Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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998 Creating Beautiful Smiles with John Lavicka CDT, Dr. Gena Pineda, and Dr. Rhys Spoor : Dentistry Uncensored with Howard Farran

998 Creating Beautiful Smiles with John Lavicka CDT, Dr. Gena Pineda, and Dr. Rhys Spoor : Dentistry Uncensored with Howard Farran

4/27/2018 6:25:59 PM   |   Comments: 0   |   Views: 241

998 Creating Beautiful Smiles with John Lavicka CDT, Dr. Gena Pineda, and Dr. Rhys Spoor : Dentistry Uncensored with Howard Farran

John is the second generation owner and president of Dental Ceramics Inc, since 1988. In 2006, John founded The Center for Exceptional Practices; an ADA CERP and AGD PACE certified facility designed to enable restorative dentists to achieve higher levels of success in clinical practice through lecture and hands-on programs. He has devoted more than 30 years to developing a dental laboratory that focuses on exceptional services- combining art, science and technology with personal attention and care. John is a member of the American Academy of Cosmetic Dentistry. He is an alumni, a visiting faculty, and on the Board of  The Pankey Institute. John is also the founder of the Akron/Cleveland based Pankey Learning Group. He is a member of numerous study clubs; the Spear Study Clubs, Seattle Study Clubs, Northeast Ohio ITI Study Club, Cleveland Comprehensive Care Study Club, and the Akron Dental Society.

Dr. Gena Pineda is a graduate the University of Texas Health Science Center at San Antonio. After graduating from dental school, Dr. Pineda completed a four-year tour in the United States Navy, where she completed a General Practice Residency at the Naval Medical Center in San Diego. She currently practices family and cosmetic dentistry in the metro St. Louis area. Dr. Gena values the importance of staying current with the newest dental techniques and materials. She is passionate about staying on the leading edge of dentistry and invests hundreds of hours into ongoing training specializing in general, cosmetic, and implant dentistry. She is a member of the American Dental Association, the American Academy of Cosmetic Dentistry, the International Team for Implantology.

Dr. Rhys Spoor has been a leading dental educator since shortly after receiving his Doctor of Dental Surgery Degree in 1983 from the University of Washington. Very early on, he realized that he excelled in artistic and mechanical skills. He served as an Affiliate Associate Professor at the University of Washington Dental School for 10 years. He also teaches many aesthetic dental courses each year in the United States, Canada, and abroad. Dr. Spoor lectures internationally and has been published in over 15 countries. He currently serves as an editorial reviewer for the Journal of Cosmetic Dentistry. His professional memberships include: Accredited Member of the American Academy of Cosmetic Dentistry, Fellow of the Academy of General Dentistry, Fellow of the International Dental Implant Society, and Fellow of the Pierre Fauchard Society. Dr. Spoor has completed hundreds of hours in continuing education in dental implants and aesthetics, including courses with the Las Vegas Institute. As a Fellow in the prestigious Pierre Fauchard Society and an Accredited Member of the American Academy of Cosmetic Dentistry, Dr. Spoor has been credited with the skills and techniques necessary to provide the rigorous attention to detail in the field of dental aesthetics.

VIDEO - DUwHF #998 - Cosmetic Dentists

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998 Creating Beautiful Smiles with John Lavicka CDT, Dr. Gena Pineda, and Dr. Rhys Spoor : Dentistry Uncensored with Howard Farran

Howard: It is just a huge honor for me today to be podcast interviewing John Lavicka CDT, Gena Pineda, a dentist in St Louis, and Dr. Rhys Spoor, who's a dentist in Seattle, Washington. Thank you so much for joining me, guys.


Rhys: Thank you for having us.


Howard: So, I'll read all your bios, starting with - on the left of your screen, if you're listening to this on iTunes remember you can always subscribe to us on YouTube. It's John Lavicka is a second-generation owner and president of Dental Ceramics since 1988. In 2006, John, founded The Center for Exceptional Practices, an ADA CERP and AGD PACE certified facility, designed to enable restorative dentists to achieve higher levels of success in clinical practice through lecture and hands-on program. He has devoted more than thirty years to developing a dental laboratory that focuses on exceptional services combining art, science and technology with personal attention and care.  He's a member of everything. I'm not going to read them all or we'd be here till midnight. Gena, Dr Gena Pineda is a graduate of the University of Texas Health Science Center of San Antonio. After graduating from dental school, she completed a four-year tour in the United States Navy, where she completed a general practice residency at the Naval Medical Center in San Diego. She currently practices family and cosmetic dentistry in Metro, St Louis. She values the importance of staying current with the newest dental techniques and materials. She is passionate about staying on the leading edge of dentistry and invests hundreds of hours into ongoing training, specializing in general cosmetic and implant dentistry. She's a member of the ADA, the American Academy of Cosmetic Dentistry, the International Team for Implantology. And my first question to her will be, how the hell did you move from San Diego to St Louis? I mean, what was your next best idea? Dr. Rhys Spoor, Accredited Member of the American Academy of Cosmetic Dentistry, Fellow of the Academy of General Dentistry, Fellow the International Dental Implant Society, Fellow of the Pierre Fauchard Society. I guess Pierre's birthday was yesterday, wasn't it?


Rhys: I think so.


Howard: Yeah, yesterday. He has been a leading dental educator since shortly after receiving his Doctor of Dental Surgery degree in 1983 from the University of Washington. Very early on he realized that he excelled in artistic and mechanical skills. He served as an Affiliate Associate Professor at the University of Washington Dental School for ten years. He also teaches many aesthetic dental courses each year in the United States, Canada and abroad. He lectures internationally and has been published in over fifteen countries. He currently serves as an editorial reviewer for the Journal of Cosmetic Dentistry. His professional memberships include Accredited Member of the AACD, Fellow of the AGD, Fellow of the International Dental Implants Society, Fellow of the Pierre Fauchard Society. Dr. Spoor has completed hundreds of hours in continuing education and dental implants and aesthetics, including courses with the Las Vegas Institute. As a Fellow in the prestigious Pierre Fauchard Society and Accredited Member of the AACD, he has been credited with the skills and techniques necessary to provide the rigorous attention to detail in the field of dental aesthetics.  That is so cool, man. It is so fun, on a Friday night, to be talking to three dental super-achievers. So, my first question to you is very simple. I always ask my listeners to shoot me an email -, tell me your name, how old you are, where you live, all that stuff. I'm telling you, they're all babies. Twenty five percent are still in dental kindergarten school and the other seventy five percent are pretty much under thirty. I only get maybe one email a week that says that they're my age. So, my first question would be: how do you walk out of dental school and then end up being a great dentist? What steps on their journey would you recommend?


Rhys: Well, I think one of the first things is that they need to have a vision of where they want to end up. In this group we have right here now, we're doing a class presently in Ohio, and we have about eight dentists here doing a hands-on course where they're treating a patient. One of them is a year out of dental school. We also have another dentist who's prepping right now, that's been in practice for thirty-five years. So, there's a range. What all of them have decided is, they have decided that aesthetics is something they're interested in, and it's partly because I think it's one of the more interesting parts of dentistry, but it also is an avenue that can get you out of a lot of the day-to-day things that we get stuck in with practices and one of the main things, one of the main reasons I got into aesthetics to begin with was because it gave me freedom from being told by an insurance carrier what I could and couldn't do. A lot of the aesthetic cases involve more than one tooth and what it really is, it's a side door to comprehensive care and what we send out to the public is what we get back. So, I look at what we create as being our total responsibility. In the environment around us, it doesn't matter if you're in Seattle or Ohio or anywhere else in the world, it depends on what we send out to the people that are there.


Howard: So, you're at Dental Ceramics right now?


Rhys: Correct.


Howard: And that's in Richfield, Ohio, south of Cleveland?


Rhys: Yes.


John: Yes, between Akron and Cleveland.


Howard: So, you're teaching in class now?


Rhys: Correct. Ohio has a unique licensing structure where we can bring dentists from anywhere in the States and go through a temporary licensing process. They will allow them to treat a patient here in the facility. We have eight dental chairs and we have a clinic to do aesthetics. There's also a lab that has a lot of very skilled technicians in the lab works down here at the same time.


Howard: What's your class size?


Rhys: Well, it can be up to sixteen at the time. We have eight chairs and this particular class we have eight participating this time.


John: Nine.


Howard: So, the course has eight chairs.


Rhys: Correct.


Howard: You said eight chairs?


Rhys: Correct.


Howard: And the class size can be sixteen, and they get a temporary license for the State of Ohio?


Rhys: Correct.


Howard: And how hard is that to do?


John: It's very easy to do it. It takes about ... they've streamlined it, because you can do a lot of it online, and so we get some people in within three weeks. You want to be three months out knowing you're going to do it and apply, and the license is good for a year. You have to bring your own patient of record and it works out very nicely to be able to bring doctors from all over the country here, with a live patient. It's a totally different learning experience than over the shoulder or auditing an over the shoulder program. They're actually prepping the cases, temping, impressions, everything's being done here. And then, four or five weeks later, they are seating the cases and they're under our supervision with our systems and Dr. Spoor's systems and it gives them systems to work with and understand.  A lot of these doctors have been in practice for thirty, thirty-five years. Some are, as Rhys has said, they learn how to do eight to ten, twelve units of veneers, crowns, bridges maybe, or maybe not, with implants, and then restore it and be able to go home with confidence. They see everybody else's cases, they see the problems that exist, and they come up with and they learn that they're not alone and that they can make a phone call. We're there to help guide them through cases when they're back home, and they develop a lot of confidence. So it's been very valuable in that sense.


Howard: Is it called The Center for Exceptional Practices or the Cleveland Dental Institute?


John: It's The Center for Exceptional Practices and the lab is Dental Ceramics Inc. I own both. And my vision for the business was to train doctors to become more insurance independent, because this generally takes them out of the realm of insurance usually, if they're doing ten units at one time, and then that develops confidence to do larger, more extensive cases, more comprehensive care. It takes them to a different level. We do have some ... we have an occlusion mastery series, where we take doctors through a series of four programs over nine months and then they learn how to put cases together, comprehensive care cases.


Howard: How many different courses do you have? You said occlusion?


John: We have implant courses that are mainly in the area of ceramic implant courses, solid zirconia implants from CeraRoot systems to Zeramex and utilizing the PRF with ... we have brought in people, Richard Miron from, he's with [sounds like: Yosef Shukrun], and so utilizing those materials and those techniques for placing live patient placing ceramic implants. That has been also a very good program that we have here.


Howard: So, the titanium has ninety-nine, probably ninety-nine point something percent of the market. Do you see that changing in the future with these all-ceramic surgical implants?


John: I do. I think there's a place for them and personally we've restored over thirty-five hundred of them and, when I go back and look at the photos and tissue and the health of these patients, they look much better. We see very little peri-implantitis with them and they look like natural teeth when they are restored and, of course, they've got to be done properly.


Howard: And what's your favorite system?


John: A new system coming out from a Switzerland, from Swiss Dental Solutions. It's very good one. Zeramex is a very, very good system.


Howard: Repeat them again.


John: Zeramex.


Howard: Zeramex - Z-E-R-A-M-e-X?


John: Yes.


Howard: Zeramex. From?


John: CeraRoot, they're from Spain.


Howard: CeraRoot from Spain.


John: Their system is a one-piece system. The others have one-piece and two-piece systems, and they've also developed a screw-retained system as part of it. We're going to see a lot more of it. Nobel just bought a company in Switzerland that produces zirconia implants. So, there's going to be, I think, more going in that direction, absolutely.


Howard: But you think there might be less peri-implantitis with ceramics?


John: Definitely. There's no question about it. The CeraRoot has got great histological slides and research that they did on it, that's amazing. It's really incredible.


Howard: I mean, that in itself is a whole game changer. I'm reading that in just five years, sixty months, 20% of implants have peri-implantitis and then at five to nine years, it's 40%.


John: Right. Well, when I've taken a number of lectures and courses, live patient courses with Ulrich Volz in Switzerland and, done properly, he claims no peri-implantitis with these cases, years later.


Howard: So, what do you think about that? What do you other two dentists think about that? I mean, if that really pans out to be true, then that's just a complete game changer.


Rhys: I would agree. I have been more of a traditional titanium implant. That was my training, and that's still what I do the most of, but the one thing that's changing is, I think that we're looking at a lot of dentistry as being not just isolated. In other words, it's not just about the mouth, it's about the whole body, and there's another concept that we're starting to look at a lot more carefully and that's how it impacts overall health, through like peri-implantitis or chronic periodontal disease or chronic inflammation, that if you get that chronic inflammation there from whatever the source it is, whether it's from an implant placement, whether it's from poor restorative dentistry, whether it's from a particular material, or it's just a natural process of people having surfaces that plaque attaches to, but if that inflammatory response is there, it does affect cardiovascular health and this is all part of it, and I think that even though we're teaching a class right now on aesthetics, what we're really talking about, again, is a window to get into comprehensive care. Some of it involves all the disciplines, but the comprehensive care where dentistry's not just decided by someone that's not involved in it.  And we've got the philosophy here that the care comes first, the commerce follows. If you keep those things in the proper order, what you end up with in the end is good for everyone. Everybody wins. The patients win, the dentists win, the laboratories win, the suppliers win, everybody in the system works and the fact is, dentistry is an affordable thing for everyone. You know, most young dentists particularly, they're always concerned about what things cost, but the fact is, I think, that in our society people tend to put value on things and if they have enough value, they will spend the money and time and make the effort to seek what we do.


Howard: I love that quote: the care comes first, and the commerce will follow.


Rhys: Yes, it does, and there's always a natural conflict between care and commerce. We all have to balance it in private practices. I've been in practice thirty-five years, so I'm at the autumn of my practice, but the fact is I've learned how to do it well and I love coming here and showing dentists that there's another way, when they're younger. They don't have to fall into the traps of feeling like, well, I have to do this because somebody else is saying it. They're doctors, my gosh, and they have a skill set and we should foster that.


Howard: And what are your thoughts, Gena?


Gena: Yes, I agree. I think one important thing, one of the points of the course is that giving patients what they want. I think the one thing that this course teaches is it gives us the ability to provide more to our patients. We're able to do more dentistry, better dentistry, and see patients get healthy. That's important.


Howard: But, Gena, do you think that if ceramics have less peri-implantitis, do you think that's going to be a huge game changer?


Gena: I think it will be a game changer, but I guess when is the question. I don't think everybody's going to catch on to it right away. I only place titanium implants right now, but I intend to do more and more research on it. I think eventually it may catch on.


Howard: Now I want to ask a different question. A lot of the kids feel they didn't get enough training in occlusion. A lot of the labs, when they see ... I remember when Carl Misch - you know he nailed removable first - and what got him interested in implants was when these people were saying that the titanium was breaking and when he would look at the case, he'd say, "Well, g*d, your bite's off so bad. Of course they're broken." So, he thought that the cross training of learning inclusion and removable and finding a bite and all that was just a critical element to his success in full mouth restoration. But the problem with occlusion, if you talk to a hundred endodontists, they really don't argue about anything. It's hard to even get a fight going with a bunch of endodontists. Go take five of them to dinner and try to start an argument with them - it's hard. Pediatric dentistry, about the only thing, very little, but when you start talking occlusion, it's like sitting down five people from five different major world religions. Why is that? Well, first of all, do you agree with that assessment? Do you agree that occlusion has all these different camps?


Rhys: Occlusion is like talking about religion and politics. Just add occlusion to the list. That's the best way to start an argument typically.


Howard: Yeah! So, what advice would you give to these young kids? How do they go out and learn occlusion?


Rhys: Well, I think, you have an open mind. There are a lot of different ways to view it. The fact is the human body's pretty tolerant, a good thing we are, because you can see people from all different ages and they have all kinds of things in their mouth and some of them work really well.  For example, I had a patient who passed away recently, and she was my record age patient, she a hundred and seven and a half when she died. And I treated her for thirty years and the dentist that saw her before me saw her for most of her adult life, and he literally did thumbprint amalgams and she had teeth in her head. So, what I learned by treating her, it was one, she had a genetic disposition that was different. She lived to be a hundred and seven and a half and you don't make it that far unless you're different. So, if we could take that magic thing she had, it would solve most of the problems we have, but we don't get that. So, when you talk about occlusion, everybody's got their base to start from, and what I've learned is it depends on the patient. I've used pretty much every philosophy and technique that I have been aware of, LVI had one, Dawsons, Spear, Kois, you go down whatever the current list is, but the fact is they have a lot of common things about them. Usually the starting point is the [sounds like: arguing point]. After you get past that, they're really common. I mean, you have to have maximum intercuspation, you have to have the muscles aligned so that the envelope of function works in a way that the teeth don't run into each other, and if you get that, it pretty much works. Then you get these fringe things where you get a few patients that, either they're always painful or they've got some other issue that their functions are compromised, but the fact is most people fall into the center and what we've learned from doing the aesthetic approach, and the reason I got involved at even looking at occlusion because inherently it doesn't interest me all that much, but if I make an aesthetic set of veneers, I want them to last. If I put them in and they immediately can break off or they become painful, then obviously something's wrong. So, what we've come to understand is that the occlusion is the base and whatever system you use - and they all seem to work because they all exist, and the fact, is if one of them worked profoundly better than the others, we wouldn't even have the argument - but it's about the tolerance that most people have. We're all different and I think most of it depends on the details and the skill level of the individual dentist doing it. Because I've seen every one of the systems work.


Howard: Well, let me ask all three of you. I want to ask us some specifics, because this is what they specifically ask when you're lecturing in dental schools: how do you make the judgment between a triple tray versus I need full arches upper and lower versus I need a facebow transfer and an articulator?


John: I think you need to ...


Howard: I see that no-one wants to answer this question.


John: [inaudible] you need an occlusal background and you need a philosophy. I'm very involved at the Pankey Institute, I'm visiting faculty there, I'm on their board, so I am very fond of the Pankey Institute. I recommend many doctors to go there and you develop a philosophy. But also, we have developed a system that we also have here at the Center, and that we teach, and it's utilizing basically, a better word would be a Lucia Jig, and this is similar to that, but it's more as an appliance. It's just a way of learning a system, or having a system in place, that you can see where these patients are going. If they're going to have problems, do they have problems? You get them out of pain before you start any treatment. And that's where we like to begin, work on these patients before you do any dentistry, make sure that they're not in pain, they're comfortable before you start and then know where you're going before you start.  And that's where, as a laboratory, I say, why are we getting these cases mid-stream, or there's ten implants in and all of a sudden, I get a case with impressions and I go, where's your wax-up? Where's your diagnostic workup? And there is none. So we're working backwards now to recapture all that. We like to do that in the beginning with getting a diagnostic workup, making sure that it's there where we want to go, and we know ahead of time it's going to work, before we start, because we can try it in. We can make matrixes, we can take these wax-ups using the [sounds like: visicryls] and get to the final stage where we're going before we start, and that's, I think, where we need to be going more with our philosophy.


Rhys: I would add to that, the question specifically about if you do a triple tray or if it's a full arch or if you do a full workup, it depends on what the patient presents with. There are certain patients, which is a large group, especially younger ones, you can get away with the triple tray, and a lot of dentists do that for convenience. It's still probably not the best way to do it, but it's an effective way to do it. I do most of my dentistry with full arch impressions, even if it's single crowns, because it's a more reproducible occlusal pattern, and, again, it depends what's there. If you look, for example, at a patient that has a wear pattern, what that wear pattern is, whatever it is, it's a history of what they did, and if you're going to change something, like for aesthetics or if they're in pain and you want to change it, you have to change the underlying environment, because what causes the pain are the muscles that drive the teeth and they're all dynamic and, if you don't change that environment, they're to just recreate that.  One of the things we all agree on here is we do a lot of test driving. If we're going to do a case where we've got either someone's starting in pain or if they have severe wear, even if it's not severe but they have significant wear, or if there's a combination of things where we're doing a lot of dentistry, we want to get the maximum longevity. We want to know that that's going to work before we start. So we'll do a lot of things with either removable appliances or test driving the final occlusal position and provisionals to find out if that patient can tolerate it. I've done that for most of my career, and the fact is, most of the time it works. It works very well, but you don't go into it blindly and you don't necessarily use the easiest way because it's the cheapest to get there.


John: And Gena can tell you because she's digital. So, let Gena speak to you about it.


Howard: That was actually my next question. Do you guys prefer old-fashioned wax-up or do you like these digital mock-ups? Gena, what are your thoughts?


Gena: We, more recently, have been using the digital scanner and doing digital wax-ups and ...


Howard: With what system?


Gena: The TRIOS.


John: And we use 3Shape in the lab.


Howard: Well, 3Shape makes TRIOS.


Gena: Yes.


John: Correct.


Rhys: That's an interesting one because just today ... we do a lot with this in this aesthetic course through mock-ups. We'll do a diagnostic wax-up, make a matrix, put it in the patient's mouth. We use that for a lot of things. We use it for showing what the case is going to look like ahead of time, looking at the [sounds like: phonetics], looking at the occlusal interferences [inaudible] developed. We use it a lot in the process as we're doing the preps. We usually start from the end result and prep backwards. So, we prep through the mock-ups and it keeps them more conservative. But what was interesting today, we had this discussion. I'm more of a traditional wax guy. In fact, I do all my own wax-ups at home, always have, and I haven't really gotten into the digital, but here at the lab, it's all digital.  So, today we were comparing some diagnostic wax-ups that were done traditionally with a stone model and wax compared to the digitally produced printed models, and there's pros and cons to both of them and I can see that. One of the main things we can see so far is if you're actually in a clinical setting and you're looking at a model in three dimensions in your hand and you're trying to use that to reference how to prep, if you can't see differences in coloration - printer models right now that I've seen are all one color, and you can't see where the [sounds like: dentilation] is between the added part and the natural tooth structure underneath, it's a little bit of a hindrance - that's where I still like wax - but what we came to find out today is you can use a combination. You take a printed model, if it's not quite right, you can carve it back, you can add wax at the time, it's easier than going and reprinting one.  So, I think there's a way to do both.


Howard: What printer are you using?


John: Formlab.


Howard: Out of Boston?


John: Out of Boston, yes. We're also in the beginning stages of printing dentures and getting cases set up for the surgical guides, and surgical guides are printed and we're also milling dentures out of PMMA, and that's been very successful.


Howard: I want to remind the young kids of this: I practice in Phoenix. My dental office just celebrated its thirty-year anniversary, September 21st of last year, and a lot of people retire here from the north. It's 10% Canadians, it's North and South Dakota, all that stuff. But when I was in the doing free implant mode because I was trying to get cases going, and I'd see a case and I'd say, "I'll do this for you for free", I was shocked at how many people said, "Well, I don't have a problem. I love my dentures, I can eat anything." And it made me realize all the way back then, if you make a denture perfect, if you make it right, if you really master that craft, you'd be surprised at how many people love them, and it's the lowest cost, full mouth, cosmetic rehab case you could ever do for so many poor people that the live here in the Valley.


John: Absolutely, and we're seeing where right now we're printing the economy denture and then we're milling the higher end denture, and the PMMA, it's milled, you've got tooth colors that are [sounds like: on the sides of the gingival], and then we use the composites on the facials to finish off the pink. And that's going to change, that technology's going to change, where we'll have the [sounds like: pink pucks] to place in a full arch. We're milling the full arch, not individual teeth, so we mill the full arch and then glue it to the base, basically. Right now, we're doing it all in one piece.


Howard: If you look at GM, for years they had five price points, they had Chevy, Pontiac, Olds, Buick, Cadillac, and so many of these young kids don't understand market segmentation where there's a lot of upgrades in a denture. I mean, Ivoclar makes some amazing, gorgeous teeth. So, when people are throwing price around, they should throw a lower price and a higher price. In fact, some of the most successful implantologists I know, what they actually did is they bought the overlooked denture world that had been in the poorest part of town for thirty, forty years; they picked it up for nothing and then they took that denture world and all that existing brand name, and then when everybody was coming back they'd say, "Well, we can upgrade it to a nicer denture with nicer teeth, or put it on two implants or put it on four implants, or All-on-4." It was just amazing. And they said, if you just converted 1% of their clients coming in to All-on-4s, they built three ... there was one in Bakersfield, I think he took it from three hundred thousand to like nine million a year in revenue. Again, market segmentation.


Rhys: But, the only way that works is they obviously provided care that was proper enough that the people that were getting it, valued it. And when people start to value what we can really do, they're willing to buy it. They buy everything else. And for some reason we think that dentistry is at the bottom of the totem pole, and it really isn't. It depends on how we put it out there, and if we can show people there is really that kind of value in it, they will seek it. That's what we've all seen.


Howard: You know, they come out of school - we were at A.T. Still a couple of Sundays ago and there was one kid that was going to graduate $550,000 in debt - a lot of them, when they come out of school, say they're 250, 350 in debt, if they go buy a chairside milling machine, that's a buck thirty-five; if they go buy some of these lasers, those are going to be between seventy-five and a hundred and thirty thousand; they go buy a CB/CT, there's another hundred grand. They literally come out of school and say, "Dude, if I buy three things, I just doubled my student loan debt." So, the question specifically is if they want to grow up to be great dentists like you, what do you think they have to buy?


John: I think they have to buy knowledge and skill, they have to learn how to do this and do it efficiently and do it well, and that's what we don't see. They're not getting the skill. We went through that era of [sounds like: Pack Live], Aesthetic Advantage, LVI, all these live patient courses and then they sort of disappeared for a long time, but now there's a whole new generation of dentists that haven't experienced that live patient program that's so valuable. These doctors leave here, they haven't even prepped a veneer in their career, and now they're doing ten or twelve units and they go back and they learn to market it properly and start learning how to sell or educate their patients, and in the next year they're doing ten or twelve or fifteen cases they would have never even looked at. So, now, if they do that, now they can afford those other toys they'd like to buy and they'll pay off their loans, which would be the first thing I would do, their school loans. So, we're seeing a resurgence in the live patient program because they're learnt systems and systems are efficient. They learn to do them efficiently.


Howard: You know who should get credited for that whole revolution was Bill Dickerson. He literally led that revolution. I remember taking his course when it was still in his dental office. My gosh, he knew something was going on and he built a monster. But, you think they're having a resurgence now?


John: I think so. I think there's a place for this type of course. You can't do this online, you've got to prep teeth, you've got to experience something breaking, the impression not being taken properly, something not fitting properly. You need to experience that with somebody with more confidence, more charisma, more whatever, to then get through that case and learn how to fix it, or when you [sounds like: punt] and re-do it. And that's really important. Go ahead, Rhys.


Rhys: We've tried to set this up - in fact, our tagline is 'Learning by Doing'. It's not learning by showing, it's learning by doing. We purposely make it so that I may jump in or Gena may jump in or whoever else is helping - we have several people that come in and assist - but we'll show them something, we'll let them do it and then we'll let them struggle with it. So, just for example, today we were in the clinic. They actually started prepping at one o'clock p.m. It's now quarter to eight p.m., and they finished about forty-five minutes ago, most of them. So, they basically went through the muck for the last six hours. We helped them, we're not going to let them make a mistake, but that is the best way to learn and I've found that to be the most effective. So, one of them in there, he's been out of school a year, he's never prepped a veneer; he left today after he prepped twelve and his level, the quality of the result was about equal to mine, and I've been doing it thirty-five years. And that's the point: we want to pass on that knowledge because they can get a jump start on this. There's a lot of people that want this. I know they're in debt, but that doesn't mean they have to give up.


Howard: Something profound that you were saying, what's more important than buying shiny boxes with lights on them is to buy the training. So, you'd say invest in the hands-on training would be the best return?


John: Absolutely, and learn how do comprehensive care. I'm going to be biased because I want the doctors go to Pankey, it's a nonprofit institute, so it's very different from all the others. Very different. And I just think it's a wonderful place to go, so I will definitely push my doctors, or doctors when they ask where should they go, but as far as a live patient experience, that's what we have, my marketing away from Pankey. But I think Pankey is one of the best institutes in the country; was for a long time, sort of faded, and now they're making a resurgence. Lee Ann Brady is back there. She's clinical director.


Howard: [inaudible]


John: Exactly. Dale Sorenson. Mike Fling. You've got some really wonderful, wonderful people there. Ricki Braswell has done an incredible job. She came from the laboratory again. She was at NADL, National Associated Dental Laboratories - ran that for, I think, ten or twelve years and then came over to Pankey. So, it's been a phenomenal place. There's a resurgence. Gena went there on my recommendation.


Howard: I went there. I spent five weeks at - what is the name of that resort across the street on the ocean?


John: Key Biscayne.


Howard: Yes, Key Biscayne, but what's the name of that hotel right across from the Pankey?


John: There's a Ritz. They're on Key Biscayne now and they have their own building and they're building dormitories.


Howard: Ryan, do you remember swimming there? You don't remember? I took you guys there five times for a week and they don't even remember. I should've left him at home with a babysitter.


John: Okay, I'm going to be calling you for an alumni donation. That's going to be my next phone call.


Howard: Alright! When I look back at everybody in my neighborhood, that I've been running with for thirty years, the number one variable they all had in common, that rode to the top, was they all devoured about a hundred hours of CE a year. And then when you meet that one guy across the street and he's always complaining about why does he have to take these three classes to get his license renewed, I'm just like, "Oh, my g*d!" I mean, that just separates the cream.


Rhys: All of those that you just commented on, Howard, the reason that they sought that is because they actually care about their patients. The care came first. And I still believe ... I remember filling out forms to go to dental school, and one of the things they ask you is why do you want to do this? And I think almost all of this said we want to care for someone, and somehow that gets lost when you get into big debt. I understand that. But this kind of a process where you can show people a way - and that was what was interesting about this guy that prepped today: he was proud of himself when he left. I mean, he accomplished something he thought he couldn't do. We helped him through it and he's not quite finished, but he's got that confidence, so when he goes back he's going to be different, and that's the first step.  That's how you dig out of the hole.


Howard: But are you currently doing it all? I mean, can it all be done? Old school impressions, sending it to lab, not needing a chairside milling, not needing an oral scanner, not needing ...?


Rhys: Absolutely, it can, but that's not how the future's going, and I think you can do both. I mean I'm learning, I don't need to learn. I could do this the way I've been doing it, but the fact is it still works. It's just like computers. They were wonderful, but you know what? Pencil and paper still works. And there are times when it's still an appropriate thing to do. So, the basis, the whole care concept and wherever you decide to take it - if you're going to do it in aesthetics or periodontics or oral surgery or whatever it is - it's still, if you can put that first, I truly believe that other people seek that, and they understand that, and that overrides a lot of the other parts that get in the way.


Howard: By lecturing around the world - and I've lectured dentists in fifty countries - you see this rodeo playing out. You know how a rodeo starts and you see the rodeo - like when I got out of school thirty years ago, the NHS ruled the UK, but it was starting to crumble and crumble, and they just kept lowering the pay, lowering the pay. So, now you go over there, and they've got five thousand dentists in the UK that walked away from the system and said, "I can't even treat my family with these types of fees!", and they walked away. And I see that race to the bottom swings back, and I'm starting to smell it in the United States, because when I got out of school, I would send my fees to Delta and they would pay a 100% of my fees for cleaning, exams, x-rays, 80% fillings and root canals, but now, thirty years later, I'm getting 42% less than I did three decades ago - but every time the earth goes around the sun, you have inflation. It seems like if they're just walking out of school right now, I wonder if they're walking out into the NHS back in the late '80s, because these insurance companies show no thoughts of increasing your fees. What do you think about that rant?


Rhys: Well, I think it's absolutely right. I haven't participated with an insurance company in almost thirty years. I've been a true fee-for-service, and I'm in the middle of Seattle and Delta country. My office in Seattle has got four hundred and fifty dentists within a five-block radius and I've done okay.


Howard: Are you serious? Four hundred and fifty dentists within five blocks?


Rhys: Yes, medical-dental buildings full of dentists, and I actually just semi-retired. I just sold my practice to a specialist. But we've got an idea of a model there. I've run it as a fee-for-service practice. What I figured out is you go after what people want, and aesthetics was my door. There are a lot of people using implants as that door now, because there's a need for it, there's a want for it, and that's a big difference. People want that. But I still believe that people will always seek aesthetics, because every one of us this morning looked in the mirror. We care about how we look, we care about what other people think about us, but most importantly we care about how we feel about ourselves, and dentistry helps with that. We hear it over and over.


Howard: You know what I think the most important piece of high tech equipment is that no-one ever talks about is your camera, because these dentists that document their cases and put them on their website, they don't realize these Millennials, they're going on their iPhone to your website and when they see amazing work done, they're getting on Southwest Airlines and flying to other cities, or driving there. They might think, "Well, there's no one in Parsons, Kansas, that can do this. I have no problem driving to St Louis or Kansas City", but the dentists getting all those have their cases where it says, "These are my cases!" It's amazing.


Rhys: Yesterday, the first day of this course - it's a five-day course - guess what the subject was? It's called Photography.


Howard: Nice.


Rhys: We spend all day learning to do, not only intra-oral, but we do studio shots for that exact reason.


Howard: Yeah, that's was probably worth the whole course right there. If you could develop the staff of getting the pictures and digitizing them and getting them on their website - that's just a game changer.


John: The other thing that we encourage, we want their team members to come to this, front desk assistants, so they understand when the doctor comes back from a program by himself, the assistants aren't on board, the front desk isn't on board. The whole team needs to come here and be on board to see what's going on. They're learning a lot more, and then they're are a team when they go back, and they go, "Yes, this is the kind of dentistry we'd like to do. We'd like to provide this for our patients."


Howard: And I'd like to remind the dentists out there listening of where there's some solid research in America. There's a third of a billion people, there's 325,000,000 Americans, and all throughout the thirty years, right out about half of Americans will always survey that they buy on price, they want to go the cheapest, whatever their plan covers, whatever, but the other half doesn't. They actually care and want better. And a lot of people think, "Well my neighborhood's poor", but look at the money they're spending on their nails, their hair, their teeth, all these things like that. When I was lecturing, when Ryan and I were in Cambodia - and what was the other country? - Malaysia, it was amazing in these poor cities, how many girls had Invisalign, and you're looking at their house and you're like, wow, that house, that country, and her beauty, her self-confidence, her self-esteem was, "I'm buying Invisalign!" I mean, it was amazing, and it's very, very common. In some of the poorest villages you'll ever find in the world, all the cute girls are walking around with Invisalign, because it's important to them.


Rhys: It is important to them, and we discount that. We forget that. And it's really a shame it's happening. And I think some of it's by design. I mean, the insurance companies stick their nose in the middle - and I'm not totally anti-insurance - but I'm anti-insurance at the point where it starts to decrease the quality of care. I've been in practice thirty-five years and I can tell you the whole thirty-five years, insurance has decreased the quality of care, because they keep doing what you said, they just keep lowering their rates, and everything costs more. We've got businesses to run.


Howard: The exact point I have with insurance and basically the government health care systems is, they're not trying to help anyone. They're trying to control everyone. For instance, if Medicaid said, "Okay, I'll only pay $100 towards a filling, but the dentist can charge whatever he wants", then they'll have a list: these are the dentists take the fee as fee, but the other ones it will be a subsidy. They don't allow their benefit to subsidize a nicer decision. So, you're not going to have a Chevy, a Pontiac, an Olds, a Buick, a Cadillac. They're going to try to destroy all the Cadillacs and Buicks and Olds, and bring everybody down to the Chevy, and for no purpose at all. I mean, if I am an insurance company and I gave Megan Sue $100 towards her filling and she found someone that would do that filling, but it would be a silver filling, but she wants to go across the street and pay $200 because she wants a tooth-colored, why isn't that her call? And then the same stupid idiot government people are always talking about why so many dentists don't take Medicare. It's because it's not a subsidy. You're trying to control the industry. Just take away the controls and let them apply it to that procedure at that fee or apply it to a nicer procedure to a higher fee. Why are you trying to control the people?


John: Well, that's a good question. My parents left Czechoslovakia in 1948 because of that reason. They wanted freedom. They escaped and went to Italy, then came to the United States. They wanted the freedom.


Howard: And another thing they're talking about in Congress right now, which hits a very raw spot with me. I'm actually living in a house that an American sold me, because she had to go get her drug, made in America, but the only place that she could get it was in Scandinavia. And I'm like, okay. The same thing with the FDA. I'm a consumer. I can see this drug is not FDA-approved, but I'm going to be dead in a year and the only long shot is this new deal and they're spending five years on monkeys and rats and mice, but you're telling me as a taxpayer that there is a federal agency that won't let a dying American try a drug from an American company. And every time I ever saw Senator McCain, I said, "You let these casinos on the Reservations. Why don't you make those Indian Reservations FDA-free zones, so that people don't have ... I mean, look at hospice. What's the whole point of hospice? So you can die in the comfort of your home. How would you like to die in a foreign country because your own country wouldn't let you take a medication even though you're dying? It's about control and that's the specific issue that gets under people's skin.


Rhys: Absolutely, and it does ours too, and that's part of the reason we're doing this. We want to give back to the level we can, to give some of these other people a chance to do what we've done.


Howard: Okay, talk specifics. This five-day course, do you ... like Pankey, it was real easy because they have week one, week two, week three, and you had to take them in order, there was no decision to be made. Do you have a recommended pattern? You said this is five days. Are all the courses of five days? How much do they cost? Talk specifics to my homies about how they would do this.


John: We have the aesthetic course that is approximately five thousand, plus lab work. And then we have our occlusion mastery series that is about ten thousand and has four sessions over a nine-month period, but that course also includes an upper arch or lower arch of restorative crowns and bridges that we make here as part of the course, so they understand where they can phase their cases in. Those are the two programs we have.


Howard: So, the main program is one week, five day, Monday through Friday?


John: No. The aesthetic course is three days. There's Photography, then two days of Prep session and prep and temp, and then about four to five weeks later is a seat session and that's two days. And doctors bring their patients back and seat the cases.


Howard: And that whole course is five thousand spread out over ...?


John: Five thousand. You give your deposit and pay up front and you go from there. You pay for the lab work at the end of the sessions.


Howard: Is the average person bringing one patient for one case?


John: Yes. One of the other marketing tools that I use at Dental Ceramics, for our clients and doctors that are coming into the course and become our clients, we give them diagnostic work-ups, mock-ups, so they can provide these for their patients, show their patients. We provide them upfront at no fee. When they do the case, we do charge them for that wax-up, but then there's no hindrance as far as doing a mock-up for your patients. We have some doctors that are doing ten a month and we have other doctors they're wondering why they haven't done any. They're don't have to pay for this upfront. You only pay for it when you do the case. So, it's been a great project, I guess you would say, for us and it's worked very well. We're doing a lot of aesthetic rehabs and then those are leading into full mouth comprehensive care cases also.


Howard: And you're talking about all these courses are at your facility in Ohio?


John: Yes, correct.


Howard: How far are you from the water?


John: We're half an hour from downtown Cleveland and about twenty minutes from downtown Nashville.


Howard: My gosh, you've got the NFL Football Hall of Fame, the Rock and Roll Hall of Fame. I love that little bar district by the Rock and Roll Hall of Fame. I love that downtown, that Lake area, that is really nice,


John: It has changed dramatically over the last number of years. It is a great place to be. Beautiful.


Rhys: And in that aesthetics course - we call it Aesthetic Excellence - we purposely designed it so that there was a gap between the prep and the seat, not only because of the lab works done, but what I know from thirty-five years of experience is anytime you do a significant aesthetic change for a patient, they need time to adapt. So, it allows time to see if the design we came up fits an occlusal pattern that works for the patient, does the phonetics work, but most importantly, psychologically, you're going to accept what you do. The last class we did last fall, we did approximately a hundred and forty units and I think we seated almost all of them at the second time; we had maybe one or two that didn't seat, but that kind of success range is what we've seen consistently. And it's partly because we wait long enough.  A lot of times I think, especially with younger doctors who are so used to the fast food society, meaning you want it now, you get it now and you're finished, and that's not the way this works. A lot of these people that are coming and seeking aesthetics particularly, it's taken them decades to get to this point and if you reverse it too quickly, they just don't psychologically accept it. So, there's a process. But the nice thing about it is if you get them through that initial process, they're way more interested in the rest of the dentistry and they follow-up on everything once they get what they want.


Howard: Well said. I'm going to go back to Gena. She thinks she's going to get out of this podcast without talking! Man, what a pioneer! You went and joined the Navy for four years, and that was a long time ago. You got out of school in 2000. Was that pretty much an all-male deal? And what would you say to someone in school that's thinking of a residency and is thinking about the military?


Gena: I thought it was a great opportunity. I loved serving my country and I got great training during the residency in San Diego, so I would definitely encourage anybody. In fact, my daughter's a second year in dental school now and has applied to one of the programs to try to go.


Howard: And what percent was it male back then in 2000 when you went?


Gena: It was probably majority, I would probably say 80% male, but I think at the time that I was in school, at least in my school, we were becoming more ... we had a higher percentage of female dentists in training.


Howard: So, you were four years in San Diego?


Gena: No, I did one year in San Diego, and I did three years in Norfolk Naval Station, Little Creek Amphibious Base.


Howard: How times a week do you wish you still lived in San Diego? Is it three times a day or three times a week?


Gena: Especially in the winter.


Howard: I just visited my mom in Kansas last weekend and, my gosh, I left here and it was 76, and you get there and it's freezing cold, and the wind, it's always blowing. In fact, I remember when I was little, the wind only stopped blowing one time and everyone fell down. I mean, it was crazy, crazy. That was an hour. I can't believe that we already went a whole hour. Just to end, closing thoughts, you're basically talking to two markets. They're either young kids and they're a quarter in dental school, the rest are out of dental school, they're under thirty, most of them are all working as associates.  I know everybody talks about associateships as the big DSOs, but the truth matter is 80% of those associates are in private practice and they all want to leave. I always tell everybody in dental school, "Well, if an associateship at a DSO was a great deal, then why does their average dentists only say one or two years? And then, if being an associate in a private practice is a great deal, it's the same statistic." I mean, it's just the same statistic. Most dentists, at the end of the day, they want to call their own shots. They want to be their own boss. What advice would you give her? She's walking around the swimming pool, just dipping her toe in it. What advice to get her to dive in the pool and open up her own business?


Gena: I would say, begin with the end in mind. Start where you are, but I think you need to look towards where you want to end up at the end of your practice. And I think one thing about this training, it's just another tool in your toolbox that you're able to provide your patients. One thing great about Rhys and John and taking this particular course is that they're very approachable. It's not like going to a large course with seventy people and you're trying to get a takeaway from it - and you may get one or two takeaways; when you go to this particular course, I think you're coming away from it more confident in your ability to practice and do more large cases, and I think that's something that a lot of young dentists want to have, but they don't know where to get the training.


Howard: Another profound thing you said. I'm so dumb, when I go on a vacation, if I see a dental office, I walk in. I just do, every time, but it's so funny how you'll be talking to dentists in these small towns in Kansas, like Derby, Kansas, Rose Hill, Kansas, and sometimes people will say, "We know these people here don't have a lot of money, so I don't really want to do that high-end stuff." And I'm like, "Hey, Bozo, what does that F150 truck cost right there?" And you look at the Circle K, and Kansas, you can almost never see a car and there's like six F150s at the Circle K. You know how much those things are? A hundred thousand if it's totally decked out and sixty-five to seventy thousand if it doesn't have anything in it, and it's like, that guy who's got seventy thousand bucks for a truck but he's not going to get his teeth fixed. That doesn't even make sense. People will always find the money for what they want.


Rhys: That is correct.


John: We have two doctors here from Kansas.


Howard: Oh, yeah. What cities?


John: I don't know, but I know they're from Kansas.


Howard: Are they the two best students in the class?


Rhys: But you're right, you know, it's about creating enough value that patients want it. Dentistry is a good thing. We're not selling death here. We're not selling tobacco - and that did really well for a while. We've got something that makes lives better and it's certainly that the people that provide it, they've spent a lot of their life training for it, so they might as well enjoy it because at the age I am now, I'm a little older than you are, Howard, but the fact is life is short. You better enjoy every day because you don't get to do it again. And like Gena said, if you have that goal in mind and you wish for it, I still believe it's possible.


Howard: Ryan's thinking about doing this really neat project that I'm going to keep nudging him to do every day about finding all the hundred year olds retired in Ahwatukee, and ask for their parting advice, because I've always done that in my practice. I can't believe you had someone that was a hundred and seven and a half. That's amazing. But every time I had a patient that was ninety to a hundred, I'd always say, "What's the secret to life?" They always say that you're asleep a third of the time, you're at work a third of the time, you're with your family a third of the time. But with regards to work, they go, "Never do things you don't like to do for money. Get some job that you love." And the happiest people liked their job. They liked going to work. That is so important. I feel so sorry for people who go to work every day and they hate it. It's like, well, fix it. I had one dentist tell me he'd rather be beat with a stick than do a root canal. I said, "Dude, they're called endodontists.  Don't ever do a root canal again because it's going to take away your smile, you're going to get burned out, that might lead to drinking or beating your cat or whatever. Just fix what's broken. You spent all this time becoming a dentist and you don't like it. Well, what part don't you like? Fix what you don't like."


Rhys: But I know a lot of them feel overwhelmed, but there is a way out. They chose to go there in the first place. They actually have the brains to do it. They got through dental school, so I know that they possess that. It's just that sometimes it just gets beat down and it's still there and that's one of the reasons we like doing this, especially with people that are younger, because there's a spark that gets lit, and once that spark is lit, it does not go out.


Howard: Nice.


John: Their ability to dream and then actually create their own type of practice in their minds, develop the end in mind, in the beginning, see the end and picture it, and you can get there. I see it. I see that happening all the time. I've been doing this for many years and I've seen those practices succeed and grow and I've also seen those that have just fizzled and quit.


Howard: And you've seen cities shrivel and then come back. I mean, even cities have this type of deal. But, gentlemen, it's Friday night, it's eight o'clock at night, and you decided to spend an hour talking to my homies - I really, really appreciate it. Thank you so much for coming on the show. What do you going to do now? Are you going to go down to the Rock and Roll Hall of Fame?


John: No, the Diamond Grill in downtown Akron, it's this old steakhouse.  It's a great place.


Howard: And do many of the students go to the NFL Hall of Fame?


John: They do. And then the Rock and Roll Hall of Fame and the Science Museum down there, and then the Cleveland Museum of Natural History and art museum. Phenomenal places to go.


Howard: Yeah. And just one shout out to Americans. Football is really soccer in every country except for a couple. It's the United States, Canada and Australia. And do you know why soccer will always be the most famous sport ever? Because it’s the lowest cost. I mean, imagine if hockey was going to take off. You can't build an ice rink in all these poor countries. But it's so cute when you go to parts of Asia. I remember when I was in Brazil, these kids were out on the street, they're all barefoot, just got shorts on. All they need is a soccer ball, but they would take the number of their star - they didn't have the money for jerseys - they would just take black charcoal and write the guy's number on their skin. It was so damn adorable. Okay, well, I hope you guys have a rocking hot Friday night. Thank you so much for coming on the show.


Rhys: Thank you, Howard.


Gena: Thank you.


John: Thank you very much.



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