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AUDIO - Dino Nepoletano - HSP #95
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VIDEO - Dino Nepoletano - HSP #95
Dino Napoletano, DMD talks about his sloppy college beginnings, why dentistry captivates him, and how he learned to do the impossible.
Son of Italian immigrants, born 1960 in Middletown, NY; BA Biology/Zoology with minor in Psychology Saint Leo University, St, Leo, FL (1983); DMD Boston University (1987)
GPR UAB Veterans Hospital, Birmingham, AL (1988); Solo Practice (Donato Dental, PLLC) since 1988
Affiliate Medical Staff Member Orange Regional Medial Center, Middletown, NY since 1989; Integrated 3 wavelengths of lasers, Cerec, Lanap, and microscopes in 18 months (2004-2005). President & CEO A&D Management Inc, a commercial real estate development and management company since 1991 with majority of tenants being dentists
Dental Technology Integration Consultant, Donato Dental Systems, LLC since 2008
President & CEO of D&R Management, LLC, a commercial & residential property management company, Belleair Beach, FL since 2010
Authored numerous articles on dental technology integration.
Howard: It is a huge honor today to be interviewing one of the original townies from 2003. We both graduated the same year in 1987. Dude, you have 7500 posts. I feel like you're a brother, a cousin, a nephew. Thank you so much for giving me an hour today.
Dino: It's my pleasure.
Howard: Your name, Dino Napoletano, but on the board you go by Dino. I'm a huge fan of your 7500 posts. In all those years, the last 12 years, you've covered everything from A to Z. What I love the most about these podcasts, believe it or not, is not that I guess as a certain know-it-all expert in one little area, but the feedback I'm getting, I've had a monthly column since '94 and I get fan mail from that. I've had the 30 day MBA. I've had different tape series, books, lectures, but I've never got anything close to the fan mail I get off these podcasts. It's always the same thing. It's always someone telling me they're either juniors or seniors in middle school; they're 10 years out, from every country on earth.
I got one this morning and a dentist said, last night I drove home an hour commute from work. I listened to your podcast and I was thinking ... It was all free. What is the chance I could have had dinner tonight with you and your guest, and to hear that conversation for an hour was just so amazing, and it was free, and it was fun, and it's metaphysically impossible because this dinner between you and I right now, like we're having dinner or a beer at a bar, this is just a really cool technology to be able to podcast.
Dino: You know, to be honest with you, Howard, I never really listened to many of the podcasts before you asked for me to be on one, and I've never done one of these, but after you asked me to be on one I started listening to quite a few of them. I just thought it was so cool that it's just like having a conversation and you can do other things while you're listening to it. It's amazing, I always come away with something after listening to every single one of them. It's just unbelievable to me.
Howard: Well, it's an amazing progress because, at the end of the day, they just ... Dentists want to learn more about dentistry. At first it was just you had to go to a course and the problem with going to a course is that the average dentist is going to do 4000 bucks a day, so to go to the course, it's going to cost you 4 grand. You're going to have to close your office.
Howard: A lot of times you're going to have to travel, and take your staff, and pay your staff, and all that stuff. Then it would, to Desktop, we put up 307 online courses on Dental Town, and granted they got AGD, ADA approval, whatever, but you got to sit at a desk, staring at a computer. Those have a half million views now. Those 307 course have been viewed a half million times, but here's what's interesting. I've only been doing podcasts for 7 months. We've been doing online [inaudible 00:03:05] from '98 to 2015. That's 17 years for half a million views. We've only been doing podcasts for seven months and we're at 100,000.
Howard: It's exactly like you say because they can listen while they're commuting home from work which is half rural. The rural dentists have an hour drive just like then dentist in LA has an hour drive. It's the commuting and it's the multi-tasking, you're on the treadmill, you're doing laundry, you're doing dishes, you're cleaning the house. I have several friends that say that Saturday morning their routine of cleaning up the house for the week and getting all the laundry and everything is about four hours and they listen to four one hour podcasts back to back in their headphones while they're doing all the dishes, the laundry, the vacuuming, sweeping out the garage and everything's done.
I want to start first since ... You guys were in '87, are you 52 years old too?
Dino: No. I'm 55. I lost a year ... Well, I have an interesting history.
Howard: It's always a good story when a dentist starts out with the word, this is an interesting story. That means it's really going to be interesting.
Dino: I barely graduated from high school but funny, I knew I always wanted to be a dentist since I was a teenager.
Howard: How's that? Was your dad a dentist?
Dino: No. My dad was a painter but we were going to a dentist for a long time and these new guys came to town and so they had a super modern practice at the time in the early 70's. I went in as a patient and it was a completely different experience than what I experienced with the other dentists. It just made such an impression in my mind that I was like, wow, this is a really cool thing to do. Dentistry isn't as bad as you hear people say. The dentist that I went to who actually became my role model ... When I went and asked, "How many years is it to become a dentist?" and they said "eight", oh man, there's no way I'm doing that. I hate school. At any rate, I barely made it out. I got accepted to two schools. One in Florida, Saint Leo College and one in Marist. Coming from an Italian family, very strict, my parents wouldn't let me go to far. They said, "No, you have to go to Poughkeepsie which is 45 minutes from Middletown where I am now.
I went to Poughkeepsie, partied my butt off, and I never had a chance to grow because I was home every weekend. My mom would cook me lasagna and stuff and put it in tupperware so all I had to do during the week was just shove it in the toaster oven, warm it up and I was good to go. She'd do my laundry. I think I never really had a chance to grow. Basically, that whole year I just wasted it. I partied like heck. It was a great time but I got a letter in the mail telling me that you can't come back. You're done. At that point, that's when reality set in. My dad says, okay, you're going to paint with me now. After about a couple of weeks, he looks at me and says, "you want to give it another shot?" I said, "Yeah, I do but I gotta get out of here. I can't stay near home. I've got to go to Florida."
I call the school in Florida. I hadn't applied that year but I was accepted the previous year. I just call them. It was a very tiny school at the time. I said, "I wasn't accepted there this year. I was accepted there last year. Any chance I can come this year?" She put me on hold for like twenty minutes. She came back on the phone with a real heavy Southern accent and said, "Dinado, come on down." That's where my life started. Needless to say ...
Howard: How old were you at that time? Were you 19 or 20?
Dino: I was 19. Right? Nineteen because I finished ... 19-20. I get down there and the first most important thing that happened to me was that I finally end up meeting with the right people. I ended up meeting one person in particular who ... See because coming from an Italian family, my dad only had a second grade education. My mom only went up to six. They were immigrants. I didn't have the support at home that say my kids had through school. I didn't have help. I couldn't get any help so school was always a very negative thing. When I went to Saint Leo in Florida, needless to say, I didn't even need to tell them I went to Marist that one year because I wanted to start clean, fresh. I met one person and he basically just sat with me and he said, "You know, you can do this. I'm going to teach you how to study." Just a few sessions and the next thing I know, I get the first A in my life and after that it was like a drug. Once I knew I could nail it, it was like, oh man. All right, no problem. I can do what I want to do, what my dream of being.
The only reason why I share this in such detail is because I want people to understand the perspective that I come from when I'm on a thread on Dental Town and someone says something can't be done. I went through all of my life up until 18 years old thinking that I couldn't do something and then finally realized that I could. When I see these threads, it always reminds me of that. I'm always looking for things that can't be done to see if there's possibly a way of doing that in a little different way. Man, Dental Town has been a complete ... If I didn't discover Dental Town, I wouldn't know anything what I know today.
Howard: It's also a great parenting lesson for dentists listening that have children the fact that so many people do poorly in school because they don't have a dream or a vision. It's hard to tell someone to work hard and study all day when they don't know why. Why am I busting my ass learning English and history and philosophy and chemistry? They'd rather go sit at a bar and have a beer and try to find the meaning of life with a friend. When that kid finds a mission or a purpose, then boom, the tires hit the pavement and they take off.
Dino: That's exactly what happened to me. Once I realized I could do it, there was nothing standing in my way anymore. That's it, I'm going for it.
Howard: We all know people that made C's, D's, F's and flunk out of school and change majors six times. When they finally decide what they want to be, then they were the all-star student and everything took off.
Dino: I'm saying it's funny because I look at my kids today and ...
Howard: How many do you have?
Dino: Three boys. One just graduated college. He graduated from the same college I graduated from, Saint Leo.
Howard: You have three boys?
Dino: Three boys.
Howard: What are their ages?
Dino: One is 22, his name is [Omberto 00:10:52]. He was named after my dad. He graduated Saint Leo just a few weeks ago. The second boy is Sergio. He is 17, actually 18 and he's just finished his freshmen year at Saint Leo and I have another little guy named Dinado and he's a freshmen in high school. I don't know ...
Howard: Did you marry late or just start having kids late? We're the same age and my boys are 20, 22, 24, and 26.
Dino: Yeah. I started late. There's actually 13 years between my wife and I because I was 32 years old and I wanted to have a family and I was so lucky to find her. What luck that was, just a great person. She even actually works together in the office for the past few years. She went back to school. When we got married, she was always ... When I met her she was 17. She was 18 when we were married so she didn't finish high school in Rome. She was born and raised in Rome. We happened to meet in Middletown just by chance. When the kids were halfway through school, she decided she wanted to go back to school so she went to college. She got her high school diploma through there and she actually ended up going into hygiene and she's a hygienist.
Howard: She's an RDH?
Dino: She's an RDH.
Howard: Awesome! That is awesome.
Dino: She does everything and that's great. She can cover the front if I have somebody out in the front. She's my chair side assistant two days a week and she'll pick up hygiene, she has a few patients that prefer her and request her and also if my regular hygienist who's been with me forever, if we can't squeeze in a patient, she'll take care of them.
Howard: I am still bummed I don't have an RDH degree. I knew I wanted to be a dentist in 6th grade. I don't know why I didn't go the RDH route because in dental school, about 12 RDH's were in the class so they already knew half the curriculum at least. Their part time job back in the 80's, they were making 20 dollars and hour doing hygiene back in '84-'87. I was at Walgreens making $3.50. They were making $20 an hour while in a dental office and learning all about dentistry. In med school, the same thing. The street smart physicians, they became Phlebotomist or Registered Nurses first so they were making bank all the way through med school and all their undergraduate applied to their med school, dental school. If someone wants to be a lawyer, they should be a paralegal first. If you want to be a dentist, go become a hygienist first. If you want to go to med school, go become a Registered Nurse. If that's too much of the time, become a Certified Nurse Assistant. That's smart. I also think there's RDH's were the best in dental school because when the instructor was saying something, they worked in it. They knew it. They saw it. They could see patients faces in their heads with the cases they were showing on the power point.
Howard: That's just amazing. What struggles and hurdles have you encountered on your journey to becoming a dentist and while starting out in private practice?
Dino: I spoke about the major one when I was in school. Then, of course, coming out of school, I started two scratch practices a year apart from each other.
Howard: You graduated in '87 and you started one in '87 and one in '88?
Dino: Well, I missed one part in there. I actually did a GPR residency at University of Alabama at VA Hospital. I didn't finish it off there because they didn't deliver what they had promised at the time. An opportunity came where there was an office actually where the first dentist I went to as a child. He had passed away five years prior and the wife wanted to just rent the space. It was in a house of a basement. One room had the old barber style chair. The other one had a real old Ritter lie down chair. I got rid of the barber chair and just shoved one brand new chair in that room and I was in business. I thought that coming back to my hometown that I wouldn't have a hard time starting a practice but unfortunately, things were not going well at all.
Howard: In the town?
Dino: In my hometown, right.
Howard: Where was that?
Dino: In Middletown where I am now.
Howard: Were you born in Middletown?
Dino: I was born and raised in Middletown.
Howard: Is that also where [Zuckerberg 00:15:53] practices?
Dino: No. Not in Middletown. I think he's closer to the city.
Howard: Is there a Middletown Connecticut too? Is that where [Kinka 00:16:01] practices?
Dino: Yes. It's amazing that you mentioned Dr. Zuckerberg. I had never heard of him until I heard his podcast the other day. That was a good one.
Howard: Yeah. We're friends on Facebook. Kinka is in Middletown, Connecticut and you're in Middletown, New York?
Dino: Dr. Kinka is near Middletown, Connecticut correct. Not Middletown, New York.
Howard: Middletown's like a Springfield. They say Springfield is the most common name in America. Forty three states have a Springfield.
Dino: Yeah. A lot of states have a Middletown.
Howard: That's why on the Simpsons they went with the name Springfield because it's the most common name. You went back to where you were born and raised and Middletown was having economic hardships. Is it a suburb of Manhattan?
Dino: No. It's about an hour and a half north of the city.
Howard: Okay. Small town upstate New York.
Dino: It's a smaller town but really saturated with dentists. At that time, over 50. Today there's probably over 100.
Howard: What's the population of the town?
Dino: Middletown itself 25,000 and surrounding town, another 25,000 so we're really looking at a population of about 50,000.
Howard: With 100 dentists?
Dino: With 100 dentists actually today, right. With over 100. Things weren't going well the first year so I said, you know what? I'll go ...
Howard: That's a dentist for every 500 people.
Howard: Did I do the math right on that?
Dino: Yeah. That's rough.
Howard: That's real rough. The United States averages a dentist for every 1890 and you're in a town of 1 to 500.
Dino: Right. At that time it was 50 dentists with 50,000 so at that time it was 1 to 1000. Today, it's more like 1 to 500 like you said.
Howard: Even back then, it's almost 1 to 2000 for America. Even back then it was 1 to 1000 so you already had twice the number of dentists as the national average so it's always been tough.
Howard: You opened in Middletown?
Dino: Yup. After not even a year, I said I think I think I'm going to start a place in a smaller town where there's not so many dentists. There was a town near me in Montgomery, New York about 15 miles away. I opened a satellite practice there. Another scratch start. Interestingly, at that time, when I went to the bank to get the loan to start that office, they didn't require to see any paperwork for the chairs or anything. They gave me like 80 grand and 40 was supposed to be for the build out and 40 for the equipment. Since they didn't ask anything about the chairs, I said, you know what, I'm going to keep that 40 as working capital and then I'll just lease the chairs for that second satellite. It's a good thing I did because I ended up going through that entire 40 grand. I remember thinking, that's it, I'm done. The very next month I freaking broke even. It's like, okay. Then made a profit every since.
Howard: Let me throw in an MBA tidbit because I got my MBA from Arizona State University. Believe it or not, the number one cause of a business going bankrupt is cash flow. The business was profitable and the point is ... They make a sale, they had to pay their bills for that sale, the rent, mortgage, [inaudible 00:19:44], computer, insurance, payroll, [inaudible 00:19:45] but maybe the terms are net 90. They're selling, they're making a profit but since the money's not coming in for 90 days later, they don't have the cash reserves to pay.
The number one reason for any business ... There's about 40-60,000 bankruptcies a year in the United States depending on a boom, it's closer to 40 when we're in a bust, it's closer to 60. The number one reason that businesses go bankrupt is they run out of working capital. This is a great lesson for these kids listening to this thinking I'm going to start my own practice that working capital, people borrow money for a chair or carpet or paneling or a build-out or a toilet but they don't borrow money for working capital. You've got to have working capital. There's a little luck in every success story. You lucked out that you turned cash flow positive before you cash flow reserves of 40 grand ran out.
Dino: I was very fortunate. Things started really cooking along. From that point on, everything started clicking along very well.
Howard: Also, a lot of physicians, dentists, lawyers, all have to be book smart. You can't be a doctor in anything without being book smart, obviously. A lot of them aren't street smart and it's interesting how you had the street smarts to realize that supply and demand in a small town needed a dentist. There was less dentist per population ratio and you were in a town that were saturated. Dentists still deny demographics. They still go to the busiest intersection in America where there's 20 dentists in a medical building and say, "I'm going to set up here" and you're just sitting here like ... How do you think that? You never see 20 McDonalds in a McDonald's building. There's that one building in San Francisco that has 166 dentists in one building and seven labs. YOu're like, what?
That's neat that you're street smart and you went to the rural area where they needed you.
Dino: It's not really rural. To be honest with you, I never wanted to come back to Middletown because I knew the demographics weren't in my favor. Tight knit Italian family, especially my dad, he was like you've got to come back to your town. No dad, I want to stay in Florida. You've got to come back. All right, fine. I'll give it a try. I have no complaints. I'm so happy. Middletown's been great to me. It's great to meet people that I know since I was a kid that are now patients of mine. It's been a really rewarding experience from that aspect of it.
Howard: Every time I get patients that are from out of the city, I always wonder why are you here? They come from the other side of town and I say, why did you drive an hour or two hours or three hours? They say, "You were my mom's dentist for 25 years." Wow. So many of my new patients are kids from far away and their mom came to me.
I want to back up a little bit. One of the most asked questions we get from the dental schools, probably the number one question is should I do a GPR or should I open up my own practice or should I get an associate? That dental student who's a junior or senior right now and she's listening to this, and saying should I do a GPR? You've been out 28 years and you got 7500 posts on Dental Town. You know all the thoughts an opinions on GPRs. Talk to that little kid about whether they should do a GPR.
Dino: That's a great question. It obviously depends on the GPR program. The one that I went to at that time, promised the world and I ended up being stuck in the clinic just doing fillings and dentures. I didn't feel like I was really gaining anything more from a learning perspective. Which is the reason why I didn't end up finishing there. I taught courses on microscope integration at the Tuft's GPR program. Completely different story there. They have all the technology. The instructors are great. They expose the students to a lot of things that they probably would not be exposed to if they would have just went for a job right away. It really depends on the program. Each program's going to be a little different.
My reason for wanting to do the GPR was because I wanted to do cases in the OR. That was really my main purpose for doing a GPR. That's the reason why I left. Nine months into it, I haven't even stepped foot in the OR.
Howard: What interests you about the OR? Did you actually want to do sedation dentistry or what about the OR did you want to do?
Dino: I've been on staff at our local hospital here, Orange Regional Medical Center since 1989. I always had an interest and I'm still trying to get them interested in starting a program here. Right now, when I have a patient that requires special needs, they need to schlep down to the city. It's already stressful enough as it is and when these patients have to drive an hour and a half, just to get some teeth filled under general, that's a major pain. Middletown is slowly getting there. They just opened their first medical school called Touro medical college last year. They're going to have a residency programs here at our hospital. I'm actually hoping that in time they would maybe consider a GPR program, hospital based right here in Middletown which I would be more than happy to-
Howard: You're doing hospital dentistry cases?
Dino: In the beginning I would just go in for emergencies but right now the hospital is not set up to do hospital dentistry cases. I've been working on it. I'm still trying to work to see if we can get something like that started.
Howard: Why do you have privileges with the hospital since '89 if you can't do dentistry in there?
Dino: It's kind of ridiculous, isn't it?
Howard: You don't even do sedation dentistry in your office?
Dino: They don't even have a dental department per se so they just throw ... THere's only a few of us dentists on staff there. They just throw us on the ENT department. My goal is to eventually get an actual dental department. I'm sorry, can you ask that again?
Howard: Do you do sedation dentistry in your office?
Dino: I used to do oral sedation for a couple of years and I stopped doing it because I wasn't comfortable with that mode of sedation. I had a few instances where the patient after the second Halcion pill or third where they were really, I'd have to keep shaking them to get their pO2 levels up again. I don't really like doing this.
Howard: I just want to say one thing to our listeners out there. Another thing about this is 20% of these listeners on every podcast are from every country on earth. They're listening to this in Tanzania and Itria and everything. I'll tell you what. I see the claims made each month from some of these dental malpractice that give me the data all the month from all the claims paid. Whenever it's a full max, whenever it's a complete disaster, whenever it's the whole million dollars, the three million dollars or whatever. It's always an IV and it's always a death.
I didn't do it because let's say you provided a service and it was good and you did a case a month for 30 years. One death would negate all that times three. Not to mention you'd have depression and want to quit and it would be hard to go back to your office after someone died in there. It's so bad and the standard of care in every hospital is that the anesthesiologist does the anesthesia and the surgeon does the surgery. No where in any American hospital ever is a cardiologist doing the IV and the sedation while doing a bypass on your heart. You won't find it in any hospital. You only find it in America in oral surgeons offices, dental offices, and man when something goes wrong, that's the first thing they point out to the jury.
Where else could a surgeon have done the IV and done the surgery. I would say if you're going to do anesthesia in your office, granted I'm in Phoenix which there's a lot of anesthesiologists. THere's 10 different anesthesiologists that I can call and they show up at my office and they open up their van or their truck and they've got a dolly. They wheel everything right into the auditorium. It's all their equipment, all their drugs, all their expertise. They do the IV sedation and I just do the dentistry and I have the patient's pay the anesthesiologist direct with their medical insurance. I don't get involved in the money. I don't do anything. It's a pure independent contractor. Do you know what I mean?
Dino: That's actually a fantastic idea. I think I'm going to consider actually doing that.
Howard: What's amazing is there's a half dozen dental schools that do the anesthesiology residences so instead of a ... You can get an MD anesthesiologist, you can get a Registered Nurse anesthesiologist. You can get a DDS. Oregon has one, several schools have one. They're dentists. They can literally do the root canal, they can do all the dentistry that you're doing and it's really cool because the anesthesiologist is a dentist. They know what a pulpotomy is. They know everything that you're doing. It's not like explaining to a nurse anesthetist or an MD anesthetist. You don't get these questions like what is this going to entail? When you tell a dentist anesthesiologist we're doing a root canal on #3, they get it.
Dino: Even the surgeons that I refer to, right across the street from my office here, when they do extractions under anesthesia, they have an anesthetist come in. They don't do it themselves anymore.
Howard: Yeah. They probably talked to a lawyer. You've got to remember in this country of ours, there's 940,000 MDs and there's one million attorneys. Your government, the congress, the senate, the governor, they're all attorneys.
Dino: That's right.
Howard: They don't make rules for dentists and physicians, they make rules for other attorneys.
Howard: Yeah. There's one million attorneys they bill out a trillion a year. Basically, in America's 17 trillion dollar economy, we pay one out of every 17 dollars spent goes to the lawyer country club. Know what I mean?
Dino: Right. Exactly.
Howard: It's a hell of a game and you need to be aware of that game. It's bigger than dentistry and it's bigger than medicine and it's probably bigger than anything because it's the government too. When I read your posts, nine times out of ten, you're talking about technologies. You're talking about doing a microscope and this residency deal. Why are you teaching ... What are your favorite technologies? What technology do you like? Some dentists are into tech more than others. What technology do you like and think they have a good application for dentistry?
Dino: The technologies that I love and use regularly are #1 microscopes, #2 LANAP, #3 CEREC.
Howard: Okay. Let's take those one at a time. First of all, I want to say this. Whenever two 50 year olds are talking about microscopes and loops, the 25 year olds, they just see two grandpas, these old guys, you need that because you're old and you can't see and you're blind. I'm 25, I can run 5 miles and my eyes work. Talk to that kid. Does a 25 year old with 20/20 vision need to wear loops in the office and would they do better dentistry with a microscope?
Dino: I don't know about microscopes. You have to start out somewhere. I don't think anybody can start fresh out with a microscope. For me, I gradually got into it. I started with 2.5 loops, 3.5, 4.5. The thing about magnification, the more you see, the more you want to see. You evolve into scopes because there was an interesting thread on Dental Town not too long ago where some have a hard time even wearing loops because it can cause some dizziness or nausea. I've heard that before. Certainly a microscope for them is not going to be a good investment. When I speak to other dentists, rather than trying to convince them, this is what you need to buy whether it be microscopes or a laser for CEREC, this is what you need to do. I'm more interested in looking at their practice dynamics because some things are just not going to work in some offices unless certain changes are made.
A big pet peeve of mine is every time I hear of an instance where somebody went and they followed through the whole process of what I call the technology integration phase, right, where they went through their discovery period, researched technology, asked people, and then they narrowed it down to which manufacturer should I go with? They go all the way through to the purchasing part and then either lack of training or whatever, maybe they didn't think the whole situation through completely, like how this was all going to flow in their current practice but the technology then is thrown to the side and you have 25, 50, 100,000 dollar piece of equipment that's now just sitting in the corner just collecting dust.
With my consulting thing that I do, I'm not interested so much in convincing someone that they need technology. I'm more interested to see if they're going to be able to integrate the technology. There's no such thing as a good technology or bad technology. The only bad technology is a technology that's not being used. Okay? Again, I'm more interested in knowing, is this going to work for them or not because I would rather prevent them from getting into a situation like that or let them know what is going to need to happen in order for a particular technology to be integrated fully. You're going to have to do A, B, C, D. Are you willing to make that commitment? Yes, great, go for it. No, save your money, buy a car, do something else.
Howard: I want to tell these young kids a couple things. When you fall down and break your arm or your leg, you always know what caused an acute accident. Yeah, I tripped and fell and broke my wrist or I fell down the stairs and broke my ankle. What you don't pick up on is the small, repetitive moment injuries. When people go into the chiropractor or the orthoped and they have no idea why they're having this massive pain in their arm or their leg, or their knee, it's some small repetitive deal that they never saw.
I'm telling you that god, when you're 53, all those years you spent without loops and leaning your head over and torquing your back, and now there's so many 50 year old doctors that are in two camps, they're on a bunch of pain pills and muscle relaxers and go to chiropractor three times a day or they're like me who do yoga every morning for an hour and a half because you've gotten so much pain that by 50, you'll do [inaudible 00:36:36] and that reversed you out of all those years of bad posture and leaning your head over. Your head's a ten pound bowling ball and it doesn't need to be upside down half your life looking into a tooth. You need to get loops and you need to set up straight and you need to get focused so that they're not even at the right focus until you're sitting up straight. I know a lot of older dentists that got into microscopes because of their neck and their back and their shoulders and the only way they can do root canals for eight hours a day is sitting up straight looking into a microscope. Are you using a microscope now?
Dino: Every day.
Howard: For what procedure. Is it just certain procedures or anything?
Howard: Is it one microscope?
Howard: Six different types and brands?
Dino: No. Same brands.
Howard: What brands are they?
Dino: I went with the Globals.
Howard: Global. That's a very common one. Is that the most common?
Dino: No. I think Zeiss is common too.
Howard: Zeiss out of Germany is very common. Where's global out of?
Dino: Global's out of St. Louis, Missouri.
Howard: St. Louis. You talk about loops, 3.5, 4.5 then you went to 4.8?
Howard: 4.5 is that all the same types or is there two major brands. Design [survision 00:38:00]?
Dino: That's the one.
Howard: Design survision.
Dino: That's the through the lens type.
Howard: Through to lens.
Dino: Through to lens design survision.
Howard: That's what I have too. I'm at ... You said 2.5, 3.5, 4.5 or is it 3.8?
Dino: No. Mine were 3.5.
Howard: And then 4.5?
Dino: And then 4.5. When I got into them, that's what they were. I don't know if they changed.
Howard: I think mine were 3.8.
Dino: They may have changed it now. I'm talking early 2000.
Howard: This Global microscope? Is this on wheels? You have six of them, is one mounted to the ceiling above six ops?
Dino: They're all mounted to the ceilings in every op.
Howard: They're all mounted to the ceilings?
Dino: They're all mounted to the ceilings and I have them in every op including the hygiene ops because ...
Howard: How much does something like that cost?
Dino: It depends on what kinds of accessories you get put on them. If you get something called a beam splitter which allows you to attach a camera or a video device to it, then it can raise the cost to over 20,000.
Howard: You have the video on there for filming?
Dino: All my microscopes have a double beam splitter where I have a video feed on one side and I have a DSLR camera on the other side. The video feed side goes into a live monitor so that my assistants can watch what I'm doing which by the way, for them, they totally get sucked into the procedure when they're able to see exactly what I'm seeing on the TV monitor. It's also then fed into the computer system so that while I'm treating, every single tooth that I treat, I'll take a preop shot, intraop shot, and a final shot that all gets recorded directly into the patient chart.
Howard: This is for a filling, crown, root canal, doesn't matter?
Dino: Doesn't matter because when I, especially with newer patients that don't know me for a long time, they come in and I'm telling them they have this problem and you can see they're not sure if I'm really telling them the truth or not. I get into that tooth and I've got that number 4 or 6 round in there with [cheese 00:40:25] coming out of that tooth. I snap a shot of that and just put it right up on the screen for them when they come up.
Howard: You've got to make an online CE course on this. No one's talking about it. Can you do that?
Howard: I've never heard of any general dentist with six Global microscopes mounted on the ceiling, beam splitting and all this stuff. You've got to ... There's people listening to this and I bet 10% of them are like dude, I want all the details on this. That is something that has to be visual.
Dino: Okay. I'll work on it.
Howard: I call stuff like that dental porn. That is just fun to watch.
Dino: The really neat thing about this is not only does the patient see on the screen what I actually saw, I will print them out a copy of what I did for them to take home. That ends up being an internal marketing tool. They go home and show their significant other and their family and say, wow, he went into this tooth and look what was in there. A lot of times I'll end up getting the spouse or another family member. It works as a great internal marketing tool in addition to an educational tool for the patient. And, it creates an unbelievable amount of trust very, very quickly. You can show instantly your patient. Dentists that are probably listening to this right now are probably thinking yeah, I can do this with my intraoral camera too. Which is true.
Howard: If the loops were 2.5, 3.5, 4.5. What would the x be for these global microscopes and what would the intraoral camera be? You can get a picture with the intraoral camera would that be 10x, 12x, and what is your microscope?
Dino: The microscope I can take the picture at whatever magnification of the 6 magnifications. It starts at 2x, 3x, 5x, 8x, 13x, up to 20x, right.
Dino: I can go to 20x.
Howard: 2 to 20.
Dino: I rarely use 20.
Howard: What do you usually use?
Dino: My favorite actually is the third step which is 5x and then when I get towards the refinement of a preparation I'll get up to 8. I'm always between 5 and 8 but actually, microscope users ask this question a lot. They do have 3 step microscopes instead of 6 step, where they don't have that lower end magnification of the 2x and 3x. That's equally as important because when you're doing the preparation, you want to be able to not only zoom in on it to refine it but also zoom out of it so that you can get a good downward profile look of the preparation to see how it's tapering, make sure there's no undercuts anywhere. Really, anyone that's thinking about purchasing a microscope, in my view, you either go for the 6 steps so you have all the ranges from low to high and not go with the 3 step which starts you out at a much higher level. That's my feeling on that.
Howard: What is the general cost on that with accessories?
Dino: 20-25 grand.
Howard: 20-25 grand.
Dino: Yeah. Here's another thing that I see. I also do training, private one on one training with dentists that say recently purchased a microscope. I prefer actually to go into their office and do it rather than coming to my office because I get a chance to inspect their environment and make sure everything is mounted properly and set up properly. If you can't just grab it and use it, you're not going to use it. If you have to go through hoops of rolling it in, it's just not going to get used. It's important that if somebody does aquire a microscope, it gets mounted in an ergonomically friendly position where you're going to be able to grab it and use it when needed.
They'll buy the microscope and they won't spend the extra 1000 bucks whether it's global or Zeiss for what's called a binocular extender. The binocular extender does is it brings the eye cups closer to one's eyes. Now instead of having to scope and having to scoot over, those binocular extenders bring the oculars out further and now the operator can sit in a more straight up position. You get a microscope without the extender, I don't feel that that's money well spent.
Howard: Dino, let's be honest. What percent of the 120,000 general dentists in America do not have a microscope? What would you say?
Dino: What would I say? I don't know the answer to that exactly but I think [Glenn Van As 00:45:47] mentioned something like 1 or 2%.
Howard: Yeah. He's the finest dentist from Canada.
Dino: He's a great guy.
Howard: Love Glenn Van As. Bottom line is about 4000 people are going to listen to this and 99% of them don't have a microscope so we need to back up a few steps. Why should somebody listening to this podcast buy a microscope?
Dino: For some of the reasons that I mentioned. You can work comfortably.
Howard: Ergonomics. Safety of your neck, shoulders, your back.
Dino: I used to be like this all the time. I have a chiropractor right in my own office building. I used to see him once to twice a day. Mind you I didn't get a microscope because of my back issues but I found that once I started using it, I didn't have to see him anymore. I haven't seen him since 2004 which is when I started using the microscope. I discovered that by accident. Holy cow, I didn't realize.
Howard: Think how much money you saved by not having to be the dentist that has to retire at 60 because they physically can't do it anymore versus the dentists that are still doing it at 70. The oldest dentist that went to my seminar for years was last year. 93 years old, he survived Auschwitz. Guess what he did on his 90th birthday?
Howard: Bought a CDCT and now he's crazy into surgical guided implants.
Dino: That's so cool.
Howard: [inaudible 00:47:30]I thought he was going to break out in the chair like give me an O, give me an M, give me ... His assistants, his young little darling assistants were all like 70. He's 93. That $25,000 microscope saved your physical instrument so you can still do surgically guided implants when you're 93 years old. That implant is free. You said ergonomics.
Dino: Ergonomics and what I was getting to before was that some dentists as far as taking photography, picture part and sharing with patients, you can do it with an intraoral camera also.
Howard: We'll call that marketing.
Dino: Yes. An internal marketing standpoint or a patient education standpoint if you just want to quickly show them what you're seeing when you're inside working, you have to think of the ergonomics of that, right? You have the patient down, you have to stop what you're doing, you've got to grab the intraoral camera. More times than not, you're running behind, you're not going to go through that trouble. Whereas, I do it with every single patient because it's just so easy. I literally just tell my assistant, while I'm working. A lot of times I don't even take my hands out of the patient's mouth. I just tell my assistant, snap this for me. Bam, snap.
Howard: I want to ask you this the reverse way. The American Dental Association recognizes nine specialties. Seven of them are clinical, two of them are non-clinical, oral radiology and public [aldentistry 00:49:09] but of the seven clinicals, which one of those are using microscopes? The most seven clinical specialties using a microscope to the least. That might help a general dentist to think her mix of procedures. What are the specialists doing with the microscopes?
Dino: The most obviously number one would be Endodontists.
Howard: Explain why.
Dino: For locating canals, accessory canals. Also-
Howard: Which they say the number one cause of a failed root canal is the missed canal.
Howard: All the dentists want to talk about is what do you obtrate with.
Dino: Did you see the poll thread I just posted just last night?
Howard: Last night, no I did not. There's no wifi in the bar I go to.
Dino: It basically showed a case where most dentists thought it was a gonner. I thought it was a gonner myself 10 years ago but-
Howard: You started a thread on this last night?
Howard: What was it called?
Dino: It was just a poll on whether you think this tooth-
Howard: Oh it's a poll. You're saying p-o-l-l.
Dino: It's a poll but I posted some photos and-
Howard: Oh really? I love polls.
Dino: I posted some photos, I showed some beginning shots of all the decay that was present in a tooth. Something like I think so far 75% voted to extract it and pull it and put in an implant. I find that interesting.
Howard: What did you do? Did you pull it or you retreat it?
Dino: No. I excavated it and I treated it.
Howard: What number of tooth?
Dino: It's number 14. It's funny. I remember when I shot that case seven years ago when I treated it, I had it all ready, I had it on my computer. I was ready to share it on Dental Town because I just thought it was awesome. I'm enabled to do things like that when I can see so well now. Then I started thinking about all the questions that were going to start coming. Now it won't last. I said you know what, I'm going to skip that one. I waited until I got enough time behind. I have seven year posts out of this tooth.
Howard: You waited a long time. You've been a townie since 2003.
Dino: It's not so much ... A post said I don't know that we should be teaching younger dentists to go after teeth like that that look so hopeless. My deal was I don't know that I'm really teaching anything to anybody, my main purpose is I see so many posts where you can't, you shouldn't, don't do this, that's going to do that. I read this stuff and it's like it's just not my world. I post on Dental Town because I just like to share and not to really teach but just to enlighten. To maybe rethink that maybe that tooth that you're thinking is not savable maybe it does have a shot instead of going right to the extraction which you see a lot today.
Howard: For me not having a microscope has now cost me money because I bought the CVCT. I bought the 100,000 peristream CVCT and now a lot of the cases I would have gone endo I'm now referring to an endodontist because I thought, this is a no-brainer and then you look at CVCT. One canal for 15mm divides into two. I can't see.
Dino: You can actually see from the CVCT even accessory canals or lateral canals.
Howard: The main canal turned into two. I'm looking at it and thinking before CVCT I would have assumed it was canal and cleaned and shaped and turned it loose and I'd have all been fine, we would have been good. Now I have a conscience and a little birdie on my shoulder saying dude, it splits into two and you know ... To me I look at that and say it's not worth it. I call my endodontist friend and I say do you get mad that I send you all this crap? They say, "Howard, with a scope, I just make my preparation. I can see the V." With a scope, it's just not a problem. They love em, they do em, whatever.
The CVCT will actually increase your endo referral and acutally it increases it all across the board because you see those [periachal radial illucencies 00:54:13] when they're a millimeter when on a PA you don't see them until 3 so I'm doing a lot more pulp vitality tests because you look at this tooth and you're like, that tooth is perfect, it doesn't have a cavity, nothing's wrong with it but it has a lesion on it and it's small and you pulp test it and it's dead. I would have pulled back on that.
Dino: Can I just say something?
Dino: What I was saying before was that the microscope not only enables me to better determine if something's really a gonner or savable, but it also works the other way where in the past, let's say I would have done an endo post crown, three months later, the patient's calling, pain whatever, there's a lesion. Tooth ends up being extracted and there's a refracture that I wasn't aware of. I can't tell you how many times I'll go into a tooth and while I'm opening the canal to do the endo, even though I'm doing less and less of them now. I refer more of them out now than I ever did before, especially after seeing some of these cases on the endofiles but at any rate, when I'm in there, sometimes you can see the fracture going down the [palatable 00:55:36] root of the upper molar and you instantly know that's a gonner. Whereas before I wouldn't have caught that. I would have went through and did all the work and not found after all the work was done that it was a gonner.
Howard: I don't even trust an endo retreat anymore because there's so many assumptions I don't get into. Number one assumption they don't have a microscope. Number two assumption is you're sending them to the endodontist who makes a living out of retreats and they don't have a microscope and they can't make money doing the implant. I go out of my way to send my failed endos to an endodontist who has a microscope and can make money doing an implant. If you're only tool is a hammer, everything looks like a nail, they won't retreat it, they won't give a five year money back warranty. They just say "I don't have any warranty, I just did the best I could." Yeah, you just want 1500 dollars. If you give a five year warranty where every year that it lasts, is worth 20% of the value. If it fails in one year you get 80% of your money back. They won't do that.
The ones that have a microscope, they see this stuff but if an endodonist can extract a tooth and place an implant, now you've got an endodontist who can make money doing either way and you have to be patient centric. It scares me when a doctor can only make money doing a surgery because you look at some of the international data. The United States has, our women have four times the amount of Cesareans than in other advanced countries. You look at the payment where they get $700 for a vaginal delivery and $4000 for a C-Section. As an MBA, I'm thinking that alone might explain it. Of course the OB-GYN patients I have say they just do it because they're afraid of the lawyers. If they see any complication, they just go straight to C-Section because they're afraid of lawyers.
Dude, I am out of time. I can't believe we passed an hour. It's an hour and one minute.
Dino: Are you kidding me?
Howard: Yeah. Our hour went fast. YOu're so amazing. I love you so much.
Dino: I love you too Howard.
Howard: Would you come back and do a part two? I've done 75 of these things, I've only asked one other guest to come back and do a part two, that was Gordon Christian. Would you come back and do another one because I want to hear the microscope for the other five clinical professions and I want to hear about LANAP because that is a very controversial thing. Either you believe it or you don't believe it.
Howard: Would you come back and do a part two someday?
Dino: I would absolutely love to.
Howard: We're going to pick up on microscope use besides endo, the other five clinical and I want to hear the whole LANAP story. I want to end on one question that I feel safe enough to ask you but I was too embarrassed to ask [Koys 00:58:21]. I was interviewing Koys and he's such a legend that he's so ... He's Greek and I wanted to finish the questions saying, "Hey, Jon Koys, you're greek. Big, fat, greek wedding, did you find that offensive or funny?" I didn't ask him that til I turned the podcast off and I asked him that and he just busted out laughing. I thought Damn it, I should have asked him that on tape. I'm going to ask you, you're Italian. This is a serious question.
Howard: The Godfather series and the Sopranos, most guys, the Godfather in their top ten. A lot of times you read in the press the Italians say I find the Godfather and the Sopranos extremely offensive to my Italian heritage. I'm going to ask you a cultural question. The Godfather, Sopranos, as an Italian, do you find those offensive or are they just American history or world history?
Dino: Not at all. That doesn't bother me.
Howard: What are your thoughts on it?
Dino: There's good and bad no matter what their nationality, right?
Howard: Absolutely. Except Irish. I'm 100% Irish. We are absolutely the most normal people on Earth. We don't even drink too much, just ask us.
Dino: I actually love Italian jokes.
Howard: Do you see it as just authentic world history?
Howard: Do you think the Godfather and the Sopranos is there any truth to that or is there just way too much Hollywood drama and blown way out of proportion or do you think the Godfather kind of gets the story right?
Dino: I think they probably got it right. I have family in Italy, not part of the mafia but have businesses where they've been confronted, where they want payment or something will happen to your store. A family member of mine there had a friend and they actually blew their store up. I don't think it's inflated at all what you see in the movies.
Howard: I have four boys and one of my sons loves the series. You always want to do things for your boys so I have watched more than my share of Godfather movies because one of my boys has watched every Godfather, I, II, and III, ten times each.
Dino: Is that right?
Howard: Hey, you're coming back for part two, you promise?
Dino: I promise.
Howard: Thank you so much for an hour buddy.
Dino: Thank you so much, Howard. Take care.
Howard: All right bye-bye.
Dino: All right. Bye.