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AUDIO - HSP #267 - Doug Schulz
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VIDEO - HSP #267 - Doug Schulz
• Dr. Schulz' early adoption of CAD-CAM
• How Cerec has evolved
• Delegating functions of same-day-dentistry
• And more!
Since his graduation from dental school in 1980, Dr. Douglas Schulz has spent thousands of hours training in advanced dental techniques and procedures. He was one of the first dentists in the Kansas City area to offer the breakthrough CEREC 3D technology, a tooth restoration system that allows a dentist to provide permanent, all ceramic crowns in a single office visit. Dr. Schulz is so proficient in the use of this technology that he routinely trains other dentists in the technique.
A true humanitarian, Dr. Schulz has contributed his dental skills to the Pacific Partnership, a charitable mission with the U.S. Navy to bring medical and dental care to those in need across the entire Pacific region. He was the first to bring CEREC technology to Vietnam.
Howard: I'm here at Greater New York Dental Meeting. I'm here with my buddy Doug Schultz who is one of the first guys ever use CAD-CAM.
Doug: Well I'm early adapter, so I won't say ...
Howard: Very early adopter.
Doug: Yeah. 1997-1998 was the first voyage into CEREC communities.
Howard: Is that my coffeeWhat year? '98?
Howard: That was CEREC 2?
Doug: That was CEREC 2. It was not Windows. It was DOS if you remember DOS. You had a screen with three different windows that opened up. They weren't even windows. There was a projection screen, there was a cut screen and there was a something else on there if I remember right.
Howard: Talking to the CEREC people, because I think I got CEREC 1 in '89.
Howard: Then 2 was, you said '97?
Doug: Ninety-seven, '98.
Howard: When you look back at the journey of CEREC between CEREC 1, CEREC 2, CEREC 3. It really wasn't a must buy until probably CEREC 3.
Doug: 3, and 3D came out. Then, it became really, really motivational for docs to buy it, because they understood Windows.
Howard: When you talk to the CEREC scientists going all the way back to Germany, the problem with CEREC 1 and CEREC 2 was the computers weren't fast enough.
Doug: The computers weren't fast enough, but also we didn't have the ability to do crowns. When crown software became available in, I'm going to say '97, '98 CEREC 2 then became viable, because a lot of docs wanted to do crowns. They didn't want to do inlays and onlays, because when who've got CEREC 1, you can just do inlays. You could make a piece of porcelain that went into the tooth that reinforced the tooth, and then you equilibrated it in and ground it in like crazy, and had a great restoration.
I still taught a doc back in 2004 that was still using a CEREC 1. Until he saw CEREC 3D come into play he said, "I'm still going to keep using my CEREC 1." Then 3D came out which really changed ...
Howard: What year was that?
Doug: I think 2003, 2004. That changed the whole environment. Iit really put it out there it was a lot easier. Now with the Omnicam it's really simple.
Howard: Explain what that means, the Omnicam versus the 3D in the CEREC community.
Doug: Okay. In the early stages we always had powder to deal with, so with the Redcam, the Bluecam we still had powder. First we had titanium dioxide, and we had all sort of different devices. Do you remember ever a Powder Meister that somebody came out with?
Doug: Spray, and it was clumpy you had to filter this powder. You had to shift it. You took a Coleman fuel filter to filter your powder. Then, you filled up your powdering machine and you powdered the tooth. We had this white coating. You had to take compensation for that in your cement thickness and how you designed your restoration. Then, along came the Bluecam. The Bluecam still required powder.
Howard: What year is the Bluecam?
Doug: 2008? Omnicam's been out 3 years. 2008, somewhere in there. The Bluecam came out from the Redcam. Then, we got into Optispray. Optispray was a spray that with a much finer ... like misting the tooth. We never really said powder was an issue, because it wasn't, because that's what we had to use but now that we don't have to have powder that's where the Omnicam comes in.
We are now into streaming color video and converting that into 3D models instead of taking images. Stitching images around an arch is different that streaming a streaming video of an arch. The accuracy of Omnicam versus Bluecam for full arch restorations improves greatly.
Howard: What would you tell a young kid now who doesn't have CAD/CAM? I'm just going to play devil's advocate with you. They're saying, "I just got out of school. I have $350,000 student loans. I just bought old man Charlie's ... " Charlie Schulz, his Dad.
Howard: His Dad has the drawer of Peanuts, and Lucy. "I just bought old man Charlie Schulz practice for 600 and 1,000 so I'm almost $1,000,000 in debt, and now Doug's coming along saying I should buy a $150,000 CAD/CAM." What would you say to her? She's scared.
Doug: I know.
Howard: That's a lot of debt.
Doug: I'd be scared too. I was scared. The thing is if your practice is going a certain number of restorations, I don't care what it is. All you have to do is look at the number of restorations you're doing on a lab bill, because really when you buy a digital imaging system you're just trading lab dollars. You're going to either pay a lab guy x thousands of dollars a month, or you can keep that in house and then control the quality of your restorations.
Howard: Talk specifically how many restorations. What is that payment?
Doug: You can look at it two different ways. You can look at it as far as what your lab costs per restoration is. If I'm paying $100 to $150 a restoration with my local lab.
Howard: Is that about the average? $100-150?
Doug: Yeah. You can go to a middle lab where you can go like to I'm going to say Glidewell. The Wal-Mart of dental labs in the US. You can get a E-max restoration for $99. The difference is going to be I get a Miller block that's $26 versus $100. Every restoration I'm going to make, I'm going to save $75, but really I'm going to save a lot more, because you have no temporaries. You have no impression materials. You have no second visits to do, because single visit dentistry is really the savings. Whatever it costs you to turn a room over.
Howard: Explain that. It might have gone over everyone's head.
Doug: Okay. If you do 2 visit dentistry where you take a prepared tooth, put a temporary on. You've got the cost of making that temporary which has a fee. I don't know if it's $10, $20. You've got the cost of an impression. If you have re-take the impression you've got double that cost. Let's say it's $25 every time you take an impression.
Now you've got the cost of the temporary, the cost of the impression material. Then you have to change the room over. If you look at Gordon Christensen, every time you have to wipe down a room the downtime of that room you've got a cost associated with that. I don't know, 45, $50? Now you're saving that time because you only have to see that patient one visit.
Howard: It reminds me of when you and I were little. You're from Iowa, I'm from Kansas. I went to UMKC Dental School in Kansas City. You practice in Kansas City now.
Doug: I do practice in Kansas City.
Howard: You didn't go to Kansas City?
Howard: You went to University of Iowa?
Howard: When we were little so many farmers had a semi-truck. A lot of times they would do long hauling as a side job. They all went bankrupt to big firms that got rid of dead heading which means the small town farmer guy in Kansas would take a load from say Wichita to Omaha, make money but then drive back empty. It was the national chain who could coordinate that. "If you drop off something in Omaha we'll schedule you something to pick up in Omaha, and bring it back to Wichita." It the efficiency of not having a dead head or what you call a second appointment coming when nothing's going to be billed out.
Howard: When I go into dental offices, and I'm looking at efficiencies, it is crazy how some of these dentists, they're only billing out revenue maybe 20% of all the patients in that week, because he had this guy come back just to check the bite. He had this guy come back just to check this. This one was just a ortho adjustment. You're looking at the schedule saying, "How do you have 100 people Monday through Friday and you're only billing something out on 20 of them?"
Doug: That's crazy.
Howard: Then you want to know why your overhead is 74%. What you like is [inaudible 00:08:26]. I'm going to keep playing devil's advocate. What would you say, because I understand what you're saying is if you're going to pay $100 a unit to the lab, why don't you buy the block for $25, and pay $75 to yourself?
Doug: If you've got a $2,500 a month payment for your equipment, you've got to make enough on top of what your costs are to mail those blocks or to mail those restorations to pay for that payment. Everything above that goes to the bottom line.
Howard: Is that about the monthly payment, going to be about $2,500 for an Omnicam?
Doug: It is if you finance it. For an Omnicam, the mailing unit, a porcelain veneer, you're going to be $130-135,000 plus tax.
Howard: That payment over what are we talking about?
Doug: Let's say a 5 year.
Howard: A 5 year lease to own is going to be $2.500?
Doug: About 23 to $2,500. The doctors that do a ton of restoration, that do 30, 40, 50 restorations but really the savings point is you convert a lot of big composites to ceramic restorations. Then, we can talk about the benefits of doing ceramic restorations versus big composites, because you and I both know big composites just don't last.
Doug: They don't strengthen a tooth.
Howard: I want to talk about something else that with Omnicam that I see that I'm doing a lot in my practice. A lot of times in my practice, you're pulling an emergency. You've got a broken tooth, things like that. I don't have time to do the whole CEREC thing. I'm using the scanner and taking a digital impression, sending it to the lab. What are your thoughts on that?
Doug: I do about 99% of my stuff in house, but the beauty of where the technology is going is that you can delegate a lot of it now. Before when you had to powder, you really needed 2 people to keep the tongue and the cheek out of the way. You could use an Isolite and everything like that, but it really was a technique sensitive type procedure. Today with the Omnicam, anybody, I could hand it to your son. He can take that Omnicam and take a scan of an arch. All you have to do is say, "Fill in all the voids, make it look just like you see it in the mouth." Teaching auxiliaries, assistants, hygienists to scan is a real easy process today compared to where it was 5 years ago.
Now you break a tooth, you come in. It's a real easy procedure. You talk about those offices that don't bill out procedures. You got to be able to do same day dentistry. That's the beauty of CEREC technology is put them in another operatory, take a scan, get them numb, get a hygienist to get them numb. Your time chair side is going to be minimum, because I can just go over and prep a tooth, I can do an onlay, an inlay, a full coverage crown, whatever it is. They can scan the opposing, the buckle bite. I can finish the scan of the prep. They can design it, mill it, try it in, stain and glaze it I can be there and cement the final restoration.
Howard: How much time are you talking about between when you first numb up the patient to when you cement?
Doug: Hour and a half or less.
Howard: Hour and a half or less?
Doug: Yep. When you get your systems down, but let's say it's 2 hours.
Howard: Are you saying that you never in your real world never get to a point where I don't have time for this, I'm just going to digitally scan the impression, send it to a lab, because I seem like I'm doing that more, and more from just an operation logistics point of view.
Doug: No, I really don't, Howard. Yeah. We always find a way to work it in the schedule or if somebody breaks a cusp off a tooth and it's not sensitive, you can put some temporary material in there, you can leave it, you can take a sharp edge off and say, "Okay tomorrow I've got an opening here, or next Tuesday. What's good for you?" You always want to take somebody out of pain.
Howard: I want to ask you another thing that's huge in our industry. What percent of the CEREC posterior crowns milled out in a dental office would you say are E-max?
Doug: Probably 95% of them today.
Howard: Yeah. What do you say to some guys who say, "Well is BruxZir stronger? Maybe I should be taking the CEREC and scanning it and sending it to Glidewell to make a BruxZir?"
Howard: Some people believe that the BruxZir is stronger.
Howard: So they don't break the crown.
Doug: Why, because E-max doesn't break either.
Howard: Do you feel that way?
Doug: Oh, totally. In probably the last 5 years, I may have had 5 or 6 posterior restorations break.
Howard: In how many years?
Doug: 5 years.
Howard: You're having one a year.
Howard: Some people call it the aesthetic health compromise where E-max is for beauty, and BruxZir is for strength. You don't really see it that way?
Doug: No, talk to Rella Christensen. I've been doing the five year study with monolithic ceramics. We've tested BruxZir. We've tested layered BruxZir. We've tested E-max. We've tested Lava, Enamic. They don't break. The question in dentistry today, how strong do you need? I think people go to BruxZir, because it's a easy one to cement.
Doug: You can get a crown, squeeze some cement in, dry the tooth off and shove it home, clean it up. You don't have to bond. If you're doing same day dentistry, where you're doing E-max, you really want to bond them on, because you get the strength from the bonding.
Howard: Will you go through your bonding? How you bond an E-max on step by step?
Doug: Protocol is really got to be there, because bonding is all technique. You got to have isolation. You can't have saliva, putting a cotton roll in. An Isolite or some isolation device is really critical.
Howard: What are you using?
Doug: I'm using Isolite.
Howard: Yeah. Will you talk about that? A lot of people might not know what Isolite is.
Doug: Isolite's a great device. Tom and his group over there have all sorts. From an Isolite to an Isovac. It has light. It has suction. It has a bite block on the other side of the mouth. It keeps the tongue out of the way. It wraps around the distal of the second molar and keeps the cheek out of the way.
Howard: I'd love to do a podcast with Tom. He's a dentist.
Howard: The founder of Isolite, Tom Hirsch.
Doug: Yeah, Tom Hirsch. He's the founder.
Howard: What I like about Isolite is I'm 53, how old are you?
Howard: Oh man. You look good.
Doug: Hey, thanks.
Howard: I had no idea you were older than me. When you're 53, magnification's important but so is light.
Doug: Light's incredible.
Howard: The Isolite, oh yeah it retracts, oh yeah keeps drug but it is so much damn light in there that with my 3 point of magnifications, I really feel like I see what I'm doing.
Doug: If you have a head light. I switch from one head light to another. You really need to talk to somebody from Pro*Lite. Pro*Lite's a really neat new light. Most of them are LED today but instead of having a switch and a lot of times you've got a little switch on your battery, the Pro*Lite has a button about this big. You hit it with your elbow, and it turns it on and off, and so you don't have to.
Howard: Oh my god I want to see that Ryan. Can you send that guy over or is he talking the booth?
Doug: I'll try to find ...
Howard: You know what I hate the most about my head lamp?
Howard: What I hate about the head lamp is people say, "Oh well you don't have to adjust the head lamp." Yeah, I don't have to reach up and adjust the head lamp, but I have to reach back and adjust this stupid, silly thing. You move wrong and the dial turns. Then, the other thing that's hard about it is in between patients how you hang it up moves the lens, moves the light.
Doug: You'll love this one.
Howard: What's it called?
Doug: Pro*Lite. Pro*Lite. P-R-O-L-I-T-E.
Howard: You know the what? Is it www dot ... ?
Doug: Prolite.com I think.
Howard: P-R-O-L-I-T-E .com?
Howard: Okay. I'll look for that.
Doug: I'll see if he's got a booth here. If not, I'll send him over.
Howard: Go back to what cement do you ... how do you bond on E-max?
Doug: Bonding. There's multiple bonding systems. All of them are good. I etch enamel. I don't use self-etching cements. If I have a ring of enamel around a preparation, I etch that with phosphoric acid for 15 to 20 seconds. I try not to get etch on the dentin as much as possible, because now the bonding agents whether we use Ivoclar's adhesive, or whether we use 3M's, Scotchbond, whatever. A lot of the bonding systems are self etching self bonding but I don't believe that they really bond enamel properly. You don't get the optimum bond strength. When we're bonding to tooth structure, we're really looking at, I don't care if it's a little ring of enamel that's left or not. That's our key. We need to really get that bond complete. Then, you follow a manufacturer's directions. Most of us don't read manufacturer's directions.
A lot of times you'll get a agent. You dip, your assistant gives you your little brush, and you put it on the tooth, and you blow it dry. You forgot to read that it said scrub it for 20 seconds. You really need to scrub it for 20 seconds if it says that, because you need to get the HEMA down into the tubules in the dentin so that the bond into the dentin is as complete as it can be. Plus your sensitivity goes away.
Now once you've done that then you got to follow the directions. Does it say to air dry it for 5 seconds, or just blow it dry? Whatever it says for that manufacturer, follow those directions, because each system is different. You're going to use multiple system, because not one system is right for every restoration. We've got a lot of good manufacturers to choose from.
Howard: A lot of scientists in dentistry are saying that one of the biggest problems in adhesive dentistry is that oftentimes the dentist's light isn't even working and that some dentists don't know their light's not strong enough to cure for a year. What do you think about that comment?
Doug: I totally agree because I've gone through that. I use plasma arc curing lights.
Howard: Who makes plasma arc curing lights? Is that the name of the company?
Doug: No. It's a really high intensity light. We're talking 23 to 2,500 lumens of output.
Howard: Is that the Den-Mat sapphire light?
Doug: Den-Mat makes one. I use one, I don't even know who makes it anymore.
Howard: You like plasma arc lights better than LED?
Doug: Not anymore, because LEDs have now become more powerful and more powerful and more powerful. You need to get one that's 1,000, 1,500 watts or whatever the measurement is so that you get complete curing.
The other thing you have to check is there are certain bonding agents that bond at a low wavelength and there are certain ones that bond at a high wavelength. Sometimes with certain plasma arcs, you'll have it only putting out a high wavelength and then you get into a product like Ivoclar's new ... Ivoclar has the new aesthetic cement. It cures at a lower wavelength in the curing. You need to have a light that really has a broad spectrum of output so that it cures all the materials. There's so many lights out there now. The Bluephase from Ivoclar is one of my favorite.
Howard: Are you one of the kind that likes to when you cement your E-max, tack it, then clean off the excess cement or do you like to clean off all the cement, and then cure?
Doug: I don't like to clean it all off because if you do that you pull the cement out of the margins, so I'm kind of a combination. I like to tack it, peel it away, but I like to have a little extra at the margins, because if you remember that air-inhibited layer? Remember your dental school stuff? You still have a air inhibited layer that doesn't cure at the margin. Then, you wonder why you have that little black line that happens at a margin. If you peel that off in the air-inhibited layer then goes away you've got that little gap at your margin. Then, 3 years down the road, you get this little black line, you go, "Hmm. Wonder what happened?" It's because you pulled the cement out of the margin.
Howard: I always think it's funny when ladies come into your office, and they're 50 or 60 years old. Their tooth just dies, and they're always like, shocked like, "Well, why would my tooth just die?" I always try to tell them, I say, "Well, humans are about 50,000 years old and at 4,000 years ago. the beginning of the Neolithic age they were living about to 17 years of age. Then, at the copper age, they made it to 36 years of age. Now, they're averaging 74 years of age." Obviously, some of these teeth that we crown whether it be with an E-max or whatever. Later, they're going to die.
Someday we're all going to die, everything's going to die. Someone comes into your office with an E-max crown and now it needs a root canal. Are you going to prep an access hole through the E-max or you going to just take off the whole thing?
Doug: I'm going to take off the whole thing.
Howard: Now, I do that, too. I see some of these cases on Dentatown. It's like they're trying to do this root canal through this little bb-sized whole. To me, just taking the whole damn crown off …
Doug: It makes access so much …
Howard: Let's talk about that.
Doug: Being a CEREC dentist, it's easy to remake a crown. I hate to see in somebody's mouth an old PFM that's packed with an amalgam or composite because like materials just don't bond. You go, "Okay. I've had a root canal but I've got this PFM and now somebody puts a composite in here." You see the staining around it and you go, "Okay. It's a cesspool for bacteria underneath there." I guarantee you, it's leaking but it doesn't hurt. Then, one day, you convince a patient to take that crown off and it's mushed underneath there so you really don't have a lot to restore.
You think about the quality of care. We get paid very well for what we do. We have to make an access hole in it. It's your choice whether you charge the patient for a new crown or not but if I just did a crown on the last couple years and the tooth goes south, we have the ability to do that very economically in a practice and not really do the patient a favor but it makes me feel good about how we practice that I stand behind what I do. I can restore that tooth. Now, I don't have leakage. Really, leakage is what kills teeth today in the dental world, leakage around a class 2 composite, leakage around a crown.
The good thing with ceramics, we can see underneath it through an X-ray so we can tell if we get massive leakage failure. They don't debond but you'll see if you get decay.
Howard: I agree. I warranty everything I do 5 years. If I did that crown 4 years, 11 months and 29 days ago, I'm going to warranty it for you but a lot of that is selfish reasons because for me, it's so much easier to do a molar root canal with that crown off.
Doug: It is.
Howard: It's lower to the top 2 millimeters, the prep is flat so I'm not …
Doug: The file length is less. You can see what's going on. Today with rotary endo, it makes it so much faster.
Howard: I want to ask you, everybody's talking, we're at the Greater New York meeting 2015 in Manhattan. Everybody's talking about the big DENTSPLY-Sirona merger. [Armengets. 00:24:35] That's 2 big companies.
Doug: It's fantastic.
Howard: What do you think of that merger? Does that effect the little guy dentists like you and me or not really?
Doug: No. It's great for all of us because you have a company that is totally about products, DENTSPLY. DENTSPLY is everything from Ankylos and ASTRA Implants to impression material to every supply you can imagine. Sirona's a technology company. They have treatment centers, CEREC, Galileos, Schick Imaging but they don't have the consumables. You're looking at a company that now becomes a mega company, a company that's going to have great, great power within the field to do a lot more. Deeper pockets.
Howard: I want to ask you what are the errors of thinking as linear thinking? When you and I got out of dental school in the 80s, there were 15,000 crown and bridge labs in America. Now, there's 7,500. Are you a linear thinker, where you think it's gone, 15,000, 7,500 and it's headed in 25 more years down to 2,500 or are you think this is more of a pendulum swinging deal? Do you think labs are going to make a comeback?
Doug: I think labs will make a comeback but labs will put their emphasis in different areas. As we do more implants, you will see more bar retained overdentures. You will see more screw retained dentures. You will see more All-on-4-type procedures because the baby boomers have more money. You will also see dentists doing more and more in office posterior single units but when you get into larger cases, the average dentist doesn't want to do that. You get into veneers, cosmetic things. They're going to send that to the lab no matter what.
The labs have to position themselves as aesthetic masters not just, "I can wax up," or now it'll be, "I can mill out 50 units out of a puck." Those will still be there but you're going to have to segment yourself and position yourself in the aesthetic world because we just keep wanting more and more and more as far as how we look.
Howard: Are you also placing implants yourself?
Doug: I am.
Howard: Tell us about that. How long you been doing that and what are you doing?
Doug: Oh, my gosh. My implant journey started in '82. Got out of dental school in '80.
Howard: You got out in '80?
Doug: Yup. Practiced at Iowa, in Cedar Rapids for 2 years and taught at the dental school in the pros department for 2 years at Iowa. Then, I got married and my wife was a dentist. We decided to locate and finally finished up in Kansas City.
Bought a practice and had the pleasure of practicing with a doc who was placing blades and subperiosteal implants. My first venture into implants was blades and subs. What a change! Flapping a whole lower arch, taking rubber base impressions, having Dan Root fabricate a titanium framework overnight and sedate the patient again the next morning, screw it on, have 4 posts, put a denture on it but it was a great service.
Then, along came root form implants. At that point, root-form implant systems were running about 30 to $40,000 per system and not one system had an answer for everything. I wasn't doing enough single teeth to justify it. I had an oral surgery group upstairs in the same building I practiced in. I said, "Okay. I'm done with implants. I'll just restore them."
Then, I got 3D 6, 7 years ago because I was tired of seeing implants come back from oral surgeons where I couldn't restore them or they weren't ideally placed. Now, we do 99% of our own implants. We do them restoratively driven. We plan where the final crown's going to be and now we do surgical guides for 95% of our cases, especially since I can mail a surgical guide in the office in an hour. Somebody breaks a tooth at 8:00 in the morning, I can have an implant guided that afternoon.
Howard: Talk specifics. What 3D? What software? What system?
Doug: Okay, so the beauty of Sirona is Sirona has a system of integration. Within the system, I can take a Galileos scan. I can take in intraoral scan with my CEREC unit. I can integrate those 2 into each other.
Howard: For the audience, Galileos is Sirona's …
Doug: 3D imaging.
Doug: Right. CBCT. With Sirona you have small volume, you have a medium volume and you have large volume. I'm a real believer in as big a volume as I can because I really want to treat as much for the patient as I possibly can but because CBCT shows me the bone and everything. Virtually, I can seat that implant in my cone beam image, I don't have any pucker factor as far as putting implants in.
My first guided implant took 12 minutes. I was almost just ashamed to charge the patient what we charge for them but you have to realize, all your planning is done ahead of time. Why should surgery take an hour and a half to put a single implant in when you can do it in 10 or 15 minutes and you can do it with a better outcome for the patient? It's going to go right where you want it plus the patient doesn't have any post-op problems. There's no pain. There's no sutures. There's no second visit to take the sutures out. Certainly, there are cases where we have to graft and stuff like that but now putting implants is really viable for the general practitioner.
Howard: Okay. It's safe to say that in the United States, 94% of crowns,
Howard: … are single unit. If a lab gets undercrowns, 94 out of 100 times, it's a single crown. The most common tooth to be crowned is the first molar. The most common tooth to be missing is a first molar. When you're saying that your first implant took 12 minutes. Are you talking about any of the 4 first molars?
Doug: Any of the 4 first molars.
Howard: Three, 14, 19, 30?
Doug: You bet.
Howard: Okay. Talk about that because I know what she's thinking. She's thinking, "Are you not aware that there's a sinus above the upper molar and are you not aware that's an inferior alveolar nerve on the lower?"
Doug: No but when you can see that in a CBT scan. My Galileos scan shows me exactly where the sinus is. It shows me the width of the bone. It gives me an idea of the density of the bone. I can track the nerve canal completely,
Howard: For the lower?
Doug: … for the lower and I can see the sinus on the upper. If I know that the sinus is 8 millimeters away, I can punch it right up to the sinus or I can punch it into the sinus. I can put bone up in there. I can do a vertical sinus lift if I want to.
Howard: Let's talk about that because I think a lot of naysayers are saying, "Okay, the most common tooth is a first molar," and they usually only have 5, 6, 7, 8 millimeters. Talk about that sinus. Let's talk about the upper and then we'll switch to the lower.
Doug: Let's talk about the upper sinus. Then you're going to get your training. What implant system do you want to use? I use 4 different implant systems. There's an implant out there called Bicon which is a plateau design which is a short, squatty little implant. You can put those almost anywhere and put a 5 millimeter implant in. I can have a restorative platform on top of that that is almost 5 times the height of the implant. Even if it's way up high but I got 5 millimeters, 6 millimeters of bone, I can put a short Bicon implant. On the other hand …
Howard: That's really changed in our careers, hasn't it?
Doug: Yes, it has.
Howard: Because back in the day, everybody just thought it had to be as long as possible.
Doug: And needed a big screw.
Howard: Now, it's short and fat is getting out.
Doug: Yeah. Even in Nobel and Zimmer's implants, we now have 6 millimeter implants that are wider. We have 7 millimeter wide implants, 6 millimeter in length. We have 5 7 by 6s. We have a lot of surface area in a smaller implant.
If we don't have a sinus but what we also have to understand, the sinus isn't that, "Oh, god. I got that forbidden area." It's an area in the skull that's got a lining and it's a space. It keeps our skull light. You learn that if I have to break into the floor of the sinus and if I have to pack some bone or if I have to just push the implant up into the sinus, as long as I don't violate the membrane, I'm fine. I've got a sterile piece of titanium that's going up.
Howard: Would you also say is as long as they don't have a sinus infection, it's usually not an issue.
Doug: It is.
Howard: But someone has a cold, has a sinus infection, has something like that, then you really should …
Doug: I want to clear that up first and then I want to do the implant. I don't want to go into an infected area if I possibly …
Howard: If you are a place an implant in a maxillary first molar area after surgery, do you prophylactically put them on antibiotics or …
Doug: Depends on what's going on with them. If I have to graft anything, I usually put them on antibiotic but if they have an infection, let's say I have an immediate extraction. I'm going to cover them with antibiotics, probably a Z-Pak or something that's short term but lasts a long time to knock that down and give me a little more success but I don't think it's mandatory. The big discussion in the literature. Do you or don't you. I just do.
Howard: Okay, now, let's switch to lower. I don't want to do these implants because I really don't want to get a paresthesia. I want to slam the titanium implant into the inferior alveolar nerve. [Crosstalk 00:34:41]
Doug: I'm not worried about paresthesia. I'm more worried about the lingual cavity and perforating lingual concavity and having a bleeding artery and having somebody bleed to death because I went through that really nice lingual concavity that people don't see. I think that's a bigger concern for dentists down on the lower arch.
Paresthesia is one of those things that if you happen to put pressure on the nerve, you can back up an implant or you can take it out and put a shorter one. In the time I've been doing implants, I've never had that because we can actually section the bone in any direction. I can show you exactly where the nerve canal is. That's a real comforting procedure. You do this in front of the patient. I place the implants virtually in the software. Patients then see right where we're going to put that implant.
Howard: Do you do that in front of the patient? You do that?
Doug: Oh, totally. It's about a 5 minute …
Howard: You do that in the operatory or do you have them go into …
Doug: You can either do it in a council room or you can do it in an operatory. Your hygienist can do it. Your assistant can do …
Howard: How do you do it?
Doug: I do it both places.
Howard: Both places?
Howard: What software are you using?
Doug: I use the Galileos implant, the Sidexis?
Howard: The software?
Doug: Yeah. With your system, you get the software, Sidexis and you get Galaxus implant …
Howard: Let's talk numbers. How much is the Galileos CBCT?
Doug: Full volume's about 140,000. Small volume can be 90,000.
Howard: Okay, say that again.
Doug: Okay. For a large volume, a flagship of Sirona's product, probably around 135, 140,000, depending on what you want to add onto it.
Howard: That's the one you recommend?
Howard: Okay. What would the least payment be on a 5-year least?
Doug: Twenty-one hundred.
Howard: Okay, so how many implants would this person have to be placing a month to be at a break even point?
Doug: I don't think you even have to place an implant to break even with this because the beauty of CBCT is that you get to section teeth and see stuff that you cannot see in 2D X-rays. I can show you case after case where you look at a pan. You look at a periapical and you go, "You know that tooth that's been sensitive for the last 5 years, you know?" You have those patients. Come in and go that tooth, it's sensitive. You look at it in a regular x-ray and it just doesn't. All of a sudden, you open up a 3d scan and you see that there's an abscess that should be showing up on 2D x-ray and it doesn't or you see a fracture that you don’t know that there.
3D imaging increases dentistry overall for you. It's very humbling. If you've looked at 3D, you see your mistakes. You see your endos that aren't as good as you thought they were. You see endos that are done perfectly by you, by a specialist that still failed. Suddenly, it changes how you do dentistry and what dentistry you do. It makes you rethink how many molar endos you do versus and which molar endos you do to instead of placing an implant.
Howard: I've noted one thing in our lifetime. You have to admit, the percentage of apicoectomy on failing root canals has been trending downward.
Howard: Wouldn't you say that it's …
Doug: Totally. If a root canal for me doesn't become successful the first try, it's not worth doing it again.
Howard: Do you do a CBCT for your molar root canals?
Doug: We take a CBCT on every patient in the practice. We have a scan. If you become a new patient in our practice, we do a scan and 4 bite wings.
Howard: Okay, so would you say … Devil's advocate, someone says, "That's too much radiation."
Doug: I'm going to tell you that if you're doing a full mouth series plus bite wings and everything else, you're giving them too much radiation because a full volume is 76 microsieverts or less. Add 4 bite wings in that, it's about half of what we used to do when we did film-based full-mouth surveys. I'm sure that you've never had the issue like I did where you did a full mouth series and it didn't develop properly or somebody didn't take the right films. You had to add films to it. Suddenly, you're doing a lot of radiation and it still less than what the medical profession does.
Howard: More devil's advocates. That's a lot of storage. Where are you storage all these files? Are you using a cloud-based system, hard drive?
Doug: No. Hard drive and it's really not. A terabyte of storage anymore is dirt cheap so we're into megaterabytes of storage. I think we could store about 6,000 scans.
Howard: On what?
Doug: We have a server for our CBCT and then we have a server for our practice management software.
Howard: What's the name brand?
Doug: Okay. I'm using Eaglesoft so we have … I have a Dell server, a regular old whatever Dell makes for server for my practice management. Then, Sirona provides their own servers for their CBCTs. It's called a reconstruction because when …
Howard: Is all the server?
Doug: No, I don't have no idea what it is but …
Howard: Isn't that funny? We're so old, we saw Dell do an IPO and go public. Now, Dell's delisting?
Howard: I've lived through the beginning and the end of Dell. You don't think the storage is really an issue?
Doug: Oh, storage isn't because if you don't like hard storage, do cloud-based.
Howard: Okay. I want to ask you another question about … Some dentists, when they're looking at CBCT, they're saying, "Well, you kind of more want this one if you're more placing endos and implants but you kind of more want this one if you're doing orthodontics."
Doug: I'm an endodontist …
Howard: What would you say to a general dentist who likes to do ortho and endo and implants?
Doug: Okay. I get this question all the time because …
Howard: See, I'm not making this stuff up. He said he gets this question all the time.
Doug: I do.
Howard: HoGo's always saying, "Your questions are so stupid." [Crosstalk 00:40:55]
Doug: No. This is the perfect question because you have to look at what you want as far as … When you buy a hand piece, what do you want? You want something light or do you want something that's efficient. When you buy cone beam, what do you want? You want to see the TMJs? Do you want to see the joints so that when I do restorative, I don't restore somebody in an improper position. Do I want to see airways? Do I want to treat the patient these …
There are tooth dentist and then there are dentists. there are people that only see a patient for a tooth but I believe that we should treat as much and we should be as a general dentist the quarterback and not throw everybody to the wolves. You refer a patient to an EMT. You refer aa patient to an oral surgeon. You refer a patient to an endodontist. No, I want to control that. I want to know who's going to treat you and how they're going to treat you. I want to know what your condition is. I want to know if you have a possibility of sleep apnea. I want to know what your airway size is because a lot of people die today of obstructive sleep apnea. We have the technology to evaluate that for people.
I can't tell you how many people I refer out for sleep studies so that instead of breathing through a McDonald's straw, they can either be on a CPAP or an oral appliance to open up their airways. Now, we can measure that airway and we can actually do a scan before, put them in an appliance and now measure their airway after they've been in it for a while so we can see the volumetric changes in their airways. That's huge.
Also want to be able to see their sinuses. How many teeth up on the maxillae have been treated or people treated for sinus infections when they really have an abscessed tooth. If you don’t have that volume that shows it, we're treating the wrong thing so people are over-medicated with too much antibiotics because they think they have a sinus infection and really, they got a blown out number 2 or number 3.
Howard: Which CBC would you give them?
Howard: The big? You're calling that the large volume?
Doug: The large volume.
Howard: That'll work, too, with your molar endo and single plant?
Doug: Totally, because I can actually even take a large volume and I can enhance an area so I can pick a first molar or second molar and get even a higher resolution. You're going to look at pixelation in those areas.
If I were an endodontist and all I'm treating is a tooth, than I might go to a small volume. If I'm an orthodontist, I'm going to go to a big volume because I want to see what's happening if I take little Johnny and I take him from a class 2 to a class 1 and what's happening with his joints or if he got a class 3 patient.
Howard: A general dentist, you'd recommend large volume?
Howard: Yeah. Anything else? I'd love to get an online CE course from you on Dentaltown.
Doug: I'd love to do one.
Howard: I would love it. We pass 205,000 member dentist now.
Doug: That's awesome.
Howard: Howard [Wilstein 00:44:03] put up 350 courses. They've been viewed over 500,000 times. I think you're a wealth of information. Is there anything I'm missing that you'd want to tell these dentists?
Doug: No. Go to Dentaltown. Find out about me here in the future.
Howard: Also, I want to say that you're from Iowa. I'm from Kansas. You practice in Kansas City. I get a lot of emails from the young kids that they're scared. They're often asking, "Do you think the glory days were last …" Do you think we passed the glory days?
Doug: No. I think we're just getting into the glory days.
Howard: Tell the young dentist who are scared because she's saying to me, "I double down on $350,000 student loans. I'm buying a practice for 600 and the economy, Obama," blah. Do you think the good days are ahead of us or behind us in dentistry?
Doug: Always think they're ahead of us. When I got out of dental school … Howard, how much were you in debt when you got out of dental school?
Howard: I was $87,000 in student loans in 1987. Real and constant dollars in 2015, that'd be $250,000.
Doug: Yeah. I got out of dental school in 1980. My wife and I were a total of $33,000 in debt. I thought I was going to die. I thought, "How in hell am I going to pay this off?" You pay it off and you go ahead but I believe that the cost of dental education is a number one pressing problem in the United States these days, especially when you have new dental schools opening up that charge $100,000 a year in tuition.
There's a point where they can't pay it off. We're getting closer to that but there are options as far as how you practice. I look at my buddies that went in the military and they practice 20 years. They come out as full bird colonels and have a pension and their 20 years of service. Now, they're in private practice or teaching or doing that, too. Those are choices that everybody has available to them. There are options.
Technology will only increase how much dentistry we can do and how we can be more efficient. We can place implants more efficiently, if it takes a half an hour to put an implant versus where it used to take an hour and a half or 2 hours. That's a pretty good dollar per hour income but you have to learn to be more productive.
You hit it earlier when you said, "They're only doing 20% productivity during the day." You got to be 80 to 90% productive during the day. Those other little checks have to go away. You have to get good. You have to learn more. The practice of dentistry is a practice. We keep learning . Continuing education is so critical. You offer some of the best continuing ed out there.
Howard: HoGo does.
Howard: HoGo does.
Doug: Yeah. He does.
Howard: With a name like Howard, though, how could he go wrong?
HoGo: I had to change my name to HoGo because of him.
Doug: I understand that but …
Howard: Let me ask you that question that we get all the time. I'm just going by all the emails that we get. You got out of school in 1980. What percent of dentist worked for a corporate chain that was in multiple offices in 1980 versus what percent do you that is in 2015. Then, I have to go out on a limb. What do you think will be in 2030?
Doug: It's growing.
Howard: What was it when you got out in 1980?
Doug: I didn't know about corporate dentistry when I got out in 1980. It just didn't exist.
Howard: We'll say that's 0. What do you think it is today?
Doug: You have more people in the military. You had probably 5% of your class that went in the military. Everybody else went in private practice. Today, probably 50% of the dentists getting out go into corporate dentistry, partly because they will pay you a salary plus break it down into a commission. You've got those huge loans. It's changing the atmosphere.
The difference is going to be how do the baby boomers sell their practice? How do they transition to the next generation? Dentists are going to have to be a little create and to bringing people in as far as associates and making them partners within their practice and making it financially affordable for them to buy in and be part of that corporation or that practice and then transition that over a number of years. You're going to have to be creative as a dentist. You're not going to be able to expect that kid go out and say, "Okay, banker. Give me 450, give me $1,000,000," because it's not going to happen today. The financing of practice transitions is e a big change.
Howard: It's also interesting. At the end of World War 2, believe it or not. Most people don't believe this but the average American female at the end of World War 2 in 1945 is having 5.1 babies. Back then when the older people wanted to sell their businesses, there were more people wanting to buy their business than there was people selling it. Now, it's 2015. It's reversed. When you go to business brokers like in Arizona that are trying to sell old man farmer's 65 year old $1,000,000 business that's doing 3,000,000 a year. He's taking home 1,000,000. He wants to sell it for 2,000,000. There's 5 guys selling for every 2 kids looking at businesses to buy. It's really a buyers market for a business in general.
Doug: Even that, so you see a lot of private practices now selling to corporate people because you can get …
Howard: It's liquidity.
Doug: It's liquidity, exactly.
Howard: One of the biggest explanations of corporate dentistry is people like Rick Workman went out and got a huge line of credit from Wall Street and then going into small towns like Bruce Baird and all these guys and being able to just buy whereas, there's a liquidity problem.
You also see that in car dealerships. If you have a big car dealership and it's worth $10,000,000, who you going to sell a $10,000,000 car dealership to because anybody with $10,000,000 doesn't want to buy a car dealership.
Howard: You had some rollout chains that were going around who got a big loan, a line of credit and were going around and buying up all these car dealerships that didn't have liquidity. What Rick Workman and Heartland Dental have done for a lot of older dentists is provided liquidity, someone to sell their price. That's that [crosstalk 00:50:34] of the corporate dentistry equation is liquidity.
Hey, thank you. I know I just stalked to you at the Greater New York. I saw you stopping by and me and HoGo grabbed you but …
Doug: It's always good to see you.
Howard: It's good to see you. I hear great things about you. Love to have a course with you online with Dentaltown sometime.
Doug: Will do.
Howard: We really, really would.
Doug: Then I'll talk to you a little more because we've opened a training facility in Kansas City.
Howard: Tell us about that. What's the website for your training facility?
Doug: You know what? We're in the process of building the website. It's so new. We bought a new facility. We now have an 11 chair dental office and about a 3,500 square foot training facility associated with that with a full surgical suite.
Howard: Wow! What you going to call this?
Doug: It's Corporate Lakes Education Center. Corporate Lakes Dental is the name of the practice. We're in an area called Corporate Lakes.
HoGo: Your own independent …
Doug: It's going to be an independent so I'm not obligated to any manufacturer or supplier.
Howard: Which is very rare in CAD-CAM. Most of the CAD-CAM educations, I would say, owned by Sirona, Patterson …
Doug: It is.
Howard: The [Still Center, the Sphere Center. 00:51:48]
Doug: Yeah. I want it to be an independent. I didn't want to be really obligated to Sirona or to Patterson or to a Scottsdale Center. We're planning on doing a lot of CEREC courses. We're doing a lot of integration courses where if you do buy 3D imaging, whether it's an iCat, a Galileos, whatever. You still need to know how to read images. We wanted to advance radiology. You also get basic training but where do you go when you need more? I want to bring in some good orofacial radiologist and put on some 2 day courses so you can …
Howard: What ones are you thinking of? Who are your favorites?
Doug: Tom Deal is a favorite. I've got a good friend down in Atlanta named Tom Kauffman who's just a whiz at sinus pathology and maybe twice …
Howard: You know both of them?
HoGo: No, I don't.
Howard: Can you email me their names. Howard?
Doug: I will.
Howard: I like Dale Miles and I like that … Who's the woman? [Shaunee 00:52:49] Gonzales?
HoGo: Yeah. Shaunee, Shelly?
Howard: Shaunee Gonzales. She's a real … You know her?
Howard: She's a real whiz but anyway.
Doug: In the Midwest, having grown up in Iowa and you're from Kansas.
Howard: Wichita, Kansas.
Doug: Wichita, Kansas. That's right. We're just an isolated area. A lot of people don't want to leave their practice and go to Arizona, Texas, California. If you're from the East Coast, it's a big trip. We're really situated in a really neat area because Overland Park's great. We got a lot of little good restaurants. We got a lot of good hotels.
Howard: Did Kansas City ever get a baseball team?
Doug: No. Hell, no. Just the best baseball team this year.
Howard: You know, it's funny. I was in dental school when they won the World Series against St. Louis. That was in … I was in …
Howard: Yeah. I was there '84 and '87. I couldn't believe it during the World Series. It was 30 years ago. I'm like, "Ugh! Wait a minute. I was there. It couldn't have been 30 years ago." How did that feel to be in town when they won the World Series again?
Doug: I was really proud of Kansas City because what was really, really disheartening was the celebration after the World Series, the Tuesday, a gorgeous 65 degree day and 800,000 people showed up. In Kansas City, where do you put 800,000 people? I think there would have been 200,000 more but they couldn't get anywhere. There's some photos out there that show and you're aware of them, the Memorial and Union Station. It's a sea of blue. You have 800,000 people and you had 3 arrests for disorderedly conduct. You had no vandalism.
Howard: That was probably my cousins.
Doug: Who knows? You got to be proud of the community. How they celebrated …
Howard: I want to say something. I lived in Kansas City and I lived in Phoenix. Phoenix has better weather in the winter.
Howard: But I'll tell you what, Kansas City with the plaza, with the West Court for the bars, for the culture, the museums. Kansas City, if you go there when the weather's right, if you don't go there in February but if you go there when the weather's right, I think it's one of the coolest, classiest, most cultural cities in America.
I want to go back specific. You could have gone and made it all CEREC center but you stayed agnostic. I'm wondering on a business point of view, is that because when the big company about a plan mecha out of Helsinki, Finland bought A4D out of Dallas, Texas, do you think that is going to be a major competitor someday and also at the Cologne meeting last year in Cologne, Germany. There were some other CAD-CAM entrance to the market from Korea. Do you think there's going to be lower price competitors entering the marketplace? I don't know if CEREC just walk away with this.
Doug: I don't know if price is an issue. If it has to do with quality and what you can do with the technology because, certainly, when you look at interoral cameras, just in general, you can buy a $100 one or you can buy a $4,000 one but they do take different pictures. Sirona invests a lot of money in R&D and because I've been a beta tester for 10, 11 years on the CEREC side, I see what they have to do and what it takes to make the software as good as it is.
Yeah, you can build a better camera. You can build another camera. I don't think you can build a better camera but you can build a good competitive camera but now you got to have a system that integrates totally. Sirona had this vision of this integration. There's nothing more frustrating than you buy a camera from Company A and you buy a milling chamber from Company B and you buy a cone beam from C. Now, you want those 3 to work together seamlessly and they don't but they say, "Yeah, they do." Who do you go to when something goes wrong?
The cost of part of that is when you buy a Sirona product, it's under one telephone number. If I have a problem with cone beam or milling or imaging, I make one call and it's fixed and it works. I can be more efficient. You might save $20,000 but it's like seeing the forest for the trees. You save $20,000 but it costs you $400,000 in production. Is that a smart move?
Howard: Also, when you go into a dental office and labor is the largest expense. It's 24 to 28%. Equipment's usually 4% or less so you have labor all confused and needing more training and not knowing how to get the CBCT into this and that and the CAD-CAM. You got labor all standing around, not getting it done, needing more continuing education, needing more this, needing all that because you save money on equipment.
Doug: Right. The training facility's about that, okay? So, it's a big investment so why not have an area that people can drive from 5 states so you can come from Nebraska, Minnesota, Iowa, Missouri, Oklahoma …
Howard: When is your center open?
Doug: It's open. We'll have a curriculum up online probably by the end of January and really 2016 will be a kickoff.
Howard: When it opens up, send me an email and I'll push it out on Dentaltown and social media and all that stuff.
Doug: I appreciate that.
HoGo: I would love to start recording some of your training sessions and [crosstalk 00:58:46]
Doug: Ah, yeah. We can do that.
HoGo: This would be your online conduit.
Howard: You know, it's counter-intuitive. Here's what is counter-intuitive about it, online, see. I tell everybody this. They say, "Well, I don't want to put my case on Dentaltown because then, no one's going to see my lecture." I say, "Which concert is the last one you went to? You went to U2 and that's because you have all the records."
Doug: That's it.
Howard: Everybody that puts an hour course up, that’s like U2. Then, they want to come see your band live. No one's going to …
Howard: It's the same thing with bonding agent. You know what, you can watch a bonding course on Dentaltown but until you go into a course where you put on the bonding agent yourself then bond and then test your bond strength and realize, "Wow, if I don't scrub it for 20 seconds, I don't get these great bond strengths."
Howard: I was just in my office, I was just painting it on and curing. When I do that here, the bond strength is half. Dentists work with their hands. They always work with their hands but all the people that do the online CE, their attendance is the highest. You listen to U2 on the deal, the Rolling Stones, then you want to go see their concert. I think the more courses you filmed from your facility and put online from Dentaltown, the more people get to meet you, get to see you,
Howard: … get to like you. Then, the next thing you know, they're going to your center in the flesh because at the end of the day, doctors work with their hands.
Doug: They do.
Howard: But hey, I think you're an amazing man. Thanks for spending an hour with me [crosstalk 01:00:18]
Doug: You're welcome. Always good to see you.
Howard: All right. Thank you.
Doug: Howard, thanks.