Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
How to perform dentistry faster, easier, higher in quality and lower in cost.
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1113 Building Your Practice with Dhiren Agrawal, BDS, MPA, DMD, FICOI: Dentistry Uncensored with Howard Farran

1113 Building Your Practice with Dhiren Agrawal, BDS, MPA, DMD, FICOI: Dentistry Uncensored with Howard Farran

11/29/2018 2:06:34 PM   |   Comments: 0   |   Views: 352
Dhiren Agrawal, BDS, MPA, DMD, FICOI, earned his first dental degree in Gujarat, India, before coming to the U.S. and obtaining a master's in public administration with a healthcare minor from Fairleigh Dickinson University. He then went on to receive his doctor of dental medicine from Boston University. He is an active member of the Lake County Dental Association as well as a Fellow of the Academy of General Dentistry, the American Dental Association, and the International Congress of Oral Implantologists. Dr. Agrawal has engaged in ongoing postgraduate education with a focus on implant dentistry, including masters level seminars. He also has specific training in sleep apnea treatment, which allows him to help his patients achieve a better night's sleep without the use of a CPAP machine. His commitment to lifelong education means he is constantly evaluating emerging dental methods and technologies in order to provide his patients with the best results in the least invasive manner with a high emphasis on comfort. This commitment ensures the highest level of care, both today and tomorrow. Dr. Agrawal is also a member the prestigious Academy of General Dentistry and has earned over 600 hours of continuing education credits toward his fellowship.

AUDIO-DUwHF #1113 Dhiren Agrawal

VIDEO-DUwHF #1113 Dhiren Agrawal

Howard: It's just a huge honor for me today to be podcast interviewing Dr. Dhiren Agrawal BDS, MPA, DMD, FICOI, he earned his first dental degree in India before coming to the U.S. and obtaining a master's in public administration with a healthcare minor from Fairleigh Dickinson University. He then went on to receive his doctorate dental medicine from Boston University. He is an active member of the Lake County Dental Association as well as a Fellow of the Academy of General Dentistry, the American Dental Association and the International Congress of oral implantology. He has engaged in ongoing postgraduate education with a focus on implant dentistry, including masters level seminars he also has a specific training in sleep apnea treatment which allows him to help his patients achieve a better night's sleep without the use of a CPAP machine. His commitment to lifelong education means he is constantly evaluating emerging dental methods and technologies in order to provide his patients with the best results in the least invasive manner were they high emphasis on comfort. This commitment ensures the highest level of care both today and tomorrow. Dr. Agrawal is also a member of the AGD and has earned over 600 hours of continuing education towards his fellowship. Thank you so much for coming on the show.

Dhiren: Thank you, the pleasure is all mine Howard.

Howard: So what year did you graduate, how long have you been out?

Dhiren: I graduated in 2013 from Boston University so this is my sixth year out of school.

Howard: Well that's awesome and I've been out of school you know my office is over 30 years old and so many of the listeners are about 1/4 of them are still in dental school and the rest of them are pretty much all Millennials. I hardly ever get an email from someone who's a grandpa like me with six grandchildren. So now that you're six years out and you can relate better to those dental students and those people just coming out of school. What advice would you give to someone who's coming straight out of school, do you recommend that they go get a job at a DSO what do you recommend there steps out of school should be?

Dhiren: I would say that they should try to as much clinical experience as possible within the first two or three years because that helps them get into their own private practice down the line helps a lot. So whether it's DSO, there's a private practice doesn't really matter. I myself started at Aspen, I worked there for three years and I got a lot of clinical experience in a very short period of time a lot of surgical experience I learned their systems they're great systems in place, they do a lot of marketing a lot of business insights how to train the staff, they have a lot of checklists for the front desk for the office managers for the dental assistants. So all that is very helpful down the line when you when you in private practice so that's what I would tell the new grad to do.

Howard: You know it's amazing I see some of these dental students walk out of school and they'll go work for a big DSO like Aspen and they'll do their entire dental school requirements every month they said 50 fillings 50 extractions 15 canals of endo and they're doing it every month now that's just incredible.

Dhiren: Yes that is so true, yeah I actually in Boston University we didn't get a lot of clinical experience so for me at Aspen I was doing pretty much the clinical requirement less than a week which I did in two years. So it's so much work out there.

Howard: In a week?

Dhiren: Yes

Howard: That's amazing

Dhiren: You're prepping four, five crowns a day you are probably 20 30 teeth, you are doing new patient exams of six seven patients that's a lot of experience you get which is better than most AGD's out there.

Howard: So you you stayed with them for three years with Aspen?

Dhiren: Yes

Howard: and who's the CEO is that...

Dhiren: Bob fontana

Howard: Bob fontana, did you ever talk to him or meet him?

Dhiren: Yes when I just joined them the second week day they flew me to Syracuse where their headquarters is and you get to meet all the CEO the CFO the COOs. It's a one week on wording, they try to teach me you the model, how to what they want to do what the philosophy of treating the patients is different kind of dentures they made different kind of packages and all that so yeah you get to meet all of them.

Howard: and how far is Syracuse from Amherst New York?

Dhiren: I have no idea.

Howard: Because Amherst is where Ivoclar was and this is a long story but I'll make it short. Last time I was at Ivoclar anyway friend and friend went to dinner we drove over we went to Syracuse we're having dinner and as the guys leaving he points across the street he says that's where Bob Fontana lives and I'm like dude white you know let's go over there right now and he goes no we can't crash his house but I've been trying to get that guy on the show do you think there's any way you can call them or send them an email and tell them to come on the show?

Dhiren: I can try I know quite a few people who are in there in the company, work for the company so I can try and see if he's willing to talk.

Howard: Because what I love about Aspen is they seem to be the only DSO that's really focused, I mean they they tend to go where the competition ain't there they tend to go where there's a large number of Medicaid patients and all the general dentists are flocking out to rich Scottsdale and they want to go where all the lifestyles of the rich and famous and then they find these big voids in the market where there's a lot more dentists per a thousand I mean a lot more patients per dentist and did you do what would be do you kind of agree that Aspen is more focused on like a Medicaid population?

Dhiren: Yeah absolutely not just a Medicaid population is just it's just like like you said private practitioners are mostly focusing on the higher patients and Aspen is filling the void by bringing a lot by going to the patients and telling them that we can fix your mouth you have bad teeth and they're not gonna judge you this is a no judgment zone if you look at the market and compare they have no judgment zone kind of stuff so a lot of patients who come there they they are afraid to go to private practice because they feel like they are scared also ask them what they do is the finance to the third party to Care Credit through the teaching the second company but the first year is Cair Credit and a lot of patients come in to get the treatment done because they think that they can finance five ten fifteen thousand dollar of Dentistry which they don't have sitting there bank account and get the work done or easy monthly payment. So that's another thing which Aspen that's a great thing about because once you start doing that in a private practice, once you start breaking down those huge treatment plans it was easy monthly payments it's easy for you to do those comprehensive treatment in your private practices now so then when the private practitioners are complaining about the Aspen taking their business I don't think has been stealing business from the marketing expenses growing business it's just increasing the market share by select industry which would not have been sold in the first place and that's why they do that's why they don't even make you sign a non-compete you can open a shop next no to them because they know they are going to do well regardless of who is next to them.

Howard: Wow that is amazing is Aspen the only one that doesn't make the doctor sign a non-compete?

Dhiren: Yeah I think so because most are DSO's want to five ten mile radius non-compete but as Aspen doesn't really care you can open right next to it then you can lead them and then you can open them and sue you nothing they require you to give a 90-day notice if you don't they don't really care the doctor and they'll start doing dentistry.

Howard: You know your attitude determines your altitude its attitude is everything. I always cannot believe when I hear some dentists complaining because they're an associate ship as some DSO and I'm like dude the average dentist can't even manage their own office and these guys our managing 50 a hundred, Heartland 900 offices Pacific dental 500 offices. You're telling me you can't learn the business of dentistry while you're getting all this clinical experience every forum they have was probably hammered out over years by several really smart operations and logistic people so I just can't believe people don't see that as the glass half full.

Dhirem: Yes I mean dentistry is a half business half clinical skills, you need to have both if you just have clinical skills and you're not thinking about the business part of it then you're gonna struggle to do really well but I think when you work for a DSO and you keep your eyes and ears open and see what they're doing you can take a lot from those and implement in your private practice and still do really well you don't have to do everything they do but they have a lot of things a lot of systems in place which the private practitioners don't really look at all and not even aware of it and that's why DSO's do great and their's a reason why they have so many offices they have to be doing a lot of things right.

Howard: So Care Credit was their primary finance what was their second choice?

Dhiren: They changed their financing I think they were using GreenSky at some point I'm not sure there was one more after that it was two and a half years ago but they were using GreenSky and I use in my practice I use three financing also I use Lending Club which is primary Care Credit I found the fees they charge of the practice is really high it comes out to ten percent on average which are paid to Care Credit. So the in my practice I often Lending Club which is the primary the secondary is a GreenSky which is also really good and we are Care Credit it is a lot of patience use Care Credit for their other medical needs they use you know they use for a birth they use eye doctor for you know whatever so they already have it so that that's why we accept it but we don't really offer it as a primary finance because the fees are a little bit higher for private practitioner.

Howard: That company I mean they were owned by GE I never thought I would see GE trip and fall down like it has over the last couple years they've spun off care credit but you said you think care credits about ten percent of total costs what do you what do you think the total cost is for a Lending club or GreenSky?

Dhiren: Lending Club is about 5.8% on an average that's what I pay in my practice. We did about four hundred thousand or financing this year and Lending Club and we paid about 23,000 in financing fees year-to-date so Lending Club is pretty good. GreenSky pretty much similar 6.5% of the practice but the good thing about Lending Club is they don't have a flat finance charge like Care Credit will charge you 10% regardless of the patient's credit score so whereas Lending Club if a patient has a good credit then you won't really get charged a lot of fees. Sometimes you pay a 3% fee on a patient who has a great credit so if you are financing $10,000 then you fee is only three hundred bucks but with Care Credit regardless of the credit score  the fees is ten percent.

Howard: So do you think when you were at Aspen their really big in promoting NASCAR then they advertise a lot of NASCAR does that do you think that really brought in new patients to your office when they're out there do the NASCAR thing?

Dhiren: All the patients why they came to Aspen there were two primary reasons where the patients came number one was we accepted their insurance because Aspen would except everything under the Sun except Medicaid they would not accept Medicaid but they would accept all HMOs all PPOs, all kinds of plans so that was number one reason why majority of the patients came second came for free consultation it was a free consultation so if they need dentures they would come in for a free consultation. A very small percentage would say they would come because of NASCAR but when I was there they were starting out there at that time and they had that Patrick lady when I signed up for the brand ambassador before that they were just very small level but now I think they've got a bigger with NASCAR over the past two or three years so I think now they get a lot of my patients from NASCAR.

Howard: So after three years at Aspen then what did you do after you left Aspen? What was your journey until you finally owned your own office?

Dhiren: I was working in an implant practice, the owner had two practices I was working one and he was in the other practice and I was looking to get my own practice when I left Aspen but for me I'm on a work visa so it's very difficult to own your own practice on a work visa, their is no clear path for someone from India to get a green card they come on work visa so for me it was very difficult to be able to own a practice because we don't get business loan, when your on a work visa you don't get a business loan from the bank so I was saving up some money so I can buy a cheap practice because I cannot really afford to buy it.

Howard: Now are you still on a work visa?

Dhiren: Yes I'm still on a work visa but now they have investment based categories so you do sell a lot of investment creates American jobs then you can apply and then can get Visa after like two or three years she keeps increasing after Trump came in so he's increased instead of three months now we have to wait two years to get a visa so next year and hope I have dont what was needed in terms of investment and American jobs and all that.

Howard: On behalf of the United States of America I apologize profusely for your struggle I mean that what the the single biggest irony I have in economics and not just me but you hear from Milton Friedman and all the great economist is that if you ask anybody on earth what made the United States the biggest economy in the world and it was because of open immigration for 500 years and when humans vote on their feet and they leave their mother country and go to another country they are a cut above the cloth and ambition, intelligence, risk-taking. You look at all these startups almost all of them like 80% or more we're not born in the United States America and if you truly wanted to see the United States ever return to double-digit growth in the 10th percentile you would open back up Ellis Island and yet they're taking the exact opposite turn and they're trying to shut down immigration and then the journalists don't do the jobs because you know they're always whining about some small town and the company you know it's a town of 5,000 and the employer that owned 500 they shut down it's like well continue the story who started that company if you go back a hundred years ago some man came all the way from Armenia and opened up that company and it was the biggest employer in town until you know now that guy is dead and takes about three generations for the kids to ruin everything you created and it's like well how or right now that guy that started this factory that you're crying about closing he couldn't even come from Armenia or India or Vietnam or China and they don't realize. I mean they just they can't they think in fear and scarcity that if someone comes in this country they're gonna steal a job and what they don't realize is that a quarter of them a quarter one in four start their own company but if you're born in this country it's about 1 in 18. I mean it's just so frustrating when you see your country going exactly the wrong way in fear and scarcity and saying look though you came over here from India and you've started a business how many employees you have?

Dhiren: 8 employees right now.

Howard: Yeah you come all the way from India and you created 8 jobs and what's the chance those eight employees working for you would ever start a company that had eight employees?

Dhiren: All

Howard: I would pull my hair out but I can't because I don't have any hair to pull out but if I had as much good-looking hair as you I'd be ripping it out of my head but and I don't call this politics when people say don't talk about politics keep it on dentistry, it's not politics dude its economics it's business and if you read any of the classics you read any of the business cycles you read in anybody that's got a nobel prize in economics does not believe in limiting immigration. So we'll move on there but i'm good luck on getting your green card thank you for joining the american team coming all the way from India that's amazing. So now you have your own practice so again back to these Millennials when that when they come out of school and there's and say five years out they're gonna own their own practice like yours. What type of dentistry should they start learning what clinical skills, I mean they come out of school there's so many things to learn there's so many Institute's on your journey where what clinical did you recommend that they learn more about?

Dhiren: Implants hands down is the number one thing they should learn. Get as much surgical experience under your belt that make learning implants very easy implants are so easy to do it says it's just the most Millennials now nowadays the dental schools don't train so you can do extractions so when they come out of school they don't have that kind of experience they're scared to do implants they're scared to do you know full mouthpieces and stuff like that but implants hands down is number one. I would say Invisalign and Six Months Smiles those are also really good and will build up your practice because I was actually fortunate that I started working for Aspen because I learned they taught us to do comprehensive dentistry on every single patient that came in. So you presented whatever the patient needed and then you made treatment plans based on that and that kind of just was my point now because when you come out of dental school you don't really have the confidence to present five ten fifteen thousand dollars of treatment plan to the patients because you yourself don't have those clothes and you don't see the do you feel like you'll be able to see the case through and once you develop those skills the pathology is out there are patients who need that work and once you develop the model and implement financing and those kind of things in the practice will be successful.

Howard: but you know it's so bizarre how so many dentists say they just they don't want to sell they're not salesmen they didn't go to school eight years to be a Salesman and here Aspen which has how many offices right now?

Dhiren: I think they have 600, 650.

Howard: 650 offices under Bob Fontana and he's teaching you comprehensive dentistry and to present the whole treatment yet you're talking to a bunch of dentists when if you walked in their office they had 28 teeth and every one of them had a cavity they would just look for the worst cavity there and say well let's just start with this one and do a root canal and a build up in a crown how do you how do you get a dentist from going from one tooth dentistry to comprehensive full mouth dentistry which Pete Dawson has been talking about for literally 50 years.

Dhiren: Well they have to see the value in their own service before they have to see it's not if you if a patient needs a five or ten thousand dollar work it's not your fault as a dentist it's the patient's mouth their habits their neglect that got them their. It's your responsibility as a dentist to present whatever they need and then if the patient decides to choose it like you say yeah once it needs if the patient has the money once it needs it's the same thing you got to do when you when patient comes to you you don't have to worry about the financial aspect of the about the patient for example I had a patient who came to my practice last week Medicaid patient we don't accept Medicaid but he came in and he's like I want to get dentures I want to get implants done and I made a treatment plan for him about $25,000 and and he had good credit he applied for it and he got approved and he accepted the treatment he said like I just bought a truck up a couple months ago which was $60,000 now ford doesn't feel bad when a patient someone goes to them and sell them a $60,000 truck and they don't worry about the person's income it's what they want so basically I feel that dentists should also look at it the same way it's not bad to sell dentistry, the person's gonna spend his money one way or the other. So if they have a healthy be able to enjoy the life a little bit better.

Howard: that Americans will buy 13 new cars between the ages of 16 and 65 with the average new car costing $33,000 and then 95% of all dentists in the United States will go their entire career without ever doing one treatment plan that's as large as the median price of a new car $33,000 and in every county in America where every but every dentist is complaining my people don't have any money in my area you go look at you go to any grocery store and there's all these new cars they're all buying and those cars are all financed over 60 months less than 10% of cars are bought in cash they're all financed over 60 months and that dentist can't do that one time. What would you say to that dentist?

Dhiren: not presenting is defective to the patient is also in terminates a neglect neglecting the patient's needs so you should believe in your skills and you should believe that what you are providing to the patient is worth it.

Howard: The first thing they're gonna say is oh you don't understand I bet he's practicing in a really rich area you're actually halfway between Orlando and Gainesville is your city lifestyles of the rich and famous?

Dhiren: No that's a big misconception actually what I've noticed is the patients who have the money who drive the most expensive cars they are the most difficult to sell the easiest sale is the patience that make between 30,000 to $90,000 a year and they accept the treatment if they can afford the monthly payment the patients who can pay down cash those are the toughest sales per day like anything and I hate treating those patients so those are not my target patient population.

Howard: and when you do installment credit how many months is the usual term?

Dhiren: So we offer six months interest the 12 months interest fee and if there were interest plans it can go with Lending Club you can go up to 72 months.

Howard: 72 months?

Dhiren: Yes Lending Club is the only financing company which would give 72 months, Care Credit maxes out at 48 sometimes I'll do 60 month in it's about 15,000 I think and but learning from the go if it's about 10,000 you can go to 72 months.

Howard: Holy moly and is that very common in your practice?

Dhiren: Yes we did about four hundred thousand this year and most of the treatment are about 10,000 with Lending Club.

Howard: So that's six years the the average the average car is gonna be 60 months Lending Club will do 72 months which is six years. I mean it's just a game changer when you can do that I mean when you can walk in the room you know most of us walk in the room and you know the person has 20 cavities they need three root canals and crowns and all this stuff and they go well I'm sorry but your insurance will only cover a thousand so we can only fix the most rotten tooth in your mouth today and then in the same medical della building next door somebody walks in there says hey congratulations you got excellent credit we can do everything you and the doctor talked about for just three hundred dollars a month for 72 months and the patients that are laying oh my god three hundred dollars and I'd have a moviestar smile and all my teeth fixed up that would just be awesome and then to think that 95% of the dentists will never do that one time in their entire career.

Dhiren: It's just bizzare why they wouldn't want to do  it it just makes practicing dentist is so easy because you're worried about it and then you make a treatment plan and then the patient gets lost then they come here a treatment plan a year ago because of the PPO insurance and the PPO is still a thousand bucks it just doesn't make sense to just spit out the treatment over the period of a year or two whatever they can finance it's best to get it done and that time that way they save money long-term that's what I believe if you need something hang in there it's not gonna it's just costing more money.

Howard: and what's so sad is when anybody gets a new car they always drive it over to your house they always want to show you you always have to get up and walk out on the street and they always jump in there and turn on the radio and they're all excited and all this stuff and they'll go through that excitement 13 times in their life yet I mean I've had I remember one time I cemented a full case on this beautiful young lady she was probably about I don't know 45 and when she looked in the mirror she had to take a knee. I mean she just bent over in tears I mean she couldn't leave that her mouth was brand-new I mean she she couldn't talk for five minutes and these dentists will never do that because they can't do installment credit they can't think like a business person.

Dhiren: It's just not right you have to be able to finance if you want to be able to do if you want to be extracting all the teeth doing dentures that's a full month we have that's still a lot of money. So it's if you finance it's just easy and the other thing and the other advantages that builds up your practice very quickly in a short period of time because if someone spends ten twenty thirty thousand dollars in their mouth their going to go tell their friends and that's what every for you the patient. So that's how you build up your practice sooner if we're doing $100 filling all day long that pitches I'm gonna talk to the angle of committed one costly this ten grand top ten to twenty people invest ability practice really fast. So I think that's another practice builder because if you're not doing that then you're not getting the cases in your practice routine basis.

Howard: You know another thing all the dentists want to talk about like clear choice and all on four and all this high-end dentistry well they always want to talk about all on four well all on zero which is a denture is ten times bigger market than the all on 4 and I see on your website which I love your website it's called you talk about custom dentures. I can't tell you how many dentists never ever want to do a denture the rest of your life what do you do more dentures or all on fours?

Dhiren: If I do 100 dentures I do two cases of all on fours some cases I get patients from Clear Choice I actually think Clear Choice is a great practice builder because they do marketing for your practice, they bring the patients they are doing 60 70 , sixty thousand dollar treatment to a patient and then they come to your practice and then they want extraction that just maybe two implants and they're happy to get it done for twenty thousand case will never come to your practice if your choice will not sell at $60,000 cases. You're not able to get the capture that wanted in the first place so I don't think Clear Choice is a competitor I have gotten three or four patients this year for clear choice and they didn't want to spend sixty grand but they spending 15, 20, 25 thousand dollars each for just regular dentures, it's a great market. I don't think Clear Choice eats up the market I think they are creating their own market share.

Howard: Absolutely and the reason you think that is because you think and hope growth and abundance you don't live your life in fear and scarcity. I remember when clear choice came here I I knew the when they when I saw their first commercial which periodontist and oral surgeons were gonna think it was the end of the world and the sky was falling and then and I knew which ones would love it and they weren't even open in this town a week and you already heard patients coming in on a recall saying oh I saw on TV blah blah blah and you could tell that was the first time they'd even thought about this a rising tide lifts all boats have you thinking I hope growth and abundance and it's just a way to live I mean thinking and fear and scarcity it's just insanity so let but I want to go back to that millennial. So did five years out of school you bought a practice right, and you it was about and how much did you what were you able to do to the revenue that office if you bought that office and was doing a dollar how long what was it doing the next year the third year?

Dhiren: So I got the practice last year in August and because of my work visa I was not able to work there for about five months because I had to transport my via to the practice and all that so I had an associate who was there who was willing to help me out, young dentist, really good dentist, so I told him my situation that I bought the practice that I need about four or five months so he said ok so he managed to practice for me for five months and this in January I started working there so this is my eleventh month in the practice. The practice lets say if it was doing $1, its doing $3 right now. I grew it by three times just by marketing and just systems in place then you can financing itself it was relatively new practice it was just nine years old it was only a denture practice the dentist who sold the practice only did dentures. He did little surgical procedures even for extractions he was referring it out. So when I saw the practice I just knew it that this is just the kind of practice I want because I do that from day one who ran back to the practice in the last five years sent patients letters and in the first two months we started getting patients that know dentures and getting two implants on the bottom and started getting. So that the first couple months that helped me out it that we started marketing started getting a lot of patients through marketing and now by doing a lot of the large cases started building the practice and we get a quite a few patients from there so yeah that was a pretty straight forward.

Howard: So what year were you born?

Dhiren: 1984

Howard: So in 1980 I was a freshman in college when you were three years old and it was the worst economy I'd ever seen in 1980, you had 21% interest rates you had double-digit inflation double-digit unemployment stagflation it was just horrible after four years of Jimmy Carter was just absolutely horrible and you just talked about you bought this business and you couldn't even work it for five months and in 1980 we got a new president it was Ronald Reagan and you know what he did one of the first things he did not only did he do the tax cut not only did he do the deregulation but he opened up amnesty and three million Americans got amnesty and what did they do them and if they got a MC they went to work and they went open and said having an underground economy now they could borrow money and finance and pay taxes and he that was the biggest economic, you know 1980 was that and then an 87 I graduated May of 87 then October 87 was Black Monday where the market fell a quarter and then that was the longest dispantion all the way to the y2k bubble in March of 2000. Then I went through Lehman Brothers in September of 2008 so I've lived through 80 87 2000, so I've lived through four crashes and the 1980 one was the worst and the biggest part of that solution was Ronald Reagan given amnesty to all the people that were living here underground and it was 3 million and if they did that today it'd probably be 10 million and instead of our 20-year anemic growth of just about averaging about two and a half percent growth a year for the last two decades it would immediately go to five or six and if you just flat-out told the world Ellis Island is open it'd probably grow at ten percent for as long as you left it open it just again I'll quit getting into that. So this kid comes out of school and I'm telling you what what he's thinking listen this he she's commuting to work she graduated last year and she's saying okay you do dental implants how the hell do I learn that you do dent you're talking about dentures I did two dentures in dental school how does she learn step by step how does she learn implants and dentures where would you start her off at?

Dhiren: I started right out of school, even before I started the job at Aspen I signed up for the implant course because I worked as assistant before heading to dental school because the dentist I worked for before that did implants so I knew that I need to do that. So any course you can do any course which is closer to you so you don't spend a lot of money traveling and flying and stay in hotels and all that so so that would be some basic understanding of the implants and get some go to a life surgical implant placement program there are bunch out there there is a live implant seminars with Dr. Mongalo there is a transudate the New York implant Institute that's in Dominican that's really good.

Howard: Which course did you just recommend? What was his name?

Dhiren: His name is Dr. Mongalo

Howard: This is what you're recommending where is he where is it it says, the best live dental implant course work on patients.

Dhiren: He just moved back to Dominican Republic they were in nicaragua and then because of the rise they had to move down to Dominican Republic this year so that's a good course to take.

Howard: Right on and you did that course?

Dhiren: I did I did Arun Garg course in Santo Domingo because it was closer to me and I at that time was living in Melbourne and it was only a two-hour drive from my place so I did his course I did the whole continuum for two years.

Howard: Your still talking about Dr. Mongola?

Dhiren: No I did the Garg's course for two years.

Howard: Oh are you saying Arun Garg?

Dhiren: Yes

Howard: So you did Arun Garg first and what's his course called?

Dhiren: His is called Implant Seminars

Howard: Implant Seminars then you did Virgil Mongalo?

Dhiren: Yes and his course I find Mongalo's course a little bit better than Gargs course because of the faculty-student ratio and it's more interpersonal. Garg is a much bigger undertaking the quality is a hit or miss over there so I'm not a big fan.

Howard: and where does Virgil live?

Dhiren: He's based out of Miami I think

Howard: That's where Arun's out of too.

Dhiren: Yes

Howard: I wonder why all those big implant guys are all out of Miami like Arun and Virgil is it because of access to foreign countries and the Caribbean for training?

Dhiren: It's possible because it's just a two hour flight to Dominican from here so it makes a lot of sense to have a center over here in Miami so.

Howard: Are they is are both of those guys are they implant system agnostic or does Arun Garg and Virgil recommend a certain type of implant system?

Dhiren: So Virgil he likes the Blue Sky Bio Max, he likes that and Arun has his own system vision implant system it's a knockoff of Zimmer so the...

Howard: Zimmer is out of Florida so are they just private labeling him is own implant?

Dhiren: No, he has different manufacturing so it's not the same thing but I know that Zimmer is out of West Palm Beach so...

Howard: I still can't figure out from anybody I can't pin down Zimmer listed their dental implant division for sale and then that I read that in Forbes or Wall Street Journal one of the two and then I haven't heard anything since have you heard anything about that?

Dhiren: I place Zimmer implants at my practice so I spoke to the rep he comes periodically and I asked him about it he said it's, they have put it on sale so they don't really know when it's gonna happen.

Howard: So that's the system you use Zimmer?

Dhiren: I use Zimmer and I use Implant Direct Interactive I use both of them. I use the screw in from Zimmer and the Interactive Implants from Implant Direct.

Howard: So what I don't understand about these kids is that so many of them pull extract molars and wisdom teeth but don't place implants. What do you think is a harder skill to learn, removing wisdom teeth or placing implants?

Dhiren: Removing wisdom teeth is harder.

Howard: I know, it's like how do you pull molars and wisdom teeth and you don't place implants I mean that's like saying I can run a marathon but I can't run a 5k I mean it just makes no sense at all to me.

Dhiren: I think it's just the specialist have created all the scarce around placing implants failing and all the hoopla all the other countries the general dentists are placing most of their implants in India place more implants and it's just I think America the general dentists are scared to do surgery or any implant procedures it's really easy to learn implants and to be able to do any practice on a routine basis.

Howard: Right

Dhiren: You can take your practice to the next level in a very short period of time because if you have a PPO practice there is not much profit of they're doing indemnity procedures anymore because every time you do a cleaning on a PPO patient you're losing money believe it or not because your paying your hygienists thirty five forty dollars per hour and the dental base fifty dollars for pro-fee. So it doesn't make economic sense to be able to have just a restorative and hygiene based practice and make profit out of it.

Howard: Correct, so that was your implant system and what about dentures and what would you say to this young lady if she says look dude I've only done two dentures in my life how where would you recommend that she goes and learns all on none?

Dhiren: Dentures, I mean you can just read a book and start doing dentures. I didn't learn dentures I didn't take a course for a denture I just in India when I did my dental school in India we have to make our own dentures so we have to do the lab work and we have to do the teeth setting and all that in the processing we even have to do the press processing with people required to do thirty dentures so that's where I learned my dentures in India where I did thirty dentures from start to finish, where I did the teeth set up, processing in everything.

Howard: How many dentures did you do in dental school in Boston

Dhiren: 2

Howard: and how many did you do at Aspen?

Dhiren: I was doing about 80 units a month

Howard: Wow for three years

Dhiren: Yes

Howard: So eighty times 360 eighty times 36 that's 20 880 that's 3000 units the way to go that is just amazing did you do any online training like Dentaltown has 400 hour-long online CE courses did you find any of those beneficial?

Dhiren: I watch course based on the podcast a lot stuff I've done my practice those are not Dentaltown but to your podcast, the Dentistry uncensored like I did the Jamieson Spencer online training for my sleep apnea I did that to him, I heard about six month smiles I did I'm doing that right now because I heard on Dentistry Uncensored and a lot of things which are implemented in my practice are to your podcast because it's such a great source of information everything I need to  know if you like now I want to teach flooring in my practice and we're discussing about different floor and so there is so much information out there so if you want to learn anything nowadays or do anything is so easy to do it's just you have to be wanting to do it and just put some time in it but I think Dentaltown is by far is this my biggest biggest source of information and because general dentists are putting their experiences out there.

Howard: Well thanks and what I like about is that the message board forum I all the other social medias are like Twitter and LinkedIn and Facebook it's all just last in first out and there's no archived and some of those grand what I love about Dentaltown is like when you talk about flooring you can go right to flooring and there's a long archived thread on flooring and it's just amazing. Well I would change subjects, you're doing you talk about ortho, you're talking about six month smiles, do you do ortho curriculum or you did six month smiles or are you doing Invisalign?

Dhiren: Yes I've started with Invisalign so I've done a few cases of invisalign I told that I need to do a little bit more ortho is not a complete solution so I looked into other stuff like power props and six month smiles and then I just signed up for six month smiles, I'm going to take the whole curriculum with them and try to implement that in my practice because I feel that it certain film out we have cases and my might be my practices in a retired community where the median age is 67 years old. So a lot of patients have a deep bite and have bite issues so in order to fix that I want you to do some ortho. So I'm already doing Invisalign but my next thing is sixth and smiles.

Howard: and what is your average Invisalign fee, when someone comes in and gets Invisalign what do you think the average fee is?

Dhiren: $5800 for the Invisalign then $550 for he retainers so $6350.

Howard: Okay so $6350 and how many trays how long would you say the average Invisalign case is how many trays or do you do one tray a month or do you do two trays a month how many trays would you say?

Dhiren: I do two trays a month but I see the patient once every two months I give them four trays and on average its about 20 trays per case  those patients you can finish between 18 to 20 trays. So you need to see them the first visit is record taking and then the second visit is attachments and then the visits after that are really good visits they're five to ten minute visits maybe follow up see the patient's complaint you need to pay back you know you can expedite the treatment zone it's really easy once you have the system in place and you can also train your systems to do the records so that makes they can take the photographs the pictures so you once you clean them then you can really have to do that anymore so it's easy it's good to do. They have different tiers in them I do think this line assist so I don't have to worry about like the case going on if I need more trays or find a treatment plan I can do it the fees is a little bit higher but it gives me peace of mind because I'm an ortho specialist. So it's just easier for me.

Howard: Well Invisalign is now opening up independent stores that don't even have dentist in orthodontist how many Invisalign stores near me do they have one in Miami or are they have any in Florida I think they've opened up a hundred?

Dhiren: They had one in Orlando and one in Tampa, I don't know about Miami and it's okay I mean they again I think they're targeting the market which you would have not gone to the dentist in the first place and the patients cannot be treated by smile direct will come to you if you are an Invisalign provider. So that I think it's a great thing that they're doing that.

Howard: So like in so here's my point, so Invisalign which is owned by align technology and they own Invisalign they own I think nineteen percent of smiles direct Club which is in the middle of doing an IPO which is gonna be huge and Invisalign stock has been amazing because they know that as women get as people get richer and richer and richer they want to be prettier and look younger and when I was little in Kansas you know there were seven kids in my family all the families had five six seven eight kids my friend Brian Hesse in high school was one of 21 children the guy who I thought was his dad for like two years of school turned out to be his oldest brother. I mean but now that you have children rate down to less than two per family every child is gonna get ortho so Invisalign huge but here's the math on this most dentists are paying a hygienist $45 an hour to do about a hundred dollars average in production and then this Invisalign case you said your average total case is 6350 including retainers over 20 trays that's 317 dollars a visit and what I've seen and then Here I am in Phoenix Arizona where in Scottsdale Invisalign stores opened up their own store the Scottsdale Fashion Square they don't have any orthodontists and they don't have a hygienist there they don't have anything in there and the bottom line is so many of these dentists like I can give you a name a 5 different dentists in Florida where you live and that hired an orthodontist from Central and South America who again is on a green card doesn't have the money in time to go back all the way through you went through Boston dental school and then the Aurn Grag program and there I know one dentists in Miami who has five I think he has four hygienists that he's paying the $45 now to do one hundred and then I think he has three hygienist from like I mean three orthodontist from like I think they're all from Venezuela and down there and his hygienists are $45 an hour and his board-certified orthodontist from Venezuela he pays them $25 an hour and that's 6350 divided by 20 trays is 317 dollars an hour. So why does every dentist pay a hygienist $45 an hour to do $100 of perio and they'll have two or three hygienists but they don't go get somebody who is an orthodontic assistant for ten years or an orthodontist from a foreign country who can't go back through school and they won't hire I mean you could hire that person for $30 an hour and they'll generate 317 dollars in revenue and they're flipping orthodontist and you say well I don't know if you should have a orthodontist from Romania doing your ortho well gotd Invisalign what do they have in their store. I mean what do they have in their store they don't have you know they just have what do they what do they I have they have they have girls who come from makeup booths who know how to sell makeup. I mean when you walk into Scottsdale Fashion Center where this is at The Scottsdale Fashion Center I mean those girls are in high heels or dressed to kill and that 60 year old frumpy Scottsdale woman walks by and they're like oh my god you should do this the next thing you know she's all smiling and they're putting Rouge on her and all this stuff like that next thing you know she bites several hundred dollars worth of makeup and now they're saying no no no girl let's get her to straighten those teeth let's get $6,500 forget forget $50 a makeup let's go with $6,500 Invisalign. So they're doing that they're setting the stage so my question specifically is why do you why does every dentist that has one two or three hygienist not have one operatory that's just full-time Invisalign by a staff member who comes from the orthodontic community whether they worked in an orthodontist office for 10 years or an orthodontist in Romania why do you think that is not the case?

Dhiren: I think because dentist dont think business, I think it's just a lack of understanding of the business and the cost of running a business and the way I look at dentistry is it's a half business half clinical skills. If you have the clinical skills but you don't sell it then there's no point having the clinical skills there is no point investing in yourself and put it that many hours in the store if you like you said if you do the math if your paying the hygenist actually I feel that hygiene you don't make any money you're doing three cleanings on these patients for one hundred dollars per hour because by the time you pay the overhead and the hygienist there is no profit left in that so if they start taking business and if they start dividing the cost of per chair per hour then they'll be able to do the business a little bit better they'll start thinking that way, it's just a mindset.

Howard: So what do you think is more important which is you said your average person near you is 62?

Dhiren: 67 yes median age is 67

Howard: So you live in a retirement community.

Dhiren: Yes I do

Howard: So you're probably not doing much Invisalign or ortho. Is grandma and grandpa getting Invisalign?

Dhiren: So the patients who are between 55 to 65 your recently retired you know they've been wanting to get the teeth fixed they still get Invisalign because they didn't want it to get it done they never had the time or the money now they have it and this together sometimes you want straight teeth and sometimes you have to do ortho correction before you can do a full mouth you have before you can do sixteen years or ten years of problem here so so those are the cases so you don't get it as many as you would do it on a patient but there is still you still get about twenty thirty cases a year of Invisalign from these patients who've been wanting.

Howard: 30 or 40 cases a year you're doing on grandmas and grandpas man you're an amazing man. So whenever you get a study done at a university by someone with a PhD in marketing analyzing the dental industry for the last thirty years it's always divided the American dental industry into two halves half is afraid of the cost of the dentistry and 1/2 is afraid of the pain of the dentistry. You have crushed it and you talk to the beginning of installment credit but you also do sedation dentistry and laser dentistry. So talk about that other half of the market where they're mostly just afraid of you coming in and give them a shot and hurting them and all that stuff so talk about sedation dentistry and lasers and fear.

Dhiren: So I have been doing oral sedation since last five years I did the combination of valium the night before and then I gave in the class eleven .25 and then .25 if they need more. So I do that pretty much all my major surgeries and now I've signed up for the IV sedation so next year I'll be able to do IV sedation in my practice also and you are right that half of the patients are worried about the cost between mastered the financing and IV sedation. Sedation dentistry I think it's a it's a good practice builder because a lot of patients would get a lot more done if they did not have to.

Howard: Where did you learn the oral sedation?

Dhiren: I did the whole it was a whole deal when I signed up so it included the the TV the initial implant knowledge like the basics of a plant that I went to Dominican I did about 25 implants over there when I was there then I came back and then I did the sidation which was part of the course they have their own training also its seminars. They both are pharmacologists they teach this it's a I think Donaldson and the other guy so two of them. I did it through them addition in the first year and I've been doing it since five years and it works really well.

Howard: Okay you said its

Dhiren: Yes I did training with them and it was a two-day weekend course not two or three-day I don't remember it was a long time ago but yeah I was very informative so I did that and I've been doing it and now I signed up for IV sedation through ADMA which I will be doing

Howard: ADMA?

Dhiren: Yeah it's a dental medical anesthesia training

Howard: Do you know the exact website

Dhiren: Yeah it's So I've looked up in a three different places I think the best one I saw was a one in Georgia out of Augusta but that doesn't meet my timeline because I wanted to get it done in January and want to start offering in February but they don't have any available until May. So I didn't want to wait that long so and then there was another one I think and I looked into that and there's always I always information I found at Dentaltown, I went on IV sedation the sedation for when I read about it and then I go into the web sites and I look into that so it's not that it's just pretty much very basic research on Dentaltown and Google and I call them and I found out the dates and this was working out with my schedule the best so I thought that I'm going to do this.

Howard: So when are you when you start that?

Dhiren: January 2019

Howard: Is that in Scottsdale?

Dhiren: I'm not even sure they have two programs I have not even seen the...

Howard: and you're still talking about ADM training .org

Dhiren: Yes a DMA I signed a point they are gonna send me the schedule it's 3d and I think one of them is in Arizona I think.

Howard: Yeah so the ADMA stands for Academy of dental and medical anesthesia training .org. So and the ADMA stands for Academy dental medical anesthesia and

Dhiren: It's in Glendale, Arizona

Howard: The reviews is by a big fan of the show who's been on the show Jared Pope DDS says the course is great he appreciated the smaller class size and Jared is a one of the best dentist in Arizona he's up the street in Maricopa an amazing dentist an amazing businessman. So then what about laser do you think a laser is a big part of pain free dentistry or not really?

Dhiren: I don't have a hard tissue laser but I do a lot of times for gingivectomy and the soft tissue thing I use that and that is relatively pain-free when you use a scalpel. So I do like it it works really well so that's a big practice builder as well but not as because IV sedation, oral sedation or hyper sedation for implants that's by far brings a lot of value to the practice.

Howard: and you said when you yeah you do probably fifty all on non dentures for every one all on four what do you think the ratio will be when you learn IV sedation what percent of your sedation cases do you think will be IV versus oral sedation.

Dhiren: I would prefer to do all extractions and I still do a lot of implants I do, I don't do all on fours but I do two implants on the bottom and the four implants on the top and then fix had fixed arch is there silver because of the patient population it's just easier for them to maintain and I just I do that a bunch.

Howard: Now some I personally don't like full arch fixed implants because they they come in and they have a ham sandwich between their implants and the denture and they're just a mess it seems like whenever they can snap them snap out they're removable and then brush it with their hand I mean it just seems like everything is so much better but so many dentists report that patients don't want it to be able to come out they want it fixed they want a permanent. Do you see that do you think that dentists is carrying that bias into the treatment plan or do you do you think they're just as happy with removable?

Dhiren: Most of my patients 90% of my patients have not complained about having something removable which snaps in. You know they are happy taking care of it because for them by their in removable denture the temp denture which is not attached to implants or they'd be very good just for a long time and then they get something which is more functional that's automatically upgrade for them so they really complain about it that this is a removable product. Their are sometimes some patient would want something which is both fixed and in those cases we can do fixed fixed but that's a lot to maintain because that something the maintenance is something which cannot be dedicated to your to hygienists. So as a dentists you have to find the time to be able to clean that processes every year and the company and the home care the patient has and you can't expect someone who has a dentures most likely had a table care hygiene hygiene habits over the over the lifetime and the fixed habit processes you expect them to have the number one highest hygiene oral care that's very difficult to do.

Howard: I know I always tell dentist you know the people getting dentures and fixed you know they're not your vegan yoga instructor they're smoking drinking hillbillies from Apache Junction and do you see less peri-implantitis around implants where the denture snaps out as opposed to fixed?

Dhiren: Absolutely i've done over a hundred dentures with locators and it's just amazing product I just truly believe it's it's just really it's better than fix hybrid processes in a lot of ways because hybrid processes you cannot go back you need to do so much reduction of the bone to be able to fit 15 10 15 millimeter of zirconia in the mount that if case fails that there is no going back there's no you don't have to do that much reduction of the bone you don't have to take her you will have to cut the patient half of the patient jaw to fix it to put their hybrid in there so I just feel it's not necessary to put that hybrid in there.

Howard: In order to preserve your health we need to shave off half of your mandible.

Dhiren: Yes

Howard: That's wrong with that picture. Well hey we went ten minutes over were so I just want to tell you seriously I'm so damn proud of you thanks for coming from India to Florida. By the way I don't know if you know this but all the jokes and the United States you know if you retire and you're over 65 and New York and New Jersey you go to Florida but west of the Mississippi River from like Minnesota over you come to Arizona. So Arizonans always say that Arizona is the Florida of the west and it's so funny but it's basically I've been to Florida so many times and I love Florida and it really is Arizona but thank you so much for coming on the show and sharing all your amazing success with my homies you've been an inspiration to everyone.

Dhiren: Thank you. Thank you for having me Howard, it was nice talking to you.

Howard: Alright have a rockin hot day buddy.


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