early on.
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Howard:
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Bicon out of Boston.
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Jonathan:
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Bicon out of Boston, yep. The little Boston miracles. I actually, philosophically, am a Bicon guy at heart.
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Howard:
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Is that what he places now, Bicon?
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Jonathan:
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He does Bicon, ANKYLOS. I think for certain reasons he's moved a little bit more towards ANKYLOS.
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Howard:
|
ANKYLOS, is that by Dentsply?
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Jonathan:
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Yeah, they bought the product. It's a German design. It's got a good long history on it. I think '85 or '86.
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Howard:
|
That is Dentsply, right?
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Jonathan:
|
Dentsply, yeah.
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Howard:
|
That's your first really top-line implant system. They've had a few systems over the years.
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Jonathan:
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ANKYLOS, that stuff's built like a German tank. For me, however ...
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Howard:
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Is it made in Germany, you said?
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Jonathan:
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Made in, I'm not sure, but the designer is German.
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Howard:
|
The designer is German?
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Jonathan:
|
Yeah. I use Megagen though. They've got a lot of very similar design principles to ANKYLOS. Good solid conical connection. Just good common sense design on the prosthetic parts. It's nice to put it. It's nice to restore. They've taken a lot of the principles that made the other implant systems, like ANKYLOS and Bicon and ASTRA successful and they've incorporated into their own designs.
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Howard:
|
Didn't a third of Megagen get picked up by Straumann?
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Jonathan:
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Big chunk, yeah. Straumann put [crosstalk 00:16:37]
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Howard:
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Was it a third?
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Jonathan:
|
I'm not sure about the raw numbers but there was a hefty chunk of money that they invested into Megagen.
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Howard:
|
Is Straumann out of Switzerland or Sweden?
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Jonathan:
|
Switzerland.
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Howard:
|
Switzerland?
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Jonathan:
|
Yeah.
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Howard:
|
I want to ask you a question about you and Bill. The most common email I get in my inbox at howard@dentaltown.com, the most common email is always the same thing. It's a link to a thread and they tell me, "You should get on there. You should say this, or you should post this." I'm just sitting here going, why the hell should I say it? These are your words, why don't you say it?
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If you look at the data on DentalTown, 9 out of 10 people just lurk. They just lurk. Here's Bill that can post a case going back years and years, where people are saying, "You're crazy. This is too short. This will never work. Talk to me in a year when this fails."
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Why is it that some people, like you and Bill, can post thousands of times, yet 90% of the human condition of a dentist is, "I'm just shy. I just lurk." What advice could you tell them? How many times did you post?
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Why can you psychologically post? Why can Bill post something that is controversial as short implants, and 9 out of 10 dentists on DentalTown just cannot pull the trigger and post?
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Jonathan:
|
Sometimes you just have to take the first step. How would I put it? Nothing ventured, nothing gained. It's like when a patient's not quite sure if they should do something. I always tell them I believe there's the UK Special Air Service has a saying, "Who dares, wins."
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I also heard, I think it's the Navy Seals, they have a saying, "Pain is temporary. Chicks dig scars. Glory is forever." Sometimes you have to take the first step.
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Howard:
|
Chicks dig scars ...
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Jonathan:
|
Glory is forever.
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Howard:
|
That is a funny thing. I always said that, I have sisters and friends with stretchmarks from babies. I said, man, if men got a stretchmark from having a baby, they would show everybody. You could not meet a man and within five minutes he'll show you the scar of their knife, their bullet wound. I said only a woman would be embarrassed of a stretchmark scar from a baby.
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When men get those stretchmarks on their shoulder areas from lifting weights and building their pecs too fast. They love those scars. They show everybody those scars. That's a great saying.
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Do you think they do it because they're thin-skinned or do you think they're afraid?
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Jonathan:
|
I think they might be a bit afraid. Sometimes it takes a certain something to stand up and say, "Hey, I've got a different opinion," because everybody wants to be loved. It's the same thing when you need to break bad news to people sometimes. You're mouth has problems. We need to sit down and talk about this.
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Sometimes you just have to take a deep breath and do it.
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Howard:
|
Go back to implant systems because my whole motto with DentalTown is that at DentalTown, no one should have to practice solo again. When you walk in to the Cologne has the meeting every other year, last Cologne meeting, 175 different implant systems. Here's someone listening to you alone. They see all these systems. Why did you go Megagen? How could you help them pick a system?
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Jonathan:
|
Megagen was a bit interesting because, just like Bicon, I actually knew the system by reputation before I even met a single sales rep. Why was that? Because of DentalTown. We have a lot of users. Jerome Smith, I think, is a Bicon user. Some of the other guys who are hardcore Straumann have started moving towards Megagen as well.
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Megagen, they were already discussing things like, I'm finding that it's working very well in my hands in this way. We also had one particular poster. I haven't seen him on for a while now, Con-te-ho. He's a Korean dude and he was an automotive engineer before he went to the US and got his DDS. That's a strange combo, you know?
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What he brought to the table was a really long, heavily-illustrated thread on how implants work from a mechanical perspective. How you design those implants so they're going to work. They're going to go in. They're not going to break. Which are the good connections you need to look for. Megagen ticked off all the boxes.
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Howard:
|
Yeah. He had some very amazing illustrations, drawings of things, that you could just tell that I'm a dentist, I wasn't a mechanical engineer. He explained it so eloquently.
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Jonathan:
|
He did, yeah. By the time the rep popped by, that was Moon by the way, she popped by and said, "Hi, doctor. Would you like to look at my brochure?"
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I said, "Megagen! Where have you been all my life?"
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|
That was great. The other thing that helped me out with that, they've got a really good service culture. I think Dr. Morgan from Bicon always jokes that if the reps in America heard about what the reps in Asia do for their customers, they would kind of freak out.
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|
I think the culture over in the US is you buy a whole box of implants and you buy your own motor and you buy your own stuff. You buy your bits and pieces and then you bring all that inventory into there and you just put it there and then, okay, where's the patients?
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The way that it works in Singapore is a little bit different. You can actually go to the supplier and say, "Okay, this is the a la carte price for one fixture." If you're a new user, they'll come down and they'll bring a motor for you. They'll bring the hand piece for you. They'll bring a whole suitcase full of fixtures, so you can just pick the one that you want. You do the surgery with them over your shoulder and then you stick it in. They'll just bill you for that one thing.
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After that, when you send the stuff off to the lab, after the impression's been done, they'll hook up with the lab and then they'll get the stuff, and then they'll send the invoice to you later. I think that makes it a lot easier for a clinician who just wants to get his feet wet in the system without having to commit to thousands of dollars of inventory, especially if you're not quite sure what kind of implants you're going to put.
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|
Are they going to be the long ones? The short ones? The fat ones? The thin ones? You don't know the sizes you're going to be putting in regularly and you don't have the stock that's just going to sit there and expire because you bought a 10mm long, 8mm wide implant that's never going to be used.
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Howard:
|
Hit on the other controversial parts of implantology. Surgical guide, yes or no?
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|
Jonathan:
|
Well, I'm a bad boy. I do a lot of freehand. If I do all of them freehand. Honestly, what I'm finding is that when I have to do more than two, that's when my placement starts to suffer a little bit. It's not enough to make it unrestorable, but it's enough for me to look at the x-ray and think, "Damn, that could've been better."
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|
I think those are the places where the surgical guides ...
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Howard:
|
For multiple units.
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Jonathan:
|
Yeah. That's when it starts to [crosstalk 00:24:09]
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Howard:
|
Why do you say you're a bad boy, because that's one of the reasons I keep hounding that question. Every single dentist I know personally who's placed over 5,000 implants, they never use it. They wouldn't even think of it. They would say, be a real surgeon. Especially single tooth. When you've got a tooth in front of it, a tooth behind it, you've got the buckle [inaudible 00:24:29], they think it's comical.
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|
I like to go to where there's a lot of noise, where there's a big variance. There's a lot of noise that you have to have a surgical guide, you got to make a surgical guide. Then, I've done 10 podcast interviews with 10 guys that have each done 10,000 implants who never use a surgical guide.
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|
You're saying that, for a single, it still makes sense to do freehanded, but for multiples [crosstalk 00:24:56]
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Jonathan:
|
Yeah, it's the multiples. Those are the ones, unless you've got really good eyes. Maybe I just have average eyes. On the other hand, when you think about it, you take say 30 minutes of doctor time to put in the first implant, but you take five minutes of doctor time to put in the second implant, you know.
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|
When you're doing the impression, it takes maybe 40 extra seconds to screw on the culping. It takes 40 extra seconds to screw off the culping. Maybe the issue stage might take about the same time if you're doing two but that means that your profit versus your time for that second implant, which you placed at the same, is not so bad and you probably more able to absorb a guide cost anyway.
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|
|
Of course, the other thing is how good are your guides? Are you just making a thermoplastic stint? Okay, it's kind of in that neighborhood, let's bang it in there. Or are you going to do one of those foofy guides with the rings and fully restricts it and have to buy a guide kit as well. Long story short, Armen, come to Asia.
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Howard:
|
Tell me about Armen. What's got you excited about Armen? How do you pronounce his last name? Mananas.
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|
Jonathan:
|
Mer-ZI-an.
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|
Howard:
|
Mer-Zi-an?
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|
Jonathan:
|
Yeah.
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|
Howard:
|
Armen Mirzayan, out of southern California. What city is he in?
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|
Jonathan:
|
I'm not sure, man. I also only know him by internet reputation.
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|
Howard:
|
I love Armen.
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|
Jonathan:
|
He's made it his mission in life to make dentists use guides for their surgeries.
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|
Howard:
|
What's his website? Cad-Ray?
|
|
Jonathan:
|
Cad Ray.
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|
Howard:
|
There's a hyphen in it. Isn't it Cad-Ray.com?
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|
Jonathan:
|
I think there's a hyphen. He probably bought up all the internet addresses, so they all just direct in.
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|
Howard:
|
Let's just find out. You talk and I'll see what is up.
|
|
Jonathan:
|
Armen, his vision was to basically find ways to make guides more affordable to the dentist and by reducing that cost, you increase the usership of guides and that's also going to help dentists with reducing errors in terms of placement, which once again reduces your issues in terms of restorations, which can sometimes cut costs rather than having to use custom abutments in a case where a stock abutment could be modified and used.
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|
|
There are definitely benefits to it. It's just that, on our end over here, it is challenging, first of all, to get the logistics, to get a good guide done.
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|
Howard:
|
Well, you're right. He did buy CadRay without a hyphen. It's Cad-Ray, but he did buy CadRay, because I just did CadRay and it redirected me to Cad-Ray. Sorry to interrupt you. Go to Cad-Ray. Continue about Armen. Sorry to interrupt.
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Jonathan:
|
He was finding ways to get these scans done. He was doing the legwork. He was trying to find ways in which he could take that patient, either model or STL file, and find ways to get that integrated with a cone beam so that he could figure out, "Okay, sinus is there. Nerve is there. Where are we going to avoid it?"
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He was trying to find ways to get this linked up with clinicians so that they could look over the thing rather than just a technician, working over the models and they could coordinate with the surgeon dentist. He was trying to find ways to do this economically, which is a really good thing you know.
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Howard:
|
If you do a stint now, what are you doing?
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Jonathan:
|
Unfortunately, it's probably going to be something homemade. I would probably be making something thermoplastic and filling it with resin and then drilling a hole through it with my pilot drill. Basically, a pilot guide.
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Howard:
|
We've talked about implants. We've talked about you have access to CERAC on one of your offices. Is ortho on your horizon?
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Jonathan:
|
Ortho is on my horizon, yes.
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Howard:
|
Are you doing any of that? What are your thoughts on ortho?
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Jonathan:
|
Actually, my first interest in ortho was because of Ricky Paul.
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Howard:
|
Power Prox [crosstalk 00:29:10] is that what it's called?
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Jonathan:
|
Power Prox, yeah. The way that we were taught in school, honestly, there wasn't a lot of hard skills. There's a lot of diagnosis, so it's okay, take the let-sef, take the opg. Examine the patient. He's class three. Okay, let's move it to the post grads.
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Unfortunately, this is an area that our skills are lacking in. There are certain concerns about it, of course, sometimes the stakes are a bit higher in ortho. There are things you can do on a case, if you don't know what you're doing, and you can mess things up and it can be difficult to treat. We're not in the business of messing up young ladies' faces. Of course, there should be proper caution, proper diagnosis.
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What I think Rick has done is he's found a way for us to, first of all, diagnose which are the cases that can be done simply. He's found a way to treatment plan them so that they can be done predictably. He's even got marketing tips on there and how to deal with these cases.
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What he's teaching through the Power Prox concepts, I wouldn't even call them a system, Power Prox concepts is how to find cases whereby you can treat a patient in six months or less, predictably and safely, and then go ahead and do it.
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Howard:
|
Now, you're saying Power Prox a lot, but the website is sixmonthbraces.com, right?
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Jonathan:
|
Yeah.
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Howard:
|
You're doing that now?
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Jonathan:
|
I'm doing that now.
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Howard:
|
How long have you been doing that?
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Jonathan:
|
Maybe close on to about one-and-a-half, two years.
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Howard:
|
How did you initially learn? I know he has a CD program or he's got a course on DentalTown.
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Jonathan:
|
I got it from the CD program.
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Howard:
|
You got the CD program?
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Jonathan:
|
I got the CD program.
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Howard:
|
Tell us about that. How many hours was that? How much money was that?
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Jonathan:
|
That was six DVDs. It was long, but when you just bring a DVD to the office and then at lunchtime you just play one and then you come back from work and then you play another one. It goes by and sometimes you just watch them again and again. Come back to them in a couple of months. You'll pick up little things here and there.
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Of course, you know, a DVD series is not going to tell you everything and he doesn't say that it's going to tell you everything as well. I think what some people have said is that Power Prox is like a gateway drug to ortho. It's a way of introducing the style of thinking because to us, sometimes tooth movement is a foreign thing.
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|
You look at that case and say, "Oh, I'll never be able to fix this up," you know. It just opens up options. Hey, that tooth over there is sticking out a little bit and if we line that out nicely, it's going to be easier for you to brush and that might take about 4-6 months.
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Howard:
|
The website's sixmonthbraces, but they're confused because they hear you saying Power Prox or Six-Month Braces. They hear other terms like Invisalign. They hear Inman Aligners, the tiff out of London. What's the other one? Six-Month Smiles out of London. What's the other one of Six-Month Smiles? What's the one Ryan Swane started?
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Jonathan:
|
Yeah, that's Ryan, yeah. Six-Month Smiles.
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Howard:
|
Okay, so Rick Duvall, Six-Month Braces. The other one's Six-Month Smiles. How do you pick between Six-Month Braces or Six-Month Smiles, or Inman Aligners? Any advice on picking an ortho starting point?
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Jonathan:
|
They actually all serve different purposes and different markets. I can only really speak for Power Prox, because that's the one that I've actually looked into and bought and sat down and gone through the materials and learned from it personally.
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First of all, they're not selling a system. They're not going to say, "Okay, here's what you can do with braces, but you need to use my lab and my wires and my bracket set up by my technicians." He teaches you how to think. He's not out to sell fancy tools or something that can only be used in a situation. He's teaching you how to look at a case. How to bring it through your brain.
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|
He's actually selling orthodontic knowledge. It teaches you how to approach cases, either simple cases or if you go on and do comprehensive cases later. The knowledge is all applicable.
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|
Invisalign will teach you how to treat a case. It could be simple cases, complex cases. It's basically just another tool.
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Howard:
|
Invisalign?
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|
Jonathan:
|
Yeah, Invisalign. The Inman Align gives you a good option for very limited correction cases but sometimes if all the patient wants is to just get that tooth moved in, that could be a good option if they don't want to have fixed and you find it's a little more economical than sending it off to the Invisalign lab.
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|
They all serve different roles and purposes. The Inman Aligner, that's also something that's been gaining traction on DentalTown, I see. Donald Inman, he runs a lab in the US. Tiff from London, Inman's getting pretty big there.
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Howard:
|
Inman Aligners is from Donald Inman in where?
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Jonathan:
|
Somewhere in the US. He owns a lab.
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Howard:
|
One of the things that's so neat about dentistry is, I was talking to some graduates one year out of school and I said, "What's got you excited?" They said that their whole career, they're not going to be sitting at a desk doing the same job over and over. They're not going to be in an assembly line doing the same thing over.
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|
There's always something new. There's always something to learn. It's just amazing how you can be out 10, 20, 30 years and there's just always so much more to know.
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|
What advice do you give to someone who might feel overwhelmed and they're sitting there saying, "Jon, I can't learn to place implants and do ortho and learn the CERAC machine. I just can't. There's not enough hours in the day. Plus, I'm married and I got a three-year-old at home." What do you say to that person who's feeling overwhelmed with so much to learn that it's almost suffocating?
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Jonathan:
|
Pick one thing. Sometimes the best way to approach a complex problem is to reduce it. You've got to reduce it into different parts, reduce it into different steps. No one said you have to tackle every single discipline simultaneously.
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|
My earliest hands-on CE courses were on endo and from there I did move on to implants and I'm going to be starting up comprehensive ortho this year.
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Howard:
|
Who are you going to do that with?
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|
Jonathan:
|
There's some instructors coming down from NYU. They're also with DSS. They'll be running a course quarterly. It's sort of like a continuum thing. Every three months, they do a module. Couple of days.
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|
Howard:
|
With Tommy. Tommy and Andy.
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Jonathan:
|
Yeah.
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|
Howard:
|
Andy Poe and Tommy Ng?
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|
Jonathan:
|
Oh yeah.
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|
Howard:
|
Am I pronouncing ... His name is Tommy NG. The NG is just Ng? Am I doing it right?
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|
Jonathan:
|
Ng. Oh, yeah.
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|
Howard:
|
DSS is going to set up a quarterly ortho program four times a what? Two years?
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|
Jonathan:
|
For one year. It's a one-year course.
|
|
Howard:
|
How long is each course? Three days?
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|
Jonathan:
|
Three days, yeah. Singapore people, DSS, orthodontics.
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|
Howard:
|
That's awesome. What else? You cut your teeth on endo. That was one of your earliest things you did, you said?
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Jonathan:
|
Yeah.
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|
Howard:
|
How's endo? Is that still part of your practice?
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|
Jonathan:
|
Totally. Just now, during the talk that you were giving just now, you said that, you know how pain is like the fun part of your practice. Pain's a major part of general practice work. At the end of the day, sadly, a lot of the reason why people come to us is because they're in pain. Endo is one of the major ways in which you're going to deal with pain.
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|
I would say, probably, 80% of the pain that comes in has something to do with a lesion of endodontic origin.
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Howard:
|
Jonathan, help me here, because in a country like America, the insurance pays 80% of their account. It's $1,000 and the insurance pays $800. That almost never gets denied. A lot of cosmetic stuff gets denied. A lot of implants get denied, but root canals don't get denied.
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|
Dentists say they don't like to sell dentistry. When someone's in pain, they're begging you to fix it. We continue to see that, no matter if we go to the United States, Singapore, Australia, or whatever, half the dentists hate molar endo.
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|
What advice would you give to someone who says, "Jonathan, I graduated $350,000 in debt. I don't like selling dentistry. I get these toothaches. It's easy money. It's an easy sell. They're there. They're in pain. I could make $1,000. I hate it."
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|
Any advice? If you're 30 years old and you hate endo, is that just, you're going to hate endo? Have you ever seen anything to where someone hated endo at one phase of their life and eventually learned to love it? Can you go from hating endo to loving it?
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Jonathan:
|
I could actually quote a real-life example. There's a dentist who just got active on the board again by the name of Scott Perkins.
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Howard:
|
Scott Perkins! I love Scott, out of Houston.
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Jonathan:
|
Yeah. His story was this. He's a very interesting man. He's very intense. He has chosen as pretty much part of his life's mission to find ways to do things just more efficiently. He would take a crown prep appointment and people would be saying, "Oh, I take an hour to do that." He'd find ways to make it flow and cut it down 15 minutes or something.
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|
He tackled crown preps first and the next thing he turned his eye to was endo. He felt that he kind of hated endo as well, but he resolved that he didn't want to hate endo, so he pumped time into it. He basically conquered his dislike by beating it to death.
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|
He would take extracted teeth and he would just practice how to get down the canals, how to fin the canals. He would find the little tips and tricks that the instructors in school weren't telling him, that the textbooks weren't telling him. He was understanding about the layout of the teeth. That helped him out.
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|
|
I would say that half the time when we're working, the reason that we feel stuck is because we're just not familiar with something. We have to stare at it for a few seconds, put down our hand-piece and go, "What do I do now?"
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|
|
That feeling of being lost can be overcome in two ways. The first way is that you just practice enough times until it's gone. The second way is to leverage on the experience of others. Which is, once again, where DentalTown comes in because you see all these other cases that people are posting. It's like being over their shoulder sometimes. Especially when the photos are really clear. You get into their brains because they're just typing, "Okay, how did I approach this?"
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|
You can ask them questions. You start to understand how they come to decisions and you know when you see something the first time, and you see it again live, you're not so scared, like when I got my first hex broken off of an abutment because I had seen about two separate cases on DentalTown, I didn't crap myself. I got it out without destroying the implant.
|
|
Howard:
|
Yeah. Another time I feel really overwhelmed is when you buy a ... I bought a CBCT x-ray machine from CareStream, and you look at some of these images. You're just like, "What the hell and I looking at?" I sit in my office with two associates and a dentist visiting from up the street and there's four dentists looking on a monitor and four guys are, like, one specific thing, you're like, what is that?
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|
|
There's four doctors of dental surgery looking at it saying, "I have no idea." Do you have access to CBCT or did you buy one?
|
|
Jonathan:
|
Yeah, the weekend practice has one.
|
|
Howard:
|
What do you think of the CBCT?
|
|
Jonathan:
|
CBCT, it's got its place definitely. I mean, you've got to understand the strengths and weaknesses of the CBCT. The wonderful thing about a cone beam, measurement of length in hard tissue. You want to know the distance from the crest of the bone up to the floor of the sinus or away from the inferior dental nerve, that's going to be great for you. You want to see how wide that ridge is, it's great.
|
|
|
Where it's not so strong, currently, is things like soft tissue. Because of the way that the cone beam technology works, it's basically they spin the beam around. They have a really complicated computer program to just piece everything together. It doesn't do so well with soft tissue. It can't tell you what kind of a soft tissue, if there is a good soft tissue or a crappy soft tissue. It doesn't tell you things about bone density.
|
|
|
With the old fan beam CT scans, they will be talking about things like Hounsfield Units and that's roughly what the bone density is there. You can't do that with a cone beam.
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|
|
The other thing that it doesn't do so well is when you have a lot of radio-dense objects crammed into a certain area because when they reconstruct, you lose data in those areas, so you may be able to measure length but if you're trying to look at things like, is that a crack in the tooth? It may not actually be the most reliable.
|
|
|
I remember some of the board members getting on a debate about that and saying that it's actually pretty terrible for cracks. On the other hand, if you want to see, is that root canal infection going to the sinus, it's boss for that.
|
|
Howard:
|
It's boss for that. I love it. What else? We talked about so many subjects. Any other areas got you excited? Do you like pediatric dentistry?
|
|
Jonathan:
|
Unfortunately not. Yeah, that was also something that I picked up from DentalTown. Sometimes, certain things, you just find that you're just really not good at it no matter how you try. Sometimes you want to put in the effort to overcome it. Sometimes you don't. I just found that I wasn't getting any joy in that one and I didn't feel like it was a growth area for my practice.
|
|
|
I think it was two years ago, I gave myself a Christmas present and I said, "No new kids under the age of 12."
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|
Howard:
|
Really? I've always thought that if ... Some kids can [inaudible 00:43:54] if they love kids, they got an ace in their back pocket. Because that is one market that always seems to be, no one really wants to go after.
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|
|
I want to ask you another thing about Asia versus around the world, the cost of a new smile. Some countries you go to, maybe England and Germany, the dentists will tell you that the people there think the bleached-out American white teeth of veneers and the B1 shades just look like a clown. They like more natural.
|
|
|
Where does southeast Asia and Singapore sit with tooth whitening? Do they think the Hollywood smile on Lady Gaga is just too white, or are they more into natural? What is it like out here?
|
|
Jonathan:
|
It can swing either way, actually. We usually try to go for a happy middle ground, just go for A1. No need to choose between refrigerator and toilet bowl. On the other hand, I always try to tell my patients, "Try not to bleach the teeth whiter than the whites of your eyes, otherwise they look like they're going to jump out and grab you in the face."
|
|
Howard:
|
That's good. I've never heard of that one. You're teeth should not be whiter than the white of your eyes. Does that mean I've got to quit drinking or do I got to whiten my teeth?
|
|
Jonathan:
|
Maybe find a way to whiten your eyes, man.
|
|
Howard:
|
That's an old jaundice joke. The jaundice, yellow your eyes from drinking. Would you say, in general, Singapore is less ... They don't use so much the bleaching shades?
|
|
Jonathan:
|
Yeah, less. We're still seeing patients who they're just really gunning for basic stuff. They want to have a slightly whiter smile. Maybe they're more interested in the take-home than the in-office. They just want the fillings to match and the crowns to match the natural dentition, which is kind of around an A2 to A1 anyway, which to them they're pretty happy with it.
|
|
Howard:
|
I want to ask you a true/false question. A lot of times, there's common sayings and common knowledge, but a guy like me, who's a journalist, who's wrote a monthly column since 1994, I try to make sure I can find citations or something.
|
|
|
You just hear people off the cuff say that Asians smoke more and have more gum disease. You try to look at the data. If someone said, "Do Asians smoke more and have more gum disease," how would you answer that?
|
|
Jonathan:
|
They don't smoke more here because smoking's mad expensive.
|
|
Howard:
|
Smoking is mad expensive?
|
|
Jonathan:
|
Yeah.
|
|
Howard:
|
What about south in Indonesia or north of you in Malaysia?
|
|
Jonathan:
|
It's a lot cheaper there, so the smoking rate's way higher.
|
|
Howard:
|
Your observation is that the price of cigarettes really affects the smoking rate.
|
|
Jonathan:
|
Yeah. I think it was 2003, the Health Ministry made a decision to raise the tax on it, if I recall correctly, and they used to be able to sell small boxes of cigarettes and big boxes of cigarettes. The small box is 10 and the big box is 20 and they banned the small boxes. I actually think they should have banned the big box because finishing a box is like a mental barrier for the patient to say, "Stop it."
|
|
Howard:
|
They banned the pack of 20?
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|
Jonathan:
|
They banned the pack of 10. Now they can only buy 20.
|
|
Howard:
|
Okay, so they banned the pack of 10, and now you can buy a pack of 20?
|
|
Jonathan:
|
Only, yeah.
|
|
Howard:
|
In 2003, what did a pack of 20 cost before taxation, and what does it cost now?
|
|
Jonathan:
|
It's probably about eight bucks a pack now. Ten bucks is pretty average, based on what I see in the supermarket.
|
|
Howard:
|
One of the most billionaire mayors of all time was the mayor of New York City, Mayor Bloomberg. He was a billionaire businessman and that was his big thing that he totally believed, that the higher you tax the cigarettes, the less you would smoke.
|
|
|
I did see a lot of economists saying, especially in ages of 16-21, the kids thinking, "Well a pack of cigarettes is this much money. I could buy a hamburger, fry and a coke three times for that amount of money." They start thinking, "I'd rather have a pizza than a pack of cigarettes."
|
|
|
You think that raising the price of cigarettes has made Singapore smoke less than its neighbors in Indonesia or China?
|
|
Jonathan:
|
Yeah. Maybe the Health Ministry's being a bit more aggressive about it.
|
|
Howard:
|
What about gum disease? There's a lot of people who believe, for some reason or another, that there's more periodontal disease in China than the United States.
|
|
Jonathan:
|
I think that's because it's not being diagnosed. Let's say China. The dental culture is different from in the US, whereby it's become a regular thing that you're in there six months and then you're going to get a cleaning done. Over there, they believe that the cleanings are painful and you only see the dentist when you're already having dental pain. You don't see the dentist otherwise, unless you're missing teeth and you want to put back teeth.
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|
Howard:
|
It's the culture of not ...
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|
Jonathan:
|
It's emergency-based.
|
|
Howard:
|
It's emergency-based instead of preventative-based.
|
|
Jonathan:
|
Yeah.
|
|
Howard:
|
You think that's something you'll see? Have you seen, in your decade of practicing, that Singapore is starting to go from more emergency-based to more preventative-based? Have you seen a migration?
|
|
Jonathan:
|
It's sort of a mix, actually. I do have my regular patients. If I've gotten them fixed up already, they're in every six months. We get new patients coming in say, "Oh, my last dentist moved away and I'm looking for a new guy." They've been maintained on six months. I also get the patients, for various reasons, they're just coming in when something hurts or gets wobbly or swollen.
|
|
Howard:
|
We've already done 50 minutes. I only got you for ten more. Anything else that's got you passionate? Anything else you want to talk about?
|
|
Jonathan:
|
CadCam dentistry.
|
|
Howard:
|
Let's hear.
|
|
Jonathan:
|
I was alluding just now to the big announcement from Serona about have they've gotten the zirconia crowns out in one hour. I think this is a rapidly changing field. CadCam, it just encompasses so many things. The Cad part is really about how you're going to take the prep and digitize it into a form by the lab technician can use it to work on it and design on it. Possible even entirely digitally. The manufacture. CERAC is already 30 years old and they've started with a subtractive method where you've got that block of ceramic and you drill it down.
|
|
|
I hear that there's buzz out about one company that's making a laser machine whereby you can take the block and you can laser it and that's going to remove the limitations of how finely the drill on the machine can drill it. 3D printing is coming up. I've heard that Valplast has actually found a way to print Valplast. There's another company called Vertex. They're looking at printing denture bases. I'm sure printed teeth will be coming out soon. They'll have all these aspects that are interesting.
|
|
|
For me, the things I like about CadCam is that it gives you a way in which, when you're taking that digital impression, you know what you're going to get. You don't get any nasty surprises. When you're taking those impressions, I would say 99 times out of 10, you know it's going to turn out fine, but sometimes you just miss that little thing and then two days later you get the call, "You know doctor, you missed that margin."
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|
|
You're like, oof, okay. Hey, call them back in. At least that way, you do know what you're going to get because you don't know what the lab technicians going to get. Of course, you can't take a crappy prep and expect that the lab technician's going to just turn that thing into something wonderful. It's still going to have the limitations of your prep but at least you know you captured everything.
|
|
Howard:
|
Do you think that was a big part of the Dentsply-Serano merger because Dentsply was a yesterday company that had all the impression materials and film x-rays and all the consumables, and then Serona was the all-digital play with CadCam and CBCT and Galielos. That was kind of a merger where now Serona would have a consumable, like a block for their CadCam machine and then Dentsply would have a future as the world goes from all consumables to all digital?
|
|
Jonathan:
|
Entirely possible because Dentsply's got a relatively new block out called CELTRA Duo and I've been hearing good things about it. It hasn't come to my end of the world, but the Australians seem to be loving it. Yeah, Serona's just going to grow. It's like the Apple of CadCam. They've got this whole environment here where they can take you from the start to the end using all of their stuff and it all just meshes so nicely. It's not just the hardware aspects, but the software itself. It just flows.
|
|
|
Even that recent announcement with the zirconia. They had, basically, a closed environment. The camera's talking with the computer. It's talking with the milling machine. It's even talking with the oven. You just need to press the go button and make sure you don't have your finger in there when the lid closes.
|
|
Howard:
|
That was interesting. If I said to you, of all the companies in dentistry, which company is the Apple company in dentistry, what company would you say it was?
|
|
Jonathan:
|
Probably Serona.
|
|
Howard:
|
Yeah. I think you alluded to that. I never heard that before. CadCam's got you pretty excited.
|
|
Jonathan:
|
Oh, yeah.
|
|
Howard:
|
What was the name of the block from Dentsply that the Australians like?
|
|
Jonathan:
|
CELTRA Duo.
|
|
Howard:
|
Spell that.
|
|
Jonathan:
|
C-E-L-T-R-A D-U-O. Two words.
|
|
Howard:
|
CELTRA Duo. What is the material of that block?
|
|
Jonathan:
|
It's lithium silicate. Not disilicate, but silicate. It comes in the color that it's meant to be and you mill it. It can either be cemented then. It's going to be pretty similar to your old style Serona blocks or Vitamark 2. If you fire it, then it jumps to pretty much slightly tougher than lithium disilicate, the Emax.
|
|
|
Because it's the color that it's going to be already, so staining is a little bit less intimidating than trying to work with the purple thing. I hear that the milling times are shorter and I hear that the fineness of the milling is really nice.
|
|
Howard:
|
Right on. Anything else you want to talk about? Anything else got your fancy?
|
|
Jonathan:
|
It's just going to be interesting to see where the CamCad market grows. It's even growing into areas like just simply replacing impressions and you get to email the things to the lab. Unfortunate because my company, the group practice that I work with also distributes Three-Shape scanners, so I have a Three-Shape machine to play with at both the places that I work with.
|
|
|
We also get to see the new materials evolving. We've gone from the Lucite-reinforced blocks all the way to Emax. I think some of the older CERAC users were saying how Emax just revitalized everything and now zirconia is on the market, so that's all just great stuff.
|
|
Howard:
|
Tell me more about Three-Shape. A lot of people have heard that. It's a company out of Denmark. What is Three-Shape out of Denmark. What are they doing in dentistry?
|
|
Jonathan:
|
Three-Shape was interesting because apparently they got their start in making hearing aids. Somehow, one of them had the idea, hey, there's a whole market here. Dental stuff. We're going to go to the labs first. We're going to have a way in which they're going to be able to use the computer and design in the computer rather than using their hands, so that they can make the materials through computer design and then either mill them or 3D print them, or somehow make them out and translate them into reality.
|
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It's actually an entire ecosystem in and of itself as well, except that it's an open platform. You can send things from a Three-Shape program to another program that's also open platform. You can send things from other programs in as well. You're not locked down by a particular scanner. For example, someone using E4D, the plan scanner, can send to a Three-Shape lab. A Three-Shape lab can communicate to a Rollin Mill.
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It's good stuff. They've got modules in the lab end for crowns, implant to scan bodies. I scan my Megagen implants. They've got modules for dentures, ortho. It's turning into a whole big area by itself. At this point, they've already put themselves pretty tight in the lab market. They are one of the major manufacturers for computer design software on the lab end and now they're starting to move into clinical as well with intra-oral scanners.
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They're latest scanner, the Trios 3, it's pretty much an OmniCam competitor. Crazy-fast imaging, great detail capture.
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Howard:
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You're a plethora of information. You are a walking, talking dental Wikipedia. I could listen to you forever. Well, that's our time. I just want to tell you that, seriously, any advice for me? What could DentalTown do to get more dentists from Singapore? What do you have, about 1500 dentists here? English is the official language?
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Jonathan:
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English is the official language.
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Howard:
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Everyone here in this country knows English better than any country in Asia, outside of Auckland. I find more fluent English here than in Hong Kong. Do you?
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Jonathan:
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I haven't been to Hong Kong.
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Howard:
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Oh, I mean it's just ... Indonesia is very tough. Indonesia, most people don't have any idea what you're saying. Everybody here is in English, how can we get more of the 1500 Singapore dentists on DentalTown?
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Jonathan:
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I would say the first step is to get them on. Advertising. There is a big conference coming up in a couple of months, I-Den. That's basically a major conference they have. They bring in speakers. They have a trade fair. That's in April. You guys had a booth two years ago, actually.
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Howard:
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Yep, we did.
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Jonathan:
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Met Carrie.
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Howard:
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Yep.
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Jonathan:
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It says something when you can recognize somebody from the back of their head by their hair. Carrie.
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Yeah, push it at the trade fair. That's going to get people on already.
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Howard:
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Is that mostly dentists from Singapore or is that from all over [crosstalk 00:59:10].
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Jonathan:
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It's regional. We get people flying in from Australia. We get people flying in from Indonesia. We get people bussing in from Malaysia. It's regional.
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Howard:
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Can you email me the information on that?
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Jonathan:
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Yeah. Hopefully, you can convert a few from just lurkers into posters and maybe some of them will be as loquacious as me.
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Howard:
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Okay, so that's in April?
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Jonathan:
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April.
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Howard:
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I wonder if it conflicts with the Townie meeting.
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Jonathan:
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I would need to check.
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Howard:
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Have you ever gone to the Townie meeting?
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Jonathan:
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Unfortunately not.
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Howard:
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I'll go to the Singapore one if you go to the Townie meeting. Okay, so you've never been to the Townie meeting?
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Jonathan:
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Never.
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Howard:
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Well, I need to get you to the Townie meeting. I'll figure a way to do that. Okay, well hey, seriously. That's an hour. Jonathan, thank you so much for all that you've done for dentistry, with your own patients. Thank you so much for all you've done for DentalTown with your 3,600 amazing posts. You know so much about so much. I had an absolute honor and pleasure talking to you for an hour.
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Jonathan:
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Thank you for DentalTown. It's given me so much.
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Howard:
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All right, thank you, buddy.
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