Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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Provide Intimate Dental Care with David Eshom, DDS : Howard Speaks Podcast #97

Provide Intimate Dental Care with David Eshom, DDS : Howard Speaks Podcast #97

7/14/2015 12:00:00 AM   |   Comments: 0   |   Views: 626

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David Eshom, DDS shares detailed stories of how he's worked to make his practice so unique.
David Eshom graduated 1985, has private practice in San Diego which takes no PPOs and is 100% fee for service, Accredited by the American Academy of Cosmetic Dentistry, BOD AACD for 6 years, Program Chair or Co-Chair for Professional Education for the AACD for 5 years, Speaker for Invisalign, cosmetic dentistry and lasers for last 15 years. Loves what he does and doesn't want to retire.

Howard: It is a huge honor today to be interviewing David Eshom, who's down there in San Diego. I'm a big fan of yours. You've got 30 posts on Dentaltown. You're huge into cosmetic dentistry,  you're on Invisalign and all things like that. First of all, I want to just thank you for spending an hour with me today.  

David: Happy to do it, and I appreciate you asking, Howard. I love Dentaltown. I know 30 posts isn't a whole lot but I do listen and lurk and learn by going through the posts. So, what you've done for dentists and dentistry is ... There's no one that's matched it. 

Howard: Oh, thank you. I got to ask you, of all the ... There's 9 specialties in dentistry: 7 are clinical, 2 non-clinical, public health and oral radiology. You're accredited in the AAC- the American Academy of Cosmetic Dentistry.

David: Correct.

Howard: A lot of dentists, they're afraid of those kind of cases. In all seriousness, there's a couple of patients ... Some patients we like, like a toothache who is begging you to fix it. Some patients we don't care so much for, like that screaming 3-year-old who needs a root canal and you're like, "Give that to a pediatric dentist." Or TMJ patients, because a lot times, those are just really high-anxiety ... A lot of times, those are just crazy people. But, man, nothing's more stressful than when a beautiful woman walks into your office and sits down with photos of what she looked like on prom night 30 years ago, pictures of gorgeous supermodels, and they want you to do that. I don't want to do that case. What attracted you to want to do those types of cases? Are you a glutton for punishment? Or are you just ... (laughs)

David: Well, that wasn't the first thing I thought about when I wanted to approach those cases. The first thing I thought about was helping somebody feel better about themselves. And, as I found out, you're not incorrect. You are correct. 80% to 90% of the patients are just fine. But the 10% that are overly picky can really make you crazy. The way I went into it was trying to help people and doing it in an artistic way. I'm very thankful for what I do, but I do have to deal with some of the people that are very, very nitpicky. 

Howard: Was that the first big game-changer in your journey of dentistry, from graduating in dental school in 1985, you were practicing along with ... Was joining the AACD your first game-changer? Or were there bigger, equally more important decisions you made before you made that decision?

David: No, that decision kind of opened the door to what was my pursuit of quality dentistry. And, really, that's what I'm all about, is providing quality dentistry in a comfortable atmosphere in a very communicative way. The AACD taught me to do quality dentistry, and scrutinize myself and then stand there in front of people with no clothes on, who let them critique me and then that would make my dentistry better. The more I listened to people and the more I could take criticism, the better I got. I feel like that was my game-changer, to seek out quality dentistry. From there, I needed to communicate what quality dentistry is to my patients so that they can quality dentistry. Once they accept quality dentistry, they need to understand that it's going to cost more, so I need to communicate the value of quality dentistry for them and for their lifetime. That's where they journey started, at AACD.

Howard: So, your journey was, first, to be a quality dentist?

David: Correct.

Howard: And then AACD just helped you become more of a quality dentistry, period.

David: Correct. By opening my eyes and letting me see the things that make things, that change things from average to superb. 

Howard: The whole mission with Dentaltown is, in 1998 I was professionally isolated and lonely. I just wanted to be able to talk to a guy like you. Now my job on a podcast interview is I'm trying to guesstimate what 4,000 individual listeners in their car, on their commute to work, they're standing on a treadmill, they're doing laundry. I'm trying to guesstimate their questions. So, I'm just going to go with, "What is the AAC? I've never heard of it. What is this?"

Well, obviously I've heard of it. But what would you tell someone who's never heard of the AACD, or they just got out of school last year? What is the AACD and what are they all about?

David: Well, the AACD is the American Academy of Cosmetic Dentistry. It's the largest cosmetic association in the world and it promotes high quality cosmetic dentistry to its members. We have an annual meeting, to which I just attended last week in San Francisco, where there's about 2,000 like-minded people interest in providing high quality cosmetic dentistry to their patients and learning how to do that better in a more minimally-invasive way. That's what they're all about. You can also be a member or you can seek credentials. In my case, the first credential you seek is accreditation. In that, you provide 5 different type cases: a bonding case, a direct veneer bonding case, veneer case, a single anterior unit case, and a bridge or implant case to the examiners or your peers. If you treat that case in a quality manner in which they give you criteria for you to check yourself, you get the accredited credential. And, so-

Howard: Is the accredited the fellowship? The "FAACD"?

David: The next level?

Howard: Oh, that's the next level. So, first you want to be an accredited member.

David: Correct.

Howard: How long of a journey would that be for the average AACD member?

David: (laughs) Well, I took the longer journey. It took me 5 years. Some people can do it in 2 or 3. Some people might take 7. But, I was one of the longer groups, but-

Howard: When you're accredited, do you get any special initials or anything? Or, not really?

David: Yeah. You get "A", AACD instead of "F" AACD.

Howard: So instead of a fellow of the Academy of Cos ... Is it a Fellow of the American Academy of Cosmetic Dentistry? [crosstalk 00:06:44] Would he be an accredited?

David: That's right. From the American Academy of Cosmetic Dentistry.

Howard: Okay. And so, the next leg up the stool would be fellowship in the AACD?

David: Okay, yeah. That's for the real crazy individuals because you not only have to submit your 5 cases, but you have to submit 45 more of those, to which they put your teeth up on this huge screen in a dark room and look at your teeth, look at your layering, look at your prep, look at the tissue, look at the angles, look at the contour, look at the color- all of that very, very scrutinized - and make sure it meets the accreditation quality- and you do that 45 times. So, the fellows are quite well-trained and very, very [crosstalk 00:07:33].

Howard: So, you present all 45 of those at one session? Or do you keep submitting them over the years until they equal 45?

David: You put them all together and then you submit them all at once. So, yes, you'll submit them. You're not there in person now. They do an oral interview at the end, but you submit your cases digitally. When I submitted, I submitted them on slides. That was really difficult. But now they submit them digitally and then the examiners look at them and then they'll do an oral exam at the end of that.

Howard: And the AACD was started in Wisconsin, right? By Jack ... Or ...

David: Yeah, Jack and also that dentist in San Francisco. I'm forgetting his name now, too. But the two of them co-founded the AACD.

Howard: Yeah, what was Jack's name? I'm so-

David: (groans) His son lectures. Sydney's lectured for you on your Dentaltown Convention, too.

Howard: Yeah, yeah. 

David: He's a Madison member, also.

Howard: Yeah. An amazing man. John Kanca was also an early president of the AACD. I think he was like the third president of the AACD. And the new president is my buddy up the street, Joyce. Joyce Bassett.

David: Joyce Bassett just got installed last week.

Howard: Yeah, an amazing group. So, I want to ask you. I'm trying to estimate these guys listening to the podcast and, I know that right now there's several ... There's really 1,000 dentists saying, "Oh, come on, David. You're in San Diego. That's Hollywood movie stars. I'm in Salina, Kansas. I mean, come on, dude. I'm in Fargo, North Dakota. Would getting a fellowship in AACD, would that apply to half on America who lives in rural, small town farm America, or middle markets of $100,000 versus, obviously, San Diego or Beverly Hills or something like that?

David: I would say to those dentists, you just have to ask themselves what you're interested in. For me, you're not going to get good at something you're not passionate about. For me, I was passionate about learning how to do artistic cosmetic dentistry, so I went. I didn't go to be accredited. I went to learn. And as you start going to the classes and seeing things, you want to try that. And when you try that that either turns you on or it doesn't turn you on. You think it's too hard. Then maybe you don't become accredited. But, go to the meeting. See what it's like. If you want to be better at cosmetic dentistry, you don't have to do veneers. Just be better at bonding. Just be better at taking care of your patients when they need a single unit crown in the front part of their mouth. If you just want to get better, go to the AACD meeting and you will see the best. You'll see people that are nice. You'll see people that like-minded, they'll talk to you. They'll share their problems and their good things, and you'll learn from them. That's what happened to me. I liked the people and I liked the learning environment and I liked the subject. That's why I got passionate about it and that's why I went through the effort of being accredited.

Howard: Okay, so you got out of school in '85. I got out of school in '87. The first 10 years out of school, the thing that just makes your stomach just like, (groans). A woman comes in, she broke 8 and 9 is fine. You got to do a single crown on 8. Walk her through that. What's the low-hanging fruit? What can this lady listening to our podcast today learn about when they come to you and you got to crown 8, and 9 was made naturally, and you've got to make 8 and you're just at talking monkey? What would you recommend? What procedures, processes and materials? How would you treat that? Or would you just refer it? (laughs)

David: (laughing) No, that's right up my alley. After AACD and being to come accredited, you should be able to handle it in both a clinical and a patient management standpoint. The main thing I would do is I would show her cases of single front tooth that I've done. As long as they're not one of the people you were talking about at the beginning of broadcast, where they're ultra crazy, if they liked what I did with 2 or 3 other people with a single point crown, then I know that's somebody I can treat. Because that has a little red flag on it. If somebody's ultra picky, they'll always be able see something about it.

Howard: I got to stop you right there because you just said something so profound and a lot of the kids might not have caught it, is: When you go to a doctor and they show you pictures of their own work, that is an instant confidence builder. That's how you can get away with charging more, not taking PPOs, whatever. I cannot tell you how many times I've heard a woman talking, where it was eyelid surgery or a boob job or something and they went to 3 or 4 different doctors and they were showing them brochures. But then this doctor started showing them cases of their own work and that's where they stopped and got it done. That is so important, to photodocument, isn't it?

David: It is. Again, what you're talking about is someone who, if they like your work, that's somebody you can work with. But if they're nitpicking the work that you've done, that you think is some of your best work, then maybe that's somebody you don't deal with. But, then again, that's 5% of the people, maybe 10% of the people. If you want me to walk you through it, that's kind of how I do it. I also tell them I need to see what it looks like underneath the tooth. Is it dark, or whatever? I guess it's broken so I can see that, so we talk about how dark it is. Then we let them know that the first time they put it in, probably, we're not going to see it. But in the meantime, I'm going to make them a nice, perfectly contoured temporary that they'll be happy with, if we have to go back and forth for the shade at least once, maybe even twice. That's how I would tell somebody new that wanted to do a single unit front crown, as to how to do it along with how to manage the patient's expectations, because that's going to be the big problem. Not so much doing the clinical work.

Howard: I still think managing that patient expectations is, these doctors listening, they need to start photodocumenting some cases because that's a big part of patient communication and patient trust, is when you open ... What do you have? Do you use a photo album or these slide presentations on your computer? Or an iPad?

David: In my office I have monitors, and there's 2 monitors. With each patient that comes into our office, we do a new patient exam with, which I would recommend for new doctors to think about the exact steps in their new patient exam. One of those new steps should be to take extraoral photos of the patient along with the intraoral camera photos of the patient. So, the patient gets a tour of their mouth. They get to see what you see. To be honest with you, most patients are going to be pickier about their teeth than you probably will with their teeth. It's a whole communication-education environment when you take the pictures. So, someone actually learns something new about themselves. Somebody could be 40 years old and they're going to learn something new about themselves by you showing them extraoral pictures of themselves. That is something that really makes them bond with you and really makes them listen to you.

Howard: Well, David, you just amped it up a whole can of worms, because probably the biggest controversy in practice management is, "The patients are calling. They just want a cleaning." Do you do a new patient cleaning, or do you do a new patient exam? What do you do?

David: My practice, Howard, to give you a little more about it, is all fee-for-service. We take no PPOs. We don't take Delta. We have patients pay in advance and then they get the insurance from them. I don't mean that as a brag. That's what I've worked towards and that's how I feel I can best treat patients. So, a new patient calls and they just want a cleaning? My staff recommends that we do a cleaning exam, but if they want just a cleaning I'm okay with that. They'll come in for the cleaning. I have total trust in my hygienist. I'll go over there and say, "Hi," and do a quick visual exam. But if that's what they want, that's okay because they don't want to get to know us, if that's the case. Once they get to know us, once they see our hygienist, once they see our office, once they see me say, "Hi," then at that point we can schedule them for an exam, but they're not going to come in and get a second cleaning, unless they've had that exam. That's how I handle it in my office.

Howard: Just to set realizations to these kids out of school, how many years did it take you to go Delta insurance free and PPO-free and have a practice? Did you start out that way, day one, or how long along your journey did that take?

David: Let's see. I can tell you the year. It was 10 years, 12 years ago. So, what is that? 2002? I was in the practice 15 years.

Howard: '85 to 2002?

David: Two. Mm-hmm (affirmative).

Howard: Okay.

David: 15, 16 years. I was in the AACD at that time. I had taken Frank Spear's hotel classes and all of his workshops. I had consulting with Jim Pride. I had consulting with Bill Blatchford. After my consulting with Bill Blatchford, he's the one that gave me the courage to try it. I did it, and I lost half of my Delta patients. UCSD, the University of California San Diego, cross the street, all Delta. But I survived. And what I started doing is just exactly what we started talking about, is I started taking pictures of patients, taking my time during my new patient exams, showing them their pictures, and talking to them about their teeth. 

But the first thing we talk about is how healthy are their teeth? After health, we start talking about appearance and whether that's something for them or not for them. If it isn't for them, then we're happy they're healthy. If it us for them, we talk about the different options for it. But, when you have their teeth up on the screen and you're talking to them, that's the best way to find out if that's something they're interested in. I don't want to push anything on anybody so, if they're interested in it, we talk about it. So, yes, it was a long time before I went Delta. I'm not sure how and if someone could do that nowadays. 

That's one of the questions I wanted to ask you, Howard. What do you think of private practice and where practice is going? You have your MBA. You've seen the business scene. You scour it. You know about it. I think somebody can, but it's not an easy thing and I'm glad I don't have to do it again.

Howard: Well, you asked me a question, so I'll answer. I think that half of America buys on price, and I think half of America buys on relationship. I think a lot of people who buy on relationship aren't necessarily just the rich people who just buy on price, and there's a lot of poor people who buy on relationships. I keep seeing analogies thrown around that dentistry is going the way of Walgreen's. When I go to other countries, a lot of their prescriptions have gone the way of ATM machines. The doctor gives you a prescription on a Smart Card. You stick it in an ATM machine. A bottle comes down. The pills fall out of a hopper. It throws a label on it. So a pharmacist is selling a product. A dentist is selling surgery and operatory hands-on, "I gotta meet this doctor." 

I think dentistry will always be very powerful. As far as the corporate dentistry going along, I see ... When I first got out of school, Orthodontic Centers of America had billion-dollar market cap on the New York Stock Machines, with [inaudible 00:18:50], Lazzara's out of New Orleans and that spectacularly imploded. And the big part of that was they weren't keeping the doctors. Every time they bought an orthodontics practice, as soon as that orthodontist would go, they ran. And then, there were another dozen on the NASDAQ and every one of them is gone. I keep telling doctors that if your business is selling dentistry, you better ... The thing I'd look at is, do they keep their doctors? And when Orthodontic Centers of America couldn't keep their orthodontists ... Today there's a lot of these corporate dentistry chains. Their average length of time a dentist stays in the clinic is one year, which shows the other problem. 

The reason we see so much corporate dentistry is they provide 2 services. Guys like me can't sell my today's dental practice to a kid that just walked out of school. But I could sell it to Big Corporate America in an hour. It's a liquidity play. They're there because they got access to huge amounts of money and guys like me, we have liquidity. If I drop dead out of a heart attack and my family wanted to sell my practice, Heartland could write a check in an hour, okay? The kids coming out of school, they with so much student loan debt, they're having a harder time getting access to capital and they just want a job. It's [inaudible 00:20:06]. It's the new day Army-Navy. 

In our generation, if you said, "I'm going to go do 4 years of Navy to get some experience," well they'd say, "Well that's good." Today, if you say, "I'm going to go do 4 years in corporate dentistry," a lot of people are judgmental about that. They have a place. They're not going away. I don't think they're nearly as significant. But the thing that is significant is that you have an incredible personality, you have incredible confidence, and you have a repertoire of good clinical skills that you're good at. If you don't have a personality, you don't have a warm and caring staff, and you're not good at doing- whether it is cosmetic dentistry, root canals, placing them- if you're not good at anything, then, yeah, you're a commodity. You're in trouble.

David: Correct.

Howard: But I want to go back to you. You got out in 1985. You dropped Delta in 2002.

David: Correct.

Howard: When did you join the AACD? What year was that?

David: It's been through '98.

Howard: '98.

David: Correct.

Howard: And then you credited Bill Blatchford. What year did you join Blatchford?

David: Blatchford we did in about 2000. 

Howard: 2000?

David: Did a year and a half with Bill Blatchford. Yes.

Howard: And Bill's the one who talked you into just going for it, dropping Delta and just going for it.

David: You have to hear things a few times before they finally click. I heard it with Frank Spear. I heard it with Jim Pride. I heard it with AACD. After I heard it with Bill Blatchford, that was the time I said, "Hey. I feel like I can do this. I want to give people the best that I can and if people want the best I can, I have to charge more." I didn't feel comfortable charging somebody who didn't have Delta $1,000 and then somebody who had Delta $800. That's not fair. They're the same people, they need the same procedure, but you have to charge them different fees? To me, that doesn't seem fair. Plus, I couldn't take the right amount of time and use the right quality lab with somebody that's paying the $800 instead of $1,200. It was kind of a rub, ethically. You have to decide what game you're going to play. Are you going to play the price game? Or are you going to play the quality game? 

At that time Bill Blatchford, who was talking to me about it, and with the help of my wife ... I want to tell you, all along, my wife's been in the front part of my practice making sure things are customer service-oriented. You don't just do this blind. You're prepared and your whole office is prepared. Then, when I did it after hearing it from Blatchford, then I was very, very pleased after being very, very scared for 6 or 9 mins.

Howard: Well, you opened up two cans of worms so I'm going to address them both. First is the wife one. So your wife is your front office, your front desk ...

David: No longer.

Howard: But she was?

David: I'm still married. She was for 13 years.

Howard: What year is that?

David: Let's see. We bought the practice in '88 and still ... Until 2001.

Howard: What was it like having your wife work the front desk? You're still married to her?

David: I still am. 32 years now.

Howard: Looking back, was that a good move, or was that a stressful move? Would you do that again?

David: Of course I would. And, if you can work with your wife, I would highly recommend it, especially if she has a caring attitude and wants the same type of practice you do. My wife worked at Nordstrom, was a manager with Nordstrom. We'd decided to move from LA to San Diego. She gave up her job. We bought a practice. And, I want to tell you the whole story, if I could. Because I bought a practice and I was young and dumb. I saw that the doctor was seeing a lot of new patients, he was in capitation, he was in San Diego and it was this nice practice. So, I walked right into it, paid a top dollar. I then found out the reason why he was seeing so many patients was he was doing $29 cleanings, x-rays and exams. So, that's how he got 40 or 50 new patients a month. 

So, I had to transition out of that $29 cleaning practice into a regular practice when I'm not doing that, taking PPO insurance, and then transition out of that into pay-for-service. I'm proud of what we did, but along the way, my wife was providing guidance in the front, customer service in the front, the Nordstrom attitude in the front so that I could concentrate on my clinical skills- I told you all the clinical skills that I was going to every year- and then let her run the practice. So, without my wife I wouldn't be where I am now.

Howard: What does she do now?

David: Now she stays at home, monitors the practice on the computer from home, does the tables, does payroll and then gets on me when things aren't going right.

Howard: Right on.

David: Yeah.

Howard: How long have you guys been married?

David: 32 years.

Howard: Oh, that's amazing. That's awesome.

David: We have a funny story real quick here, Howard. When we decided to work together, my wife would talk to me on the way to the car. We lived up in Orange County and drive to San Diego for almost a year. So, I would hear about the practice all the way home. And so, we made a rule that as soon as the car drove in the driveway, we can't talk about the practice anymore. That was one of the rules. The other rule to practice with your wife is, we drew a line between the back office and the front office. She handles everything in the front. I handle everything in the back. I don't get in her way. She doesn't get in my way. That's how we were able to still be married.

Howard: How many children do you have?

David: Two kids, 17 and 18. Again, we were 13 years like that. All the people in our office were having babies and we would go, "Oh, well after so-and-so's baby, we'll get pregnant. After so ..." Well, it got to 13 years and I was turning 40. Sorry, we couldn't wait anymore. (laughs) We finally had kids.

Howard: So they're how old? It's 17 and what?

David: 17 and 18. One's going to college this year and one's going to college next year.

Howard: Oh, right on. We see these debates on Dentaltown. Is it safe to say that CAD CAM is better for an all-purpose single unit crown in the back, but not for a high intense cosmetic case in the front?

David: Well, that's my opinion. I know other people may debate that and that's what Dentaltown is all about.

Howard: But it's just you and me. This isn't a general debate. [crosstalk 00:26:34]

David: I know. I don't think you can do a CAD CAM crown in the front unless the tooth is very dull and very monochromatic that you're matching. And unless you how to cut it back and layer it.

Howard: Also in the back, you're never going to find a prostodontist who said, "I'm going to mill out 7, 8, 9, 10 crowns in an arch." Most all your prosthodontists say, "Well, if this is multiple units, I would never do that in-office. I would an impression and send it out." Wouldn't you agree with that?

David: I sure would. I haven't had much luck with CAD CAM. I'm on the other end of the fence in terms of one-day crowns and milling out things in your office.

Howard: To be clear, what percent of the AACD accredited members would not use CAD CAM for anterior work?

David: I'd say about 95% of them.

Howard: And what percent would not use CAD CAM for posterior work?

David: That survey, I couldn't really tell you. I just know the anterior work because that's what we see from time to time as I served on the board of directors and served on the professional education committees. Posteriorly, I couldn't really tell you. I know it's up-and-coming, but I'm not seeing it prevalently. 

Howard: Can we be more specific on that anterior crown? Let's just say it's a 30-year-old woman. She fell down, it was trauma. She broke off number 8. It's not black from having a root canal as a kid, there is no metal pair of posts degrading and all that. Just a standard, clean ... She's a 30-year-old woman. She's good-looking. She's got a high lip line and she busted off probably a huge class 4 fracture. You're not going to do direct bonding. You got to do a crown. What kind of crown would you do on that? Talk through the details. What would you impress with? Would that be an optical scan, polyether? You a polyvinyl guy? [crosstalk 00:28:49] Would you do an E-Max crown?

David: My lab? We're going to do a polyvinyl siloxane impression. We're going to take a picture of the core of the tooth, or the stump. We're going to prep just below the margin without damaging tissue. We're going-

Howard: Would you pack cord before you did the margin work so you wouldn't nick the gum? Or would you prep a subgingival margin with the tissue it is?

David: No, I'd place cord and then go about a half millimeter subgingival.

Howard: Do you just place one cord or do you place two cords?

David: Depends on the case, but most of the time, I just place one cord.

Howard: Would that be a 0? A 1 cord?

David: It's a 00. It's actually a 00.

Howard: Who makes it?

David: Ultradent. Ultradent makes it.

Howard: And you do that because it's going to push the gum tissue down and out so you have a less chance of nicking the tissue?

David: Correct. And the margin is going to be either at or below the gum line. Being that there's going to be a translucent facial portion of that crown, it's not going to show. It's going to blend with her tooth, just like it would a veneer.

Howard: What type of prep would that be? Would that be a shoulder? A heavy chamfer?

David: It's a heavy chamfer.

Howard: A heavy chamfer.

David: Correct. My lab currently used E-Max and then cuts it back. From time to time we have to do zirconia and then layer it on top, depending on what the other tooth looks like. And again, I don't expect it to be the same exact match the first time.

Howard: But a lot of listeners don't even know what you just said. So you're going to send to a lab. But these guys are alone. So, would you mind sharing what lab you're going to send it to?

David: I send it to a lab called Haupt Lab up in Brea, California in Orange County.

Howard: Hop? H-O-P?

David: H-A-U-P-T. John Haupt and his sons work there. John is fellowed by the American Academy of Cosmetic Dentistry and his son is accredited. So they're accredited lab members and there's accredited dentists.

Howard: What's their "www"?

David: It's probably

Howard: H-A-U-P-T?

David: H-A-U-P-T.


David: Correct.

Howard: You should call him and do a podcast explaining your exact techniques. So you're saying he would start with a E-Max crown and then you talked about cutting it back. Explain that in a little more detail.

David: At least at the incisal, there's translucency, there's some characteristics that you need to match in the other central incisor. So, you want to cut it back to the point where you see the incisal of the other tooth and then you layer clear and colored porcelain underneath that. Then you put a glazed porcelain over the top of that. When it's baked, the translucency, or how you see through the edge of that tooth, matches the other one. IN the body of the tooth, there's gonna be certain colors that go from brighter to darker towards the gum line and you're going to cut back in there to match that transition because your E-Max is all one color and you want there to be a gradation of color from the middle of the tooth towards the gingiva. So, sending pictures, multiple pictures, and sending core shades and then sending an impression of your temporary is very important to the lab so they can match what you need. You want them to match.

Howard: When I talk to big labs, they say 99% of labs scripts just come in and say,"Tooth number 13, A3.5." That's all they get. What does your lab script look like? Is it just tooth number and one shade? You're sending photos. You're taking a stump shape, which means you're taking a shade the prepped tooth.

David: Correct.

Howard: What percent of dentists do that? Probably .001?

David: I don't know. You would know more than that than I? The people that I hang with-

Howard: Do you want to hear something frightening? When I go into removable labs ... This makes me just like, "Wow." When you go into removable labs, 95% of all the impressions that come in for a cast partial, the doctor didn't even cut a single rest seat.

David: (laughs)

Howard: Not only is there no design, but it's like, "Dude, you couldn't take a football and make a- You couldn't do anything?" 

David: You didn't even need to numb to do that, did you?

Howard: It's just like, "You've got to be kidding me." If you can't cut a rest seat on a partial, at what point do you just throw in the towel? Explain your lab scripts. So, you would take a photo. I want specifics. What camera do you use to take a photo? Is this on your iPhone?

David: (laughs) Yeah, exactly. No. Again, I don't like things to become overly complicated and so I don't us a through-the-lens camera. I know you like to not companies. They have a camera there. It's called the G16. It has a diffuser on it that nobody else has. So you can hold this camera in one hand, focus it, take a shot, and they look almost as good as you would with a through-the-lens camera. If your camera is not easy to use, you won't use it. This is an [crosstalk 00:34:21].

Howard: Wouldn't you say PhotoMed's pretty popular among FAACD guys?

David: Oh, for sure.

Howard: Oh.

David: Oh, for sure. But most dentists don't want to get up and go to that through-the-lens thing for all these shots. This G16 takes all my shots for me with one hand.

Howard: How many of your AACD buddies that have their fellowship, accredited and fellowship, use the G16.

David: They probably don't. I don't. You see my results, so I think they should really look at, especially for their everyday cases. Now, when you submit to AACD, you got to take it through-the-lens. I'm not saying you're sending these in for AACD. I'm sending them into the lab this way. 

Howard: Are you emailing that photo digital or is it like a ... How does the lab man get the photo?

David: The photos go on to my computer via Eye-Fi card, which is a WiFi card. 

Howard: So, it's a digital photo?

David: Correct.

Howard: Mm-hmm (affirmative).

David: And it goes on my email with my instructions along with the lab slip, along with the case that would hold the impressions and temporaries and all that kind of thing.

Howard: So, you're emailing the photo and the lab script and then mailing a polyvinyl siloxane impression?

David: Correct. With a written lab slip there, also.

Howard: Interesting. What PVS are you using?

David: I have to turn around. It's this Sympress material.

Howard: Sympress?

David: Yeah, I have a machine that-

Howard: Yeah, I see the machine. When I use the [crosstalk 00:35:55] I use Impregum. Same machine.

David: Yeah.

Howard: But it's Sympress?

David: Well, that's the machine. Let me take these headphones off ... Sorry. It's EXAJET from GC.

Howard: EXAJET from GC. GC is General Chemicals out of Japan- Tokyo, right?

David: Correct.

Howard: The reason, to my podcasters, a lot of the times when people ask me like, "Don't be anal. It's a PVS." I always get that. These dentists are alone and he's alone and he's listening to you and he doesn't want to hear, "Oh, I use a composite." He's like, "Well, dude, what composite? There's 50 different types of composite." They always want to know specifics because they're all alone and they want to hear what you're using. Not what some rep walks in their the office says, "Oh, use this." Because they don't know if that's because ...

David: No problem.

Howard: Okay. I want to take you through another case. Just your bread-and-butter first molar crown. The most likely tooth to get a crown is the first molar. Most likely tooth to be missing is the first molar. Most likely tooth to get an implant is the first molar. What is your bread-and-butter first molar crown on just an average face? It doesn't have to be a hot woman. It could be a 52-year-old short, fat bald guy like me. If I came into you and my molar broke in a half, what would be your bread-and-butter crown? Would it still be E-Max? Would it be just like everything you said for number 8, but it'd be a first molar?

David: Exactly not.

Howard: Exactly not.

David: Exactly not. The first thing I'd do, Howard, is I try to do the minimally-invasive dentistry. I don't do a lot of crowns. I do a lot of onlays. So, I would do a onlay on a tooth whenever I can, if I feel it's going to be strong long term. That's going to save the patient's tooth structure and possibility of future root canals. The first thing I'd do is analyze it, to see what strength it had and whether I can do an onlay. If I can do an onlay, I use a diamond onlay from Rocco Lab in Escondido. It's a blend of composite and porcelain. It's not an all-porcelain onlay. It bonds better and it's more compatible with a post in teeth.

Howard: So, this is a separate lab?

David: This is a separate lab. Exactly.

Howard: So you're using Haupt Lab for anterior work. And posterior work you're using which lab?

David: Rocco's. R-O-C-C-O-S. 

Howard: R-O-C-C-O-S.

David: Rocco's in Escondido, California. 

Howard: And the "www" would be?

David: I think it's I'll be surely getting back to you on that. Kristie Rocco.

Howard: Is he Italian or related to Rocky? Or Bullwinkle?

David: Well, I think he's Italian, but to be honest, it's a woman's lab. Her name is Kristie Rocco and she's fantastic.

Howard: Kristie with a "K" or a "C"?

David: With a "K" with an "I" on the end.

Howard: Okay, so the first thing this dentist's listening to is, why do you have a separate lab for front teeth ... Anterior teeth and posterior work. Explain that decision first.

David: There's a huge aesthetic difference, or scrutiny in the front part of the mouth versus the back part of the mouth. Nobody's going to ask me for more translucency on a first molar. There's an economical difference. At Haupt the fee is going to be higher. At Rocco the fee is going to be lower because they're [inaudible 00:39:11] a lower cosmetic value or artistic value in making that crown. So that's why. With Kristie, she's right here in town. I can get things in the back with her. We have a long-term relationship. She does anterior work, but when it needs to be AACD quality I go to an AACD lab.

Howard: First of all, to our young viewers, a lot of dentists are in denial. They don't want to hear that amalgams last longer than composites. You tell them that and they think you're speaking in forked tongue. But others don't want to hear that when you file a tooth down, a molar down for a crown, a huge portion of them die and need a root canal within 10 years. Do you agree with that statement?

David: I try not to do a crown when I don't have to.

Howard: Right.

David: I agree with that statement.

Howard: It's extremely destructive. But you said when you're doing an onlay it's not all porcelain. You said it's porcelain and composite.

David: The material is a hybrid of porcelain and composite called diamond. It's a lab out of New York and I'm sorry I don't have that lab that makes that specialized material. You can ask Kristie Rocco exactly where she would get that. It's called diamond. It's not made out of diamonds, but it's called diamond onlay. 

Howard: Diamond onlay. That's the material. Is that like a stacked porcelain? Or is that-

David: It's more like a composite than it is a porcelain because I can take away from it and add to it if I'm missing a contact. I can sandblast it. I don't need to etch it. I just sandblast it and then place it that way.

Howard: Okay. Do you care if I switch the whole subject to a whole 'nother deal?

David: Not at all. I've got another topic I'd like to ask you about, if you have the time. If you'd leave some time for that. 

Howard: Absolutely. There's so many dentists ... I bet you 3,000 out of 4,000 listeners have never done an Invisalign case. What is that all about? Explain Invisalign. Do you think that dentists should learn Invisalign? Talk about Invisalign. First of all, how has your journey been with Invisalign? Did you start this in 2002 or did you start it when you joined the AACD in 1998? Is Invisalign a big part of your practice? Is it something you just do once a year? Talk about Invisalign.

David: I started Invisalign about 6 years ago. But when I first got out of dental school, I took a study club/continuum in orthodontics with fixed brackets and wires.

Howard: Who was that with?

David: A gentleman up in the Valley in LA. And I'd have to get you to see him, too. That's how bad I am with names. I apologize for that, Howard. But, I learned how to do fixed orthodontics and I did that for a while because the practice up in LA before we moved to San Diego was kids. We did some orthodontics with kids. Then, when I moved down to San Diego, I didn't see a lot of kids. Keeping brackets, keeping bands, keeping all the sizes made me crazy. So, at that moment I put it off to the side. At that point I got interested in the AACD and started doing cosmetic dentistry. Then, 6 years ago. What is that? 2008, 2009 an associate of mine started some Invisalign cases. I thought it was interesting, but I was still busy doing my stuff. Then she left, so I had inherited these Invisalign cases. Then I started finishing them off and learning how to do it. It became a new passion for me that I'm more passionate about than cosmetic dentistry. Invisalign is cosmetic dentistry in the most minimally-invasive way possible. Now, I do fewer veneer cases because I offer the patients Invisalign first.

Howard: Exactly.

David: That makes me feel so good. And I feel so bad sometimes about some of the teeth I ground down in the past. But it's just a learning process and I have to let it go.

Howard: You treat other people like you want to be treated. These dentists who would never, ever, ever file down their own daughters' teeth for veneers would tell their daughters, "You're gonna get braces and bleaching." But since they can't do braces, they don't know how to do braces, they're filing everybody's teeth down. And if you file 10 teeth for, just a millimeter and a half off for veneers, 10 years later, how many of those teeth die and need a root canal? Or 20 years later.

David: Well you definitely redo them, at the very least. I feel horrible about that but that was my knowledge base and no one should feel bad, I don't think. But, now my knowledge base is higher and I have a much higher respect for natural tooth structure and I have a way of solving it in a minimally-invasive way.

Howard: How many Invisalign cases would you do for every veneer case? What's your ratio? Is it 1:1, 2:2, 3:1?

David: Do you know how many Invisalign cases I do a year, Howard?

Howard: How many?

David: I do 200.

Howard: Wow.

David: And I might do, let's see ... 20 or 25 veneer cases that it would be significant for more veneers. 

Howard: So that's 10:1 Invisalign over veneers. So what you're saying is the Invisalign market is 10 times bigger than the veneer market?

David: In my office. And I seek it out now because it is such a good service. It makes people look better. They're healthier. Their teeth come together better. They're less damaging to themselves over their lifetime. There's nothing more fulfilling than finishing an Invisalign case and seeing someone smile, knowing that they have all their own tooth structure there.

Howard: You and I have been doing this for 30 years. Let's talk to these kids that are at 10. Do you think that you could go from no ortho to doing Invisalign, 6 month Powerprox, or 6 Month Smiles? Or do you recommend, like you and I did, to do an ortho curriculum first?

David: I think when we started, there was no way. It was like a closed club. You were lucky if you got an orthodontist to teach.

Howard: It still is.

David: Now you can learn Invisalign and you can learn a lot. You can go to 6 Month Smile and you can learn a lot. There's a lot of places where you can learn it, but I think you need to study it on your own. You can't just read it in a book or buy it in a box. You have to work it out. But you can do ortho. You can do Invisalign.

Howard: But these kids driving to work right now, what would be the first step? What would your first step? Give me. How would you start your training if you've never done a class 1 ortho case. You've never done Invisalign. Your school didn't teach it like most schools. We're on the first floor. We're going to go to the second floor where we're going to be doing 200 Invisalign cases a year down the road. What would be the first step? How would you start this journey?

David: My prejudice is I'd have them go to an Invisalign intro course. They'd teach them hot to use it. They'd teach them what cases to take and what cases not to take, have them do it on a staff member or family member to learn with, and then slowly move your skills up. There's a bunch of online stuff with Invisalign you can learn. There's a bunch of separate classes with Invisalign you can learn. You can go to some general dentistry, or a regular kids' orthodontics-

Howard: You're a speaker for them, aren't you?

David: I am a speaker for Invisalign. Yes, I am.

Howard: Why don't you make an online intro class to Invisalign. It doesn't even have to be intro. It could be a 3 part series of beginning, middle ... You know, we've put up 307 courses and they've been viewed half a million times. A lot of these dentists, they say, "I don't want to close up my office. I don't want to fly to California." Would you ever consider putting in an Invisalign or an online CE course in Dentaltown?

David: I would be happy to, Howard and I would. I'd give some people some general information. But on the Invisalign site, there is so much CE there, so I'd tell people how to get into it and what to look for and how to operate their office, because I don't think Invisalign does that-

Howard: So, that's just

David: Then they can learn how to do it. If you become a providing doctor, there's all the CE you could possibly handle on there, about class 1 cases, class 2 cases, molar uprighting ... All that stuff is on there. Which is beautiful.


David: Right. I tried to talk to doctors in San Diego and get them interested. The information is all online, so it's kind of redundant, like, "I'm a dentist!"

Howard: So how many courses are on

David: There's got to be ... 300?

Howard: Oh, my God. So 300-

David: All about a half hour to an hour each, all on different topics.

Howard: Would it talk through diagnosis, treatment planning, class 1, class 2, class 3, the whole 9 yards?

David: Generally, yes it would.

Howard: How much are those courses?

David: If you're a providing doctor, there's zero. There's zero. And I'm surprised there's not more Invisalign on your site. I was looking for a podcast, like what we're doing here, on Invisalign and there wasn't even that subject.

Howard: I don't know, but I have to guess this. So, there's 9 specialties, right?. 

David: Mm-hmm (affirmative).

Howard: The only one that didn't want to play on Dentaltown, that wanted their own website was Orthotown. I never was asked by an endodonist, peridontist, pediatric dentist, oral surgeon ... Everybody's on Dentaltown. 200,000 members. The orthodontists? "No. We're not going to play over there with the GPs. We want out own site." And on their site ... Like, on Dentaltown, say you worked for Patterson or Shiner Dentrix or whatever. I didn't name it "Dentisttown", I named it Dentaltown because I wouldn't be a good dentist if I didn't have about 500 dental companies making me stuff.

David: Exactly.

Howard: I don't have x-ray vision. I need a x-ray machine. I need materials. You need all these materials. I want those on these because, if I was Ultradent and everybody said, "Your 00 cord needs to be blue instead of red." I think Ultradent needs to see that. I think we all need to work together. But the orthodontists, they don't even let their suppliers [inaudible 00:49:27]. You could work for GAC or any of the ortho companies, Invisalign. It's only board certified orthodontics. And then the ortho supplying companies, if they start talking too much to GPs, the orthodontists get very, very upset. So there's 10,000 orthodontists and they don't want to see their companies talking to GPs.

David: I wonder if you'll find that out with Invisalign or not. Or have you found that with Invisalign? Because they can-

Howard: Let me put it this way. I don't even know who the CEO of Invisalign is. I don't even know what city they're at. I have 0.00 relationship with Invisalign. I didn't even know they had 300 courses on their deal. It's kind of a touchy, taboo area when you're selling to orthodontists and there's 10,000 of them and they do a lot more ortho than the 120,000 GPs. 

David: Well, I think with Invisalign that story might be changing.

Howard: Huh. Do you know the owner of Invisalign?

David: I know the Vice Presidents. I'll have them call you or have them call John.

Howard: Yeah, yeah. Set me up. What city are they out of?

David: They're up in Santa Clara.

Howard: Yeah, I feel sorry for them because it's tough when 10,000 people buy 80% of your business and they get mad if you interfere with or talk with the other 120,000. I know ortho reps have told me over the years, "This orthodontist bought this many brackets a month. He was one of my best clients and he found out I was selling like, 2 sets of brackets to a GP across the street and now he won't even answer my phone call or return my [inaudible 00:51:01]. So, it's tough.

David: It was like implants, so that would break down.

Howard: So what you just said was very, very profound. You and I agree that when ... What I can't stand about a lot of [inaudible 00:51:14] people is when you say, "Well, if you prepared ..." Remember in the 80s, you'd say, "I did the composite just like you said and the tooth was sensitive." "Oh, it was you, Howard, you idiot. It needs a rubber dam." "I did." "You overdried it." "No I didn't." You did something wrong. It took 10 years before the Japanese said, "Yeah, it is their bonding agent. You guys are all [inaudible 00:51:35]."

These speakers write these articles like, "The Top Ten Reasons to Avoid Sensitivity." And it's like, "No, dude. The reason is the product I use." And the Japanese listened to that and they came out with Clearfil SE and they got rid of [inaudible 00:51:49]. They showed that if your chairside chemistry set was designed better, you could get rid of a lot of this stuff. A lot of these cosmetic people won't admit that, if you do 100 posterior crowns on a molar, Gordon Christian said half of them will need a root canal in 7 years. If you prepare 10 teeth for veneers, in 10 years 20% of those teeth will need endo. You just said something profound. Even though you're a fellowship in the AACD, you do 10 Invisalign cases for every veneer cases. And it is. It's minimally-invasive. It's the only thing I would want for my 4 boys or my granddaughter, would be braces and whitening, not filing down their teeth. Then you said something more profound, that you can learn Invisalign for free, that you can go to, that there's literally 300 hours of online CE to learn that. That's just profound.

David: Now, let me talk about the AACD. The AACD is about minimally-invasive and they're getting that way. Of course, they're in the same route I was in 2008. But now they're more minimally-invasive and they're talking about ortho more. So I want you to know that they want to do things and make people smile the best they can in the minimally-invasive way. Dentists are learning that there. They're not learning how to, as my friend said, "smoke enamel." "Hey, Dave. Let's go out and smoke some enamel." That's not about smoking enamel at the AACD. It's about doing it in the most minimally way possible.

Howard: Well, you've been giving all kinds of great advice and I don't want to let you go. I've only got you for 5 more minutes. I got to jump onto ... You use laser, too.

David: Correct.

Howard: What's that about? Talk about lasers.

David: I have a WaterLase and a BIOLASE diode. I use the WaterLase to do, again, minimally-invasive dentistry. I do small to moderate size caries removal and fillings with my WaterLase. But I use my WaterLase, probably, the most beneficial thing to me is doing close flapped crown lengthening in the anterior region so that we can level gum lines and make our aesthetic cases even better, including ortho cases.

Howard: Okay, back up a little. WaterLase, what type of laser is that?

David: It's BIOLASE. WaterLase.

Howard: WaterLase, BIOLASE. Is that a diode? Carbon dioxide?

David: It's an Erbium-

Howard: Erbium-

David: It's an Erbium laser with water.

Howard: Erbium laser with water. And you, specifically, do mostly soft tissue with that?

David: Small to medium sized fillings and soft tissue-

Howard: Small to medium sized hard tissue. Enamel.

David: Correct. And I also did laser crown lengthening with it, 2 to 3 millimeters of laser crown lengthening in the anterior region, to do close flapped crown lengthening rather than surgical crown lengthening. That way I could do the laser crown lengthening, prep the veneer, make the temporary. Patient comes back 2 to 3 weeks later for their veneer and their tissue has healed, and it has healed at the same level which I left it. So, it's very minimally-invasive.

Howard: But, would you say to do fellowship Academy of Dentistry work, not only are you going to have to use an outside aesthetic lab as opposed to in-house filling. But would you also say you're going to need a laser?

David: You'll need at least a diode laser to ... Either that, or you'll have to pass on some cases where you can't change the level of the tissue and you might have to refer it out and then have it back.

Howard: Okay, so you're saying that you would need a laser for some of these cases.

David: Correct. A diode laser, at least.

Howard: And there's a big difference in price because AMD has a diode laser and that's pretty ... What is that? It's under 3,000.

David: 3 to 5, 3 to 10,000 on the diode laser. But, the WaterLase is 70? 60? I don't know what the newer ones are.

Howard: That's what I'm keying in on.

David: I wouldn't jump into that unless you were established and you know you want to do a lot of tissue recontouring.

Howard: So, you would say if you're just entering into it, you'd get a 3,000 laser? You said 3 to 10. What's the 3 to 10? 3 would be the AMD, Alan Miller diode laser. What would be the 10?

David: Don't quote me on these prices or I'll get the companies in trouble. But, I'm thinking somebody like Kebo or Adept might have a $10,000 diode laser that might have some other frill [inaudible 00:56:11]. 

Howard: But the WaterLase-

David: You only need to spend 3 to 5,000. You're fine with a diode.

Howard: But the WaterLase, Biolase laser, that's not a diode laser? That's an Erbium laser?

David: That's an Erbium laser.

Howard: Explain to these guys, what's the difference between a diode and an Erbium laser?

David: They are two different wavelengths. The diode cuts on red tissue, which is gum and blood. The Erbium cuts on hard tissue like enamel and dentin. So you need a stronger, or along with water, in order to be able to cut that and cut it comfortably.

Howard: Could you do an occlusal with the WaterLase BIOLASE?

David: You sure can. Small to medium side occlusals, smaller interproximal caries.

Howard: Do you many-

David: Without a shot.

Howard: Without a shot. And on your workday ... What are you, 4 days a week, Monday through Thursday?

David: It's busy, Howard. I'm working 5 days a week.

Howard: Monday through Friday, how many of those days would you pull out your WaterLase?

David: I probably pull it out twice a day.

Howard: Wow.

David: With tissue or with cavities. Someone comes in and we do their cavities without giving them a shot in a minimally-invasive way. People love that without going out and [inaudible 00:57:33]. 

Howard: Of the people who have their fellowship in the Academy of Cosmetic Dentistry, what percent of them do you think have the expensive, $75,000 WaterLase BIOLASE?

David: Maybe 10%. Maybe 7%.

Howard: So, under 10%. So, the other 90% can do it with just a low-cost diode laser.

David: They can do some cases with a low-cost diode laser. When you're taking more than 2 millimeters of tissue away, you start invading the biologic width, and that's where the WaterLase comes in, because you can actually remove bone and replace where the biologic width is. 

Howard: Would you say that's the hardest thing in cosmetic dentistry is when a woman comes in with a very gummy smile and she has a high lip line. Men are 27% more muscle mass. Every photo I see of me, I don't even see any teeth. But you have some beautiful woman and when she smiles it looks like her liver shows. What are you doing with those?

David: Those, if you need to do tissue and it's more than 3/8 millimeters, I would refer her to a peridontist to do that kind of work.

Howard: Do you ever refer them for orthodontic surgery, to reposition them? Or do you just think that's too extreme?

David: I'd talk to them about it and they'd decide whether it was extreme or not. But I wouldn't be afraid to refer them to that because I sure couldn't help them and if I tried to, they'd be disappointed at the end. 

Howard: Do you deal with cases like that very often? Is that a common case, or is that a pretty rare case?

David: A high lip line that can't be treated, maybe 5 times a year?

Howard: A high lip line that can't be treated.

David: Can't be treated with either tissue and veneers, then it's an orthodontic, orthognathic case. It's probably 4 or 5 a year.

Howard: Doc, I wanted to ask you one last question. One rule of thumb I have is I ask patients after they've done it, "Would you do it again?" A lot of my patients who got face lifts and tummy tucks, a lot of them say they would do it again. Some say they wouldn't do it again. Orthognathic surgery, that's extreme. In your entire 30 year career, how many of your orthognathic patient, patients, people you know or you refer whatever, would do it again?

David: You know, I've never asked them that. But I know people aren't very anxious to do it, period. A lot of people compromise their orthodontics in order to avoid it. I don't blame them. I don't blame them.

Howard: I find that an extremely weird procedure because in the 30 years I've been out, '87 and on, almost all the oral surgeons got out of it, so now they're just letting a couple of guys do them all. I would say this: All my male patients that had it done, not one of them would do it again. They said that was just the worst decision. Only women value that much pain and suffering to look a little bit better. But not one guy.

David: To look better, yeah. But you're very smart. I didn't ask my patients that and that's a very good question to ask them; not only for that procedure or any other procedure we do.

Howard: I think guys are willing to pay a lot less pain and suffering for beauty than-

David: Howard, I know we're getting close to the end, but let me ask you one question. I'm sorry I'm turning the table on you.

Howard: (laughs)

David: I'm concerned about PPO dentistry and what it's doing. As you know, and we talked about high end dentistry and clinic dentistry, in my understanding it's kind of hourglass shaped, where there's going to be the people that are on the high-end, boutique kind of practice and then there's going to be the people who are in the clinics. I don't know if dentists really know what's happening when they accept PPOs, but they're accepting a fee. And that fee schedule is not going up. It's forcing them to do things like always add a buildup to a crown, or maybe doing a two surface filling instead of a one surface. 

I'm not saying everybody knows that but, that's the tendency of doing things that insurance is going to pay for and not doing the things that sometimes the patient only needs. Bill Dickerson explained this to me a long time ago, and I just saw him up at AACD, is it's like you're boiling frogs. If you put them in there, frogs in the water when it's regular temperature, they're happy they swim around. You can turn the water up and it'll start boiling and none of them will drop out. But if you drop one in there when the water's already hot, they jump right out. 

I feel like insurance companies are boiling dentists with not allowing fees to go up and squeezing them at every point. So a dentist has to do more crowns, more fillings, more patients and sacrifice quality care because of that. That word needs to get out to people in dentistry so that they can make the choice rather that it just happening to them while they're being cooked in this water. I bring it to you and let you think about it and whether that's anything worth talking about. I'd love to see Dentaltown debate that.

Howard: That was an excellent close. We are out of time. I want to tell you that a was a good Sermon from the Mount and, I wanted to tell you seriously. Thank you so much for spending an hour with me. Taking an hour, you're working 5 days a week. You're a very busy man and to spend a Friday afternoon with me for an hour for the benefit of all these podcast listeners. Thank you so much, it was ... I had an amazing time.

David: My pleasure. Thank you for including me, Howard. Keep doing what you're doing. Thank you.

Howard: All right, take care, buddy. Bye-bye.

David: You too. Bye-bye.

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