Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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296 Esthetic Pediatric Crowns with Diane Johnson Krueger : Dentistry Uncensored with Howard Farran

296 Esthetic Pediatric Crowns with Diane Johnson Krueger : Dentistry Uncensored with Howard Farran

1/22/2016 6:56:29 AM   |   Comments: 0   |   Views: 1016

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AUDIO - DUwHF #296 - Diane Johnson Krueger

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VIDEO - DUwHF #296 - Diane Johnson Krueger

In this episode learn about:

1. Esthetic primary crowns

2. What makes NuSmile ZR different 

3. Why bioactivity is so important

4. The importance if research

5. The long-term vision of NuSmile

6. And more!


I started my career in dentistry as a dental technician and lab owner, after which in 2005 I turned my focus to dental products manufacturing.  During those early years, I heard a lot of dentists talk about how early childhood caries was a getting to be a very serious problem, and how treating this disease with stainless steel crowns or composite restorations was extremely unsatisfying and frustrating for them, their patients, and their parents. In our dental laboratory, we decided that there had to be a better way, and I was determined to find it.  So in 1991, we developed NuSmile Pediatric Crowns, our first esthetic pediatric crown--in other words, the first pediatric crowns that looked and functioned like actual primary teeth.


Today, 25 years later, we're the world's largest manufacturer of esthetic pediatric crowns, with over 4 million restorations to our name.  Our team is passionately dedicated to supporting the field of pediatric dentistry, and we're honored to be able to provide our valued customers with the best products and service possible.  We're able to do that in large part because of the family oriented culture we have at NuSmile, whether the team members are actual family members--such as my son Jason Johnson, our Chief Operating Officer, or my brother, Mark Binford, our Senior Vice President of New Product Development--or our many other dedicated and talented employees.  

Howard: It is a huge honor today to be podcast interviewing Diane Johnson Krueger who I have ran into so many pediatric dentists over the last decade that I just think that you are a godsend because you are pretty much the first person who realized that a chrome steel crown is not that pretty and moms feel bad when they look into their child’s mouth and they see all these chrome steel crowns. I’ve had moms cry when they saw them. Clear back in 1987 the mom would get so upset that we’d take an impression and send it to the lab to make some baby crown for baby tooth number A or whatever so. I really want to congratulate you for all that you’ve done for dentistry and all that you’ve done for pediatric dentistry. I really think it’s an honor.

In fact I want to read your bio. I hope you’re making a lot of crew grants off this too by the way. She says she started her career in dentistry as a dental technician and lab owner after which in 2005 she turned her focus to dental products manufacturing. During the late ’80s she heard a lot of dentists talk about early childhood caries was continuing to be a very serious problem and how treating this disease with stainless steel crowns or composite restorations was extremely unsatisfying and frustrating to them and their parents.

In fact one day a pediatric dentist came into her office with a handful of stainless steel crowns in his hand and told her that this was really the only option they had for restoring anterior teeth and especially for anterior teeth it was just not a good option. In her dental laboratory she decided that there had to be a better way. She determined right then and there to find it. In 1991 she had developed and introduced NuSmile pediatric crowns, the first esthetic pre-veneered pediatric crown, the first preformed pediatric crown that looked and functioned like actual primary teeth. Today 25 years later she’s the world’s largest and most trusted manufacturer of esthetic pediatric crowns and over four million NuSmile restorations placed. That’s got to make you feel good Diane.

Our team is passionately dedicated to supporting the field of pediatric dentistry and she’s honored to be able to provide her valued customers with the best products and service possible. She’s able to do that in a large part because of the family oriented culture here at NuSmile where the team members are actually family members such as her son Jason Johnson who’s the chief operating officer who oversees the manufacturing operations or her brother Mark Benford who’s her senior vice president of new product development and many other dedicated and talented employees. Diane, seriously, thank you so much for spending an hour with me today. How are you doing?

Diane: I’m doing great Howard, thank you.

Howard: You’re in Houston?

Diane: We are in Houston.

Howard: Which really got a huge population bump after Katrina I hear. I hear so many people actually went to Houston.

Diane: That’s very true. We did get a big population bump and most people that came stayed. Houston’s a good place to live. People enjoy being here. It’s an economical place to be. Housing’s affordable, cost of living is relatively low. It’s just a great city.

Howard: Let’s start with … you’re talking mostly to general dentists. I have no evidence that there’s any pediatric dentists listening to, so sorry about that. About 100% of all the emails I get at about this show they’re usually young dentists and they’re just devouring these things. Let’s just get right to the muscle of this, what exactly is a NuSmile crown?

Diane: We actually have, there are two types of preformed esthetic pediatric crowns available today that in relatively wide use in the dental marketplace. The first would be the product that we originally developed in 1991 which is a preformed pre-veneered stainless steel crown. That’s a stainless steel crown that has a tooth colored facing which is usually some type of composite or thermoplastic material.

Howard: You say facing. Is that just the facial or a 360 round?

Diane: On an anterior crown it would be the facial, extending a little bit to the incisal and into the proximal areas. On a posterior pre-veneered crown the two colored coating would cover the occlusal as well as the buckle surface of the crown. That is the type of crown that has been used since roughly the early 1990s although now our NuSmile pre-veneered crowns, what we call our NuSmile small signature crowns, are a fifth generation product. They’re a much different product than they were when they were first introduced in 1991. It’s a very durable, very esthetic, very easy to place restoration.

The second type of preformed esthetic pediatric crown is a premade zirconia crown. That would be for our brand that’s called a NuSmile ZR crown, ZR zirconia. They are just an incredibly esthetic, incredibly durable, as your listeners would know from adult restorations they’re just really unmatched as far as durability is concerned and the esthetics are just great with these crowns. We're able to manufacture these crowns in a very thin dimension so that really the amount of tooth reduction occlusally on a posterior tooth would be about the same as for a traditional stainless steel crown.

Howard: Basically when you put a chrome steel crown, what is the generic name for a chrome steel crown now that they’re not all chrome?

Diane: Stainless steel, SSC, stainless steel crown.

Howard: But a zirconium wouldn’t be a stainless steel crown.

Diane: No, it would not. There are ADA codes, the CDCT codebook for placing a primary stainless steel crown, for placing a pre-veneered crown that’s D2934 or placing a zirconia primary crown, a premade zirconia primary crown and that’s D2929. That is different.

Howard: Say those codes one more time. Go through those codes one more time. CDCT for stainless steel crown, SSC is what?

Diane: Actually I’m not sure what the code is for an SSC.

Howard: Or whatever you say.

Diane: For a pre-veneered crown, the pre-veneered crown which would be our NuSmile signature crown is D2934.

Howard: DT2934.

Diane: D as in doctor, 2934. Then for a preformed zirconia primary crown that would be D2929.

Howard: What is the difference in cost between just your standard stainless steel crown that you’re popping on baby tooth A versus a pre-veneered versus a preformed zirconia.

Diane: A stainless steel crown is going to be roughly in the … a little less than ten dollars, eight to ten dollars I suppose, probably around eight dollars per crown for a standard stainless steel crown. A pre-veneered is going to be about twice that much. Then a zirconia crown is just a little bit more. In our case, the case of NuSmile a zirconia crown is four dollars more in the US and Canada where we sell direct, than a pre-veneered crown would be. There’s only a four dollar difference between the pre-veneered and the zirconia.

Howard: I think the mothers would just … that has to be the best ten bucks she spent all year because our society has so much judgmental and guilt and all that. When a mom looks into her baby’s mouth and is taking her out and she’s got little gold earrings on her and she’s dressed her up all pretty, then she’s smiles and she sees all the stainless steel she actually feels like she’s a bad mom. That she did something wrong. The guilt and the shame is horrible. Do you do with the pediatric dentist, that’s your biggest fan up in Calgary?

Diane: Yes I do.

Howard: Was that Calgary or Winnipeg?

Diane: She actually practices in Winnipeg.

Howard: I lectured Winnipeg and then Calgary, so I’m getting them all mixed up. She’s in Winnipeg?

Diane: She is. She practices in Winnipeg.

Howard: What was her name?

Diane: Carla Cone.

Howard: Carla Cone. She is just an … I did a podcast interview with her and she is so darn intelligent and so smart and she just thinks you’re probably the greatest woman in pediatric dentistry. She just sings your appraise all day long. I wanted to get you on here today because to all my homies listening. You just don’t put a chrome steel crown on a baby tooth because it’s going to make the baby not like its mouth or be embarrassed, the mom’s embarrassed. Everybody is embarrassed and so many dentists call themselves a cosmetic dentist and then pop up chrome steel crowns. A cosmetic dentist isn’t putting veneers on mom. It’s putting tooth colored restorations in babies so that they like their mouth.

The effect I’ve seen with that is, you notice in America, you either don’t own a bowling ball and you haven’t been bowling in ten years or you own a bowling ball and you’re in a league. You either haven’t been to the lake in ten years or you own your own boat and go to the lake ten weekends a year. I noticed the same thing back in ’87 when we started tooth whitening people. The people that bleached their teeth, all of a sudden they’re on recall and they’re getting their fillings done. They got into their mouth. If they’re not into their mouth then they’re not motivated to brush and floss. They’re just not into it. It’s an all or none thing. Your entire NuSmile has more to do with mental health than dental health. If you can tell that mom, “We got behind. We got a bunch of cavities and we’ve got to do a bunch of work and everything, but they look good and they’re cosmetic,” then they’re fired up and into it. Do you agree?

Diane: Yes I agree. For your audience I think that probably the posterior esthetic crowns are really a great option. They’re going to be used for more of the patients that your listeners would see rather than the anteriors because the anteriors would be usually used on much younger patients. Even on a posterior tooth mom is often just horrified when she sees a stainless steel crown. Stainless steel crowns are certainly a great restoration, they’re durable, they’re easy to use, but zirconia crowns really are as well. Most doctors are charging a little bit more for a zirconia esthetic posterior crown than they would for a traditional stainless steel crown. It might be 100 or 150 dollars more, but if mom wants an esthetic option she’s really happy usually to pay that difference.

Howard: It means a lot how a baby looks to his mother. I remember when I was born my mom looked at me and slapped the doctor. You sell direct in the United States. I’m just curious, do you know how many pediatric dentists are in the United States? Something that’s around what? 4,000 is it about?

Diane: It’s between 6,000 and 7,000.

Howard: 6,000 and 7,000 thousand. That’s the problem with getting old. You learn all these numbers when you’re in dental school in ’87 and they all change. Of those 6,000 to 7,000 pediatric dentists in the United States what percent of your sales direct in the United States go to pediatric dentists versus the 100 … how many general dentists do you think there are in the United States?

Diane: About 175, maybe a little less than 175,000 general dentists.

Howard: What percent do the 6,000 to 7,000 pediatric dentists buy of these and what percent do the 175,000 general dentists buy?

Diane: Pediatric dentists are probably 80% of our customer base because they’re doing a lot of pediatric dentistry. It’s not unusual for a pediatric dentist to place over 100 crowns in a weekly period because-

Howard: Would you rather place 100 pediatric crowns or just go straight to hell? If you had the option which one would you pick? I think I’d go to hell.

Diane: I think they’re really good at what they do. They’re doing a great job. They’re really good at placing crowns. I don’t think that’s any problem for them at all.

Howard: I see that when we go to these mystery dentist retreats. We always take a dozen dental students from the school AT still and you go down there and everybody runs from all the crying kids. Then out of nowhere there’s just this one junior in dental school. I remember last time we were in Adiac, there just was this boy and the baby would be screaming. He’s just smiling and petting it, “It’s alright.” We all jumped on him and told him, “You have to be a pediatric dentist because what you did is just not right in the head. You for some reason are immune to this,” and he says, “Yeah, I really like it.” You either just like it and get it or you don’t.

Diane: Also I think that what your listeners probably need to be aware of if they’re not already is that with the affordable care act that’s really changed the landscape of the need for more dentists treating kids because literally there are millions more kids that have dental insurance coverage now. The 6,000 or slightly more pediatric dentists that there are in this country, that’s just not enough to treat all of the kids that need care. Generally pediatric dentists are really happy to have general dentists seeing more kids, doing a good job with those kids, treating those children according to … doing good dentistry, treating those children according to AAPD guidelines, using caries risk assessment, those tools that they should be using when they’re seeing children because truly pediatric dentists just can’t see all of the kids that need this care. Caries is still on the rise in the US. Early childhood caries is the number one chronic disease of childhood and is not really improving. There's a huge need.

Howard: Explain to the listeners about that Obamacare. Basically with Obamacare if you sell a health insurance plan the children have to be covered up to what age?

Diane: Howard, you’re getting a little beyond what I know that I could tell factually. I really don’t know what the age …

Howard: I’ve already been reading … California’s already having many, many congressional hearings because the demand is just crazy. They don’t have nearly enough providers. You listeners, you could be doing this. Pediatric dentistry is on an exponential growth curve because it’s being subsidized by Obamacare and it’s standing room only. In fact California, they thought … their latest best idea on that was they were going to significantly raise the fee schedule. Because the economists are saying, “If you just pay more for it you’ll get more supply of providers.” Very seldom does the government committee get together and raise all the fee schedules. The fee schedules are being raised for this and they will continue to raise them until they either get more supply of providers. How do my homies order these? They go to, and you sell direct?

Diane: We do sell direct. Of course we’ve got … they can call on the phone too. We do sell direct in the US and Canada. We don’t sell through Henry Shine and other distribution channels in the US and Canada. We like to have that direct customer contact, be able to help customers with our products should they need help. We like to get feedback from customers as well. US and Canada we are direct, but we do have over 40 distributors around the world where we really cannot be effective selling direct.

Howard: I don’t think the Patterson Shine Bercard Benco rep, how can they come in and explain 60,000 different items. It seems like people that sell drugs, and even when you go into companies like Dentist Supply, even their management will tell you there are divisions that sell direct like Tulsa dental products. It’s just so much more robust and connected. I applaud you for selling direct. I think it’s a copout to just say, “Yeah, we’ll just make it, throw it in a catalogue and let these dentists figure it out themselves. These dentists, my job on these things is always try to estimate what the heck they’re thinking. They’re probably thinking how do you prep a molar and have a zirconia crown that’s not flexible, it’s not like a chrome steel crown where you just bite into it and it crimps on. There’s zero flexibility in this chrome steel crown. How do you prep that to have a solid preformed fit?

Diane: With both the pre-veneered crowns and the zirconia crowns the tooth has to be prepared to fit the crown obviously. The crown does not flex or adapt to fit the tooth. There will be more circumferential reduction needed than for a traditional stainless steel crown. One of the really important things about our NuSmile ZR, our zirconia crown system is we offer a complete system. We actually sell the crowns as a complete system. Within the kit of the zirconia crowns there is a pink try in crown that comes in each of the slot sizes that I … So that you’ve got the actual tooth colored crowns in each of the various sizes and different tooth positions, but you also have a pink try in crown.

The pink try in crown is an exact duplicate of the actual tooth colored crown, but the try in crown is used for the preparation of the tooth and trial fitting so that your listeners will know, most of them will know because they’ve probably been placing adult zirconia restorations, that saliva and blood contain various phosphate groups that are actually chemically attracted to and will bond to zirconia surfaces, interfering with cement retention. What we know from working with pediatric dentists and they’re placing hundreds of crowns a week, always with a child you want the procedure to be as quick and as simple as it possibly can be.

We provide these pink try in crowns so that once the try in crown fits nicely in the mouth you take the try in crown out and you load the actual tooth colored crown out of the box, the matching tooth colored crown out of the box with cement. The first time it goes into the mouth is when it’s being cemented onto the patient. There’s no extra cleaning steps to remove the hemorrhage or saliva from the inside of the crown that’s been used for trial fitting. There’s no extra cleaning step to remove the phosphate groups that are bonded to the zirconia surface that interfere with cement retention. The first time the actual zirconia crown goes in the mouth is when it’s being cemented.

Howard: You can also reduce bleeding by strangling the kid. You’ll close off the carotid arteries and there’ll be no bleeding. I’m just kidding. You know what I really wish you would do? You’ve got one of the greatest pediatric dentist, Carla Cohen up in Canada, that just loves us. You should get her to build an online CE course showing them how to do this. We put up 350 online CE courses on Dental Town. They’ve been viewed over half a million times.

You know what I also wish you would do?  You know why I named it Dental Town instead of Dentist Town? I own Dental Town and Ortho Town. The orthodontists, they won’t let anybody go on the site unless it’s an orthodontist. I can’t even go on this site, I own the damn thing. It’s orthodontists only. Dental Town, my vision was that if we’re using your product and it’s rad and we’re all sitting there thinking, “God, I wish this was blue,” to make dentistry better you would have to know that. When I started Dental Town all these dentists are getting mad because there are all these non-dentists getting involved and I said, “Dude, if you closed down 500 dental companies around the world we’d be sitting outside on a rug with stuff we bought at Home Depot.

It’s companies like you, it’s singlehandedly you that made cosmetic dentistry go to pediatric dentistry. If you search NuSmile on Dental Town, I have it on my app, there’s literally 100 threads on my … read these. My first NuSmile zirconia, one of my first NuSmile zirconia. It just goes on and on. NuSmile zirconia segmentation. Thoughts about NuSmile. It just goes on forever. I think if you post on there just like, “Hey, I’m Diane, I’m the damn owner. I’m the one who made these damn things,“ They love that. They hate buying from a faceless [inaudible 00:23:53]

That’s why they don’t like government because they say, like the post office CRS. They don’t know who owns that. When you say Apple they know Steve Jobs. When you say Microsoft they know it’s Bill Gates. If you got on there and plugged your pretty face and said, “I’m the one who made these things,” and start communicating with them I know it would explode your sells. The best marketing you can do in 2015 in the industry is not with money, it’s with time. I really wish you’d get on there and post. Do you think you could talk Carla into making an online CE course on how to do these?

Diane: I can work on that, sure.

Howard: Twist her arm, because she’s a great lecturer. She lectures every month somewhere. Is there a star kit that you buy that has all this or you just buy … What is an intro kit for one of my homies that have never done one of these?

Diane: We have some really small kits. They are configured per tooth positions. It’s either first primary molars or second primary molars. They come in a small kit which contains only 16 crowns. It’s just really a minimum inventory of the crowns the doctor would need to just dabble a little bit. There’s a medium sized kit with 40 crowns and then there’s a much larger kit with 84 crowns.

Howard: How much are the prices of each of those kits?

Diane: They range in price, the crowns within the kits are around 18 dollars per crown in the kits when you buy them initially and then on reorders they’re a little bit more when you’re ordering just individual crowns. You can order just one crown at a time if that’s what the doctor wants to do or needs to do.

Howard: Do you also make conventional stainless steel crown?

Diane: We do have … we’re just introducing a conventional stainless steel crown posterior crown, not for anterior teeth, but only for posterior primary teeth because we’ve heard from our customers over the years that they would really like to have available from NuSmile just a traditional stainless steel crown that’s reliable, easy to place, is pretty contoured and is offered at a reasonable price. We do have a pre-contoured medical grade stainless steel laser etched on the lingual for easy ID purposes that we’re just now introducing. We’re real excited about that.

Howard: Nice. What do you recommend cementing these zirconia crowns with? When you go around the world there’s such a difference in cultures. You go to a dental company in Germany and they’ve got six PhDs and they don’t have a telemarketing department and they don’t know anything about advertising. The Germans just build, if you built it, great, they’ll come. You go to American companies, they don’t have any PhDs, no engineers and they have a 30 person call center and spend 6% of their revenue on marketing and advertising. Another huge difference is the Americans, everything’s inert. inert fillings, inert cement, but when you go anywhere around Japan they think, “Man, this is a biological problem. Let’s sit there and use cements that have calciums and fluorides and phosphores.”

That Japan thinking overflows into Australia and New Zealand and Hong Kong. The Americans still, 99% of their fillings don’t have one bioactive ingredient in it because they think they’re mechanical engineers when they build this engineering barn in a field and they don’t realize that six years later the termites come back and eat it. If you made that barn out of stainless steel like a dental implant now you don’t have to worry about recurring decay. What are your thoughts on bioactive, especially in kids? You must have a lot of streptococcus mutans in your mouth if you’re needing pulpotomies and chrome steel crowns, right?

Diane: We had the question and honestly when we initially introduced NuSmile ZR we did a lot of research, a lot of testing on NuSmile ZR as far as the zirconium material, the particle size, the fracture resistance in various thicknesses, the density of the material at the manufacturing process. We did a lot of testing, but what we didn’t do initially was learn everything that we needed to know about cements. After we introduced NuSmile ZR we had questions from pediatric dentists about what’s the best cement to use with this crown. We had to go do that testing.

We did test resin cements, resin modified cements, traditional glass ionomer cements. What we found is what most cement manufacturers recommend is true. That either a resin cement or a resin modified glass ionomer type of cement is the best option for use with zirconia. Traditional glass ionomers, while they’re easy to use and used by a lot of pediatric dentists and work right with traditional stainless steel crown, traditional glass ionomers do not adhere well to zirconia. Because you will likely have somo areas because you don’t have a snap fit, you have a passive fit of this zirconia crown. You’ll likely have some areas where you’re counting on the cement to fill a slightly open margin. The glass ionomers are water soluble and will tend to wash out over time.

Resin modified type of a resin modified glass ionomer is generally what we would recommend for use with any zirconia crown, but because of our testing and research we actually had trouble finding a traditional resin modified glass ionomer that was really easy for pediatric dentists to use. That would set quickly, because time is of the essence when you’re treating pediatric patients and would work well in a field that wasn’t absolutely dry and pristine.

We did professional development our own cement. It’s called NuSmile Biocem. It actually is a bioactive cement. We’re really excited about the bioactivity of Biocem. We call it actually that it’s a symbiotic, that is our term for the bioactivity of Biocem. What that means is that this bioactivity goes beyond just fluoride release which is the most common bioactive component of any type of cement. It’s actually three fold. Symbiotic is a three fold term because there is a unique chemical composition to Biocem that includes both calcium and phosphate ionic species which actually formed hydroxyapatite that’s available to integrate with and replenish the tooth structure.

We’ve got this hydroxyapatite formation with Biocem and secondly Biocem also releases and reabsorbs calcium, phosphate and fluoride. It’s got this three different types of ions that contribute to the health of the oral environment. Thirdly Biocem is hydrophilic. It actually seeks out moisture and thus sets up an environment where there’s this continuous ionic release as well as the environment is conducive to this hydroxyapatite continued integration and replenishment in the oral environment.

Howard: All the pediatric dentists I know, they say you’re extremely research driven. That’s not usually what you see in an American company. It sounds like a German company. Is Krueger German?

Diane: It is German.

Howard: See, did I call this? You go to Germany and you walk into companies like Cerona and Ivoclar and Cabo, that’s just an entirely different level of manufacturing than when you go to any place around the world. When you go to China the whole motto is just cheap. Just make it so cheap they’ll buy it. The Germans are so different and you’re German. I think there must be a correlation and a cause and effect, Krueger. What is your thoughts on research, because every pediatric dentist I talk to thinks you’re extremely research driven?

Diane: We think it’s very important because … We know that our customers trust us and we just don’t want to do anything that could diminish that trust. Before we introduce a product to the market we do a lot of testing. We did that with our NuSmile ZR crowns, we’ve done that with Biocem. It’s just extremely important so that we know if we put something out on the market with the NuSmile name, the NuSmile brand, that it’s going to perform the way that our customers expect it to perform.

Howard: Another thing that’s I think weird about American dentistry is last year it was 105 billion dollars the Americans spend at the dentist’s. You’d think for 105 billion dollars if it’d have been like a fortune 500 company, 3%-4% would have been on R&D. You think there’d be a national deal, 105 billion that there should be a 5 billion dollar R&D department just to vaccinate streptococcus mutans. Our government just doesn't get … They should be saying, “God, out of 105 billion we should spend five billion just on this one bug.” I wonder if you and I will live long enough to see a vaccination for streptococcus mutans like they did measles, mumps and chicken pox. You think we will?

Diane: I don't know. It’d be a wonderful thing for dentistry and for the kids, but I don't know.

Howard: Now I’m wondering what kind of car do you drive?

Diane: I have a Mercedes.

Howard: German all the way. She’s German all the way. I drive a Lexus. I must be more prone to glass ionomer and you’re more of that manufacturing. Another thing you’ve got, you’re just launching the New MTA. Tell us about that.

Diane: As you probably know, for many years most pediatric dentists have to use formocresol for pulp therapy. But formocresol has now been banned in a number of countries due to possible concerns about toxicity.

Howard: Does that include the United States?

Diane: No, it hasn’t been banned yet in the US.

Howard: It’s definitely on a carcinogenic list. Many people’s carcinogenic list. It’s not just toxic. Many people put it as a carcinogen, something that can cause cancer. You just can’t use it. If you’re listening to this and you’re using formocresol your mom dropped you on your head and never told you. Just throw that shit away. It’s the same as Sargeni. Angelo Sargeni of Italy had that paraformaldehyde root canal that saved millions and billions of teeth, but I just saw another lawsuit settlement last year that was for the max, one million dollars because somebody uses Sargeni. You just can’t use formocresol, you can’t use paraformaldehyde. What is yours?

Diane: What we are introducing, and I have to say that I am not aware of any … I am not personally aware of any studies that have proven formocresol as it’s used in pulp therapy to actually cause any toxicity. However I know it’s a concern of many dentists and it has been banned in some countries. We do know that many pediatric dentists and dentists that are treating kids would prefer to use an MTA material. A mineral trioxide aggregate. The problem has been primarily cost. It’s been really expensive to use in a pediatric dental application.

Howard: Originally that wall pool cement, swimming pool cement?

Diane: Portland cement.

Howard: P-O-R-T-L-A-N-D?

Diane: That’s correct.

Howard: It ended on a … what was it, UCLA or USC that started that? It’s an Iranian name, Torbison, what was …

Diane: I do not recall, but you are correct.

Howard: He’s a great guy. Portland cement when it came to the in and out was just … It was more expensive per gram than cocaine. I’ve been told by pediatric dentists. I don't know this myself. You were able to make Portland cement lower cost?

Diane: Yes. We now have NuSmile Neo MTA and it is at an affordable cost that is very close to being the same cost as using something like formocresol. It’s actually very reasonable per application. It runs right around four dollars per application.

Howard: Is this a thick mixture that the endodontists are using when they use MTA?

Diane: MTA can be used for different types of pulp therapy. It can be a direct or indirect pulp cap. You can use it for the pulpotomy procedures as well. You can mix it, our Neo MTA comes in a powder and gel form. The powder is [inaudible 00:39:15] line bottle so you can scoop out just as much as you need and then mix the gel into the powder. You can mix it in a thin or a thick consistency. Most clinicians for a pulpotomy prefer a slightly thicker consistency and this will mix to a really nice putty consistency that you can roll in your hands.

There are a couple of other things about MTA traditionally that have been difficult for pediatric dentists aside from the cost. The setting time has been long. It’s not been easy to mix or handle and our Neo MTA, NuSmile Neo MTA is a quick setting easy to mix and handle. You can dispense just as much as you need, so you don’t have to sue an entire compule or a foil sleeve of material. You can mix just as much as you need. Another really exciting thing about NuSmile Neo MTA is that it’s not staining. It is a white MTA material, but what has happened with MTAs in the past is that especially on young permanent teeth, if you were doing a procedure on an anterior tooth over time that tooth would turn dark if you used a traditional MTA material. Obviously that’s not very esthetic, but with NuSmile Neo MTA it’s not staining. The tooth will not turn dark over time.

Howard: You’re saying you’re selling this for four bucks an application, MTA. What do you think the endodontists are spending per application when they use their endo MTA?

Diane: It depends on what products they’re using, but typically they are spending in the range of more than ten dollars per application up to as much as 30 dollars per application.

Howard: I just did a search for MTA on Dental Town and there’s literally 100 threads on MTA. I’m just posting how much are you spending on MTA. Did you know you can buy it low cost from the pediatric dentist company That’s why you should be posting on that. You could be asking, you could be saying … you could be bouncing with them on this. I just posted on there. When you say MTA to a general dentist it’s like bone grafting. There’s so many things that cost 100 dollars a gram. When you start seeing bone grafting and these dentists are placing implants are like, “Yeah, it’d be nice to put a little around here,” but then you cringe like, “I don’t really want to go to the refrigerator and open up 100 dollar bill and shred a Benjamin in the paper shredder. When you say MTA and you’re thinking, “Oh …” but that’s congratulations on making a low cost alternative to that.

Diane: We’re really excited about it.

Howard: Who would be your product champion for MTA bone … You know what you ought to do? You ought to get a pediatric endodontist. Is there such a thing?

Diane: I do not know one personally.

Howard: Or do you got a pediatric instructor and … I don't know, maybe Carla can put that into her domain. Maybe she can do it on zirconium preforms. Does she use the MTA?

Diane: Yes she does.

Howard: What a pearl to my listeners today to be finding out they can find a low cost place for MTA. You think MTA endodontics, you don’t really think of it from a pediatric dental company.

Diane: We know it’s something that our customers have been wanting. It just hasn’t been feasible for them. Now it is. We’re really excited about that.

Howard: That is amazing. You’re also big into actually even the organized dentistry sport, the pediatric dental association. Why are you into that and how has that worked out for you?

Diane: We’re a smallish family owned company as we’ve talked about, but we’ve really prided ourselves in being supportive of pediatric dentistry and what’s important to our pediatric dentist customers. We know that organizations like the American academy of pediatric dentistry, the Canadian academy of pediatric dentistry, the European academy of pediatric dentistry, Mexican academy of pediatric dentistry, it goes on and on, but over the years we’ve been supportive of those organizations and have funded, provided some corporate sponsorships and funding for different initiatives with those groups. It’s something that we’re really happy that we’ve been able to do. Over the course of 25 years that support has reached now about two million dollars in support from our company.

Howard: You’ve given them two million dollars?

Diane: Various organizations over the years.

Howard: You are an amazing woman, Diane. That is just amazing. My best friend who’s a dentist, Tom [inaudible 00:45:06], practices down the street from me, his daughter just, she’s about to graduate from pediatric dentistry in New York. What do you think the state of the profession is for pediatric dentistry? Obviously Obamacare was a massive macroeconomic game changer by mandating that all health insurance cover kids at the dentists which is standard operating procedure in all advanced countries like Canada, Australia, New Zealand. What do you think the state of pediatric dentistry is? What are you hearing on the street?

Diane: Pediatric dentistry is booming. Actually the American academy of pediatric dentistry is a great organization. Pediatric dentists are just a wonderful group of people to work with. Truly they’re doing great work for kids. They care about what they do in a way that is really refreshing. It’s about the kids. It’s about their patients more than about the individual dentist himself or herself and what’s in it for me. I do know that the pediatric dental residency programs are flooded with applications. There are around 80 some pediatric dental residency programs in the US. I think that what I have heard is that many of these programs have received just this year applications for residency spots that reach well into the hundreds. They’re sorting through lots of applicants to choose the … Usually it’s somewhere around four to eight applicants they will take per year in a pediatric dental residency program. They literally receive hundreds of applications.

Howard: Let me ask you a macro question on that. I grew with five sisters, so I’m very sensitive to all the issues of male female because my mom used to put me in blue jeans and I had no curfew. Then she put my sister in dresses. If they soiled then they got in trouble and grounded. We lived 100 yards from the Arkansas river. I was allowed to swim in it. They weren’t allowed to be within ten feet of the edge of the river. I never understood ten years old why my best buddy sisters couldn’t swim in the river with me. When I was little all the gynecologists were men and now it’s just all women. Do you see the same thing happening in pediatric dentistry? Not to be sexist, but is this a more female profession like gynecology or not really? Or does sex of provider have no data or bearing on that?

Diane: It’s definitely been shifting with a greater number of female pediatric dentists. I don't know that it’s the majority of pediatric dentists at this point, but definitely there is a greater shift towards female pediatric dentists where it was once a male dominated profession.

Howard: You think it’s shifting more female than just the general dentists at large population? You think it’s even going more female?

Diane: I believe so.

Howard: I pick up these little nuances like men, pediatric dentists are like, “Mom and dad stay in the waiting room. They’re not allowed to come back.” Women pediatric dentists are like, “I wouldn’t let somebody take my kid in a room and not be there.” The female pediatric dentists say, “She’s going to come back. I’d want to go back with my kid.” They’re different. Don’t you think they’re different?

Diane: I think so, but I’m not sure if I would agree that all female pediatric dentists would say, “Mom, come on back while I treat your child.”

Howard: The trend is I see it going. It used to be non-existent, but now I see that trend. It seems like every time I get a small sample size by someone talking to me at a lecture or whatever it’s a woman pediatric dentist. With Obamacare and then the fact that I’ve read several times that 2013 was the first year the United States consumed more calories liquid than it did eating. The sugar consumption … By the way the sugar consumption has finally plateaued. It got up to 150 pounds of sugar a year per person. Then it’s just been drifting there and it actually looks like it’s even coming down. Yeah, pediatric dentists are splitting …

Last year was very sad for me. No, wait, last year, this is what? 2016 next week, so 2015. I think it was 2013 in one year I was able to meet the first pediatric dentist in Hong Kong and New Delhi and Katmandu. I had dinner with them and they were saying that when … they were all my age. They were all in their 50s and they were saying when they got out of school kids under six didn’t have decay. Now in those countries you told me the age of the child, that’s how many cavities they have untreated. That’s just all from switching from water to soda.

Diane: Influence of the western diet.

Howard: That is so amazing. You gave two million dollars over the years. If you gave me two million dollars that would refund half my divorce settlement. You think you could double down and throw me another two?

Diane: I’m not sure if you qualify as a charity Howard.

Howard: I am charity case. What are these other organizations I’m seeing? You’re speaking of the ICPPD. What is that?

Diane: Your listeners would be interested to know about ICPPD, the institute for the clinical practice of pediatric dentistry. NuSmile is a founding sponsor of that organization-

Howard: Say it again, what is ICPPD.

Diane: Institute for the clinical practice of pediatric dentistry. What this is is an organization that has been founded specifically to help a pediatric dentist, but also general dentists that are interested in seeing kids and doing pediatric dental procedures better, faster and really incorporating good pediatric dentistry into their practice that’s profitable. The institute for the clinical practice of pediatric dentistry we’ve got a faculty that has a combined experience in pediatric dentistry of well over 150 years. We are running through this organization two courses annually that are being called the foundation course. It includes some pre-course videos and also some lecture during two days. These courses are being held at UNLV, University of Las Vegas, Nevada.

The foundation course also includes a lot of time in the sim lab. The doctors are actually doing clinical pediatric procedures during the program. That’s something that we’ve run two courses to day with this faculty and gotten rave reviews from the doctors that have attended. These are both pediatric dentists and general dentists that are attending the course and they’re separated out into two tracks so that if it’s a pediatric dentist who just wants to learn new skills, work with some of the newer materials that are available, but they have a lot of clinical experience in pediatric dentistry they go into a separate track. If it’s a dentist who is just starting to do pediatric procedures then they go into a separate track as well. They’re split into two different tracks.

Howard: Did you have this in Vegas because pediatric dentists are so stressed out that they develop gambling addictions and drinking addictions, so they were going there anyway?

Diane: No I didn’t [inaudible 00:53:56] say that. Actually we have it in Vegas because we’ve got a great partner with ULNV. It’s a great facility and it’s really a nice place to be able to have the course.

Howard: Implants Direct has a facility there too that they rent out. They have this amazing hands-on … have you seen the Implants Direct place?

Diane: I have not.

Howard: They have one because I have our townie meeting every year there in April. Every year 1,000 of us go there and we can have hands on course. By the way Dental Town has an annual meeting if you go to, we’ve added an annual meeting. I think this year’s 13, 14, 15 something, I forgot. We also have meeting throughout the year just because you can’t have a department that does something once a year. To make it a department. We’ve been putting on lectures. You know what our most successful online CE, what category online CE and our townie meeting live events throughout the year, is pediatric dentistry. It’s with Josh Ren, you know Josh Ren?

Diane: I do not.

Howard: You have to meet Josh Ren. He’s my buddy and he’s a fellow ironman. Me and him are both ironmen. You wouldn’t believe it if you saw us drinking and smoking at the bar, but we’re seriously both ironmen. He’s in-

Diane: I know where he is. He’s in Mississippi, is that correct?

Howard: He’s in Mississippi. You haven’t met him?

Diane: I have not met him.

Howard: He is the … we put up 350 courses. He’s the most viewed course presenter on Dental Town. Then we have live events with him. We went Fort Lauderdale, sold it out in like a week. They just love him. The reason they love him is because … where do you say he’s from in Mississippi?

Diane: I know he’s in Mississippi, but I don't know where.

Howard: You don’t know where. He’s just this down home southern country boy and he’s not pretentious, he’s not arrogant. Everything is what you said, when someone tells me of a new dental product I have four questions for him. Is it faster? Is it easier? Is it higher quality? Is it lower cost? If you get all four of them right you’re going to knock it out of the ball park. He just is into … he explains pediatric dentistry, when you’ve got a kid you might only get three minutes. You’ve just got to get in and knock it out and there’s no messing around. He should be your best friend.

Diane: Another thing that sometimes general dentists don’t realize about seeing kids is that when they’re treating primary teeth and seeing kids, these are not just little adult teeth that they’re treating and they’re not necessarily to be treated the same way as an adult tooth would be. I’m sure that doctor Ren speaks to that in the courses that he gives with performing a caries risk assessment and determining how many caries surfaces there are and whether or not a full coverage restoration is really the best thing for that child in limiting the number of appointments for that child because you really want to do a definitive treatment in many cases, that you don’t have to come back and redo. You also want to, in many cases, most cases, don’t want to see that child back for multiple appointments to complete the treatment. Do as much as you can in one setting.

Howard: Your email is NuSmileCrowns, is

Diane: Yes.

Howard:, I just sent you … oh my god, did I mess it up? DJohnson … Ryan, here, you do this. Send it to that. I’m sending you and Josh Ren an email right now. If you’re the number one seller of these pediatric cosmetic crowns and he’s the number one most viewed guy on Dental Town you guys need to meet each other.

Diane: Howard, one other thing I just wanted to mention and thank you for this opportunity, you had a new category in the Townie choice awards this year and it was esthetic primary crowns and NuSmile took that award. Thank you very much. We appreciate that addition to the Townie choice awards.

Howard: A lot of people say … they’ll say things about whatever and I’ll say, “I need to see the data,” because humans, they’re not data research. We’ve started Dental Town in ’98. We’ve had a monthly polling site. I’ve been polling them every week from ’98 to 2016. I’m one of the only guys that when I tell you dentisting this or that, I have reams of data. The thing that the Townie choice awards are so important is these dentists in dental school, they knew that thousands of people applied for 100 seats. They know these are people that get As in calculus and physics and biochem. You can’t go to dental school and not know that you’re in an elite smart group of people. That’s why you market shared data is so important.

When thousands of dentists vote on a product and you’re sitting there and you say, “Oh wow, this got the Townie choice award,” and then you’re like, “I’m having problems with this,” and then you look down. We show the whole voting, we show all the category. Then you look down and say, “Wow, I’m one of only eight people using this product. No wonder I’m having problems.” Market share data is extremely important with dentists. The Townie choice award is just huge. It’s one of the most interest innovations we did, was showing you what you’re-

Diane: A great idea.

Howard: Whereas a review on a B to C market like movies or music, I’ve noticed that my life, that whatever the movie people say is a great movie doesn’t really correlate with me and a lot of times when they say it’s a box office flop I’m like, “That one might be what I should look at,” because I’m just a different ace. I want you to hook up with Josh Ren.

Diane: Thank you for the introduction.

Howard: Again, if pediatric dentistry is our most viewed subject course, you get Carla on there and knock out some more courses on that or whatever or maybe do something at the Townie meeting because I really want general dentists to quit using chrome steel crown just because it’s just hard mental health on the baby, it’s hard mental health on mom. We have enough shame and guilt in this society. You don’t need to be putting a bunch of metal in baby’s mouth and just remind to every friend that, “Look, I screwed up, I gave my baby too much sugar, too much juice, put her to bed with a bottle.” You know what I mean? Did you send it?

Diane: We’re happy to help in any way we can. If there’s anything that we can do from NuSmile to help your doctors, your townies, we’re more than willing to participate.

Howard: If someone’s listening to this and they want to see any explanations or whatever, the NuSmile website had videos. Does it show any placement? Is there any information on the site?

Diane: Yeah, there is, but I would really like to point your listeners to our YouTube channel. That has the most videos and it does have a number of clinical videos for both the NuSmile ZR crown system and the NuSmile pre-veneered crown system, NuSmile signature. Our YouTube channel. Just go to YouTube, type in NuSmile, find the little channel icon.


Diane: I think you just go to the YouTube channel and then when you get to YouTube search for NuSmile. You’ll find the NuSmile channel.

Howard: Is a NuSmile just a play on the sound, N-E-W, like a New Smile, N-E-W?

Diane: It is.

Howard: If you already got the YouTube channel videos you’ve already done the work. You should roll that out into a course because I think the reason this podcast show is a huge hit is because number one, it’s free, and they’re listening on their smartphone on their commute. They’re multitasking to work or they’re on a treadmill or they’re working out. Everybody tells me the same thing. I’ve got a commute to work. If they’ve got an hour commute it’s the whole show. If they’ve got a 30 minute commute half there, half back. I think the reason the online CE course is so huge is because it gives ADA and AGD credit. They’re trying to get their FAGD, their MAGD, their state requirements. You’ve already got all that stuff on YouTube. You should just take all that content and roll it up into one course and the guy that does that is Howard Goldstein. I’m Howard’s friend. That’s why I’m Howard@DentalTown and Howard Goldstein, he went with HoGo, You should email HoGo and send him the link to that YouTube channel and start figuring out how to put all that so that when they watch it they get AGD credit.

Diane: We’ve actually started that process.

Howard: With Howard Goldstein?

Diane: Yep. I think we’ll have one or maybe two things coming out this year with Dental Town.

Howard: Between me and Howard which Howard is more bat shit crazy would you say?

Diane: I have not actually met the other Howard.

Howard: We're going to go with it’s Howard Goldstein, not me.

Diane: Okay.

Howard: He’s got to be crazy because he’s an Eagles fan and I’m a Cardinals fan. That alone proves that he’s completely insane. I can't believe it’s been … god, we’re four minutes over time. We should have stopped five minutes ago. Diane, seriously, from the bottom of my heart, thank you so much for all that you’ve done for dentistry. Thank you so much. I can’t believe four million little kids got a cosmetic crown instead of an ugly stainless steel crown. I think two million dollars to the pediatric dental association of the world, you’re just … you’re the mother Theresa of dentistry. You really are one of the … You should be called the patron saint of pediatric dentistry.

Diane: Actually we’re really happy to be able to support pediatric dentistry and doctors that are seeing these little kids. Not a lot of manufacturers, it’s a small niche market and the big manufacturers don’t pay a lot of attention to pediatric dentistry or products for pediatric dentistry. It’s just small. It’s not that important to them. That is hugely important to us. It’s just a pleasure to be able to work with this group of people and do what we do.

Howard: It speaks volumes of you that you got your son and your brother working for you. That just means you’re a great person, you’re a humble person. You’re listening. You’re not playing the power card. To be able to have your son and brother work for you speaks volumes of you.

Diane: I haven’t run them off yet, so that’s good.

Howard: I hope to see you again some day.

Diane: Thank you Howard. It was a pleasure.

Howard: Have a happy new year.

Diane: You too.

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