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 : It is an honor today to be interviewing Nancy Duque, a dentist in San Antonio, and we first met at the AADOM meeting in San Diego. Is that correct? I loved your energy, I loved your karma. I wanted to get you on for a podcast, and so my first question I want to ask you is why were you at the AADOM meeting?

Nancy: I was there because my office manager had come across the organization, it was new to me and her, and we decided that the list of the speakers, including yourself and Sandy Pardue who we were familiar with and some of the other ones looked like there would be great information to get there like the idea was in San Diego, so we had a little vacation out of it, and it was a wonderful meeting and I really think more dentists should know about that meeting. I think there's a lot to be gained from the dentist as well as the office manager attending. I think somebody told me there was only six dentists there and you and I must have been two of them.

Howard : It is a rocking hot huge meeting too. I mean they must have even had a hundred vendors, didn't they?

Nancy: Oh yeah, and we're planning to go again, it's in Nashville this year. 

Howard : Oh this year it's in Nashville?

Nancy: Yeah, it travels, and I guess it's going to be in San Antonio maybe the following year. 

Howard : You're in San Antonio. A lot of people confuse that with Austin, but you're in San Antonio, you're on the River Walk where the Alamo is.

Nancy: Right. 

Howard : I think that's the coolest city in all of Texas.

Nancy: I know. It is awesome.

Howard : Now you weren't born there though, you were from ...

Nancy: No, I moved here in 2008, but I'm originally a Midwesterner like yourself. Went to school in Michigan for college and dental school and then I lived and practiced in Illinois, Indiana, spent some time when I was real young growing up in Ohio. Midwestern girl but done with the snow and the cold.

Howard : You're going back to the AADOM meeting in Nashville.

Nancy: Yeah.

Howard : Most people do realize, but the most organic music to America is Memphis and Nashville. Memphis on Bill Street is to jazz. How would you describe the music on Nashville.

Nancy: I'm not that much of a country aficionado but that's where country music lives.

Howard : Most people who think that they're not really into country music or jazz still just have the best night in the world with their jazz in Memphis or country because it's not what you think. It's not twangy guitars. That six or seven blocks on Nashville or that six or seven blocks on Bill Street in Memphis, that might be two of the funnest, partiest nights out you're ever going to have. Oh my gosh, I always love any time I go there, and maybe Bourbon Street or something.

Nancy: I've never been to Nashville.

Howard : Oh my god, you'll just love it. It's just crazy. Every block you walk down it's nice restaurant, nice bar, then live music. You almost listen to live music and you can hear the other live music bands across the street. It's amazing. I'm going to ask you this question. There's a lot of dentists, I'd say half the dentists out there don't have an office manager and they even say things like, "I don't believe in an office manager." I'm like, "Well you have to believe in them because they're not like unicorns, they do exist." They don't believe in the concept. This office manager that you took, how long has that person been with you and what are your thoughts about to have an office manager or not?

Nancy: Well she's been with me, I purchased this practice about four years ago and she and I started here together. We had previously worked together when I was an associate, so I knew her from that office and she and I had left there and gone on to some other things but stayed in touch. She said, "If you ever get your own office, I'll come back and work for you," so that's what we did. 

Howard : Is this the first time you've had your own office?

Nancy: No, actually in Texas yes. I owned a practice in Indiana and I also owned a practice in Chicago. I am very different than most dentists I think. I've moved around. I've taken multiple board exams. 

Howard : Why have you moved around? What was the primary driver in making you move?

Nancy: Initially I started out in Arizona. I was going to school in Michigan. I had an aunt and uncle that lived in Tucson. I'd been out there a few times, and I thought, "Hey, I think I'd like to go live in that part of the country." So I got a job as an associate right out of school in Arizona. I went out and took the Western Regional Boards at Loma Linda, which is where they gave it back in the day. They didn't give it in Arizona. 

Howard : That's where I took it for Arizona. 

Nancy: Yeah, and so then I practiced math for a year but I was very homesick. I was in a practice where my hours were one PM to eight PM every night, which is great for patients and everything, but when you don't know somebody in a town, it's a little hard to meet friends, so it was lonely. I decided to move to Chicago where I had spent five years as a child growing up in Rockford, Illinois. I always liked Chicago, wanted to go to a big city. Nowadays on Dentaltown everybody's saying doing the research, go where the demographics are good. I knew none of that. I just thought I wanted to live there. It's close to family and friends. 

I initially got to Chicago by getting a job as a dental school instructor at the University of Illinois, and that got me into Chicago, and I thought I wanted to try teaching. I loved teaching but money is not there. I was making $25,000 a year in 1987 as a full time assistant professor, and that's a little hard to live on in Chicago. I did that for a year and then I had a couple associate positions and I purchased a practice in 1990 in a suburb of Chicago. I was a situation where the dentist had started the practice three years prior, same age, guy, and then he had joined a group practice and moved basically most of his patient base to that group practice and I was working as an associate in the group practice.

Well he was going to sell his physical office to an associate of his, and the associate didn't want to buy it so he offered it to me. I kind of had a startup practice because there weren't very much patients, but it was already built and it had been running for three years as a dental entity, so it was easier. I didn't have to physically build it. It was already there. I started there in 1990. I was there until 2003. I took on a partner in 2001 who was a dental school classmate of mine. Along the way I purchased a retiring dentist patient base, and we thought that the two of us would have enough patients to keep it going for both of us. That proved not to be the case, and I had gotten married in 2000, had a daughter in 2001, and decided that one of us had to go.

My partner was going to go first, and then my family ended up relocating, my parents and my brother and his family ended up relocating to Indianapolis and so we thought let's give that a try. My prior partner stayed at that practice, I sold my half to him and then I moved to Indianapolis.

Howard : In that time period, you were married to a man and had a child.

Nancy: Yes.

Howard : Professionally you were married to a man in partnership and office. What do you think of partnerships? What is it like being married to a man professionally where you don't have children and live with each other versus married to a man where you're married and live with and have children? Do you think that's a complicated thing having dentist partner?

Nancy: It was not for me. I had known my partner since dental school, so I had known him way longer than I had actually known my husband.

Howard : You had known him longer than you'd known your husband?

Nancy: Yes. We met in dental school.

Howard : Wouldn't it have been easier to marry him though because he was a dentist?

Nancy: He was already taken, so it wasn't an issue.

Howard : I guess what I'm getting at is I never wanted to marry a dentist and have a partner. I look at all the pros and cons and I just say, "Yeah, but I just emotionally don't want to go. I just don't want to do that." You went there.

Nancy: No, my husband's not a dentist.

Howard : No, I know. You went into partnership at a dental office, but I think what I'm hearing is that's very different because you knew this person for a long time.

Nancy: Oh absolutely.

Howard : You already had faith and trust and chemistry.

Nancy: Yeah, he had owned his own practice in the different Chicago suburb, and we had always been good friends and we always talked about the struggles of being a solo owner and struggling with our practices and wouldn't it be great if we worked together. There were things he liked to do. He really loved doing dentures. I didn't care as much about them. Once we got together, he did more what he was passionate about. 

Howard : To the listeners out there, that's very different than a scenario I see all the time where a dentist advertises for a partner, and you go in there and they say, "Okay, I'll pay you thirty-five percent of collection and then at the end of one year you'll buy half of this." In that one year it's like you're dating and you need to go out for dinner after work and you need to go to each other's houses on the weekend because if you don't have any type of chemistry or relationship ...

Nancy: Yeah, it's not going to work.

Howard : ... that's a scary thing because when you marry a man and have a child, you have a lot of glues. You have a family and a child and relatives. There's a lot of social glues that hold you together. When you marry someone in business and you have no social glues and then it turns out you don't have any chemistry and then it turns out you don't even have anything in common, and those are just messy. 

Nancy: No, and I can't imagine doing it that way. I mean we have stayed to this day very close and my office is still putting along. He still has my same dental assistant. She's sixty-eight years old. I mean she was with me for thirteen years and she had been with him ever since and they planned to retire together.

Howard : That's another huge flag that we see is the people have a high turnover of their spouses, have a high turnover of their employees, also have a high turnover of their patients, and they always want their patient turnover addressed. Like, "No one's on recall. I've had ten thousand charts and only a hygienist one day a week," then you have to plan out, yeah, you also have high turnover of staff. You also have a high turnover of smiles. It's a relationship bill. 

Nancy: It is.

Howard : It's all relationship. The fact that that dentist has held onto the same assistant all those years speaks volumes of that person. Volumes of that person. 

Nancy: He only has two employees and his other employee was with him at his prior office.

Howard : Let's go back to office manager. I want to take advantage of you as my guest for another question. You had your office manager at the AADOM, what is it I? American Association ...

Nancy: Academy of Dental Office Managers.

Howard : It's the American Academy of Dental Office Managers?

Nancy: I think it's American Association.

Howard : Of Dental Office Managers.

Nancy: They refer to themselves as AADOM coloquially.

Howard : I feel nervous asking you this question because it could be perceived as rude, but at that convention there were young women dentists saying that women staff react differently to women dentist owners than male staff. I heard several women complain about that. I heard this specific scenario. "I was the associate for Dr. Mann and he would act like this and all the staff responded. Then after three years, I bought the practice and he's gone. I say the exact same things, and they react different." As a male, I feel embarrassed to ask that. I'm going to ask you, a female dentist who's been crushing it for thirty years, is managing women different for a female dentist versus a male dentist?

Nancy: Not being a man myself, but it is a fine line because throughout the workplace, if the man is being tough or acting like a leader, people go, "Great, great." Then when the woman does it and she gets called the B word sometimes. I've just tried to be very much with my staff, this is a business and I had expectations on how we will run our business and I'm the team leader. I liked what you said in the article or whatever, that I'm the coach and it's a team driven practice, so as the coach I'm going to lead you by laying out the plays but it's up to you to execute them, and if you don't want to be on my team, then we need to part ways. We're all in it for the patient and the dental care, that's our goal, but we all have to work together.

I tried very hard to communicate that and I've lost people along the way. I had a situation where I inherited a staff member at this practice who'd been there for a long time, but the idea is that they preferred the male dentist that I had brought the practice from much more than they preferred working for me. I ultimately thought can I correct the situation and I got to the point where I don't enjoy going to work and seeing that particular person. Even if she made all these changes, I just get underlying, she wasn't a teammate. I dismissed or severed her, and nothing personal but I just felt like you were not a good teammate for the team I'm trying to, and I think there's a better option out there for you personally. I don't want to hold you back. I don't think you're as happy as you could be.

It's been fine. I'm sure it actually came as a big shock to her. Because it wasn't like you could say, "Oh you're late everyday and we need to correct that. Only you start coming to work on time, we'll be fine." It wasn't that. It was just the overall, she was very resistant to change, just one of the personality types that is and of course I came in with a lot of change from male to female, as we're talking about.

Howard : Yeah, it's amazing. I tell individuals when you have a job where you're trading time for money, that's a bad scenario. That's going to lead to drink and drugs and escape. There's people on assembly lines that pour LSD into their chewing tobacco and are choosing acid all day, they hate their job. That's just a bad deal. I also think it's equally very bad to pay people money to be your employee that you don't want to be in the play box, in the sandbox and play with all day. 

Nancy: Exactly. Because you spend far more time with them than your own families. You have to come in and be happy to see everybody everyday. 

Howard : Oh my god, I just love seeing my team. When there's someone in there that not only do I not love to see them, I don't want to see them, and then people are saying, "Well they're doing a good job," there's some underlying psychological thing. It's probably a mutual feeling. It's probably Newton's Law for every force is an equal amount of force. We're feeling each other's karma and you know what, there's a hundred and fifty thousand jobs in Arizona, go find another one. Don't give people money you don't want to play with. That's going to be about it. I'm going to ask you this. You and I have both been out since the 80s. Next month five thousand kids are going to graduate, and now that you've been doing it for almost thirty years, because there's a lot of seniors watching these or listening to these podcasts on iTunes, do you think that they should try to teach at a school a year? Do you think they should do a residency? Do you think they should go to the military, or do you think they should just open up their own practice?

What do you think they should be thinking about, a senior in dental school?

Nancy: I think there's probably a very few people that are seniors in dental school, unless they have some external prior experience that could open a dental practice. By prior experience, I mean if you went in and you had been a dental hygienist or you've been a dental assistant and then you went to dental school, you'd have a leg up maybe on opening your own practice. I think that what you've got going on Dentaltown is the greatest resource out there, and every dental student should be subscribed and be on the threads because you're going to get more knowledge there and certainly if you wanted to open a practice, I know there's been some dental students that have been on Dentaltown following it closely since their first or second year.

Those people do go out and probably open practices and do well. Now the vast majority of students, they probably need to work someone else and I know that it's tough to find places as far as a private practice setting. It's very difficult, especially for full time, expect a full time job unless there's a full time associate there who's happening to leave. You don't just double your practice overnight by saying, "oh I'm going to hire an associate. I'm going to have enough work for them immediately to be there four days just like I'm here four days." 

One piece of advice for dental students is don't go thinking you can just find one job. You're probably going to have to associate in multiple places, and that's not a bad thing. It's going to give you a lot of exposure to go to office A on Mondays and Wednesdays and office B on Tuesdays and Thursdays and another one on Friday and Saturday. You're going to learn a whole lot just by working in there. You're going to know what you like and what you don't like, and that's all going to shape you as to the kind of practice that you want to have yourself someday. 

Howard : Excellent advice because you might find out one doctor's office is great for teaching you management and marketing and maybe you have a killer office manager, but this does restore your dentistry. The other one might have a totally mismanaged office, but you're learning how to place surgical implants and bone grafting and all that kind of stuff, so mentorship. 

Nancy: When you're in those practices, don't just do the dentistry. Talk to the front office staff. Find out how their software works. Find out how the world of insurance works. Find out about what different types of insurance that are out there that's traditional or PPO or HMO and what do those things mean in terms of the monies that come in.

Howard : You're in San Antonio. What insurance are you dealing with? Are you dealing with HMO capitation? Do you do PPO? Do you do [inaudible 00:19:35].

Nancy: I have a handful of PPOs. I purchased a practice that had been here for thirty years, and the dentist that I purchased this from took multiple PPOs. I've pared them down somewhat, and I'm just getting ready to maybe pare down a couple more. I do the quality dental plan that we offer to the fee for service patients, the in-house plan. I'm in a relatively affluent area. With that being said, there's more and more dentists coming in all the time, so you do have to watch what your participation is and be smart about it. 

Howard : You said the quality dental plan that you offer in-house?

Nancy: Yes, which is something that has been talked about on Dentaltown. Dan Marut.

Howard : Oh Dan Marut's plan.

Nancy: Yeah, we offer that.

Howard : Are you good friends with him?

Nancy: I met him once at a conference and talked to him for a few hours.

Howard : You just gave me a lead on my next podcast.

Nancy: Yeah.

Howard : Yeah, Dan Marut, Quality Dental Plan. I can so remember when he was in my house. God, that must have been twenty-five years ago. I'll never forget because he was so excited. He was in my front room and he just kept flipping through this oral surgery book and I said, "Dude, you can have the book." He's like, "No, no, no, this is a $100 textbook." I'm like, "Take it. Take it." That'd be good. Will you talk about that plan, Quality Dental Plan?

Nancy: Sure.

Howard : How long have you been taking it?

Nancy: I've been taking it pretty much ever since I bought this practice.

Howard : Four years?

Nancy: Four years. 

Howard : Now does the selling doctor already have this ...

Nancy: He did not have it.

Howard : You bought this practice and you implemented Dan Marut's Quality Dental Plan.

Nancy: Yes, and the driving force behind it is because the previous dentist had taken every PPO plan under the sun, several of the PPO plans were more like a discounted fee plan. They were under something like Humana or Aetna, and they were primarily aimed at senior citizens. The senior citizen would purchase this plan, come in and go, "I have dental insurance." Well you're paying a few dollars a month to the big insurance company, but all they're doing is saying you get your cleaning paid for by paying your premiums basically, but if you need any work, the dentist is going to have to provide you with the work and you pay a hundred percent but at the reduced fee, so it's not really dental insurance.

Howard : Where would you call that, a dental plan?

Nancy: A discount fee plan. 

Howard : Yeah, discount fee plan. 

Nancy: There's no check coming from the insurance company. They're just saying, "You need a filling, but a dentist that accepts that plan can only charge $50 bucks on just round numbers and patients got to pay the $50 bucks, even though your regular fee might be $100 bucks. There's no co-pay coming from the insurance company.

Howard : You saw Dan talking about Quality Dental plan on Dentaltown.

Nancy: Yes.

Howard : Explain exactly what that is and how it implemented and how that's worked for you.

Nancy: The way he explained it to me is it's a membership plan, not unlike a Costco membership. You go to a warehouse club and you pay your yearly fee, and that way you're getting the products at a discounted rate at Costco or Sam's Club or something. Well for a yearly fee with QDP, we charge $299 and the patient gets two prophys a year, any necessary x-rays that occur during that time period, whether it's bitewings once a year or whatever the patient needs, and to exams that go with the prophys.

Howard : $299 a year?

Nancy: $299 a year.

Howard : They get two prophys.

Nancy: Two prophys.

Howard : Exams.

Nancy: Exams and x-rays.

Howard : And x-rays.

Nancy: Yes.

Howard : Basically they're giving you $300 bucks and they get two cleaning exams and x-rays.

Nancy: Right, and they pay it that day, upfront. Must pay the $299. They come in and they pay the $299, they get the first cleaning and that's six months later typically they're reappointed. Well they tend to show up for that six month appointment because they prepaid for it. You're incentivizing them to show up, and then any work that is needed, it's twenty percent off of your fee for service fee. 

Howard : Your usual and customary fee?

Nancy: Your usual and customary fee.

Howard : You started that four years ago; did you just have some brochures at your front desk or were you advertising this?

Nancy: Yeah. My office manager is very good at informing the patients about this plan. Generally in the course of working with the patients that came in with the less than stellar plan already, she's saying here's the reality of what you're getting from your Medicare type plan. You're paying all this money but you're getting very little back from it. We have an in-office plan, and this is what it's all about.

Howard : You call it QDP to them or Quality Dental Plan?

Nancy: We call it QDP. We have the brochure and we explain it to the patients. Sometimes we just say, "Why don't you go home and read over it." Other times what she'll do is she'll bill out our regular fees and then tell them if you sign up for QDP, I'll adjust the fees that we just charged if you call me back within twenty-four, forty-eight hours or something. 

Howard : You think this has been good for your practice?

Nancy: Yeah, very good. I think it's retained a lot of patients.

Howard : What percentage of your practice is QDP do you think? Five percent? Ten percent? Twenty?

Nancy: Probably between five and ten.

Howard : Five and ten percent?

Nancy: A great majority of my practice does have other types of dental insurance.

Howard : Right, because you said you're in an affluent neighborhood.

Nancy: Yeah.

Howard : Let's talk about clinical. Some people recommend to grow their business, have a wider things that they do like offering maybe Invisalign or implants, whatever is your clinical mix? More specifically, these kids graduating senior or dental school, what do you think they should be leaning how to do how clinically? Should it be only what they're interested in or are there areas that you would recommend that they learn? What are you doing clinically?

Nancy: I think that you should give them the biggest mix that you feel comfortable with, and some of it's going to require other training after dental school obviously. Since I've owned this practice, I've started placing implants.

Howard : Really?

Nancy: About three years ago. Never done it before. Now I may have done a lot of surgery before, and I think that's key. You have to be very comfortable doing standard oral surgery, in my opinion, before you graduate to implants that you're comfortable laying a flap. 

Howard : When you say that you were comfortable doing oral surgery, I mean were you taking out wisdom teeth?

Nancy: Yes. It was third molars, I pulled off extractions.

Howard : What types of third molars? Would you take out semi impacted?

Nancy: Yeah. Because I have no problem laying a flap.

Howard : Okay, so you first develop your surgery skills. You had no problem with oral surgery.

Nancy: Oral surgery.

Howard : You feel that's kind of a prerequisite for implant surgery.

Nancy: Yeah, I felt that it was very easy for me to pick up implant surgery.

Howard : Three years ago you place your first implant. Did you have to upgrade from 2D x-ray to 3D or not?

Nancy: Well no, we have a company in San Antonio and they have multiple locations. I think they are definitely in Louisiana. I don't know how far they go. It's called iMagDent.

Howard : iMagDent.com?

Nancy: Yeah. 

Howard : iMagDent.com.

Nancy: Yeah, it's I-M-A-G-D-E-N-T. If you want to interview the president, I can hook you up because he [crosstalk 00:27:40].

Howard : Will you do that?

Nancy: Yeah. Absolutely. 

Howard : All right, I'm Howard@DentalTown.com, you know that. I would love that.

Nancy: They're less than a mile away from me, and they have the 3D CT scan, and so I send my patient over there and they get scanned, and then I have the option of ...

Howard : Now do they bill the patient?

Nancy: You have a choice. 

Howard : Okay, they can bill you?

Nancy: I have them bill me and they can charge the patient.

Howard : What do they bill you and what do you charge the patient, or is that personal?

Nancy: No, it's $240 for a CT scan. 

Howard : iMagDent charges you $240?

Nancy: Yeah. I honestly don't make money off that. I charge them iMagDent fee.

Howard : Do you care what type of CBCT machine it's taken on? Do you care about the name brand?

Nancy: No. I honestly couldn't tell you what they have.

Howard : so you don't even know what they have?

Nancy: I don't even know what they have. I'm sure they've told me.

Howard : Do they email you the image or put it in a drop box or is it on a CD?

Nancy: They have their own website interface that have downloaded on my computer called Implant Concierge.

Howard : Nice.

Nancy: When they get the scan, I get an email in my regular email box that says, "Your patient has been scanned and there's a scan waiting to review." I have the choice of reviewing it on my own, or I usually do what they call a VIP consult. I sit down with one of the tech's there via a Skype thing. We just go to meetings. We look at it together and I plan out the surgery, what size implant I'm going to put in there and where we're going to put it and we talk it through. 

Howard : With a tech helper?

Nancy: A tech.

Howard : Nice. 

Nancy: They're willing to train you to manipulate the software, but for me it's just been easier to have the tech and I look at it together and he's very knowledgeable, the on that I work with.

Howard : This is in San Antonio or you said also in Louisiana or is it all over Texas?

Nancy: No, they have it all through Texas. I know they have it in Louisiana. I'm not sure if they've gone beyond that, how many states they have now. It's a rapidly growing company. 

Howard : Then I want to ask you the question, the big controversy, some people say you should use a surgical stent.

Nancy: They provide those. I have that option.

Howard : Do you recommend a surgical stent?

Nancy: In certain instances. I don't do it a hundred percent of the time.

Howard : Talk about that. Let's talk about surgical stents. You don't do it a hundred percent of the time. When would you not use it? When do you always use it?

Nancy: If I have a denture, partially, if I'm going to do two implants, I'm going to do two molars in a row or something, I do the guide. It's so much easier to have it all planned out, know exactly where it's going to go on the guide because it's got to have the right distance between them and all that, so I don't freehand that.

Howard : Do you also not freehand two molars because of the depth stop, because you don't want to worry about hitting the inferior alveolar nerve? 

Nancy: No because I've already planned that out without the guide. When I do the planning, I know from looking at the CT scan how deep I can go, what size implant I can use.

Howard : If the CBCT guide tells you that you're going to place say a ten millimeter implant on a mandibular molar, how much room would you want above the inferior alveolar nerve?

Nancy: Usually two or three millimeters at least?

Howard : Two or three? 

Nancy: Yeah.

Howard : If you planned out, what would be the average length for you on a mandibular molar implant? What would the average length be?

Nancy: Ten, 11.5, something like that. I've also got an implant system that if I want to put an eight millimeter one in, I can get like a six by eight. I can make a wide one and it's not very deep. 

Howard : Did you pick just one implant system? Do you mostly use one system or do you use a couple?

Nancy: No, actually I use one. I got my implant training through Jerome Smith. 

Howard : Oh my god, he's my idol. I love that guy. I love him. How did you meet Jerome Smith?

Nancy: Well I read all his stuff on Dentaltown and I used to get the brochures in the mail about his courses, and I was like, "I want to go there. It's not that far from San Antonio."

Howard : Lafayette, Louisiana.

Nancy: Lafayette, Louisiana. I have relatives there, so that was part of it. Like visit my aunt and uncle.

Howard : Did you drive there or fly there?

Nancy: Drove there.

Howard : How long a drive was that?

Nancy: Seven hours.

Howard : Seven hours?

Nancy: Yeah.

Howard : Is he not the nicest girl in the world or what?

Nancy: Absolutely, and I took my office manager with me.

Howard : The same one you have now?

Nancy: The same one. 

Howard : Awesome. Does he still do these hands-on courses?

Nancy: Yeah he does I believe, and he's got his nephew working with him now.

Howard : Daniel.

Nancy: Yes. When I was there, which was four years ago, three years ago, he was using mainly Zimmer and he also was using a lot of Megagen, which was a South Korean company.

Howard : Right.

Nancy: The Zimmer rep was there as well as the Megagen rep, and I think you know the Megagen rep, Joel Gonzales from Phoenix.

Howard : Yes I do.

Nancy: Okay.

Howard : Was he the Megagen rep?

Nancy: Yes.

Howard : Oh really? He does San Antonio? He does Texas and Arizona?

Nancy: He does Texas, Louisiana, whatever. He's all over the place.

Howard : No kidding. I thought he was only my rep.

Nancy: He was only yours.

Howard : I ddint even know he had naother customer. No, I'm just kidding. You met Joel there.

Nancy: I met Joel and he was as nice as can be and friendly and we hit it off and I actually when I got back, I called the local Zimmer rep just to see what their kit costs. I didn't get a call back for like six weeks. I guess they didn't want to sell me a kit. In the meantime, Joel just made it happen and he was like, "I'm going to get you hooked up. I'm going to come here." He says, "I want you to line up three or four patients and I'm going to come in for a couple of days, and I'm going to stand behind you and watch, tell you what to do," and that was that.

We developed a great friendship, and then I went back a second time with a dentist in New Orleans that does a ton of implants named Darryl Burg who's also known as Jerome, and spent a couple days in his office watching him.

Howard : When you did Jerome's course, how many dentists were there? Is it small or large?

Nancy: There were probably like ten, fifteen dentists. Fairly small.

Howard : There was fifteen dentists?

Nancy: Maybe ten or fifteen.

Howard : Ten or fifteen in his dental office watching live surgery?

Nancy: Yes, but he's got it set up that he's got it all on closed circuit television or something, so he's in his operatory doing the surgery but he's got the GoPro camera on his head. It's up close. You're looking at exactly what Jerome's looking at, and he's talking you through the surgeries and we're all up in an upstairs conference room watching it on the TV.

Howard : What is Jerome mostly placing?

Nancy: Joel told me now he's quit Zimmer and he's only doing Megagen.

Howard : Really?

Nancy: He's said himself whenever he posts in threads lately, Jerome, he's touted Megagen.

Howard : It really comes down to the relationship. A lot of people ask me what supply I use. Do you realize I use one major brand that you can think about. I'll just name the three players. It was Patterson, Shine and Benco, and I've gone through all three of those companies because I follow the same rep. That rep is in tight with Jan whose been my assistant for twenty-eight years and she doesn't care about where the package come from. She likes her Valerie. If Valerie started buying from a penguin in Antarctica, we'd buy all of our [inaudible 00:35:54] from a penguin in Antarctica. It's all relationship based.

Nancy: Absolutely.

Howard : That's two fine men you've hooked up with, Jerome Smith and Joel. Is this a fair words to put in your mouth? Titanium, titanium, titanium, buy from someone you have a relationship with?

Nancy: Yes. Also it's very easy to use. I mean I still have to restore implants that come from specialists, from [Strauman 00:36:24], from Nobel, whatever. Maybe because I use Megagen all the time, but I just think it's just a very uncomplicated system, and it's worked well in my hands, very well.

Howard : I'm going to ask you another question because Megagen's from South Korea.

Nancy: Yes.

Howard : South Korea has twenty thousand dentists and last month fifteen thousand out of their twenty thousand last month placed an implant. 

Nancy: Yes.

Howard : Now we're in America, a hundred twenty thousand general dentists and ninety-five percent have never placed one in their lifetime.

Nancy: I know.

Howard : What up with that?

Nancy: How many of them still don't pull teeth?

Howard : How many of the will say to you, "I don't like blood." It's like dude, shouldn't you have been an electrical engineer? Shouldn't you be a programmer? How did you apply to dental school and not like blood? How does that work?

Nancy: Right. There's plenty of those people. My former partner in Illinois is like that. He doesn't do any oral surgery. He doesn't do any endodontics. 

Howard : Then let's talk about this. I want you to spend a few minutes on, right now these podcasts are mostly, they download the Dentaltown app, so then they have them all on their phone. When then Internet hooked up with the cell phone and made it a smart phone I think everybody thought the websites on the small phone would be just be the same as your desktop, it'd just be smaller and you couldn't read it. The technology of the GPS locator is different than the desktop, the blue tooth. Most of these people are doing the podcast thing on an hour commute to work and they're turning on the podcast. Right now, talk to this dentist. They've been out of school ten years. They pull teeth. They don't like pulling wisdom teeth. I'm trying to guess the question they're having.

They're saying, "Well I pull second molar forward, but I don't pull wisdom tooth. Could I place an implant? If I don't do wisdom teeth but I do pull other teeth?" What do you think?

Nancy: I guess my next question would be how skilled are you at laying a flap? Because you have to know how to lay flaps and suit your flaps when you place implants for the most part. Yes there is getting all the time with the guides and sometimes you're just using a tissue punch and there is no flap, it's a flapless surgery, but I still think you need to have the know-how to open it up sometimes.

Howard : If you could lay a flap like you peel a banana, not scrunching tissue down and causing a bloody mess.

Nancy: No.

Howard : Let me tell you one thing about flaps, because I've been in a gazillion dental offices and damn it, the number one problem with the flap is they're too small. I mean you're trying to lay a flap so you can see, and a two inch flap is going to take the same length of time for a one inch flap, and every time I have ever been in an office or had an associated needed help because they couldn't get a tooth out, I walk in and it's like, "Well I can't pull this tooth. I can't see what the hell you're doing." Then I go back to the flap, and as soon as I can see it, then the dental assistant can take it out.

Nancy: Yes.

Howard : You're saying flap surgery is ...

Nancy: I think flap surgery is necessary in my opinion.

Howard : Okay. You're saying flap surgery. Okay, so I want you to do this. We're going to go right now from the first floor where we've never placed an implant, ninety-five percent of American dentists, to the second floor where we've placed one implant. You talked about the implant system. I put the words in your mouth that you agree that titanium is titanium, find a relationship, find someone that's going to help, that you don't need to buy a $150,000 CBCT machine. 

Nancy: No. 

Howard : There's places you can outsource it and all that kind of stuff and you don't even care what a CBCT machine is. 3D's 3D. Okay, then keep going. What would be the next step? What would be the low hanging fruit, easy first case for you? What would you recommend?

Nancy: Lower first molar I think.

Howard : Lower first molar?

Nancy: Yeah, and I'm left handed, so I'd want to do number nineteen. You're right handed, you might want to do number thirty. Because you've had good vision or twenty or twenty-nine. You want to start with a fair amount of bone, someone who hasn't had their first molar missing for twenty years and they have a knife edge ridge or anything like that. Maybe the tooth came out in the last five years so they got a lot of good bone. It's nice to have, it's easier if you have the adjacent teeth on either side. You want to put it kind of in the middle of the two adjacent teeth.

Howard : On this first hundred, would you recommend surgical guide or non surgical guide?

Nancy: Honestly, I did probably my first twenty or so without a surgical guide because iMagDent didn't have that technology then, and I learned to do it without surgical guides when I took Jerome's course and Dr. Burg's course. They weren't using surgical guides, so that wasn't the thought.

Howard : For every oral surgeon like Jay Reznick that says, he uses surgical guide on every single case, on a hundred percent of his cases. I could find you ten oral surgeons and periodontists who say they don't and they wouldn't even recommend it. Because they say they already have a surgical guide by the two adjacent teeth. They said if there's a tooth in front of it and a tooth behind it and I got to mesial, distal, buccal, lingual, what's the deal?

Nancy: Yeah, I know. That's where I am. I just visualize is it going to be easy for me to visualize, and I do that when I do my initial exam on a patient and then also when I see the CT scan of whether I'm going to need a guide or not.

Howard : Talk more about that, because we're talking to someone whose never placed implant. They're driving to work right now. They just flipped off a car that cut them off on the freeway. That low hanging fruit, case selection, would you recommend they do surgical guide or not?

Nancy: I would say no, with my experience. I think they should lay a flap their first time. I think they need to get comfortable with that whole process of it. When you can physically see it, visually see the bone after you've laid the flap, that's very valuable to be able to see where the little ridges and things are, where you really want to put that implant.

Howard : You're right. If you're right handed, a lower right first molar and swinging that chair around, get that head right in your lap.

Nancy: You don't have to use your mirror and all that like you would if you were trying to put in number fifteen, and I wouldn't start with that. I will tell you, I haven't done a lot of anteriors. I've been very selective about that because I haven't been trained to getting the smile line right and all that. I'm doing them on say an elderly guy who doesn't care about his smile, I lost number seven, and [inaudible 00:43:21].

Howard : By the way, when she said that elderly guy she was talking about me. 

Nancy: People our age Howard.

Howard : If it's a short fat bald guy that's fifty-two. We are great candidates because I'm a dentist so I'm conscious about teeth. If I see ten pictures of myself, I don't see any teeth in nine out of ten pictures, and if you did botch my cosmetic case I wouldn't care.

Nancy: Right.

Howard : You're saying don't do an anterior on some woman with a high lip line, don't open up that can of worms.

Nancy: I have a case right now I'm restoring who's a twenty year old college student, and I sent her to my local good surgeon to have her implant placed. He also had to do some tissue sculpting and get everything, and I'm set to deliver her crown next week, but I didn't want to go there. She was so picky about the temp we put on, which she's a twenty year old very attractive college student.

Howard : Did you pick a periodontist or oral surgeon to do that?

Nancy: I work with both. I'm fortunate to be physically my office, across the parking lot there's a specialty group that has a periodontist, an orthodontist and endodontist all together, and then I'm across the road I'm on, the opposite side of the road is a hospital and they have a hospital based oral [inaudible 00:44:43] group and I use them as well. 

Howard : Do you think it's a bad slander to say that periodontists are better with gums than oral surgeons or do you believe there's truth to that? I mean some people if it's an anterior they say, well periodontists, they're better with gums, and if it's a twenty year old good looking girl, I'm going to send an anterior implant to an periodontist. 

Nancy: No, actually the oral surgeon's doing this one.

Howard : So you think that's a bad rap?

Nancy: Yeah, I think it's a bad rap. I'm sure you're going to find variation within, there's going to be some oral surgeons that aren't as good as others and periodontists that aren't as good. 

Howard : I like to point that out. I'm a hundred percent Irish, had two parents, four grandparents, and a lot of people were racist against Irish and say that we're all a bunch of drunks, and I just want to say that only thirty-eight percent of Irish are alcoholics. 

Nancy: You have to insert your inspirability.

Howard : I want to ask you the next question. Bone grafting, what percent of the cases do you have to bone graft? It's one thing to learn how to place an implant; it's a whole other to learn how to bone graft. Are you bone grafting?

Nancy: As need be, but I don't find that terribly difficult either. This is how I explain it to a patient, because the patients get freaked out if you say bone graft. They go, "Bone. Oh bone," like bone is like scary. I say, "Well we might have to use a bone graft. This is how it works. I'm just taking your tooth out and there's a hole there, and I want there to be enough bone in the hole for when a few months later we put an implant in there." The bone, if you look at it, it comes in a little jar and it looks like kosher salt.

Howard : Kosher salt?

Nancy: I think it does. Freeze dried bone, mineralized bone. Yeah, you want to put it in patient terms. I say, "I'm going to take that bone." 

Howard : Give a name brand to these people. What type of bone are you using and where would they buy this?

Nancy: You know what, I'd have to go ask my dental assistant honestly.

Howard : Is this cadaver bone?

Nancy: Cadaver bone, yeah. I know we get it from a place in Ohio that's not one of your big name companies. I think it just came out of Jerome's course. I order things because of that. 

Howard : Your local rep may be able to give you a source.

Nancy: Absolutely. I tell them that my dental assistant is going to take some of this and they're going to mix it with some sterile saline, or some water, and then I'm going to put it in the hall. Then I'm going to put this little covering over it, the collagen plug thing and then I'm going to put the stitches over it. That's the bone graft. I'm not taking it from you, from another part of your body. I don't know if that's what they think.

Howard : You said you use Megagen, what do you think of their new tooth crusher, that $2,500 deal where you pull the extract tooth, throw it in there, close the lid and it turns it to mulch in one second, but since it's all ground up it's like three times the volume and then they're using that for the bone grafting.

Nancy: I have not seen that. I know you just went to the meeting, so you're ahead of me. I got to talk to Joel about that one.

Howard : Yeah, I thought that was pretty interesting. It reminded me the last scene of Fargo. Did you ever see that movie?

Nancy: Yeah.

Howard : That was the ultimate bone grafting solution where you graft the whole body in a wood chipper. Then I want to keep going on this deal. You said the low hanging fruit was a first molar, which also happens to be the most missing tooth. You get one that's been pulled the last five years so there's bone.

Nancy: Young healthy patients, somebody that's got a good open, that can open.

Howard : I always recommend also, I always says use a family member. Come on, you've got a whole pedigree of ape research between your uncles, and everybody's got a few uncles where if they had an accident and the implant went south, he wouldn't even care. He literally wouldn't even care.

Nancy: What we did is, I didn't have family members locally to practice on, so to speak, but we just told our patients, that Dr. Duque is just venturing to place some implants, we're going to be placing some and if you'd like to have yours placed we're going to give you a discount on the implant.

Howard : Right on. If I was a patient and you said, "Howard, you're missing that lower first molar and we're going to do an implant," would you just shoot them a whole case fee or would you sit there and itemize? Would it cost more if you were going to bone craft around my tooth or not, or a membrane? Is it one fee?

Nancy: We give them quote/unquote the "worst case scenario," which means my office manager will say, "You need an implant, and first you're going to need a CT scan and it's this much money," and then we all go through the surgical guide, costs this much. If we don't use it, then we don't charge it. We put in the bone graft and we put in the custom abutment even though we might end up using pre-fab abutment. 

Howard : Furthermore, why are you doing this? Do you just feel it's a better service than a three in a bridge?

Nancy: Oh absolutely.

Howard : Talk about that. Why?

Nancy: Because I don't want to cut down the teeth on either side if there's no need to. If you got two virgin teeth there, why am I going to prep them for a bridge? Because the implant, if we just put the bridge on there, the space where the missing tooth used to be is going to continue to have bone dissolve over years, and so that bridge that we make now might get a gap under the false tooth of your bridge. It's a pain to false. You have to use the false threader. I go through all that with the patient.

Howard : No one uses the floss threader.

Nancy: No, I know.

Howard : I bet the only people that really use a floss threader in their bridge, I bet both of them are hygienists.

Nancy: Right, and when have you ever seen a hygienist with a missing tooth that had a bridge? Yeah, I know. I have a model that shows that you get from one of those [inaudible 00:50:53] or the informational tooth models, and it's got the two teeth prepped as you would for a bridge with the little bridge on it, and then the other side of the arch has got an implant with an abutment and a crown on it. I go, "Well I can do this bridge and this is what I have to do to the teeth on either side." There are times when a bridge is a better way to go. They're missing number three, they've been missing it forever, and there's two millimeters of bone between before you get to the sinus. I don't do sinus lifts, so they're going to have to go get that done. Maybe number two got a huge filling in it, number four has got a huge filling in it, so you know they're heading for crowns down the line. Okay, maybe a bridge is a better way to go there.

Howard : You're not a black and white extremist or indications for both.

Nancy: No. I just look at the situation and I try to know what if it was me or my mom or my dad or whatever. I just put two implants in my dad. I gave him a partial denture a couple years ago before I learned to do implants, and now he's got implants and he loves them.

Howard : I want to ask you another question about implants. A lot of times when the dentist comes out of school and buys a practice, you got to look for the hidden value. I can give you names of twenty, thirty guys over the last twenty-five years that found some old man who hadn't even found a tooth in thirty years, and all they did is these big old MOD BL amalgams. They bought this little three operatory practice, one hygienist chair, and on average every day about three or four of his patients with a big old MOD BL amalgam broke in half, and they just come in and simply do a crown. These guys sat on a PFM machine and they were just doing four PFMs a day at $1,000 a piece, it was like they won the lottery.

The other one I've been seeing more of and more of and more of this these kids, someone will learn how to place implants and will go buy that Denture World that's in downtown that they've been making flippers, and all they do is Denture World and these dentures come in small, medium and large, $299, $499 and $699, and they'll go by the Denture World, but then they'll say, "Oh but for $49.99 we'll place two implants or $99.99 we'll place four implants and a bar." These little Denture Worlds that were doing about $350,000 a year now they're doing like $3 million a year. I want to ask you more specifically about this.

A lot of these people driving to work placing their first implant might be thinking, "Well I get a lot of people that have a loose lower denture. Is that low hanging fruit, placing two or four implants with some either ball and locators? Is that low hanging fruit or do you think that's advanced?

Nancy: Well I have no experience with it because my patients have teeth. Now I can't speak to it. 

Howard : You're saying your affluent area of ...

Nancy: My demographic, if they happen to have a denture they probably already have the implants in in a surgeon place. My patients have teeth. I'm doing a denture right now because this little old lady who's ninety-four years old lost her denture at the nursing home and she can't find it. I'm making a new upper denture for her. This is the first one I've done in, I don't know, twelve, eighteen months.

Howard : Did you do a search on Craigslist to see if someone's selling it.

Nancy: Yeah, I know.

Howard : Poor old lady.

Nancy: She's got a teeny tiny mouth so there'd be a lot of potential that it won't fit anyway.

Howard : Someone threw it away at the cafeteria. You're saying you don't know because that's not your patient base.

Nancy: That's not my patient base. Now what I do miss out on is I like doing surgery, oral surgery. I do mostly third molar extraction because I have college kids and that kind of stuff, but the people are keeping their teeth. I do get occasionally the person that got a vertical fracture on number five, and so I take it out and they're going to have an implant.

Howard : I want to go back to your clinical mix. Are you doing endo?

Nancy: Uh huh, I do endo. I tend to refer the upper molars to the endodontist across the parking lot because I don't have a microscope and it's upside down and sometimes you can't open very well and I just figure they're going to get a better job there.

Howard : Are you referring any of your endo to get a CBCT?

Nancy: They have one in their office, so if they're going to need a CBCT for endo, they'll probably get the endo done over there anyway.

Howard : Do you like endo?

Nancy: Yeah, I do.

Howard : What do you like more?

Nancy: The pretty straightforward endo.

Howard : Put in order what you like the most, molar endo, pulling a wisdom tooth or placing an implant.

Nancy: All three are probably high on my list.

Howard : Think about she's saying, is look at the nine specialties. Endodontists have thirty-five percent overhead. It's not about your gross, it's your net. Endo's very lucrative. Oral surgeons are the next on the list who are forty percent. Extractions and implants are very lucrative. The thing I'm telling these kids is when I go into offices and there's a lot of busy, there' s a lot of work, but they can't even pay they're taxes at the end of the year, it's all fillings. It's all MOD composites.

Nancy: That's my worst nightmare, when someone needs MOD, MOD, MOD and a whole quadrant of them.

Howard : Not only is that a lot of work, but probably when it was all done, whatever you build out you probably didn't make enough money to go buy a Mexican lunch at the Mexican restaurant up the street.

Nancy: Absolutely.

Howard : It's just all overhead. It's all overhead, it's all slow, it's all time. If you're going to learn how to make net income, you're going to have to learn to make dentures or partials or place implants or remove teeth or do endo. If you just say, "I'm not going to do any of those things," now you're just down to a crown. 

Nancy: I know.

Howard : You're just down to a crown. I only got you for three more minutes. Any other advice on these kids' graduating in gosh, literally next week. In fact, I'm going to the graduation, it's next Thursday.

Nancy: I think that you have to be creative when it comes to finding a job, and don't just rely on that someone placed an ad. Well before you got out of dental school, if you've identified where you want to live, go around and knock on doors and meet these dentists. Go and talk to the specialists in that town. Go and talk to the dental labs and the dental reps in that town. Those are the people who are going to know the good, the bad and the ugly about the dental community, and get to know those people. I mean network, network, network.

Howard : That's great advice. Go backward. The lab's dealing with twelve dentists in your neighborhood. 

Nancy: That's true. They're going to tell you who's the busy guy and who's got good work. Ask them to see the models.

Howard : I want to throw a plug in for Dentaltown, the fact that the classified ads on Dentaltown are very robust. We get about a thousand unique dentists per day and they're all free. There's dentists that are putting ads up, looking for an associate, and you can also put an ad up for you with an associate. You can upload a photo. You can upload your resume. You can upload all that, so the Internet's good.

Nancy: Yeah, if I were looking for someone, I would love to just get on Dentaltown and go "Hey, who are the potential candidates?" 

Howard : Another great question is say you were going to move into a small town. A great question to go ask is you go in and you find the manager for Shine or Patterson or Burkhart or any of those and ask them this question, "What part of town are dentists calling wanting to add an operatory, and what part of town is your account receivables over thirty, over sixty, over ninety." If you ask everyone that in Arizona, they'll say well pretty much all the bankruptcies over thirty, sixty, ninety is all in North Scottsdale, and everybody that's adding an operatory or expanding is all out in West Phoenix and out on the rural twenty miles away from town.

Nancy: Of course. It was the same thing here, but I'm in the North Scottsdale of San Antonio where these kids are coming out of school and they're building a $600,000 office and they're seeing one patient a day, but they think if they hang in there long enough it's going to get better.

Howard : The more that you get out and scream about it, the more you'll stop it, even if you stop one guy from going up the street. That 2008 meltdown, Arizona had about eighty bankruptcies and like sixty of them were North Scottsdale. The other thing bad about the affluent area is that acre of land only has like one house and three people living in it. Whereas when you go to the poor area, an acre of land might be an apartment complex with fifty people living there. 

Nancy: I've heard there's a little town maybe twenty, thirty miles west of here that the periodontist that I utilize, he'd been going out there one day a week to do perio, and I guess they have one dentist in town, didn't pull any teeth. This isn't that far out of a major city.

Howard : I know. We still have Eloy, Arizona, which is thirty minutes from Phoenix still doesn't even have a dentist. It's crazy. Hey, I am already into overtime. I'm out of my limit. Nancy, seriously thank you so much for taking an hour out of your day.

Nancy: You're welcome.

Howard : It was awesome meeting you at the AADOM in San Diego. I might do the Nashville one since you said it.

Nancy: Yeah, come to Nashville.

Howard : It'd be fun to see the meeting and even twice as much fun to go to the bars on that street. It's just amazing music and all these artists that come from around the world trying to make it big. They want t perform where all the talent scouts are. It's just a rocking hot atmosphere. Hey, thank you for your posts on Dentaltown, for being a townie, for all that you do and thank you very, very much.

Nancy: Okay, take care.

Howard : All right, bye-bye.

Nancy: Bye-bye.