Dentistry Uncensored with Howard Farran

How to perform dentistry faster, easier, higher in quality and lower in cost. Subscribe to the podcast: https://podcasts.apple.com/us/podcast/dentistry-uncensored-with-howard-farran/id916907356

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Howard Farran: Oh my God this is going to be the best podcast ever. My Gosh, Sam you are a legend. You’re my idol, you’re my role model. I feel like you’re my kid, I mean when you logged onto Dentaltown were you a dental student? 

Sameer Puri: No, I graduated I believe, I’ve been on Dentaltown almost since the beginning. I think I was member number 3000 or 4000 or something Howard. So I've known you for a long time and I do feel like your son, we've known each other a long time and I believe I am the only partner that you've ever had. 

Howard Farran: You are the only partner. You know my dad always told me, love many, trust few and paddle your own canoe. You know when two dentists say they want to become a partnership, ten years later you know, I mean half of all marriages fail and that’s when you’re having great sex and children and holidays and now you want to marry a male dentist? For the viewers out there, what happened me and Sameer and T Bone was that…

Sameer Puri: T Bone, yeah. 

Howard Farran: I have four kids, I had a full time practice, I was lecturing every Friday, I had Dentaltown, a magazine and people kept saying we should have an annual meeting and I though if I have one more project, I’m not going to make it and I just felt a kindred spirit with you and you and T Bone approached me and said can we do the Townie meeting? And you’re the only business partners I ever had and I am, I said well how do you know T Bone? Did you go to school with him? Did you grow up with him? Whatever? He’s like no, he lives on the other side of the United States. You lived on the Pacific Ocean, he lived on the Atlantic Ocean and you guys met in dental school. 

Sameer Puri: We met on Dentaltown Howard and I think that goes to the testament of the character of the three people here, is that you and I and T Bone, be all did the Townie meeting on a handshake and it was nothing more than just trusting each other that we're going to have the best interests of each other and what a successful partnership it was for over ten years. 

Howard Farran: And to this day, the whole thing was just a handshake. It was just a post on Dentaltown. It was amazing. So everybody knows you, I mean my God you’ve got 22 000 posts on Dentaltown. If you just mentioned CAD CAM, they immediately say Sameer and I mean you’re just the top dog in the entire CAD CAM space. I mean there’s no, you probably took the second through…number two through 100 key opinionators in CAD CAM, CEREC all combined they wouldn’t equal you. You’re a legend in that. I mean you are. 

Sameer Puri: You’re being very kind and I appreciate that. It’s been a fun ride in CAD CAM and CEREC Howard I’ve got to tell you. It started you know, I got the machine in late 2003 and have been a user ever since and you know it obviously changed my practice. We use it every single day and it just, you know one thing led to another and I certainly didn't imagine myself being a guru or anything. I’ve always from the beginning have always had a passion of sharing information and learning as much as I can and that's what we've done in and yeah, we’ve had a very successful growth in CAD CAM for my little group here in CEREC Doctors.com and it’s been a lot of fun to see CAD CAM become mainstream, whereas you know back when we started, back when I started using it, it was more like you know, you had to be on the fringe to kind of adopt the technology and today it's you know, just another tool that you can use.

Howard Farran: But you know, one lucky thing that came your way. I mean all successful people when they get older, there’s a little luck in their way and I think one of the lucky things for you was that when…I'm 52 and you’re 10 years younger, how old are you? 

Sameer Puri: I’m 43. 

Howard Farran: You’re 43 and my introduction to CEREC was CEREC One and that's…looking back I would say a lot of us older guys that you were fighting with ten years ago, we got into it when it was bleeding edge technology, not leading edge technology and I got the CEREC One and I mean I fought with that thing like an alligator and then years later I was convinced to get the CEREC Two and that was just a bigger alligator. But when would you say CEREC went from bleeding edge to leading edge? When did it go from experimental technology that’s very frustrating and not really worth it, to when it was a must have technology? 

Sameer Puri: You know, I think you can look at it a number of different ways. The people that have successfully integrated CEREC 30 years ago, they’ll tell you hey, 30 years ago it was a must have technology. But I agree with you that the earlier versions were more challenging to use. They required more training, they required more work, they required more, you know dedication to make sure that you are using the technology and using it appropriately, but I would say that for the general person, it was right around when the CEREC technology went to 3D, went from a 2D system to a 3D system where you could actually take the camera, take a picture and then have a 3D rendering of your model that you could move around in space. It was right around 2003 and at that point it started to become more mainstream. In fact that was one of the years that they had the most number of sales in the CEREC when they went from the 2D system to 3D system but from that point forward it’s really become an incremental increase in the capabilities of the technology and I would say you know we’re at the point today in 2015 where you have the ability to do crowns, inlays, onlays, that’s something that we’ve been doing for a while, but you know did you know that you can now send ortho scans digitally, full arch ortho scans digitally with the same technology. There’s no cost to the user. You can now fabricate surgical guides with the CEREC. You can now make custom abutments, whether you do screw retainers or cement retain. So it’s really becoming today, I think you can look at it and say it's, I’ll be biased obviously and say it’s a must have technology, but I think you can make that argument at any point in the history of CEREC, but it was more difficult to use, we were limited in materials, we only had a few different blocks that were available, but today you can do e-max, you can do zirconia, you have all sorts of different choices that you can use for the machine and utilize it in your practice. 

Howard Farran: I want to ask you, it might be a different weird question or whatever, but I personally think one of the most underutilized things of the CEREC machine is that you're busy, you don't have time or maybe you're doing multiple units and people don't use it as an oral scanner to send an impression to a lab. Talk about that, I mean I just think…when I talk to lab people, a lot of them say that the optical impressions, they average about one percent remake whereas a polyvinyl siloxane impression, they average about six percent remake and man, when you’re running behind or you’ve got multiple units, instead of ruining the schedule and having the poor receptionist sit up there while the next person is like hey, I had a ten o'clock appointment and it’s ten thirty, I just think it's far under utilized for optical scanning impressions. What are your thoughts on that?

Sameer Puri: Well, I agree with you. First of all, let’s talk about the accuracy. We all know that there's expansion contraction in PVS and in the stone models that you pour and you know you wax up and you cast the metal, there’s expansion and contraction so we know that, but over the years you know dentistry has mastered the technique and if you take a good impression with a good preparation you’re going to get a good result. So please don't misunderstand and think that Sam is saying that PVS impressions are poor. No, of course not. Millions have been done and they work, but they are more technique sensitive and for the average user, if you can eliminate the middleman, all of the different steps and we just do a direct, digital impression of course it’s going to be more accurate. Dentistry is slow to evolve. People don’t necessarily jump on the latest and greatest technology right away. It takes years and years and years for dentists to get rid of…for how many years have dentists used copper band impressions? How many years did they do the reversible hydrocolloid? And during those transitions people said hey, what I’m doing works. I’ve got my technique down, but if you look at outside of dentistry, name me one thing that we do in our daily lives that’s not digital and we trust all of the digital things from our iPhone to the internet and the television signals that we get in HD, all of that is digital so why wouldn’t a dental impression be more accurate? So you're absolutely right. A digital impression sent to a laboratory is going to give you fewer remakes, it's less costly, it’s less hassle and it’s easier to do, so there's all those benefits. 

Howard Farran: Okay Sameer I want to pin you down to some details because there’s probably, I mean I don’t know how many, there’s 125 000 general dentists in the United States and probably 15 000 of them have a CEREC. 

Sameer Puri: Yeah there’s in the US and Canada it's about roughly 16 000 give now give or take a little bit.

Howard Farran: So instead of doing this all about to someone who already has a CEREC, because a lot of people who have a CEREC are going to be watching this when I want to take it the other way and talk to the 115 000 that don’t have one. Walk them through how a CEREC optical scan impression works? Go through the details, how do they scan a tooth and how do they send that exactly to a lab? Give some names of labs that can accept that. So start with that. 

Sameer Puri: Okay, sure. The process of sending a digital scan to a laboratory is essentially the same as taking a PVS impression. The first part I the same, you get the patient numb, you use your favorite anesthetic and you’re going to prepare your tooth. If you're sending it to a laboratory there's really no changes that you need to make in your preparation design. If you’re milling chairside then there's a few modifications that you need to make for the milling, but if you’re sending it to a lab do your normal preparation design. Now with the CEREC Omnicam which is the full color stream and capture camera that we have now, all you do is you take that camera, you put it in the patient's mouth and you wave it around the teeth that you want to capture, so if you're doing let’s say tooth number 19, the lower first molar, if you were to take the 100 000 dentists out there that aren’t into digital technology, they would probably take a triple tray impression. The vast majority would do, well we would just do it digitally with the CEREC. I would scan my preparation arch, I would scan my opposing, I would have the patient bite down and I would scan the tooth in occlusion and that digital impression gets processes so just like the lab pours up a model, the software will kind of digitize that model, takes about a minute or two and after that you see that model on your screen. Once you see the model, just as you would evaluate a PVS impression and make sure you captured all your margins, you’re going to do the same thing to the digital impression. You look at it, you make sure you captured the impression, make sure you have enough reduction because you can see the teeth in articulation, make sure your margins are all clear and once you verified that, all you do is you click send. You’re going to send that to a laboratory and you asked which labs have the ability to receive that technology. Literally, the vast majority of labs. I don't know the numbers off the top of my head but if there’s 10 000 labs in the US, most of them being mom and pop shops, then let’s say 2000 labs that are larger operations, virtually every single one of those 2000 larger labs has the ability to receive a digital scan. So they’ll receive the scan, they can design your restoration and then send it back to you. For example, let’s just take a well known lab like Glidewell. Glidewell receives a lot of CEREC impressions and in fact, most of the laboratories will discount the case to the doctor if they receive the digital images because they don’t have to pay for shipping one way, they don’t have to pour up a model necessarily. They can design the restoration model for you and then they send it back to the doctor. So name a big lab? Chances are they can do it. 

Howard Farran: So doesn’t Glidewell give a discount because doesn’t it save them steps? 

Sameer Puri: That’s what I’m saying, they do give a discount. They don’t have to…Howard I don’t know off the top of my head but I want to say if you’re paying $110 for a regular crown, you’re probably going to be saving $15 or so. Because they don't have to pour up a model, they don't have to pay for shipping one way, so it's about you know 15, 20 bucks on a let’s say a BruxZir crown or a e-max crown from Glidewell. I mill most of my stuff chairside so I don’t send it out, but you’re going to save 10, 20 bucks per case by sending it digitally. 

Howard Farran: I don't know how much of this is true, but for our viewers out there around the world, Sam and I live in the same city of Phoenix Arizona and I swear, I don’t have a lot of data on this but when you’re UPS’ing polyvinyl siloxane in the back of a UPS truck and it’s 122 degrees in Phoenix, God only knows how hot it is inside that truck. I bet it’s 140 inside that truck. So I think there's a lot of heat and cold distortions on some of these impressions. Another thing is the time factor. I mean when your UPS man picks up a lab and sends it across the country versus the internet they're getting it at the speed of light, so it reduces your turnaround time, reduces your cost but can I tell you what the greatest thing that CEREC was for me and you were a big part of that? It was, you know when you get out of school you’re young and you think you don’t need magnification and I still, whenever I walk into a dental office and they’re under 35 they’re almost never wearing magnification and then they look at guys like me that are 52 wearing these big 4.5X loupes. Just because we’re old and senile and our eyes don’t work, but magnification is everything but man, when you scan that prep, how big is that on the screen? 

Sameer Puri: Thirty times. You’re absolutely right. I mean the ability to review that model 30x blown up. You'll hear users say hey, CEREC makes you a better dentist and that’s exactly why. Because you're blowing up that model, you're looking at every last little detail and if you’re going to mill it chairside and you have to design that restoration, well you have to have a certain smoothness in the preparation, you have to have a certain smoothness in the margins otherwise the burs that mill out that restoration, they’re not going to do a good job. So you're absolutely right that the ability to get instant feedback, the ability to look at your preparations blown up, you’re providing a better service for the patient because you’re giving your laboratory or if you’re milling it yourself, a better impression and you'll just get a better end result and who doesn't want take better care of patients? 

Howard Farran: That’s exactly what I’m trying to say is that, if you listen to 100 conversations about CEREC, in my opinion 80% of them are the least important and that’s making and milling and staining and glazing and doing all the stuff like that. When I think of a CEREC, I’m thinking of man, you’re a much better dentist because you got to see your prep 30 times larger and you can sit there and these labs will tell you, it’s got to be higher quality because if you optically send it in, the big labs are saying they only have about 1% remake with their optical sent in impressions and they’re having a 6% remake with impressions sent in. 

Sameer Puri: Yeah, no I, like I said before Howard, I mean we trust the digital process in every other aspect of our lives outside of dentistry. Everything that we do is, we’re living in the digital world but for some reason when it comes to dentistry, you know dentists will say well that PVS impression works. How can this digital stuff work? It makes no sense to me and try to convince people that this is a better way to go. I used to, like you said, I used to get into lots of discussions over the years on Dentaltown over CAD CAM and CEREC and this and that, you know I’m at the point now where I just say guys, just try it for yourself. Just see how it works and if it's not better then move on, try something else. Don’t waste your time on it, but the vast majority of people that will actually give it a good try, that will trust the process and go into looking at this technology with an open mind will say you know what, it's no longer the technology that it was 20 years ago where we had to look at a 2D screen and draw these dots and extrapolate…whatever you see in the mouth is blown up 30 times on your screen and you have the ability to fabricate a crown as good as what you get from a laboratory. 

Howard Farran: Okay tell me what you think, if my thoughts on this are right or wrong. But my thoughts on the drawing the dots and milling and all that kind of stuff like that is you know, back in the day when I was basically, you know I’m an Impregum user and that’s a 3M ESPE Impregum in the Penta mixer, whatever the heck, when I sent that to the lab, I didn’t do any of the lab work. I didn’t pour up the models and trim my dyes and wax and all that stuff like that and Sameer, truthfully when I got my CEREC machine I did it the same way. I mean when I got done prepping the tooth, the lab man used to do it all so I have four assistants, you know them all and they’ve been doing this stuff for years and years and years, seven eight nine years and I just come back when it’s done. So when dentists ask me how to do the CEREC stuff, I don’t even know what they’re talking about. 

Sameer Puri: You're a smart man Howard, I mean why should it be any other way? Why shouldn’t your team take over? Why should a dentist have to sit there and do all the quote unquote lab work stuff? I 100% agree with you. Anytime I lecture, and I’ve had the opportunity now to lecture for many years and throughout training courses here at CEREC Doctors, we train more CEREC users than anyone in the world. Me personally, I’ve trained more people than anybody in the world and that's not to say you know that I’m something special, it’s just that I’ve had a great opportunity and one of the things I love to tell people is exactly what you said, you should meet, you should have your team as part of the process. The dentist should prep…I would encourage the dentist to scan and at least draw the margin. That way you know that you’ve done a good preparation. You have feedback on your preparation but the design the milling, the stain and glazing, the processing, all of that stuff, the team should be doing it. You take an impression and you trust your laboratory to give you a good crown. This is the same thing, you come back after scanning, let somebody else do all of the other stuff, the quote unquote lab work and then you come back and cement the restoration. There's no difference in doing it with CEREC chairside versus sending it to a laboratory. Somebody else is going to make the crown, you’re going to get a good quality restoration that you’re going to cement in there and to kind of go back to your question earlier, you know why people aren’t doing more digital impressions and doing it chairside, I think one of the reasons for CEREC users at least is that you get into a workflow and you take that impression and you go ahead and prep the tooth and the process of actually fabricating the crown is really not difficult. It's easily delegated so if it’s going to take me, for example I’ve got materials that I have access to that I can mill out a crown in about seven minutes, take about two to three minutes to polish, so within ten minutes, we’re ready to cement that restoration. So if it’s going to take me 10 minutes to get the crown ready to cement, it’s probably going to take longer to make a provisional, put the temporary on, send it off and schedule the patient to come back. Why not just finish it right then and there? That’s why I think you don’t see as many of the CEREC users really utilizing laboratories as much because it’s so easy to do to it chairside but that is a huge under utilized aspect that other doctors can say you know what, just to get my feet wet, why don’t I just get a scanner and start scanning and then later on learn the design process and get my team involved into that. 

Howard Farran: So you went to USC? 

Sameer Puri: Scion! We’re going to have a great football team next year. 

Howard Farran: But you went to USC. Remember how hardcore they were on multiple units. They wanted you to make a custom tray. All the stuff like that and so, would you, so for multiple units, I mean if you prep someone…I know some Townies like Armen prepped all 14 and all that kind of stuff like that and did CEREC in Kenya, but for the average guy, if you were going to prep an arch, you wouldn’t mill out 14 crowns on an arch would you? And if you were going to optically scan, wouldn’t that be so much better than a custom tray for multiple units? 

Sameer Puri: Yeah well let’s talk about multiple units and let's just go right into the full upper arch. You know just because you have a CEREC doesn’t mean you can ignore the rules of dentistry. You still have to find the proper occlusion for the patient, you have to determine the size and shape of the teeth, you have to determine whether you’re going to open up the vertical or not and not to get into an occlusion war, if you’re a CR guy you’re going to have to make sure that the bite is stable with the CR. If you’re not a CR guy, you’re going to figure out your own way to get a comfortable bite. So all that doesn't change whether you’re using the laboratory or not but let’s take an example of, you know full arch with a CEREC Howard. So if I’ve got a patient, I’m going to open up the vertical six say 10 millimeters, whatever the case might be, because the teeth are worn down to nothing. I would still go through all of my steps of fabricating some sort of provisionals. I would test them out on the patient, I would make the patient wear it and then whether you do it in a single arch or whether you do it in a single appointment or whether you do it in multiple appointments, we have a technique in CEREC called biocopy which means copy the patient’s existing dentition. They normally use that if there’s a crown under a partial that has decay or if I’ve got a regular crown that everything is good except the margins are off and we need to replace that, we’re going to recreate the occlusion. We use biocopy. So why couldn't you use biocopy on all 14 teeth and you know maybe you don’t have to prep them all, but you know appointment number one you say I’m going to do three or four teeth today, biocopy them, put the finals one, send the patient home. Next week we’ll do the other side and then we’ll do the front part. An experienced user can do that all in a single visit. A newer user could break that appointment up into a couple of visits. So I don't necessarily agree with you that you can’t use it for the larger cases. You can, but you just have to know how to sequence the case properly and how to kind of time it out properly so that you know it becomes just another way to fabricate your restoration. You know we have, one of the techniques that we have, that we talk about in our workshops is how to make a bridges. So why couldn't I made a splinted onlay bridge to open up the vertical, put that on the patient’s occlusion and then use that as a guide to fabricate the final restorations down the road by again using biocopy, getting a new vertical bite so I don't want you to think of a CEREC machine as just a single tooth system. Whether it’s multiple teeth, whether it’s full arches, whether it’s a full mouth, you can absolutely use the technology obviously just as you’re, you know if you’re placing a single implant or a full arch of implants, you need to have a little bit more education and experience. Same thing with the CEREC. You just need to know that machine a bit deeper so that you can utilize it for more than just a single tooth. 

Howard Farran: Okay, Sam you taught a gazillion at the Scottsdale center.

Sameer Puri: And it was good to have you there by the way. Was it a couple of weeks ago or so when you stopped by? 

Howard Farran: Yeah and by the way, for the viewers out there who don’t know Sameer, my four assistants think he’s the tallest, most handsome, most beautiful gorgeous man. When I sent my assistant up to you, when Jan came back I said well, how was the course? She goes oh my God Sameer, he’s so gorgeous! He’s so nice. He’s so awesome. I just love Sameer. So when the assistants come back, all they talk about it how good looking and gorgeous you are and I always wonder well did you learn anything about CAD CAM or CEREC? But what percent of the dentists do bring their team in your 10, 15 years of doing this versus like me who, the assistants- mandatory. 

Sameer Puri: Yeah. No I would say, so we have different levels of workshops where we start with our level two workshop which is more the foundation course. 

Howard Farran: Go through your whole program with that. 

Sameer Puri: So well the first level training is that we’ve put on with, we have a lot of users out there that say you know what, I don’t know, I've seen the machine, it kind of…I saw Howard 20 years ago and he had it and it wasn’t successful. So I don’t know if I want to get it. So we put on a program Howard called CEREC Accept and we work with Patterson and Sirona on this and I'm the one that kind of organized the workflow and all it is, is a two day hands on program utilizing a CEREC machine and it’s meant for someone who's never used the machine before. So we actually on the first day we have them design restorations, they mill it out and so they can see that whether the technology is going to work for them or not. So once that is done our core series is we have a level two workshop where we talk about inlays, onlays, crowns, bridges and really go through the foundation of preparation design, bonding and the different materials that are available for CEREC. So for that program I would say, quite a few of the doctors bring their team members. We do courses that at least once a month, if not twice a month and a normally I would say two thirds of the doctors are bringing their team members. Then for the more advanced workshops we have a level three workshop where we spend a day and a half on how to make abutments and screw retained and cement retained implant crowns. Fewer people bring their team for that because that's more technical, and then we have our level four workshop where I want to do eight, ten teeth with the CEREC machine, how do I do it? We have I would say about 25% - 30% of the people bring their team to that so depending on the course, depending on what's going to be taught, we do have quite a few doctors that bring their team and I think that's the best way to do it. Because I'm in your camp, if your team is not involved, they’re just glorified spit suckers and I would love for all team members to be able to do onlays and the design and the milling and the staining and glazing. If they have access to a CEREC machine the team should absolutely be taking all of that stuff and doing it. 

Howard Farran: I want to say something about my formative years, my roots that really shaped my thinking. I was born and raised in Wichita, Kansas for those assistants had expanded duty functions whatever, so I just always thought that all assistants were career people who did it their whole life and loved and worshipped their job and then I moved to a state where basically, you know assistants were not to do anything. They were just sucking spit and when I got my assistants, letting them do more expanded duty functions and doing all the CEREC stuff, man they stood taller, they talked louder, they smiled more. They just, it takes it from a job to a career. Oh my God and they’re always, and I’ve known assistants that have been assisting for like 15 years and they’ll say something like oh yeah I’ve been doing CEREC for five years. They don’t even mention the fact that they were an assistant for a decade before that. 

Sameer Puri: Well the best part that, the best feeling for me is when people come here with their team members to one of the more advanced courses and the doctor probably says hey, I just sit back, my team does it all and the team is there with them and you know, you can see the pride on the team member’s face when they're saying you know, yes I'm in charge of this. This is my baby and I’m the one that's responsible for having great restorations while my doc has an easy time cementing these. So you and I are speaking the same language here. 

Howard Farran: There’s even a hierarchy in my office because if it’s an anterior or a couple of them are like no, I’m not going to do that. I’m going to let her do it and she’s like oh yeah. I’ll crush this and the whole team is like oh yeah, she can crush this and the other one’s like…and they’re like standing around watching her. So I think expanded duty function is key for job enrichment. So I want to talk about, we’re at halftime now, I can’t believe half is gone but, it seems like CAD CAM for me has been around since I was in dental school. I mean our dental school had CEREC One. It actually came from the French before that, correct? 

Sameer Puri: The original system yeah, France I think he was François Duret back in the early 80’s. 

Howard Farran: Yeah and for those historians out there, what it was is France was paying for their people’s dental care and they saw this huge lab bill out there and they said can we automate this and save us some money? So France worked on this like 25 years before it came to the United States and the problem the French has was, they were ahead of their time. I mean you know the computers were so small and the RAM was so small so they couldn’t even pull off something this sophisticated with how far behind the computers were when the French started this vision, but now Sam, the next big thing is really milling out surgical guides and doing implants. I mean we kind of left the golden age of dentistry and we’re kind of really entering the titanium age of dentistry. I mean every day I meet endodontists who say you know I’m just doing less and less retreats every day. I'm just pulling these babies out and placing a titanium implant and all that stuff. So tell us what you think of the titanium age and the implants? I mean wouldn’t you have to say that in the last 10 years you’ve seen a gazillion more general dentists placing implants because of technology, because of CBCT, because of surgical guides? 

Sameer Puri: It’s gotten easier. I was trained in my residency to place implants. I placed implants in my private practice and as a general dentist, 15 years ago it was not, you know the most common thing but if you look around today, implant dentistry is becoming the standard of care over a three unit bridge. You know it's funny that one of our exercises in one of our workshops is we teach dentists how to do a three unit bridge out of e-max with the CEREC. It's something that's easily done and you know there's certainly indications where you can use a full contoured e-max bridge and I have doctors come up to me and say hey, why are we learning this because I don't do bridges in my practice anymore. I do implants and the ability of the CEREC to migrate to data with the Sirona cone beam, this is a patented process and I think this is one of the reasons I’ve stuck with the CEREC technology for so long, because in the innovations that the CEREC system has is, they’re pretty far ahead of pretty much everybody else and you can design your restoration on the CEREC, you pull that data into the cone beam system and then when you pull the data into come beam system, what that does is it allows you to plan your implant placement based on where the crown is. So Howard, you remember back in the day when implants first came out? It was only the oral surgeons that could place the implants and they would stick the implants in wherever the bone was. It didn't matter restoratively where that implant was. That was the prosthodontist’s job to figure out. This is where the bone is, that’s where the implant is going to go, right? So you ended up with these abutments in the patient’s mouth and over time what we’ve come to realize is that you can’t just place the implant where the bone is, you have to place the implant through the long ax of the restoration and if there’s no bone, grow a bone. We have techniques now for that, so this whole process of designing the restoration first and then utilizing that information to determine your implant positioning, it's huge and it's really opened the door for doctors to go in and be able to utilize the technology not just for, hey I’m using CEREC to make crowns in my office for inlays and onlays, I’m now utilizing the system to do a whole lot more including implant dentistry. Once you position the implant in the cone beam software, you can actually mill that surgical guide out of your milling unit, your CEREC milling unit which, imagine not having to send your surgical guides out. Do them chairside. Mill them chairside and you have the ability to cut down cost for patients, you have the ability to do the procedures faster and obviously the accuracy of using the guide over just free handing the implants. We've all seen implants that go in the wrong way and you know close to the nerve, they’re perforated. By utilizing this technology we can now position the implants in a more ideal position. 

Howard Farran: And it’s my judgment knowing a gazillion people have CAD CAM’s and CBCT’s, if they're not made by…I’m not saying Sirona’s CAD CAM, CEREC is the best, what I'm saying is that if your CBCT is made by one company and your CAD CAM is made by another company, the bugs and the working it together is just…you’ve got to be a really high tech person to get through all this, whereas when one company, Sirona, is making the CBCT and the CAD CAM, it’s just an easy to do system. I mean it is just easy. 

Sameer Puri: Yeah I think you hit the nail on the head there, is the way this kind of started with Sirona was, there was a CAD CAM engineer…they have a building at their headquarters in Germany called the Centre of Innovation where all of the engineers from all of the different departments are housed in one building and what that allows for is collaboration between the different departments. So there was a CAD CAM engineer having a cup of coffee and a cone beam engineer came out and essentially they were discussing, hey wouldn’t it be great if we could use the CEREC restoration to determine where the implant would go in our implant planning software? And that's how it came to be. Now I don't want to give the impression that CEREC and Sirona are only company that can do this, certainly there's lots of companies, but the process that they have is patented and what you have is a very easy workflow. If I've got to jump through hoops and I’ve got to open up six different softwares and work with four different third parties, chances are I'm not going to utilize the process as much and we’re getting back into the early CEREC days right? Where the process was difficult. The end result might’ve been fine. You could get a good onlay or inlay or crown 20 years ago from a CEREC but the process was difficult. We have that same step now with cone beam and CAD CAM integration where Sirona has really simplified the process and in that workflow, they’ve made it very easy. I can scan the patient, I can design the restoration on the edentulous area, I can import the data into the cone beam system that I have and determine my implant placement within 5-10 minutes. It’s a pretty quick process. Now it’s going to take you another 20, 30, 40 minutes to get the surgical guide made if you’re going to mill that chairside, but can you imagine Howard, the power of, you know showing that patient what you’re going to do and how you’re going to do it and educating them on their treatment options to replace their missing tooth instead of just telling them that you’re going to drill a hole in their bone, but by visually showing them the entire process. It’s awesome. One of the guys that I work with, Farhad Boltchi, he’s a periodontist and he went through all of our CEREC courses and what he does is, he's got his entire team trained and the team does all of the scanning and they take the X-rays and then he'll come in, position the implant, walk them through the process and once he places the implant, he’ll actually utilize the CEREC to fabricate temporary crowns and abutments for his referring doctors and gives them to the doctors if they want to use them. What a great use of the technology and being able to, you know grow your practice that way as a specialty practice. If I’m a dentist and I’m going to refer to him and he’s going to place the implant, he’s going to give me an abutment that doesn’t cost me anything, you bet I’m going to send patients to him because that's a that's a fantastic use of technology. 

Howard Farran: What city is that in? Is that in Bensheim?

Sameer Puri: So the headquarters are in Bensheim which is about 35 or so minutes right outside of Frankfurt. 

Howard Farran: Yeah. I’ve got to tell you guys, like I say one of the greatest things I’ve ever done is just travelling around the world. I love going out but man, when you grew up an American, you’ve seen 100 dental factories. Going into German plants, I mean I don’t care if it’s Sirona or Ivoclar or whatever, I mean my gosh, you go into German manufacturing companies, you can eat off the floor. In fact I’ve got to give you a pop quiz. When you saw the space shuttle Columbia and it had that big arrow pointing to the fuel tank and in big letters it said fuel? With a big arrow? Do you remember seeing that on the space shuttle?

Sameer Puri: Yeah I think so. 

Howard Farran: I remember when I was a little kid and I used to think, how dumb is NASA? I mean my car doesn’t have an arrow pointing to the gas tank? I mean I’m not an engineer, I’m not a scientist, I don’t work for NASA but I know where the fuel goes in, and I just thought are they really that dumb they need a big arrow there? I didn’t get it until I went to Germany and go in the plants. I mean everything, there’s lines on the floor, like you don’t ask someone where the bathroom is. There’s a line on the floor that goes to the bathroom. You don’t ask…above every thermostat or light switch there’s instructions of you know, what temperature. I mean it’s just the most, it’s just a completely different society. No wonder that’s where they make Porsche nd Ferrari and I mean, Porsche and Mercedes Benz and Volvo. I mean they’re amazing. So I’m going to get into more specifics. I want to get into a little more specifics. Blocks. Different companies that make blocks. There’s different kinds of blocks. Some people use different blocks for the front teeth versus the back teeth, some people only use one block. Talk about blocks. 

Sameer Puri: Yeah I mean again Howard, we’re going back to if you’re working with a laboratory, and you’ve got a patient that you’ve got to do a crown on your second molar and you have another patient that you’re going to do a crown on a central incisor, you’re going to have a different laboratory prescription for those two patients, correct? I mean you might prescribe today full contour zirconia or an e-max in the back of the mouth and in the front of the mouth you might use a material like Empress which is more translucent, more aesthetic. That's the same thing that we do with CEREC. We have blocks that range from low strength to high strength. We have blocks that can be polished, we have blocks that need to be put into an oven. We have blocks that are very translucent and aesthetic. We have blocks that are more opaque but they’re a bit stronger. So pretty much any material that you're going to order from a laboratory, you can pretty much mill out chairside. So we’ve got composite blocks that are available from several different companies, 3M makes a material called Lava Ultimate which is a resin based block. Awesome block and gives you the opportunity to do really nice aesthetic polished restorations in the back of the mouth. We have feldspathic porcelain, we have leucite-reinforced porcelain which is Empress. We have e-max which is a lithium disilicate material. We have several e-max clones that are available. We have those people that love full contour zirconia like BruxZir. You can mill a zirconia block with CEREC as well. So there’s not really a limit in what you can do. There’s a lot of different choices and part of the learning curve today you know as compared to 30 years ago, 30 years you had to learn how to marginate and draw your restorations and do all that stuff. Today, it's more about what's the best material to use in which clinical situation. So users shouldn’t feel like hey, I don't want to get a CEREC because I don't want to do all ceramic feldspathic porcelain on a first molar. And I will agree with that, that’s probably not my first choice either but I tend to use a lot of e-max in the back of the mouth. I tend to do a lot of the feldspathic stuff in the front of the mouth so there’s a ton of choices from permanent blocks as well as temporary blocks. You can mill out four unit, five unit temporary bridges, surgical guides as I mentioned previously. There are just a whole host of choices that users have today with the CEREC technology. There’s 16 000 users in the US and Canada. There’s 40 000, 50 000 CEREC users worldwide. 20 years ago you had 3000, 4000 users. Some companies said well, this is just not a market that I want to get into. Why am I going to develop blocks and put all this R&D towards a block for 3000 customers? It doesn’t make sense but today you’ve got 50 000 worldwide, growing at a very rapid pace and what you'll find is that companies are saying this is a market that we can’t ignore because more and more people are getting into CEREC and more and more people are starting to mill their stuff chairside. We better have a block available for them otherwise we’re going to get left behind. 

Howard Farran: I also want to say, the only thing I want to add to the blocks discussion is that I do have a MBA from Arizona State University. I lot of people that have asked me why their sundries are so high, and I look at it…a lot of them miss, they put their lab blocks in their sundries and lab blocks should be under your lab supplies so I think a lot of people who think the sundries are too high and are having gastro stress over this, it’s just a miscoding. I think their check ledger is off. All that stuff should be…

Sameer Puri: You know Howard, I’ve got a question for you. You’re a MBA and I see this all the time, people start to have the discussion over, you know the cost of CAD CAM and stuff and while I think we would all agree that we want everything to cost less, but if you just look at, big corporations out there spend capital equipment so that they can automate and make their processes more streamlined, and then we have dentists who just are not willing to invest in their practices at all. I think I find it very interesting anytime there’s a MBA or accountant or someone outside who is not a DDS or DMD, they tend to understand these concepts a whole lot more. I don’t know if you agree with that or had a comment on that? 

Howard Farran: I do agree with you and I also think dentists by nature are controlling. They’re control freaks and with Dentaltown back in the day, we used to outsource a lot of software and it was just a nightmare. You’re getting it back with bugs and all that stuff. Now no one at Dentaltown will outsource anything and then you think about CAD CAM technology, it’s in your place. You’re not outsourcing, you see the whole process. When you send something to the lab and it doesn't fit, you don't know if there was a new model trimmer, there’s a new this or that but in your own office, you’re there, you’re hands on, you get to see the whole process. I think it triggers your control deals. We absolutely love it but I know if I took it away from my office today, I know who would cry the most and it would be the four assistants. It’s just a big part of their world and I also think it’s really, really cool. 100% of the time we have the patient go into the milling room and sit in a chair there and watch their crown being made and the enthusiasm of that and the bonding and staining and glazing, yeah it’s just huge marketing. And I’ve got to say something about the most successful dentist. You know the hardest thing that you do Sameer, and I do is that I’ve seen all the greats. I’ve been in the offices from you to Rosenthal, any big name, Carl Misch, Gordon Christensen, if they’ve got a fancy name I’ve been in their office and the one thing that you guys all have is you just have that passion and karma and energy. I mean when Sameer walks in a room, granted you’re eight foot four, but everybody smiles, everybody feels your energy, you shake hands, you’re touchy feely, everybody just lights up and that's the patient value and if you turned around and did the crown with a CAD CAM or a laser or beam something of NASA, it really wouldn’t matter as much as…so it reminds me of an argument I got on with Gordon Christensen one time 25, 30 years ago. He said, I said well you’re a dentist and you’ve got a master’s degree, you’re a prosthodontist but you’re also a PhD clinician and these lasers, laser doesn’t stand for losing all savings equals reality, I mean light amplification stimulation emission and radiation, it stands for losing all savings equals reality! I mean you don’t need a laser, it’s too much money…blah blah blah…and this was back when they all cost $50 000. This isn’t the Alan Miller day when they’re under $3500. But Gordon said something to me very profoundly, he said look, I do have a doctorate in psychology and you know what, if this dentist buys a toy and it makes him happy and excited and he runs 20 red lights getting to work, it’s priceless. These guys burn out, they hate their job, they’re eating Vicodin and vodka and if you’re playing in the sandbox and you throw…like my four boys when they were in the sandbox with nothing in there, they’d get out. But if you threw in a couple of Tonka trucks and some pails and shovels. 

Sameer Puri: This is what gets so frustrating for me to read some of the discussions on the ROI of CEREC online where people are analyzing every last little minutiae and they don't realize that oh my God, this is so much fun. I just spent $30 000 taking my family on vacation for, over the last two years but I'm not going to spend any money in my office where I spent the majority of my time. I want to be a miserable wretch with no fun, no toys no nothing. Sometimes ROI goes beyond just the regular numbers. You have to have fun with it and you're absolutely right, if it makes my day more you know, puts the light in my eyes, going to the office everyday, why wouldn't I get something. I don’t care if it’s a CEREC or if it’s a new chair or renovating the office, whatever it is. Have fun in what you do. Good God, we spend so much time in our offices, enjoy it. Make it a fun place to be instead of just being constantly worried about every little penny that you’re spending and every little ROI discussion. It drives me crazy when I hear stuff like that. 

Howard Farran: Yeah and the craziest thing starts with say one like when they design their office. They try to get the smallest space to fit the most operatories, so it’s like they’re going to live in a cracker jack’s box for a third of their life. And then you’re going to go home to a 4000 square foot home but you’re going to practice in 1000 square foot home without a break room and the office is only nine feet wide and you’re going to have to turn sideways every single time for the rest of your life just to get into the room and a mom comes in, there’s not even a place for her to sit and at the end of the day I think the most exciting thing you do is drive to work with the staff you all love and you all have fun and you all really just want to see each other. And then get a facility that’s bigger and brighter and spacious with a break room and…like your home and then go in there and add toys and whatever toys it is until you’re having fun because I’ll tell you this, when the dentist has your personality, and they’re having fun and they’re playing with people they like, the numbers all take care of themselves. 

Sameer Puri: I totally agree with you. I moved to Scottsdale four years ago and you were at our center at the Spear education center a couple of weeks ago whenever it was, and we've expanded so much and what I am so impressed by my team here, you know our own leadership and our CEO and everything is that, any time we were planning something, we just added 15 000 square feet a few months back, we just added a new lab. Everything is done top notch. Of course you’re budget conscious in everything that you do but let’s make it right and let’s make it a place where we want doctors to come. We want our employees to and have a great time. We have a massive break room. I don’t know if you remember that Howard, but we have a massive break room where all the people work, there’s nobody has a private office. Everybody’s out in the open and that massive break room, anybody from our team, 115 employees here now, can go in, drink some coffee, have a quick meeting, relax, you know lounge. It’s a fun place to work and that’s how the dental office should be. You should absolutely make it a place where you and your team want to come every single day, because you’re going to spend many, many years over there. 

Howard Farran: And that’s…I know you’ve got patients Sameer and I thank you so much. I know you’ve got a patient waiting but I just want to say, and the other one big takeaway from labs is, you know what every lab has ever told me? Is that they can’t talk to the doctor, because if they call the doctor and say you don’t have enough reduction and you don’t have enough this and you don’t have enough that, the doctor will get mad and send his business somewhere else. When you’re milling in house and you’re going to have your assistants milling, there’s got to be that trust where that assistant can say I think you have an undercut on this wall. I don’t think you have enough reduction and you want a happy staff and reduced turnover of your relationships, she’s got to be able to share and talk with you about that you don’t want to hear which is you’re not perfect and you prepped a crown and there’s an undercut. I don’t have enough occlusion and I don’t have enough clearance or whatever and when you go to work and you trust each other enough to be able to sit there and tell you, hey Sam, I’ve seen better preps out of you. We need more reduction. My assistant Jan used to send my preps to you, she used to send them to you and then she’d come back and she’d say well I’ve been saying this all along, but you won’t listen to me but Sam agrees with me and blah blah blah, and I’m just laughing and giggling and now it’s so much better because I listened to the feedback from you and Jan and Christine and Yoni and everybody. 

Sameer Puri: Well yeah. It goes back to what we were talking about earlier, CEREC makes you a better dentist. I mean when you see your preps blown up 30 times, hopefully those conversations happen in the beginning where you’re not quite sure how to prep and did I get my margin right, do I have enough clearance, but as you learn the software and you learn to utilize the feedback systems on the software, you have fewer of those conversations. The issue that I have when we send cases to the laboratory is exactly what you said, is if that lab tech doesn’t have the fortitude to call the doctor and say hey, your prep sucks. You need to redo this, because they fear that they’re going to lose that account.  If that lab tech does that, then that’s fantastic but most often it doesn’t happen so you send a case back and it might have the worst margins, it might have the worst reduction, it might have uneven stuff and the lab is going to do their darndest, and they’re going to do their best to try to please you and the case comes back and it doesn't go well, who are you going to blame? The dentist doesn’t blame themselves, they blame the laboratory and that's not right. When you have feedback, an instant feedback from the CAD CAM system, there’s only one person that you can blame when things don't go right. You have to give it good information and you will get good restorations out of it. 

Howard Farran: I’m going to end on this note. I know a lot of people in labs and they say just rule of thumb, you can’t ever tell a dentist anything is wrong. You just can’t. You’ll lose the account and it may be a $5000 a month account that has been going on for 10 years and will go on for another 10 years. I always thought of guys like you, you know on Dentaltown only one out of 100 people will post their work because 99 out of 100 are going to shoot arrows or throw rocks at it and I used to say back to you, back in the say when Sameer walked, his balls dragged on the sidewalk, because you have so much self esteem, if someone said something and you agreed, you’re like yeah you’re right, that root canal couldn’t been a little longer. That implant could’ve been a little wider or whatever and 99% are so afraid of feedback, the lab won’t talk to them and they won’t a case on Dentaltown and I’m sure so proud of those dental students, just the few that post their first root canal or their first crown prep or whatever and of course there’s always some loser that’s going to go on there and go wow, I can obviously tell it’s your first. There’s always a loser in every room but to have the guts and the balls and fortitude to put your work up for 193 000 Townies and then on your own personal level, your own lab man’s afraid to talk to you. That’s sad. 

Sameer Puri: Yeah. I agree with you. 

Howard Farran: So grow up. So today I hope you listened to Sameer and I hope that the biggest takeaway from Sameer is that you go to your assistants and say I want to hear the feedback. I’m not afraid of the lab, if the lab man calls you and says I don’t have enough reduction, tell me. I’m bulletproof. I’m going to grow a set as large as Sameer’s. Can we call this podcast that? Learn how to grow a set as large as Sameer’s. 

Sameer Puri: Grow a set and get feedback. I think that’s fine. 

Howard Farran: Okay. Hey thank you Sameer for talking to me. Come on dude, you’ve got 22 000 posts on Dentaltown. I own the site, I don’t have that many posts. You have more posts on Dentaltown than I think everybody else. 

Sameer Puri: I spend a lot of time posting a lot of cases, answering a lot of questions and I thank you for creating such a great community Howard. It’s been…you’re one of my idols and mentors over the years and it’s just been so awesome to have known you and what a great partnership we’ve had just and the best part…on a handshake. People don’t believe that. People don’t believe that. 

Howard Farran: It was love, trust and respect and for those of you who want to know how I mentored Sameer, Sameer said every time he looked at me he just quit snacking. He said every time he gets the urge to snack he looks at a picture of me and he walks away from his Twinkie. 

Sameer Puri: I can’t make fun of you on that because you finished two Iron Men and I haven’t. I crashed my bike training for it last year and I’ve had two shoulder surgeries and I’ve just in the last week…I was off training for six months. I just last week started working out again because I couldn’t even lift my arm. So kudos to you for finishing two Iron Men and those of you that don’t know what an Iron Man is, it’s a long, long 140.3 miles in one day of running, biking and swimming and Howard’s done it twice so congrats to you Howard. 

Howard Farran: This Saturday is the Phoenix marathon and then the month after is my first 50k which is 31.5 miles. But hey seriously,  thank you again Sameer for all that you do for dentistry, for Dentaltown and if you haven’t been to the Scottsdale center, it’s the rocking hottest dental resort in the world. Go there. 

Sameer Puri: Go to Spear Education.com, actually the center is just the name but our company is Spear Education and we have CEREC Doctors.com as a part of it, so we’re one big sister company. 

Howard Farran: So it’s CEREC, C E R E C Doctors.com, that’s to learn specifically about CAD CAM and the other one…

Sameer Puri: For general dentistry, so just a brief history. It was the Scottsdale center for dentistry when it first opened back in 2007, 2008 and just a little bit of trivia, I’ve been here ever since. I was a visiting faculty as a first visiting faculty here and then when Frank Spear joined the center we changed the name to Spear Education and CEREC Doctors.com is a sister company. So there’s two companies here but we’re all one company, but we share the resources and we have one CEO and all that wonderful stuff but the center is Spear Education and CEREC Doctors.com. So you can go to either one of those websites. 

Howard Farran: You know the only reason they names it after Frank Spear is because the Sameer Puri center was already taken. 

Sameer Puri: Yeah it was hard to pronounce and it just wasn’t going to work. The Puri Center.

Howard Farran: In my mind it’s the Sameer Puri center buddy, end of story. Frank Spear is just your sidekick. Thanks again for all that you do. 

Sameer Puri: Thank you Howard.