Howard: It is just a huge, huge honor for me today to be podcast interviewing Dr. Michael Apa. He received his dental degree from New York University College of Dentistry. He currently holds several academic and teaching positions, he is an Assistant Clinical Professor at New York University College of Dentistry in the aesthetic department and he is Senior Clinical Director and Instructor at the Aesthetic Advantage continued education program in New York, Palm Beach and London. Doctor Apa is a renowned lecturer both nationally and internationally, he is a member of the American Academy of Cosmetic Dentistry and recipient of the AACD Excellence in Cosmetic Dentistry Performance in the first five years of practice award. He is a member of the American Dental Association, The Academy of General Dentistry, The Editorial Advisory Board, The Journal of Implant and Advanced Clinical Dentistry. Approximately one year ago Dr. Apa opened a five thousand square foot state of the art dental clinic in Dubai with a dental laboratory on site. The clinic has been built around creating a seamless and luxurious client experience. The culmination of a lifetime of creating smiles and enhancing facial beauty has led to the development of the Apa Beauty product line, this product line is a unique approach that combines the latest advances in oral care research with the quality ingredients and streamlined design of a luxury beauty brand. Dr Apa has been honored with the Five Star Diamond Award from the American Academy of Hospitality Science for being one of the finest dentists worldwide, in recognition of his innovation, artistry and leadership in aesthetic dentistry. Ryan and I were in Madan, Indonesia, you've got to remember Indonesia is the fourth largest country in the world, there's China with a billion three, India with a billion two, United States with three hundred and twenty five million, and Indonesia is four at two hundred and twenty five million. My God those guys, when you walked on stage I think they clapped for half an hour, and offstage I thought you were so adorable because you stood there for selfies and photos for... I swear to God you couldn't get off that stage for two hours the line... And I saw you kept smiling and smiling, but the line never stopped, I mean, you are a rock star. I just read you're also on elle.com, E-L-L-E dot com, meet the Insta-famous dentist who charges $4000 for a veneer, DR Michael Apa is the smile guru behind Huda Kattan, Reverend Run, Rachel Roy. But anyway man you're just amazing. Congratulations on that, just tearing up the cosmetic dentistry world. So, what made you... Manhattan. Largest city in North America, I mean, it just makes sense that's your home base, what made you go all the way across the planet to Dubai and have a second location? What is that like when your commute to work is fifteen hours.
Michael: Dubai was an interesting time when we started that. Around 2007, royal family members had come to New York to get treated, and I had become really close with the family. And they kept asking me, in their own way, how would you feel about coming to Dubai? So, I went over in 2008, and it was an interesting time because it was the financial collapse of the world. So, when I went to Dubai first the lights were basically shut off and the cranes were at a standstill. At that point I think Dubai had had 80% of the world's cranes constructing the city, because that city sprung up out of nowhere. But what the interesting part is that the people that had continued to seek us out for cosmetic dentistry weren't necessarily affected by the financial collapse, so we never felt a dip in patients coming in. So, I thought what it did was it really weeded out a lot of dentists that were there from Europe, and a lot had come from the U.K. to, kind of, pop up shops there. So, it really... when the dust settled there was a lot less practices when I really first started going there. So I started going as basically a traveling dentist, I would go four times a year, see ten to twelve cases per visit, and it was just getting so crazy where we were doing, I don't know, a hundred and fifty, a hundred and seventy teeth in a week start to finish. And we had this kind of, wild process where we would go in and prep heavy for three days and then pack up all the cases, I would have an assistant from Dubai fly back to New York to my lab, he would close his lab down and make all the work, like I said a hundred and fifty teeth in two days, bag them up and then fly out himself with the teeth and then we would insert for three days. And we would do that four times a year to where we just couldn't handle it anymore and I knew it was time to really put real boots on the ground so to speak. So, we started building this clinic... actually we started building it in 2014 and I think we opened our doors 2015, and since then it's really been an amazing journey with a lot of different hiccups and highs. But the trip is standard, we have our routine down now to where we go every two to three weeks, I bring my assistant and ceramists from New York, and I have ceramists on the ground there, I have full-time surgeons and cosmetic dentists there, so it's a fully functioning office. But it's exciting every time we go because it's just such a crazy place and you never know who's going to walk through the door.
Howard: So, how many people live in New York City and how many live in Dubai, are they the same size, similar size?
Michael: No. Dubai is much smaller. But our patients from New York are, I would say 20% actually from New York City, 80% fly in to see us. So, in Dubai it's the same thing where you're, kind of, capturing the entire GCC, it's very centrally located in the globe, so you have patients from Qatar, from Saudi, from Bahrain. And then you get Europeans coming over to Dubai, and then you get Asians coming over to Dubai. So, it's centrally located, where you're not really looking at the population of the city because it's very small, but what you get is this global reach of people that are near Dubai. And then, the way Dubai is set up with Emirates Airline being so amazing, and Dubai being such a tourist attraction, it becomes easy and fun for people to travel there and at the same time get the dental work done.
Howard: So is this true or false? Rumor around the world is that, especially in Europe, they think Americans and middle eastern, their teeth are too white. But a lot of people say that the people who love their teeth the whitest is definitely the United States and the Middle East, is that...? And the Europeans, they get... almost looks like a clown, is that true or false? Or is the Middle East like their teeth as white as Americans?
Michael: Well, that's an interesting statement, and here's what I'll say. I think twenty years ago that was true. And I think what's happened right now is the world has become so globalized that there is no such thing as a typical European or a typical New Yorker or a typical Middle Eastern. I mean, if you walk around in Dubai you might think you're in Europe, if you walk around in New York or London... I just got back from London I saw a larger Arab population than I did British, so, the patients... and then the communication... and then look at your podcasts, you were just talking about the numbers of where you draw dentists from, before, to see an American lecturer you were typically going to be coming from some place in America, so, if I was lecturing in New York you'd get a New York crowd. Now you lecture in New York and you're getting a global crowd. And those dentists are talking to their patients and... the experience has just gotten so big that... Yeah, I would say maybe the snobby or the upper crust Europeans might still say that, or the upper crust old guard ceramists might still say that, but I think in general I have Europeans that want teeth just as white as my Americans. If anything Americans have pulled back because they saw how crazy it got at one point and how ridiculous people started to look.
Howard: Well, I'm fifty four, I got out in '87, thirty years ago. I'll never forget when bleaching came out, we would start bleaching teeth and then if they needed a class three or class four composite there weren't shades white enough to match the bleaching. And I can remember, a bunch of dentists getting all excited around Bob Ganley of Ivoclar, saying; Bob, you're whitest shades, they're not white enough, you need whiter shades, and that bleaching really was a game changer in dentistry, the shades everything.
Michael: 100%, yeah, and that's what happened. Even the shade guides now I mean, there was no bleach lite, OM3, OM, they just didn't exist twenty years ago.
Howard: This is dentistry Uncensored. So, I don't want to talk about anything anyone agrees on, so, my first question is going to throw you under a bus. You're a... I mean, I can't think of anyone more on top of the cosmetic dentistry game than you, I mean, no one has an office in Manhattan and Dubai, nobody does what you do, you have to be the number one, if there was anyone close to your league it would be your partner in crime Larry Rosenthal. But a lot of dentists are told that they can buy a chair-side milling machine like a CEREC machine and do veneers, same day [00:10:03] [inaudible], and they don't need a ceramist. Could you do what you do with chair-side milling in a CAD/CAM machine like CEREC?
Michael: You just really want to just...
Howard: Well, I want to hear from the man himself because it's a big chunk of change for these kids to buy a $150000 machine, and they're told they can do veneers just like you.
Michael: Yeah. Well, okay, this is going to be a good, good talk but [00:10:37] [inaudible] a little bit. The answer is I could not replicate my product currently, digitally. It's not to say that in the future it might happen, but right now it's not the same product especially from truly just using a digital set up, okay? And so, what that means is, you could not program a CEREC machine to give you anything close to what I'm putting in people's mouths. What the digital guys will say in their argument is that with a ceramist in the... and by the way, this ceramist has to be very talented, with a talented ceramist in-house that person can get the shell of whatever the digital machine is spitting out which essentially is the build up, right? That a feldspathic guy would do, and he could cut back stain and glaze something to look something like what I'm putting in people's mouths. So, the answer is no, unless you have a really talented ceramist on hand or on staff that's finishing your work from the CEREC machine. What the CEREC machine I feel is good for is kind of, mid-level dentistry, right? Crowns and fillings, it's a great marketing tool, obviously, to get patients into your office, and I think that... I hate to say this but in the back of the mouth in the dentist’s mind it's a fine substitute for something that you would send out to a lab and have a lab bill with. But here's my comment to that, okay, I've been practicing for fifteen years, and I would say that at year five my eyes have completely changed between year five, year ten and year fifteen, in such that the cases that I did in year five I didn't know what... I didn't have the clinical experience or the longevity in just being a clinical dentist to see what these cases look like in fifteen years, and I think that's where the responsibility factor has to come into play in what are we really doing on our patients, right? Because I would say that if things don't fit well on day one they may look fine year three but year ten or year seven it can be a real problem. And if you're doing one tooth it's an easy thing, you change the crown, you change the filling, it's not a big deal, but when you're involving twenty four teeth, twenty eight teeth, you've changed someone's occlusion, you've done a serious [00:13:32] [inaudible], you want the best possible... forget about the aesthetics, I mean, obviously we want it to look good, but it's got to function well and it's got to fit properly to have any chance at not having a massive disaster fifteen years down the road. And that's what I'm really seeing now, is the care that has to go into each one of these cases to make sure that you're not creating a complete mess in someone's mouth down the road. Does that answer the question?
Howard: Yes it does. So, what are 90% of your veneers made out of? What is your standard protocol then?
Michael: Well, I have an E-max guy and a feldspathic guy, in New York I do all feldspathic and then posteriorly I'll still do porcelain fused to metal crowns. So, I don't care what anyone says, I'm telling you that E-max in the mouth never looks the same as feldspathic, there's just a different level of life in a feldspathic veneer versus an E-max veneer, and every E-max guy... I have the arguments all the time with them, they say; oh, but they have the Dentin shades now and they've come so far, they have come far and they're getting closer but it's still not what a feldspathic veneer looks like. People look at my work and they say; oh, it looks so natural. I mean, okay, there's a big part of that that is designing what you think it should look like to make it look like teeth, but then the other part is the ceramist using the correct material, using the correct formula of porcelain to bring it to life. And the ceramists that I work with don't even work with one company of porcelain, they have, all of them have their own specific blends that they've created, that is not out of a bottle, consisting of different levels of modifiers in the porcelain for different problems that they've come across in the fifteen years we've been working together to really make it look like a tooth. And it's just such an intricate process, and I've tried top ceramists around the world, and I'm telling you that feldspathic veneers done properly just look different than any pressed or E-max or any of that.
Howard: I completely agree, I don't think that it's even close, I mean, I don't think it's close. And for you to be doing what you're doing at your level where you're dealing with clients where money's not an issue, they want the best, and the best would have to be feldspathic. But what blew my mind is the first time... did you ever go to one of those porcelain companies that make the porcelain for the lab men?
Michael: Of course.
Howard: I couldn't believe it. So, they send people out to quarries where they find these rocks, and then they have these big, looks like a dryer, and they put these boulders in there and they just turn and tumble and they collect the dust at the bottom. And so, remember when we were in... anyway, when my four boys were little, actually to this day, every time we go to a lecture or whatever, if there's a dental company in the area, whether it be Germany, Japan, whatever, we always visit all the dental [00:16:50] [inaudible], and I'll never forget when I was in a porcelain place, and they had, like, twenty of these tumblers going, and it so damn loud. And they would send their guy to quarries all over the world looking for rock. So, it's not like when someone gets a three five porcelain, it's not an exact science it's an art. Somebody is out there in the middle of the Grand Canyon looking for these white rocks in Italy and they go... and this one guy, his favorite rocks were from Italy and there's just one place he goes and he has his shade guide, and and then they've got to take that... I mean, it's just it's completely different. So I want to continue throwing you under a bus, you talked about CAD/CAM is, you couldn't do what you do with chair-side milling. And there's another company, DenMat, that talks about no prep Lumineers, and with the minimally invasive dentistry they don't want to prepare the teeth, could you do what you do with no prep Lumineers?
Michael: Okay, so...
Howard: A lot of people believe it, a lot of people do it. I mean, go to Dentaltown and do a search for Lumineers.
Michael: I know there's... I love it because I've cut hundreds of thousands of them off. So look, if you are claiming to your patients, and they come in to you and they sit down and they say that they want teeth, they want a natural smile, right? It's impossible to cover a tooth with anything and make it look natural. And it's not the tooth itself, it's how it meshes into the apparatus of your mouth. The gingival embrasures, the incisal embrasures, the incisal edge, all those positions get changed and the slightest change of a tooth inside your mouth, how it contacts the tooth next to it, if it's not exact it will never look or function like a tooth. So, for me that... and by the way, DenMat has done an amazing job marketing lumineers, because patients they think of any porcelain... they don't think it's a porcelain veneer, patients, they think it's a special thing, like; I don't want porcelain veneers I want Lumineers. lumineers are porcelain veneers that are just branded prep-less veneers. So, we have... 2007, 2008 when that started becoming popular, we used to do porcelain chips basically, because patients were asking for it so much, and honestly it's more of the dentist ego, when I was younger that I wanted to show super thin ceramics with no prep cases on a big screen in front of dentists so I could say, oh, look at how minimally invasive we are. But at the end of the day it doesn't really benefit the patient in order to do a full mouth, if you want to close a diastema, you want to create a peg lateral to be a little bigger it's a great single tooth solution or couple of teeth solution, you're not going to do an entire mouth of prep-less veneers consistently on the amount of cases and get a predictable result, it's just... you're going to get a result, and you'll get them to work but they'll never look the same and they'll never function the same.
Howard: So, continue throwing you under a bus, you ready to be thrown under another one?
Michael: I'll be the most hated dentist in the world after this.
Howard: Well, there's so much noise in the industry and it's nice to go after the top dog and see how he weighs in on this. Bleaching lights, it seems like every dental company sells a bleaching system that includes a light, there's a lot of guys running around talking about researchers saying the light makes no difference. Do you think... when you're bleaching your patients do you use a light or do you not use a light, does the light matter?
Michael: I'll be honest with you, I don't do a lot of bleaching, in our office it's really, kind of, an auxiliary service that we give to patients because we just don't have the room for the amount of people that would want to come in and just bleach their teeth. We have a light, we use Zoom, and we also use Boost which has no light, and I would say you don't get much of a difference. I used to do research on bleaching when I was in dental school, and the problem is there's just such variability from patient to patient in terms of their own genetic makeup of their teeth and how they bleach that it's so hard to say what's better, and that's my most honest opinion. I will say that there is certain limitations to bleach that the general public has not truly understand yet, but in terms of using a light or not using a light I don't think it really makes a difference, I think it's more the percentage in the patient themself depend upon the result.
Howard: I don't even think they know what color is. I mean, when you start reading a book on color, the hue, the chroma, the value, you're just reading this book thinking, I'm sure a hundred years from now they're going to learn more about this because you can almost tell, I mean, I remember when the Greeks said there were four elements earth, wind, water and fire, and it's, like, now there's ninety eight. So, yeah, even the periodic table, I mean, it doesn't even look symmetrical, I mean, just looking at the periodic table, you just look at it and say okay, this thing doesn't even look right so I'm sure there's more to come. I want to ask you... I have a hang up with sinus lifts, implant crowns, versus bridges, because I personally think that the dentists, since they're dentists, they worship the enamel. I mean, like, you're missing a first molar, so they so worship the enamel on the second bicuspid and the second molar, but they have no qualms of going into the sinus, throwing a dead cow in there, a bunch of paperclips, BMP, all this crap in there. And then my friends here in Phoenix, who are rhinologists, man, they have videos and pictures, they go up there and they'll show some messed up sinus lift that's been leaking into the sinus for ten years, there's white candidiasis all over the whole deal. Same thing on the front tooth, I mean, if cosmetics was the only concern and the most beautiful woman walked in your office with a high lip line and she'd got... and she'd lost number eight, would you... and you had to just nail it, what would be a better way to nail it, a three [00:23:41] [inaudible] bridge or an implant and a crown on number eight on a movie star?
Michael: So, the factors that would go into play for me are this; what does the architectural look like, if I put... I mean, look, I've put implants, single tooth implants that I've nailed it 100%, but that's knowing that they're younger, they have thick tissue, they have bone, I know I can recreate all of that. So, it's more dependent upon the situation than the restoration at that point, but what I will say for implants, and I agree with you in terms of bridges versus implants, is I don't think that people understand the problems that we're going to have twenty, thirty years from now with all these implants that we're putting in people's mouths, especially... people think posteriorly you lose all the bone but there's bone enough to put an implant in but you have this huge divot and you're going to put this massive implant crown and it's going to catch food and everything else under the sun, which is then... I see these implants, you're losing bone down to half of the threads are left and showing, and at that point you just have nothing you can do. You can't take out the implant and put another implant because you're just creating the problem to be worse. Or I see people putting three, four implants in the posterior and putting single unit crowns on them and they don't act like teeth either. And then you catch all this shit, for lack of a better word, but plaque and calculus and food and people can't clean them properly and then you lose the whole area. So, in cases where they have, let's say, a filling and maybe even a natural tooth and they're missing a tooth in the middle, to be honest I really think bridges are better restoration and much more predictable and much less complicated in the future, if a bridge goes bad you replace the bridge, you can always put the implant then, but putting an implant in on and twenty eight, thirty, thirty five year old person, that's got a long way to go in their life and it just is not going to act the same as a bridge will.
Howard: I agree, I mean, people are extremists, I mean, now I mean like, on Dentaltown you can get shamed for doing a bridge. I mean, you do a bridge and people are, like, almost like you're a hack, I mean, what's wrong with you did your mom drop you when you were little? I mean, why would you file down two virgin teeth? It's like... when you start calling teeth a virgin you're now into some weird religion of the Church of odontology. And I'll tell you what, my rhinologist, ENT friends in Phoenix, they wish the hell dentists would stay out of the sinus. I mean, we got to get that guy on and get him over to the house and do a podcast him. And I mean, he's just like, what are you guys doing? I mean, you have two teeth there, what the hell are you blowing up the sinus for? And what's really interesting, what he's convinced me of the most, this is really weird, but if anyone has a upper root canal on a second bicuspid, first or second molar it's standard of care you really have to ask, do you have any sinus issues? Because he's been seeing people that thought they had allergies for twenty years and it's a leaking root canal to the sinus, and he shows pictures of stuff, I mean, there's crud all over that sinus that is right around that tooth. And so if someone has a root canal into the sinus and they say, no, I never have sinus, that's one thing, but if they have any type of sinus or allergy you need a CBCT to see if it's a failed root canal leaking into that [00:27:30] [inaudible].
Michael: Let me back up and say one thing, and I hate to say this, but I have to because I really don't care. But all of the other things that you've asked me Lumineers, implants and what was the other thing you were just talking about?
Howard: Chair-side milling.
Michael: Oh, chair-side milling. All three of those phenomenons are from big money dental companies contracting and paying dentists to go out and spread the good word. And then that trickles down into your everyday... and now you have exactly what you're talking about. And the real truth of the matter is, something handmade that's paid a lot of attention to like a filling our a crown or even a veneer is more accurate than something milled in a computer currently. An implant is a great substitute in certain cases, it's not the only answer. And it surely doesn't... no one should be shamed for doing a three unit bridge because I can show you hundreds of x rays or hundreds of pictures where people are in real serious problem because of the amount of implants they have placed. And Lumineers have created a lot of problems gingivally, with people's occlusion, there are just so many tricks that have to be thought about when you're redesigning someone's entire bite that if you're not cutting teeth or moving teeth and you're just putting something over top of it you're inevitably going to have a problem. So it's a little scary, and you're absolutely right, it's a little scary that yeah, instead of... the same people that are worried about touching enamel are okay with shoving a metal rod in your jaw, I mean, I'm not saying one is right and one is wrong, I'm just saying dentists should really be a little more open minded and look broader at all of these things and say like, what are we really doing in someone's mouth? Just because somebody told me in a lecture that this is a new cutting edge technology doesn't necessarily mean that it is. I mean, you have to do our own research in your practice.
Howard: I think It's funny how the human mind is, you recognize patterns like, my two older sisters are Catholic nuns, do you think I could give them a one day seminar and turn them into Hindus or Buddhist.
Howard: I mean, do you really think...? I mean, I sometimes wonder what percent of dentists are even open to a thought, You know what I mean? I mean, they're such... the human mind is like, you can't file down virgin teeth and if you sit there and say, well, you know you should maybe sometimes file down virgin teeth, and I want to see a video of a non-virgin tooth, I want to see a video of some molar humping a second bicuspid, and just show me some proof. Continuing along the line where you say sometimes it's just better to make a feldspathic crown instead of milling one out sometimes it's better to do things by hand, another thing they're wondering is everybody keeps talking about this digital dentistry, I mean, so, for thirty years I buy 3M Impregum, right? I take an Impregum impression of a first molar, I send it to my lab man, I'm old school. Now they want me to buy $17000 True Definition Scanner, and I'm like, okay well, my Impregum impression's seventeen bucks, now you want me to buy a $17000 scanner because I'm supposed to be digital vs analog and I'm supposed to do this digital smile design, but then they ding me $200 a month in perpetuity, that's $2400 a month just for the software support for these True Definition Scanners. Like dude, I didn't buy $2400 of Impregum a year, So, now I've gone from a $70 Impregum impression to a $17000 True Def Scanner and a $2400 a year service contract. So my question specifically is, to be someone like you, to just get the best impressions, are you doing digital scanning or are you all this digital... we keep hearing about this digital smile design flow from your digital scan all the way to the laboratory, or are you still one of those guys old school, using Polyether, Polyvinyl and sending it to a human lab man?
Michael: Wow, I'm going to have no friends at the end of this podcast.
Howard: You're going to have to practice in some remote island in Indonesia where no one knows where you are.
Michael: Let's just look at it without answering the question, let's just look at it practically, okay? The answer is I still use Impregum and I swear by it, but let's look at it practically. You want to know... if you're using a scanner do you have a printer in your lab, in your office? If you do and you have this entire workflow in one house it begins to make sense, but I have issues with the quality, I don't think it's going to be as accurate as... as accurate and aesthetic as Impregum and somebody making it with... somebody good making it with their hands. But for somebody who doesn't have... and then by the way, is it a $5000 printer which doesn't print a very high quality model or has a $100000 printer that maybe you're going to get close to what stone actually looks like. And we did this in Dubai, where we brought technology into my lab and we did cases where we did them analog and digital. And you know my ceramists would say that the the printed model is just not as accurate as a stone model in terms... not marginal fit because every digital guy out there will say marginal fit from a digital process is better than marginal fit from analog, and maybe that's true, I would have to see the studies, I don't know. But then the question becomes, to what degree I mean, how long are we keeping these restorations, how long are these restorations lasting where marginal fit to that level actually matters, right? Because if I can keep teeth in someone's mouth for fifteen years without a problem I think I've done a pretty good job. So, when we prepare, when we do our process I'm designing what I want those teeth to look like in my preparations and I'm actually creating undercuts and things like that in my preparation so that when my ceramist gets it, then I'll take an Impregum impression, he'll pour it up in stone. And when he gets it he can see all the little details that I've done in my preparations, and then all the details are done in my provisionals so that he can copy it so that I don't have to have a conversation with my lab as to what I want these to look like, I can just say, copy what I've given you and therefore when I have a conversation with my patient there is no conversation, well, oh, the lab's going to fix that or oh, the labs going to make that better, it is a conversation of, tell me exactly what you want I'll do it in your mouth and when you like it sign this piece of paper and that's what you'll get in the veneers. Now, the point of that process is to cut down the amount of confusion from the patient and the amount of re-do's, if you can copy what they have in the provisionals into the permanents which we're able to do pretty well, it just creates a higher standard of communication to where there is no, oh, I didn't know I was getting that. So, when I'm doing all these things there's so much detail in the preparation and in the provisionals that he needs to see in a stone model that gets eliminated in a digital model. So the digital model kind of just gets smoothed out so you lose all those undercuts and things that you would normally have in stones. So, the process is if you have a full digital workflow in your office meaning you have the right scanner, you have the right printer, you have technicians that know how to use all of it, because obviously the dentist is not going to have time to design all these things, right? Or else why are you practicing dentistry? If you can create that workflow I think that you can get a reasonably good product currently, I just don't think that a lot of people... they're going to buy one piece or the other and then therefore you're doing the same thing, if you scan something you have to send it to a milling center and wait to get the model back, right? If you take an impression you can pour it up or you send it to the lab and they pour it up, I mean, what's the difference? I mean, what is the benefit if you're that guy that just has a digital scanner, that's what I don't understand.
Howard: So, you're still using Impregum?
Howard: Yeah, I love that stuff. I remember trying it in dental school and I've never seen one reason to do anything else. I want to ask you an interesting, a bizarre question, whenever I'm having dinner or talking to a dentist with their spouse and they're both talking and I can totally tell one that the dentist's spouse, that the mid-line is not on, it's to the left or the right, and then I'll sit there and tell his wife or her husband to turn and I'll ask the dentist, is your wife's mid-line straight on, or is it off to the left or right by how much, they never know, I mean, they never know. And then sometimes in my seminars I've done this, raise your hand if you're the dentist, okay, raise your hand if your the hygienist, okay, and then I'll say look away, and I'll ask both of them, is your doctor, to the hygienest, is your doctor's mid-line on or off? Nobody ever knows. I mean, so I'm convinced at 54 that the mid-line doesn't matter because even the dentist... I mean, you're sleeping with this lady every night and you don't know where her mid-line is and you're at dentist? How could it matter if you don't even know. So, my question is, does the mid-line matter?
Michael: The direction of the mid-line matters big time. Meaning if it's canted left or right, okay? Because of the direction the mid-line is canted it usually means the entire smile is canted, and what people will tell you about their spouse or their hygienist is that their smile was crooked. So, for that yes, I think it matters. Does it matter if it's parallel to the long axis of your face, if it's off to the left or right? No, except for extreme cases like Tom Cruise. I mean, I think everyone can see Tom Cruise's front tooth is still, after braces and a couple of sets of veneers, is still right in the middle of his face.
Howard: Did you see him swinging around that...? Did you actually see him out your window swinging around that building in Dubai?
Michael: I wish. No, he wasn't there. Yeah, to a degree but not... and I'll tell you what doesn't matter even more is when, every time I post a case on Instagram or something like that, most dentists I'll see they'll write, the upper and lower mid-line don't match, now that really doesn't matter, so...
Howard: Yeah. Do you do you also think that one of the reasons... okay so, you have a hygienist in New York and Dubai, right?
Howard: So, you have hygienists that are doing perio-maintenance, cleanings, exams, x rays, you only have hygienists because NYU has a hygiene school, and... but the United States closed down pretty much all the... all the dental schools at one time had a certified dental laboratory technician degree, and they pretty much all closed them down. I think Hong Kong is the greatest dental university in the world simply because they have more people in their dental laboratory program than they do in their dental program. Their dental laboratory program has twice as many students because the Chinese are very macroeconomic orientated and they see all these labs springing up all over China, like, Modern Dental has four thousand technicians, they realize that's really good export business so they're graduating twice as many lab techs, but do you think one of the reasons we're all going into CAD/CAM is because all these schools closed down their lab? And I know you're involved with many dental schools teaching aesthetic dentistry, do those schools that you teach aesthetic dentistry in, do they even have a lab program? And do you think this is something as dentists, we're going to lose a dying art and we need to go back to these dental schools and say, hey, we we need lab men and we need them trained just like a hygienist or a dentist or a periodontist?
Michael: I mean, I couldn't agree with you more, yes, I do think it's a problem. And more so I think it's a problem that, if you ask any high volume cosmetic dentist what their biggest issue is, it's always going to be the lab, you just, you can't get it fast enough, you can't get it... you just don't have enough people to rely on that are good that can do your work. And then you fall into this issue where you're relying on one guy and if he takes vacation or he's sick or he has a problem or if he's pissed off or whatever your work suffers and your whole process suffers, the patient... it's like, the patient doesn't want to hear, oh, anything about your lab because she doesn't know your lab, right? They just want to know that you give them the work that they want. So, any of those problems are the dentists problems, and I think that we're really running short of quality training for technicians, 100%. Right now, what I'm doing is I'm trying to put all of my labs on site. So, in New York I even... I bought the space next door just for a lab and I'm starting to figure out where ceramists are throughout the world, I'm looking in Brazil, I'm looking in Asia, I'm looking in Europe and I'm trying to get visas, that's my biggest thing now, I'm getting lab technicians visas to bring them into the United States so that I have a big enough volume of qualified guys that can really do this work. So yes, it's a problem.
Howard: Yeah, that visa thing is so sad, I had my entire family tree worked out and the Forrans are 100% Irish and we washed up from the Irish [00:42:25] [inaudible] in 1840, which was forty years before the Statue of Liberty. And one million Irish washed up onto New York and Boston, and there were no visas, you know what I mean? I mean, I think that's... I think it's really... I think the whole America's secret sauce was endless waves of immigration, and anybody messing with that is just messing with America. I want to ask you another question, you hear some of these cosmetic guys say that direct composite of veneers is actually the best, that it's a direct composite of veneer, and that people only do indirect porcelain veneers because they don't want to sit down and spend the time and do it direct. Do you think direct composite veneers look better than indirect porcelain veneers and is indirect porcelain veneers a time saving device for the dentist? Or do you prefer the porcelain?
Michael: It's... there sometimes when I wish that I was just doing direct. The problem is this, is that the material is just not as good, right? So, the maintenance on composite veneers it's just so much higher. So, if you're doing one case a month, right? And you have the time it's wonderful, but you have to maintain those people very, very, very meticulously in order to keep that looking the same way. For porcelain veneers, I think people say that because again, the amount of really high end restorations that come out, I see a handful in my... and I'm always looking for good technicians, good operators, good practitioners that are putting out a good product. So, if you're looking at the masses I would say composite veneers, done well, take a guy like Newton Fahl, right, who is amazing, like, he'll make anyone's porcelain look inferior, but the problem will be maintenance. So, if you can get... again, if you can get really good lab guys to work with you... and I think the direction of dentistry is going to be more digital labs, I mean, I don't think it's going to go away I think it's only going to get bigger. And then you're going to have these, kind of, smaller labs are going to move into dentists office, hopefully, and you're going to see this really skilled unit of Doctor, lab technician under one roof creating these really special products. And I think there's going to be a real separation between analog and digital as we work towards the future. But I think where that statement comes from is because the masses maybe don't look as good as composite veneers, but I don't think that composite veneers are better than porcelain veneers, no.
Howard: And I want to say one more thing, you're never supposed to talk about religion, sex, politics or violence. So, I'm going to have one more political dig is... nothing [00:45:44] [inaudible] me more than when you hear Europeans saying, I came here illegally, really tell that to the American Indians. I'm pretty sure the American Indians didn't give a bunch of Europeans visas. There were twenty million American Indians over here, and when you showed up with smallpox it killed nineteen million of them. So, nineteen million of the twenty million Native Americans died from smallpox, and then you have the audacity to say, well, I came here illegally you didn't come here illegally. I live out here in Arizona it's 25% Indian reservation and the atrocities that these guys lived through... and even when they came out here and became getting good in agriculture, the next thing the Europeans did to them? They came here and decided they wanted to canal off all the river water to Phoenix and Tucson, so, guess what that did to their farms, it dried them up. And they said, well, that's okay, OK, we'll give you welfare and food stamps. So they went from an agricultural diet to now buying packaged food at a store, and their obesity went off the charts and then they got depressed and alcoholism and I mean, it's just... God. And the defending the Alamo, tell that to Mexico when you stole 40% of Mexico. You didn't defend the Alamo you stole 40% of Mexico where the cities were named San Antonio, Los Angeles, San Francisco, I mean, that was all crazy. So, I hope you get your visas and I hope that you can bring in people. And I wish you could go, I mean, I know you've got a lot of leverage at NYU but you know NYU graduated 7% of all the practicing dentists in America today went to NYU. It's the biggest dental school, they had the biggest international for foreign trained dentist. And NYU needs to be the leader of firing back up those dental laboratory schools, because the next generation of kids, I mean, they're going to be stuck with CAD/CAM and milling machines because there's not going to be any certified dental laboratory technologist artists left on the planet. I mean, it really is a dying breed and species.
Michael: Have you ever had Ed Maclaren on this program?
Howard: What's that?
Michael: Have you had Ed Maclaren on this program?
Michael: Oh, you should.
Howard: Can you hook me up?
Michael: I will. But he's old school feldspathic... he's one of the only programs that I know of still going, that used to be UCLA, now I believe he's in Alabama, and he's really trying to figure out the digital world at the same time with that very heavy background of analog so... and he's just training ceramists, so he'd be an interesting guy to get on this.
Howard: So, most of my homies, about 85% right now listen to me commuting to work, and they have an hour commute to work and the reason podcasts are taking off, we started this one year before the election, and half of Americans didn't even vote because they just can't drive to work for an hour listening to North Korea and Putin and ISIS and all this toxic crap and then get to work and be happy. So, podcasts are exploding coast to coast, radio stations are plummeting, there's several that have gone under right here in Phoenix, you can buy them for a dime. So, they just... so, a lot of them follow me on Twitter, @howardfarran, so I like to re-tweet my guests. I just re-tweeted, you have two different accounts, one of them is APA beauty, @apabeauty, A-P-A-B-E-A-U-T-Y. And then the other one that I re-tweeted was your Rosenthal APA group for Larry Rosenthal and yourself Michael Apa, and that was @rosenthalapa and I re-tweeted: Dr. Michael Apa has been featured in an article on elle.com, and the story entitled: Meet the Insta-famous dentist, that would be you, but what is this, they know you, but what is Apa Beauty?
Michael: So, that's the product line that I created about five years ago that we launched last year. Dentistry tends to get a little mundane and the whole experience that people experience in our offices is kind of, where I had the idea to create the product line as well. But basically it's just a different experience to be able to take care of your teeth. And it also has beauty products and things to get people thinking more that... they spend all this time on makeup and things like that and they spend very little time on making sure that their smile looks great. So, we created things like tooth gloss and lip shine and lip scrubs and lip balms to really give an accent on the smile as well. But there's also oral care products like, we created our own electric tooth brush, and yeah, it's pretty amazing.
Howard: So, are you glad you did that, has this been fun for you?
Michael: Fun? It's been expensive and time consuming. Yeah, it's fun, I mean, it's fun to see companies grow and it's fun to see things take shape and take form. It's been a lot of work, I'll tell you, it's like a third job. So, after you finish working in New York and working in Dubai you put another five hours a day into the product line.
Howard: I was a big fan of Bob Ibsen because... he was an optometrist and then he went into dentistry, and he's out there in Southern Cal which was leading the revolution in wanting to go from amalgam and gold tooth color, and he didn't have the materials so he started DenMat. But where I love him the most is when I started Dentaltown, everyone thought I was crazy because all the other magazines were seventy five to a hundred years old. And he bought the inside first cover, the inside of the [00:51:41] [inaudible]. Anyway, for the first several issues he was the only advertiser and he owned all the premium positions in Dentaltown for the first decade because he wanted it to succeed. He thought the vision that no dentist should ever have to practice solo again was so important and he agreed. And even though he got so mad when people would trash talk his products online, but he was a great guy in doing that. But I remember going out there and that [00:52:09] [inaudible] when he was launching Rembrandt toothpaste that was that was a wild, wild world and it took him forever to get it, but he finally sold it to Procter and Gamble for, like, a gazillion dollars and then like, three or four months later out of nowhere Gillette acquires Procter and Gamble for, like, a 40% premium. I mean, the guy basically... but here's what's cool, I think he sold it for a quarter billion and then it was acquired by Gillette for like 40%, so he had, like, more money than God. And you know what he did when he got all that money? He was worried that since he had all that money he would get sued by patients and didn't know what to do. So, he opened up a cosmetic clinic for women in domestic violence shelters and he would do them for free because if you don't give me any money all the laws really don't kick in. I mean, if you're doing charity and the good Samaritan act... and that guy had a quarter billion dollars and Monday through Friday eight to five he sat there in that chair till he dropped dead. And I remember having lunch with him and his wife Marcy at home and Bob said: well, I can't retire because Marcy says that Monday through Friday eight to five that's her free time and that if I do retire I still can't come home Monday through Friday eight to five. And he goes, I can't golf forty hours a week so I just keep going to the dental office. But that guy was in his eighties, how many dentists do you know in Manhattan that if they won a quarter... if they won $250 million cash tomorrow would still go to their dental office Monday through Friday, eight to five? What percent of them?
Michael: Not many.
Howard: Yeah, and that's what I tell [00:53:56] [inaudible], that's my most proud accomplishment for myself is I still feel 54. I've never worked one day in my life. I worked for my dad for ten years in a Sonic Drive-In, that was as fun as hell and... but I've never never worked a day in my life. I want to ask you some demographic questions. So, what percent of your clients are women versus men, I mean, is what you do is that a woman thing?. I mean.
Howard: But is it mostly a woman thing?
Michael: No, I would say it's 60% women, 40% men.
Howard: Sixty, forty.
Howard: Who is this average woman, average man? I mean, I've always laughed for thirty years it seems like almost all the cosmetic work I do is on the post-divorce woman who's getting all fixed up and she's getting her teeth and her boobs and her eyes done and she's getting her all ready to return to Match and Tinder and whatever they are. Are these mostly... are these women getting all fixed up for round two, or...?
Michael: Well, it's so interesting, what's happened now is Instagram has changed the landscape for how dental patients find cosmetic doctors. So I would say ten years ago when Larry and I had a established cosmetic dental practice that's typically what we saw, the forty to sixty five, seventy year old, a lot of women but even men, that for work or for exactly what you just said wanted to take better care of themselves. Sometimes you would get the occasional workaholic at forty years old it's never taken his foot off the pedal and finally is going to take care of himself and his mouth has fallen to pieces so it's more of a restorative case. But now, with Instagram you're just tapping into so many different populations of people, so many different crowds that you have young like, real young, you have the 25 year olds that saw so-and-so get their teeth done so they wanted it or you have... there's just so many different pockets of populations that it's so hard to really nail it down to one. It's people from all different ages in all different backgrounds and for all different reasons.
Howard: Yeah, your Instagram, you're doctor apa on Instagram, you have a hundred and thirty one thousand followers, oh my God, that is just crazy. So, what is... so, for all the baby boomers listening, I'm sure the the millennials get it, but for the older guys, what is the difference between Instagram versus Facebook? Why do you always keep saying Instagram instead of saying Facebook?
Michael: Yeah, Facebook I mean, look the way that you can, kind of, break it down is Facebook tends to be a more family sharing platform and a purely business platform, right? Because the trick with Instagram to have a hundred and thirty one thousand followers, right? That means people had to follow me. On Facebook you can have fifty thousand friends but that just means that you clicked into somebody's profile and you became friends with them. There was no give and take, like, people didn't have to search you out to find you to follow you. So, just that thing alone I think creates much more significance to communities of populations and awareness. So for instance, Instagram like, influencers they're called now, if you have over a million followers on Instagram most companies, fashion companies, beauty companies, even dental companies, I know for sure, a friend of mine who has three million followers was just contracted by a major dental company and paid him $200000 to put seven posts of their toothpaste up, $200000 because that's the way that big companies are marketing now. And the reason is because if you have three million Instagram followers it's significant because they're people that are interested in you, they're not people that you're interested in. So you become this influence of a trendsetting, like, people with that much followers on Instagram and things like that are now controlling and shaping basically all marketing messages, and it works the same way in dentistry believe it or not. So, what better way to showcase a before and after than on Instagram. Even more so than Facebook, because Facebook you're going to get a heavy dental following and that's not going to bring patients in your door. Instagram will bring people looking, searching porcelain veneers and if they come across your profile and like your work they're going to pick up a phone and call you.
Howard: When you're doing composites and you're not doing porcelain veneeres, but you're doing anterior composites, class threes, class fours, whatever, is there a specific brand that is your go to? Or are you all over the board?
Michael: I'll be completely honest with you I haven't done a class three composite in probably ten years, so I don't really.
Howard: You don't really do that?
Howard: And now a very controversial question, I'm doing this because these kids come out of school, I feel sorry for dental students because I feel like the first thing they do is they walk into a dental school and they've got to pay for this big, huge, overly expensive dental school, they graduate with a third of a million dollars of debt that they won't pay off for ten or twenty years, so their first mission in life is to support this entire dental school apparatus and then they walk out of school and all the big manufacturers try to sell them a bunch of expensive equipment a hundred, six figures CBCT, all this stuff, and then and then their staff wants a raise every time the earth goes around the sun, it has nothing to do with profitability it's all based on astrology. And they come up to you and they say, hey, the the earth just passed Uranus so I need more money. And you're like, okay, the insurance give me less money every year, and you want more money every year... and so I feel sorry for them. But they come out of school and they think they need to learn more occlusion, and there are distinctly two camps marketed, one is more of a, like, an LVI neuro-muscular, and another one is more this Dawson, Kois, Pankey C.R, what would you call that camp? But they're at a fork of the road and they're wondering when you're doing these full mouth rehab's, you're doing twenty eight veneers, you're doing the whole arch, which camp should they gravitate towards? More the neuro-muscular LVI or the CR. Dawson/Pankey, Kois, Spear?
Michael: Look, I'm a C R guy, but that's not because I'm... I'm not beholden to any lecturer out there, so I would never say I'm in this person's camp. What I'm beholden to is what I see has worked and failed in people's mouths. And coming into Larry's practice straight from dental school I saw cases that he had done from 1983, I came in 2002, so there's twenty years of clinical experience that I got to see how things were done and how they were holding up. So, for me it's always been... C R seems to follow more the principle of form follows function. If you have a molar that because of neuro-muscular it tells you to make the molar fifteen millimeters high, which I've seen, something is not right there, right? So, I've seen some of these neuro-muscular cases where people's teeth are just so big that they just don't resemble human teeth. I've seen very few CR cases where people's teeth are so big they don't represent humans teeth. So, I'm more of a CR guy because it's predictable but more because at the end you're restoring something that look like teeth and I feel like if you're putting a tooth in someone's mouth and you're putting twenty eight of them in then you have a better chance of them actually working.
Howard: The same follow up question. What if somebody's listening to you now, she's driving to work, she just graduated two months ago, she's twenty five, she's on her way to Aspen and someday she wants to be a famous cosmetic dentist in her town just like you. Where does she learn these skills, what would you advise her to do? So that on her journey some day she could know what you know.
Michael: I think the... I get that question a lot.
Howard: The correct answer is that you're going to create an online CE course on Dentaltown, I just want to plant... well, it would be beyond [01:03:17] [inaudible]. We put up four hundred and fifty, one hour courses on Dentaltown and they're coming up on one million views because the Instagram millennial dentists, they just love online [01:03:28] [inaudible]. But if you ever have time it would be beyond an honor to have you put of course on Dentaltown.
Michael: I'd love to, just tell me what I need to do and I'll do it.
Michael: Yeah, and beyond that I think for any young dentist you have to have some... because you don't really learn much in dental school in terms of real dentistry, right? I mean, you learn a little bit but nothing will really prepare you to take on some of these cases. So, I think the best thing is to find some, kind of, mentors or pathways that you envision in how you want to practice dentistry and how you want to live your life, which I think is also very important. And then based on that really get some nuts and bolts, like, really learn the basics. And then the next step is to try hands-on courses, I think hands-on courses are so great, and they're really dying, but I think they're so great because they really allow you to get to the point where you would make a mistake in your own practice and then you have the ability of having an instructor there to, kind of, wheel you out of it. And that's where you can really learn because the only way you learn is from your mistakes.
Howard: And another thing that I see that to me it's confusing, is how many people at the AACD who claim all over their website they're a cosmetic dentist, but their own teeth look like they could eat corn on the cob through a chain link fence, I mean, they're yellow, they're brown. I remember one time I got in... I got the worst comment I ever made. I was... 1987 the local Arizona Dental Society had brought in Jim Pride, who was like, the master guru dentist of the time, he just walked on water. And he's sitting there saying, anybody could sell cosmetic dentistry and I raise my hand, I said, well I mean, what do you mean anybody can sell cosmetic dentistry? Your teeth are dark brown, extremely crooked, I mean, you have one of the worst smiles I've ever seen and you're a dentist and you got money and you say anybody can do it, why the hell haven't you done it for yourself? Oh my God, I thought he was just going to beat the shit out of me right there, and I was honest. Another one was Walter Haley, he was in Texas with this big old rah rah motivational camp. And I was sitting there with him at dinner and other cosmetic dentists were in the room saying, dude if you come to my office I'll do you for free. I mean, to say Walter Haley's teeth look bad was like saying I'm having a bad hair day. I mean, you know what I mean? They were just... it wasn't even in the park. So, what do you think about these people who say they're cosmetic dentists but they don't walk the talk? I mean, don't you think the consumer smells that?
Michael: Oh yeah. They ask all the time, I think more important... I mean, just taking it one step further your overall aesthetic, like, look at your office, look at how you're presented and you're trying to tell someone... because if you're telling someone that you're going to make their smile over you're basically saying you're going to be in control of the way they look. So, if they're walking into your office which hasn't been renovated or updated in fifteen years or you're wearing scrubs and your teeth are awful. It's not a good sell point. I mean, that is the point of the products and really the, kind of, atmosphere that we've created at both offices in New York and Dubai is to put people in that mode where they get that when they walk in that this is a place where these guys understand design and aesthetic.
Howard: So, is that magazine Elle, E-L-L-E, is that Ellen DeGeneris, or, who's Elle?
Michael: Elle magazine is one of the, I would say top three, there's Elle, Vogue and Harper's Bazaar, it's one of the top three beauty magazines in the country.
Howard: Ha. Yeah, I almost feel sorry for you sometimes, I mean, I've seen magazine pictures of you at where they're taking pictures of you in the airplane in first class flying to Dubai, I mean, it's you have to almost be, like, paparazzi ready, don't you?
Michael: Yeah, yeah for sure.
Howard: So, last question you promised me an hour of your precious time and we're over now, we're at one hour two minutes. Last question is, any advice... are there clients you turn down? I mean, sometimes these women that want cosmetic surgery, sometimes, I mean, let's be honest sometimes they're just bat shit crazy, and they think that they're going to get veneers done and they're going to look like they did when they were in high school. Do you ever have a patient come in where you're... they've got the crazy eyes going and you just sit there and think, what you need is a psychiatrist not a cosmetic dentist, does that ever happen to you or are you there for everyone?
Michael: No, it happens a lot. And you have to be really careful because unfortunately the way that the system is worked is that it is against the dentist. And as soon as you cross into that line where you touch them if they want to come after you they can come after you in so many different ways, especially now, I mean, forget it, with social media they can crush you. But even the court systems are really set up for the dentist to lose. And by the way, on a final note, one thing I will say is this is that dentists for some reason, our profession... we have to be more supportive to each other. Because the only thing that happens when somebody's work comes into your office and the first thing that the dentist says is, oh, this is terrible I could do a much better job, it makes the profession worse because it just creates that mindset for every patient that when they go into the dentist that they feel like they're getting screwed over somehow. Really the short answer is 100% yes, but the real reason and the real problem is that we really need to be more supportive of each other all the time rather than constantly throwing each other under the...
Howard: Well, you could have been more supportive of me in Indonesia by letting me go first, because following you in Madan... first of all I got on the stage an hour late because there were still... I think you took a selfie with every single person in the room. My two hour lecture turned out to be about 45 minutes and following you was the dumbest thing I've ever done in dentistry. Next time... in fact I'm going to add to my contract, does anyone lecture before me? And if it's Michael Apa I'm not going to do the gig because that is the most humiliating experience in the world to walk into a room after you just lectured I mean... and by the way I sat in the front row and watched your lecture and I mean, the things you were showing, I mean, I feel bad that people think you're a cosmetic dentist doing veneers, I mean, the periodontal work that you guys are doing, how you change the soft tissue before you even went to veneers. I mean, I was in the... I was blown away. I mean, some of that stuff looked like it just... I mean, it was just literally amazing and it truly was. I got my FAGD, my MAG my diplomats and all these things I've taken three hundred hours of CE a year for thirty years, and that was the most amazing, unbelievable before and after cosmetic dentistry... if anybody's listening to this and thinks this is some guy that just glues on anterior veneers you're out of your mind. I mean, you blew away the entire room. I mean, they ended... you ended your deal, they jumped to their feet and they were... it was a five minute applause. I mean, it was really a mind blowing presentation, that's why I want you to do something like that on Dentaltown, please please please please.
Howard: So, the guy that does that is... how far away are you from Bethlehem Pennsylvania? You may not...
Michael: About two hours.
Howard: Yeah. So, I'm email@example.com, but the, Howard Goldstein is the one that does the Dentaltown online CE [01:11:37] [inaudible], He's got like thirty thousand posts on Dentaltown. So, he's hogo, so, I'm howard@ dentaltown.com he's firstname.lastname@example.org. I just sent you, me and hogo and Ryan an email, but he could come to your office or whatever. But, my God, your work I mean, that was like Star Wars shit, I felt like I was on a different planet. I mean, it really was, it was crazy good. And it was just a huge honor that you would come on my show today and talk to my homies, I'm sure this was their favorite commute to work of the week. Thank you so much for all that you do for dentistry, your patients, and I hope you have a rocking hot weekend.
Michael: Thank you very much. Thanks for having me.
Howard: Alright, have a good day.