Howard: It's just a huge, huge honour for me today to be podcast interviewing. Dr. Chad Duplantis all the way from Fort Worth, Texas. He received his DDS degree from the University of Texas Health Science Centre at San Antonio Dental School in 1999. He continued with postdoctoral training at Baylor College of Dentistry earning a certificate in Advanced Education General Dentistry in 2000. He also applied for and will receive his fellowship degree from the Academy of General Dentistry this July. Congratulations on that!
Chad: Thank you.
Howard: He’s been in private practice since 2000 in the North Fort Worth, Texas area. In private practice he treats all ages with an emphasis on restorative and aesthetic dentistry, is a member of several aesthetic restorative continuums and most recently Spear Education Study Club. Dr. Duplantis has always had an interest in high-tech dentistry and has been incorporating CAD/CAM technology in his practice since 2004. Formerly a CEREC user, he is now a user of the 3M True Definition Oral Scanner and the Glidewell Laboratories TS150 mill. Dr. Duplantis has also written several articles regarding digital dentistry for various dental publications. He has helped 3M on various projects regarding scanner and also a member of the panel of experts on the website truedefinitiondoctors.com. He is also a clinical consultant for Glidewell Laboratories. In his spare time enjoys traveling, spending time with his wife Ellen and his children Austin and Ava. He's an avid cyclist, enjoys shooting, sporting clays and loves to be outdoors. So you live in Dallas, Fort Worth but you named your kid Austin. Does that mean you really wished you lived in Austin?
Chad: That's where we went to school, man. You know, we have to give one of the best towns in Texas some honour.
Howard: So which town would you like living in more, Austin or Dallas, Fort Worth?
Chad: You know my Dallas friends would get upset by this but I like living in Fort Worth the best. So, even over Austin. Austin has a lot of college memories, maybe a little bit too much fun down there. It's a nice getaway but Fort Worth's definitely a better place to live. In my opinion.
Howard: Texas is right now the number one hottest, growing expanding economy in the whole nation.
Chad: Yeah, We have we have a lot going on here and the real estate is relatively inexpensive and we have you know a lot of room for expansion, lower taxes, no state income tax. So it's a nice place to live. I feel pretty blessed to be here.
Howard: Well, I'm so excited that you came on the show. I mean you're a hot speaker with the Catapult Group. My gosh, 3M, It's very hard to get to be an advisor to 3M and that's one of the hallmark companies in dentistry. So I want to start out with is the first thing, that just got everybody on surprise. Probably most people don't even know that Glidewell has a chair side milling machine.
Howard: So, can we start with that?
Howard: What is the TS150? I mean CEREC probably has about 15,000 users in the United States. What made you go to the TS150 with Glidewell?
Chad: It's kind of a long story. I started with CEREC in 2004 and a little background on my practice. I have a partner in the practice as well that's about 15 years older than I am. So, when we went digital, I embraced the technology and he didn't quite embrace the technology. So, you know, we spent about $104, 000 on the machine in 2004 when I found myself using it a lot and him not using it as much, I started steering away from it and I had some failures. I won't say that it was the system because it is a great system. You know the CEREC has had great technology for a very, very long time but it was more the user. I think I tested the limits of the technology and after three or four years and more failures than I'd like to see, I kind of abandoned it and I still had this yearning to get back into digital dentistry. So in 2007, 3M came out with the Lava COS chairside scanner and they invited me to join and start using that and I did for a while. But there was no chairside mill component and so I had always wanted that chairside mill component so I stopped using just the scanner. Then in 2012, 3M approached me again with their new true definition scanner which had the capabilities to mill restorations chairside. But there were a couple of different mills that were available. One of them happened to be the TS150 which is now Glidewell’s mill. It's a relatively inexpensive option if you want to mill and you want to scan. So you know, I started using it shortly thereafter. I think that was my gateway back into digital and I've been pretty much scanning every restorative restoration I do in my office every indirect restoration. Been scanning almost exclusively for five years now and haven't looked back once. So that is how Glidewell’s mill kind of came to market.
Howard: So what's the difference in price between the two units. I mean the CEREC machine the whole bells and whistles. That's a lot of money. It's probably what a buck forty?
Chad: That's what I would say for the whole CEREC get-up is about a hundred and forty is what I'd guess and depending upon what capabilities you want to add. I mean a lot of people that have CEREC now are adding cone beam and you know they're adding a dry mill so they can mill zirconia which requires an additional oven as well. If you go with - you can get into scanning and milling in the neighbourhood of fifty to sixty if you go with one of the other options. The TS150 is actually changing course a little bit. Glidewell introduced a new electric mill. So to answer your question with the TS150, If you buy a mill, you’re looking at, just for the mill alone, let's say 45 to 50 for the mill alone. However, they've come up with an electric option that requires no additional air setup in the practice. I think that mill is going to run in the 30 to 35 range on the high end. There's talks of it being even lower but I don't think Glidewell’s come out with a pricing yet but it's going to be a pretty phenomenal addition to the dental office.
Howard: What would the true definition scan? The basic is like $17,000.00 and there's upgrades all the way to what?
Chad: That's it. $17,000.00
Howard: That’s the whole caboodle . All the upgrades, fancy stuff.
Chad: Right. I mean you have to have - data plans which you do with almost all of the scanners. There's a couple that don't require it but $17,000.00 is what you're looking at for a scanner.
Howard: Now when you say the data plan that's the monthly fee that you have to pay going forward.
Howard: And what's the data plan for the 3M true definition oral scanner about how much is that.
Chad: They have two options. There's one that's $199 and there's one that's $329 a month. You get different capabilities within the two. I would love to see just one data plan. I personally only use the lesser of the two which is the $199 data plan and it allows me to do everything that I need to do. If there's something that it wouldn't for instance if you do Invisalign in your office and use the scanner to scan Invisalign cases you're looking at the $329 data plan. But for everything that I do, the $199 works just fine.
Howard: I just found that a TS150… I googled that - and it says it … I guess you said it's Glidewell but….
Chad: IOS technologies.
Howard: Yeah do they own IOS technologies?
Chad: I believe they do. I believe that IOS technologies is a division of Glidewell.
Chad: But -
Howard: Now it says, the TS150 chairside mill provides convenient milling that could reduce your turnaround time to less than two hours, is a fast, efficient, affordable open-source milling unit. Features a powerful air-driven 150,000 rpm spindle and uses an orbital precision milling strategy to provide excellent marginal integrity. But I also noticed that they list it works with the 3M True Definition Scanner but they also list the iTero intraoral scanner. Did you look at iTero too?
Chad: You know I have looked at ITero. I have looked at all of them. You know I had the privilege of beta testing, the 3M scanner. So in 2012 that's when I continued using the 3M scanner and it does everything as the others do as well. As far as looking at the iTero, have I looked at it? Yes I have.
I just have no need to change at this point in time. You know when you look at scanners on the market right now you- know we used to have to differentiate between open and closed systems. None of the systems are really closed anymore. Even CEREC has opened their system up to a certain extent. So you know you got to look at price. You got to look at accuracy. They're all going to be extremely accurate so that's not an issue as it once was. You got to look at data plans and the ongoing pricing. You got to look at the capabilities and the success rates that people have had with the different scanners. So there's not a bad one out there in my opinion that I've seen so far. It's just that, you know, I just had no reason to change at this point in time.
Howard: I know a lot of people that got into chairside milling. That now, they just actually use the scanning component and send it to the lab.
Howard: Because when they start doing the chairside, you know these amazing hot speakers to talk about your side milling, how they do all their crowns in about an hour? But, there's a lot of people that in their office with their assistant with their gear that one hour appointment was more like three hours. The reason, I think the most exciting thing about the scanner is magnification is the key to being a quality dentist . You know everybody that puts her hands in the mouth, assistant dentist, hygienist, has to wear magnification and the endodontists all use a microscope to check their clean canals. But man when you - when the labs repeatedly tell you from everywhere I've talked to that. Impressions coming in are averaging 6% remakes. Scans coming are or about 1% remakes. Because you see your impression 40-50 times larger on the screen as opposed to sitting there in my loupes on looking at my little purple Impregum which isn't really a good color to look into. I mean I'm surprised Impregum isn't black. And so when you when you scan that I mean. Because, think about if 5% of your crowns came in for a seat and instead of having to try to get it to fit for half an hour then re-impress I mean what does that cost you? When a patient comes in for half an hour and all you leave is with a re-impress so the patient's not happy and I had a lot of cost to it. So if you really did reduce your remakes from 6% to 1%. My God, that would be worth a lot of money.
Chad: Well, you know I always tell people this and this is the honest Scott-truth since I've been scanning. In 2012, I started July of 2012. So let's say five years exclusively scanning. I've taken three traditional impressions in five years for restorative indirect dentistry. Now I've still taken some for removable but three impressions in five years. When I send something to the lab, like you said you blow it up 40 to 50 times. You know before it leaves your office if it's going to work or not. With an impression I’d hope that you would know. I mean I didn't have a lot of remakes but in those five years, I've sent five units back to the laboratory and I can tell you that every single one of them was my fault, because I either sent a restoration in that I probably shouldn't have sent off. I've dropped a restoration and broke it so that's neither the fault of the lab or the scanner it's my fault. Two of them I've screwed up bites on. And the other one was two weeks ago and it was a live and learn type of thing where I tried to do a screw retained implant bridge in the implants weren't placed perfectly parallel to one another so it's not going to work. So you know five cases that I've sent back. My remakes have dropped drastically because I would say before. I mean, I'm just throwing this out there, maybe I was sending about five cases a year. And I've gotten down to five cases of …
Howard: Whenever you have either a remake though. I think as an official policy you should blame it on at least a lab or the assistant. I would never take full responsibility.
Chad: Of course I tried full disclosure. I could take as much blame to it. So-
Chad: When the assistant stood right next to me it's always her fault. But then again she pays you back for that later.
Howard: Well you know what - what I always do with Jan for 30 years is we - it's amazing how dentists they spend their whole life with that ¾ inch mirror, and you can buy yourself a two inch mirror or a two and a half inch mirror to a quarter inch mirror …. and before I impress … I always hand that - have Jan look at but when she's sitting on the other side and she puts that two inch mirror down there. She's … can always find these aren't going to draw if it's a bridge or something's wrong but just having your assistant look at it. And my policy was always - always an impression that when we got that an item for the impress I hand it to Jan and Jan beat her that…. I didn't want her to talk to me I just want her to throw in the trash and you know the end of it so…. I like that having your assistant get involved and is this good. You know what I mean?
Chad: Absolutely, absolutely. And I think you know that's one of the beauties one of my favourite cases that I ever did. I did a - scanned a six unit bridge a couple years ago and you know that's one of those things where you kind of take your life in your hands when you go back there to seat it because it could go really well or it could go really bad. And my assistant came in… I'm sitting in the office I'd not even gotten through two sips of coffee and she says the bridge is ready to go and I went back there it was a scanned to bridge. You know manufactured digitally and it just dropped right into place and...
Howard: Now if you’re- Go ahead I’m sorry.
Chad: No I'm just saying I mean you know we're seeing great successes with it you know… Limited seat times.
Howard: But if you’re … if you’re paying a $199 a month of data plan but you're also getting a reduction on your kind of bridge fill...your lab charge does it give you a discount sending in a scan as opposed to a model? Because when the labs get a model they got to pay a human to pour it up, trim the dye, all that and some labs are giving a discount on the …
Chad: Absolutely. You know the …
Howard: What lab are you using?
Chad: The majority of my stuff. I'm using two labs. I use a... you know… Glidewell for … for mostly zirconia restorations and I use a local lab for my really aesthetic higher quality restorations… a lab called Techsource Dental out in Plano.
Howard: Yeah so on another podcaster use those guys.
Chad: They're … they're a phenomenal lab, pay real attention to detail. But they do offer - you know they're a digital lab so they offer a discounted price for digital restorations and what I tell everybody you know when I'm lecturing is that if your lab does not offer you some sort of a discount or there's not a - you know - if there's not a set fee for digital restorations or set fee for analogue restorations then your lab doesn't get digital. You know you need to go to a lab that understands digital. The problem with a lot of these labs that are out there, that are kind of trying to embrace it is you know they're charging an excessive amount for a restoration. And then a patient - doctor sends in a digital scan, and they're charging the same amount. That's not worth it to the doctor. So in my mind the labs have to offer some sort of incentive. But not only do they have to offer a price incentive. I think that the labs need to offer a turnaround incentive because there's no way that these restorations should take three weeks. You know two to three weeks …they should be able to be turned around within a week.
Howard: Nice. Yeah, you're the... I've had two guests that used Techsource Dental and I think the other one wasn’t even in Texas was - was far away. So when you think … when you know …when I get out of school in ‘87 it was the dental materials revolution it was the revolutions in adhesive dentistry with Bob Ibsen and Bisco and all those guys which gave us the tools for the cosmetic revolution bleaching, bonding veneers… And then there are ‘90s it was the - the computers and we have the digital revolution. What would - what are you most passionate about in the digital revolution that we're living through right now? What's got you excited?
Chad: You know - I think implants. You know I think implants are the future of… you know are or a big part of the future of the digital revolution. And in the way that I always look at this is - is I'll use my partner as an example. My partner has - he's - he's been out 15 years longer than I have. He’s not extremely computer savvy. Does… not that he doesn't like computers but it's just it he just doesn't want to practice dentistry with computers until we started restoring implants, digitally. And once we started doing that and he saw the ease of just restoring implants digitally, he was all in. I think … I think he's scanned three implants this morning. Our practices implant production has gone through the roof and it's not because… You know we like to think it's because we're better than the average Joe dentist but it's because patients come here. You know from surgeons they get their implants scanned it's become such an easy and seamless process that what surgeons are doing is if patients show up to their office they're sending them over here because the workflow is so smooth. And we treat a lot more implants because the workflow is so proven, it's so smooth, it's so efficient. It's just easy. So that's the restorative aspect of it. And now what we're doing digitally is I'm scanning, the surgeon that I work with is taken a CBCT, we're incorporating that into code diagnostic software. We're planning huge cases. I mean we just planned… a tomorrow or Friday we’re replacing 14 units in a patient… Full mouth restoration… Full mouth rehab and it was planned entirely digitally. So I think that's the future of digital dentistry and I think that's where this is headed.
Howard: So you're not placing them …you're working with a surgeon?
Chad: I do work with a surgeon.
Howard: And is that an oral surgeon or a periodontist or -
Chad: Both. Majority of it is periodontist.
Howard: Majority’s periodontist... And what's the name of the …So you didn't buy a CBCT then?
Chad: I did not.
Howard: Yeah and that that's why I tell those kids… I mean my cell phone... I mean I started off with a Motorola flip phone then a Nokia and I mean I've never had a cell phone that I've kept five years. I don't think I'd want to buy $100,000 iPhone and then five years later want the new model. I mean you just need access to a CBCT. If your periodontist… oral surgeon have one why are you buying? I mean you have to do a lot of scans a month to make that ROI. But what's the CBCT co diagnosis software?
Chad: You know there's several out there but the one that we use most is a coDiagnostiX. And it's dental wings you know which is now part of Straumann… Or… at I don't know exactly how their - who's part of who but dental wings and Straumann have come out with coDiagnostiX implant software. And I'm going to give a little bit so if anybody out there does not have access to coDiagnostiX software which there are several brands… There's a great company you've probably heard of them, Implant Concierge out of San Antonio.
Chad: And so the Techsource does not have the coDiagnostiX software … but Techsource, myself, Dr.Betacheck the periodontist… And we all merged with coDiagnostiX for this one case and coDiagnostiX planned it for us and man you want to talk about a fine-tuned machine… I mean Implant Concierge is a fine-tuned machine. They really-really helped all of us out in this case.
Howard: You know what? I would like to podcast interview him. Who's the head over there implant?
Chad: I can get that information for you and email it to you. I don't know who the head is. I know Google them, it'll pop up. I believe it was started by three doctors.
Howard: Yeah. You're probably like the 10th person on … out of 750 shows that mentioned Implant Concierge so they're obviously doing something really right. And I found that at dentalwings.com and you think that's owned by Straumann?
Chad: They are in part. They are together. They actually have a scanner that's out together too. The Dental Wing Straumann intra-oral scanner or whatever… You know if you look at the dental wings intra-oral scanner. That's developed or owned by Dental Wings and Straumann.
Howard: Nice. Yeah. So my homies are driving to work so they don't… they can't really take notes. So what I do is I just re-tweet that last tweet. So they're @dentalwings.com so you follow me @howardfarran… I just re-tweeted there last week. What is your Twitter?
Howard: There he is… that handsome devil. Oh I already re-tweeted when you're when I - when I sent you an email I re-tweeted you. I wanna re-tweet another one. Family, Cycling, digital, dentistry, CAD/CAM dentistry at Fossil Creek Dentistry. So you really like the coDiagnostX software. You didn't buy a CBCT. That's smart. So implants have got you pretty excited though, huh?
Chad: They do and you know just to touch upon… you know you asked about buying a CBCT. I know a bunch of general dentists that have them. And I don't think that that's a bad idea. But for me, like you said, why do I need one? Why do I need to go make that investment? I'm not placing implants and I don't have the time nor the want to place implants. But maybe I will down the road if things slow down and I'm not knocking people who do. I think that's great. But why do I need a CBCT when the surgeon that I use has one and every surgeon that I use has one. But there's also all these imaging centres that are popping up all over the place you know and there's... In Fort Worth I believe there's even a dental Imaging Centre where will you send a patient and they'll take your CBCT. They’ll take intra-oral photographs they'll do whatever you need them to. So …
Howard: Well you know I posted … I started a thread yesterday and I thought it would just explode in views. But there was, what I consider an earth-shattering paper that was published a couple of years ago that was kind of flying under the radar and regarding… It's called Bacterial Signatures in Thrombus Aspirates of Myocardial Infarction. And we had a - the doctor in Texas how to beat the heart attack gene and it's the Bale Doneen Centers and they're really exploding. They’ve really got a lot of information on preventing heart attacks. But he is - I publish under endodontics but they're showing that when you go into acute you know, a heart attack that 30% of the time, they find five bugs from gum disease. And 70% of the time, they find bugs from a failing root canal that has a periapical radiolucency. And the naturalist and the holistic doctor said they've been touting this stuff for two or three years. But when you start talking to endodontists and they start taking this CBCT of existing root canals especially if you're in the heart attack zone like a male… like if you're a short, fat, bald grandpa male over 50. You know you're not going to live forever but when they start doing CBCT’s of these existing root canals it's amazing how many of them you find that are still had periapical infection. And since the nerves been taken out and then there's some people saying that you know dentists are the only ones that try to salvage it, embalm dead organs. And I think if that really takes roots there's going to be a lot more CBCTs of existing root canals. Then when you talk to rhinologist, there's a guy in town here it says people come in here and say they've had allergies for 20 years they put a camera up in the nose... And some root canals leaking into the sinus and it's been leaking for 20 years. There's white fungi gunk all over the sinus and he says some of these things are just... So there's a lot of failed root canals that on a PA that we're not seeing it... And the nerves been taken out and the patient not feeling it but I think - in fact I am almost to the point now where once you turned 50 years old… You know when I turned 50 the doctor said, “Okay now that you're 50 you got to get your first colonoscopy and you gotta do that every five years before you die. You got to get a brain MRI because all the brain cancers are killing your 60s or just the size of pae when you're 50. But I'm almost starting to think to add that to the heart attack kills that when you're 50. You go to an endodontist and get your - all your root canals CBCT’d to make sure they're all working and fine with no infection. What do you think all that?
Chad: Well the first thing that I think is what you're telling me is I - if all this comes to fruition and CBCT's are finding man, I think that we can see that CBCT may eventually become the standard of care in root canal therapy. I think that it is going to become the standard of care and implant rest - implant placement. But I also see what I would I what I'm seeing a lot in my practice is that you know when you're looking at diagnosing a root canal, you've got to look at an implant as a viable option for that patient as well. You know and so are we going to see… I've seen that my retreatment diagnoses have dropped off drastically and I've started pushing more towards implants rather than retreats if there's not... you a shadow of a doubt that the retreat is going to be effective. And I question what it's going to do for initial treatments on endodontic therapy if we start seeing a higher rate of failures from what we're seeing in CBCT’s. Does that make sense?
Howard: It does and it's this oral health continuum connecting the - evidently take it is - it's the bigger issue even among the MD's because they broke up into 58 specialties. The dentists have nine and it seems like every MD I meet that - oral systemic you know the whole body continuum. I mean there's guys who their whole life do kidneys. I never have talked anybody who does lungs, hearts, livers, teeth, brain, you know what I mean?
Howard: So they're all starting to, I think that's a part of the revolution we're know is that all these 58 specialties are all realizing you know this at the end of the day it's just one human. And all that stuff is connected and it's amazing it's just amazing. You remember go back in the day way back in the day when LSU started doing artificial joints.
Howard: and they start doing an artificial joints and the problem was they started to break down. But where it was noticed is that they were finding the parts of artificial joint and people's kneecaps and their elbows and you know there's macrophages trying to eat it … I mean that thing was showing up in air every corner of the body and they quickly discontinued that program. So I mean dentistry has got a long history of the oral systemic link.
Chad: No, That's really interesting. I hadn't seen that study with -
Howard: I just emailed it to you it's under endo. But I was very surprised only one guy only, one guy posted on that and of course -
Chad: Well it’s because-
Howard: And of course - and of course it was just typical - typical why I post under endodontist and it's just – this is - not to throw my buddy, Al under a bus but amazing. What he said he said, I just had through a lecture by John Kadima that dealt with his subject. According to the work he code is very difficult to culture bacteria left over in and around the tooth following root canal treatment they seem to reach a quiet phase when they are non-infective. Whether they can come out of this phase anyone's guess but - okay I don't remember in Biology learning that life forms had a quiet phase when they are not infective. I mean you know it's just like - it's just like I don't think anybody endodontists- even wants to think about this or believe it but it's - I think it’s going to get - I think the cardiologists especially the - Dr. Bell in Texas that we - who wrote the book Beating the Heart Attack Gene. He thinks - he thinks failing root canals are 70% of a huge -
Chad: That's a pretty astounding figure right there.
Howard: I know. It's an insane number. I mean let's say he was 90% wrong and it was 7%. I mean that is the difference how we - how we rearranged risk and I had and like in my dental office in 30 years, if I killed someone every month, how many months would it take if I killed one person every month before the – the government shut me down?
Chad: Oh, yeah. Probably like one month.
Howard: But this – but the Phoenix - Arizona Department of Transportation built the intersection of Ray Road and 48th Street where they put a 25 acre Power Center, Target grocery store in all four corners and someone dies in that intersection every month because the research is pretty clear. When you put a Power Center on all four corners people are driving to the intersection trying to look for where that store is but if you have two Power Centers but the other side is like, say apartments or what residential whatever, the mortality rate drops out so - so the government can build an intersection that kills a person every month and it'll just go on till the end of time and no one even looks at it. But if a dental office did it - so people have a very bizarre way of treating risk you know what I mean? Like - like airplanes ...
Howard: Like - like everybody's afraid to fly an airplane and you basically can't die on airplane but 30,000 Americans die in a car every year and they all jump in their car and drive because they're afraid to fly.
Chad: Well, you're right. I mean it's a warped - warped risk assessment.
Howard: So, what are some common misperceptions about digital dentistry?
Where you think these dentists got it - are not seeing it right.
Chad: You know, I think the - the biggest is in my mind is that it's expensive. And - and I think that, you know, doctors can't see the light at the end of the tunnel and so you know you see if you're looking at - at CEREC it's $140,000. Well, I don't think you and I are going to disagree that that's expensive. However, if - if you want to go digital, let's just talk impressioning. You know, it's kind of a gateway drug to digital dentistry. Buy a scanner, you're looking at 15 to 20 grand as to what you can get in to digital dentistry for. Yes, you've got an ongoing fee but
trust me I've run the numbers. You may have to switch labs but you're gonna save money each month if you go and just buy a scanner. You're gonna save chair time, you're gonna save, you know, hard costs. You're - you know comparing it to impression material, well how much you’re gonna save I can't tell you that. But I can tell you that you can get into digital dentistry very inexpensively and
I think that that's a very common misperception that - that people have. So, you know, you touched on it earlier. You get into digital dentistry, you start – start ordering restorations. You’re lab’s gonna offer you a discount, that saves you money right there. You do 20 restorations a month you save $10 to $15 a restoration. If you don't even switch labs you save $10 to $15 dollars a restoration. You know, it just starts adding up. I can get a digital restoration 79 bucks returned in three to five days and –
Howard: Is that from Glidewell?
Chad: That's from Glidewell and I will tell you that - that Techsources pricing is very, very competitive as well. You know, I think they have anywhere from 89 to –oh, probably for the higher end zirconias, the lava aesthetics is gonna be you know, pushing the 150 mark I don't know that off the top of my head but it's still less than I was paying before.
Howard: This is June 21, so basically two weeks ago 6,000 kids just walked out of dental school, they just graduated… And when they listen to me talking about this southern they're gonna say, “I can't believe I had $350,000 of student loans and I didn't learn any of this and didn't place one implant. What would you since - since podcasters are usually millennials, what would you tell her if she says, “Man, I'm already a third of a million in debt. I've never placed one. How do I go from zero to one?” What would you tell her?
Chad: Placing implants?
Howard: Yeah. Or restore. You don't place them you restore them.
Chad: Restore them. You know -
Howard: And a lot of people argue about this. Some say that dental implants is a prosthetic art with a small surgical component that the final restoration drives implant placement and then a lot of the oral surgeons say I don't, you know, I don't buy into that. I mean you got to have your bone and you – you place your implants and you got to go from there. What would you say to someone who came out of dental school and they've never restored an implant. How would they get up to speed the fastest in diagnosing treatment planning and restoring dental implants?
Chad: You know, I think the biggest thing is that when you get out of dental school you have to find a mentor and that's what I would suggest to them. You know, go let if - if you're wanting to restore implants then what you've got to do is you've got to learn as much as you can about the restorative components and the first thing I would do is I would develop a relationship with a surgeon in the area that places the implants. I develop a relationship, I'd spend time in that surgeon's office, I've watched that surgeon place implants and I get to know the implant representatives from the various companies that that surgeon uses. And you know restoring an implant is easy, you know, I mean you just - you just got to take - take the leap of faith and do it, you know. For instance, in this area we use a lot of Straumann. So, the first implant that I - that I restored I called the Straumann rep and said, “Hey, I've got this patient coming in”. And that Straumann rep knows that if they help me I'm gonna help them as time goes on. “I can be at your office that day, Dr Duplantis. I can bring the necessary components. You only pay for what you need. Anything else we'll return. I'll go ahead and order everything. We'll have it right there in your office and I'll walk you through it”. I think that – that Straumann representative could have restored the implant that day better than I could have, you know. So I think that, you know, you need to find mentorship. It's gonna be, you know, the surgeon –
Howard: Okay, I'll - I’ll stop you right there. I know my dentist, I know they're shy, they're introvert, they could have been a Physics instructor, chemist, researcher. They're basically shy to go knock on an oral surgeon or periodontist’s doors. What percent of the periodontist or oral surgeon, would think in fear and scarcity and go away? You just refer them to me that's my business you go you just restore the crown. What percent do you think would think in hope, growth and abundance to say, “Oh yeah, come on in. You can watch any surgery. If you've got a job that you're an associate somewhere, you don't work Wednesdays you can come in here Wednesday. I usually place five a day”. What would percent of the periodontists and oral surgeons you think would be open arms?
Chad: You know, the ones that I talked to in this area are actually really receptive
to dentists wanting to place implants, you know. And you know, they're receptive because they want him to do it the right way so that they don't have to fix their mistakes but I think also it's - it's all in how you teach them, you know…and in what you teach them and what you share with them it's kind of like doing endo, you know. I mean I feel very, very comfortable doing an endo on number 8. Number 15 not so much. I don't know if I really want to touch it. So, I think that you know, I think a lot of more surgeons than you know would be receptive to that. At least they are in this area but you know, like I said I don't place them so I never test that side of their knowledge. I think I know how to place them and I think I could place them. I just don't want to place them. So, you know, and I don't know how many of the dental schools are actually training students to place some these days. You know, when I was in dental school I placed two. I graduated in ’99. We placed Kalsa Tech's Spline Implants.
Howard: Kalsa Tech’s Spline?
Howard: Now that’s - I feel like that - that Star Wars guy when he said Obi-wan Kenobi is like - ‘that's a name I haven't heard it a long time’
Chad: Yeah. You know, and a lot of my classmates are placing them but you know if I could give any advice, if you're gonna place them, you better make darn sure that you're trained well to place them and if you're going to place them
in your office, I would highly suggest for a general dentist to have a cone beam in the office because, or at least have a cone beam on that patient. If you get
in a little trouble and you placed an implant and something went wrong, I would
tell that general dentist, “You better hope that you have a cone beam that backs where you placed it and you can justify why you placed it where you placed it.
Chad: So -
Chad: That’s why –
Howard: Every malpractice company CEO I've talked to said, “If you just graduated in dental school before you retire you will absolutely be sued once”. I mean that’s –
Howard: I mean you – you can't do dentistry for 34 years moving forward with - the United States has 1 million attorneys and attorneys have practiced management seminars showing you how lucrative dentistry is and so they go to weekend courses at the Holiday Inn learning how to get into the dental lawsuit business, you know. Another interesting thing about implants, you know, those two things have exploded in my 30 years. Implants and Invisalign and both of those have two things in common. The health insurance schemes like the NHS or PPOs they're not setting the fee in implants and Invisalign. So, a lot of times when you go to these big NHS offices in - in England they're doing all the fillings and cleanings and x-rays pretty much at a loss, but if they pull out one implant and one Invisalign case a week I'm setting it at a market rate of what the market will bear as opposed to a predetermined fee by the NHS. That - that's where they – they break even and pay all their bills and make money. I mean I've seen some of the biggest welfare clinics in the world but the reason they pay all their bills because they do they pull out 50 implants and 50 Invisalign cases a month. So, learning something that the fee is not set by a third party is always a good business to be in.
Chad: Very, very true. And I found and I don't - I don't know what you're seeing out there but I found that you know, when we first started restoring implants the insurance companies wouldn't even look at them, you know. It was just kinda - that's something that we don't touch but I found that the insurance companies in the United States have actually become a little bit more receptive as far as the restorations are concerned. I still find a lot of them aren't covering the placements so I'm told by the surgeon but they are covering the restorations that - that we place on them.
Howard: So, does your office participate in PPO’s in Fort Worth?
Chad: We do not.
Howard: You don't take any PPO’s.
Chad: No PPO’s.
Howard: Wow. So that is a game of margin. I mean, there's so many offices that are signed up for you know, 8 to 12 PPO’s and some of these you know, you ask the dentist, “So, what is your overhead?” And they’ll say, “65%.” And I'll say, “Okay, this - you're on 12 PPO plans”. What - you know what the average adjustment is off these four plans in your office? It's 48%. So, if you're over at 65% and you're adjusting out 48% on these four plans and so many consultants will tell
you that when they go into offices that are on 12, 15, 18 plans that they'll drop four or five plans and the dentist actually starts making more money because he doesn't realize he's taking profit dollars from fee-for-service in cash and some plans and subsidizing other ones at a loss. It's amazing how the biggest crime in dental schools... They graduate and they can't balance their own cheque register at Chase or Bank of America. They can't do payroll on Quicken. They know zero accounting and then they start citing all these contracts for all these insurance companies and they don't read them. They didn't have one course in dental school. We actually read a PPO plan and the American Dental Association has a service that all those PPO plans they've already analysed so all you got to do is call the ADA or email their department and they'll give you a review of each one of those contracts and it's - you know when we got out of school in ‘87 you can make a lot of bad business and mistakes and still be fine.
Chad: For sure.
Howard: By this market when you get out of school. It's not as forgiving … you have to make a lot of decisions right out of the gate or you could set yourself back a decade.
Chad: No, I agree with that completely. I think you know we’ve been very fortunate that we don't participate in any PPO’s or HMO’s and it works really well for our practice and our patients are very receptive to it as well but they're informed prior to ever coming in and i think in telling a dentist who's thinking about leaving some of the PPO’s is that if you position yourself appropriately and explain it appropriately and educate those patients. It's not as big of a leap to get out of them as you think it would be, you know.
Howard: So -
Chad: If you provided a loyal service.
Howard: So, you're gonna be getting your FAGD in July. Congratulations to that. There's a lot of people that just walked out dental school. Do I doubt, even know what the AGV is or what a FAGD. Well, tell us about your journey. Why did you join the AGD, why was your FAGD important to you and what would you - what would you tell the 25 year olds about the AGD and getting your FAGD?
Chad: When I have kind of - interesting journey on that – I joined the AGD and - and obviously I'm a member of the ADA as well but I found that the AGD is a little bit more education driven… And so you know, as with many things in life you know, having the AGD and you know being able to record your hours, log your hours through them, be able to monitor that. It's an accountability thing, you know. I'm able to look at it and say, “Gosh, you know, I wish I had more hours right now or you know, it's a great storing house for your hours and it's - they have you know, a lot of great educational equipment out there. When I finished my residency I think I got 150 - 200 hours from my residency and I had the opportunity to take the exam and I didn't because I was pretty much done taking exams and just wanted to practice dentistry at that point in time. And I wish I would have because you know that was a lot - that would have been a lot easier to take the exam 17 years ago than take it now and have to learn how to study for an exam again. But, yeah I've had the hours for about ten years and you know it's just something that - that I've always wanted to do and it was just kind of trying to find the time to study for it and take the exam but I encourage every new graduate to - to join both the ADA and the AGD. I encourage them to keep up with their hours and - and take as many hours as they can. And I think that the fellowship is just another nice little notch on the wall so to say and - and another goal for them to achieve.
Howard: I think the number one variable I saw in my 30 years of watching kids come out of school and who was passionate, happy, healthy, love dentistry, love their career versus no passion, burned out, hated it, only did it because you really can't make a dentist income doing you know, they usually don't have an idea. Well, I mean, what would you - what would you do if they took your license away today, what would you do to make the money you do? I mean it … so they're stuck in a rut and if I had to pick the one variable it was hours of continuing education.
Howard: Dentists who took a hundred hours a year they were always excited and they were always passionate, they always had a mission and they always loved it. And then the ones who just took what they had to do to renew their license they weren't smiling. They didn't look like they were happy and having fun. And the other thing is that when you're in the AGD and you're trying to get your fellowship you’re a summary of the five people you hang around the most with. You're always sitting there, learning from the lecture but then you're sitting there breaking at lunch and all these guys are telling you all these things and - and man when you hang around with five people that are trying to get their fellowship in the Academy of General Dentistry, you're in the right crowd and you're going somewhere, you know I mean?
Chad: And I would say you know… make it a race you know. Don't - wait 17 years to get it like I did. Try and get it as quick as you can. I think you have to be practicing for five years before you can apply for it. And you have the hours within five years I just didn't want to take the exam so, you know. And I will say this I think I learned so many more things because when you – when you follow it continued education track you - you tend to focus on the things that interest you the most. I learned a lot about paediatric dentistry and endodontics because those are courses that I really don't go to as often as I should. But I learned a lot and I realized I had to dig deep in the memory bank to get through that exam because, you know, each aspect of dentistry is covered. And - and I will also say that - that you know sleep dentistry, that wasn't even talked about when I was in dental school but that's a part of the exam so I learned a lot about that as well, you know. And just studying for the exam so the sooner you can get it the better off you can be.
Howard: You know they - your forefathers know so much more than you because they've been around the block and I remember when I signed up for joining AGD in 1987, I actually got into an argument with the Arizona guy over here and he was about my age of the time. He was a grandpa and I said – I was just really upset because I had to take courses in implants and ortho. I said I don't do implants and ortho and I don't want to do implants and ortho. I do fillings, crowns, cleanings, and I just want to take this other stuff and I don't want to take that. And he just – he just laughed, he just put his arm around me said, “Howard, you know, you got to learn tools from every toolbox, you know. You got to learn - even though you're not good you'll be a better dentist because of it”. So, I thought, okay, well I'm just going to knock this out and getting - got out. So, I found one course that I'd never heard of before and it was seven, three-day weekends with Carl E. Misch in Pittsburgh. I mean, it was like I discovered Australia because some wiser man said you got to learn this stuff. It was love at first sight, I love him but same thing with ortho. I looked up the deal there's only two board-certified orthodontists that actually taught general dentists. One was Richard Lynn, one was Harry Greene and I was all mad and I didn't want to do it. But I mean, those are like two of my lifelong friends and even though most people, most general dentists who learn ortho and start doing four or five days usually fades away from the practice. I don't really know anybody who got into ortho. I would say 80% of dentists who learn how to do ortho after two or three years don't do it anymore but they become much, much better diagnosing, treatment planning, know when you know, you really need to get mom to intercept this case that the orthodontist. I mean, the knowledge is just unbelievable. But I want to - I want to say this. Back to the graduation class, how does a young kid find their passion? How do they how do they get - how do they find something that you're excited about it? Seems like all the dentists had a really happy and healthy and loving dentistry. They got that one thing they're passionate about which kind of gives them their mojo for all the other stuff in the office they really don't want to do like I am - who gets excited to sit down and do another MOD composite on a first molar. I mean, if you walk into that room - all challenged and excited about it. I mean, God dang if you've done ten thousand I can't wait till you can buy - forget CAD/CAM. I was surrounded to come out with a droid that you know, I just send a little R2D2 into the room and it brrr... but how do they - how do they find their passion so they get excited?
Chad: You know, that you think that's an easy question to answer and I think it's more - it's a little bit more difficult to answer than you think, you know. You come out of dental school and you think you know everything. And you think you know a lot about everything which - which is the majority of dental students. And it took me about five years but in those five years, you know, I tried to do a little bit of everything and I tried to learn a little bit about everything. I think, you know, you've got to continue being a student. You don't just hang it up when they - when they put that robe on you and tell you that you're a doctor now. You've got to read the journals, you've got to study, you've got, you know, find someone in the dentistry in the industry that you want to follow, you know. And it just hits you it's gonna hit you when you find what you're passionate about and it hit me in 2004 and I realized I was passionate about digital dentistry. I just didn't know how far I wanted to get into it and I just kept on and even when I gave up the CEREC I knew I still liked digital dentistry. But at that point in time I decided, “Okay, I'm gonna go into this”. You know when I got CEREC, I got CEREC because I thought that I was gonna eliminate a lab bill and I didn't. And that was a big misperception on my behalf. I mean, if you go into digital dentistry thinking that you're gonna be able to eliminate a lab bill that's not gonna happen. But I got into it for the wrong reasons. So, when I got out of it in 2007 or you know, and started trying to figure out what I wanted to do I wanted to go about it the right way so I started to read. I started to learn, I started to study. And - and you know just all of a sudden hit me it's like okay this is the future of dentistry and this is what I'm passionate about and if they - if they do enough of their homework and continue being a student to a certain extent I think they're going to find what they're passionate about. They're gonna find what they like doing in their practice. They're gonna find what they don't like doing in their practice and I think, you know, the more you give to the things that you like doing in your practice you're gonna become passionate about it.
Howard: And you know it's tough because all the greatest things in life don't come easy. I mean, it's not easy getting your FAGD, your blackbelt, your Eagle Scout and none of those things are easy but you know, when you're so young and you say like you hate molar endo, well okay I'm not saying you're 25 and got to do molar endo till you're 65. But you don't quit on molar endo after you've done three and say you hate it. You go take every course there is and there's a chance that after you take three or four massive, awesome courses and we have online continuums on. We have like 3, 15, 20, 30 hour online continuums on Dentaltown by the greatest endo instructors ever. Do all that, because maybe if you finally master that beast you'll fall in love with it. And you know, the same thing with - so if something's hard, I mean, even Elon Musk says that when his view of starting a business was eating glass while staring into the abyss. He says that, you know, the eating glass part is doing things you don't like to do and staring into the abyss is that you know, most start-up businesses all fail and go bankrupt. So when you're tackling endo or implants or ortho or sleep apnoea whatever, it's like eating glass staring into the abyss. But maybe you'll eat so much glass that the abyss turns into a detailed yellow brick road and you fall in love with it. And also, I also wanna tell you because you're coming up on this I tripled my intelligence in just three years. And I don't even know how I did it. When my boy was 18, he thought I was a dumbest guy in the world and then when he was 21 I was now the smartest guy in the world.
Chad: Oh, absolutely.
Howard: So, yeah.
Chad: I am the dumbest guy in the world right now. So, but you know molar endo is a perfect example as to what you said about finding your passion. You know, compare molar endo to digital dentistry for a second. I hated molar endo until I found an efficient system that I use in my office to do molar endo. And now it's not my favourite thing to do but I certainly don't shy away from it because I found an efficient way of doing it in my office and a system that I really, really like. Now digital dentistry, did I ever think that I would be passionate about taking impressions? No way. You know, and that's where it started, you know. Who would have ever thought that impression taking could be fun. No, it was an efficient way to take impressions that led to other things that made it fun. So you know trying to find office efficiency and practice efficiency and something that you're good at that's the tough part.
Howard: But anybody - I can't believe the hour is already gone but - you forced an overtime because you just said - the last thing you said is you found an endo system that was fast and efficient so you can't leave that hanging out there. Now you gonna have to go into overtime and explain to my homies what endo system you're talking about.
Chad: TF Adaptive.
Howard: Adaptive? And who make
Chad: Sybron Endo.
Howard: Okay, Sybron Endo owned by Kerr.
Howard: Which is owned by Danaher. So, Danaher Kerr - Sybron Endo.
Chad: Yeah and I started using it and I absolutely loved it. I love the hand piece, I love the file system it's quick it's efficient. The obturation is easy. You know, I will say another piece of advice is that if you find something that you like and it's a little bit more expensive than what you didn't like, then you know what you do? You increase your fees. You make it worth your while to do it. There is an easy way to do it, you know. You got to increase them within reason but you got to be able to make money off of things too.
Howard: I know. So I live in a big metro like you do, you're in the Dallas, Fort Worth. By the way, where's the cowboy stadium? Is that in Fort Worth or is it in Arlington?
Chad: It’s in Arlington.
Howard: And so we've got you know, out here in Phoenix it's a 3.8 million metro to drive from the furthest southwest corner - Queen Creek to the farthest northeast corner of Sun City on an interstate going 70 miles an hour taking an hour.
Howard: So we have the big denture world factories where they’re advertising complete dentures for $199 and this and that and - and for the last 30 years every once in a while, I can't stand dentures. I mean, you know well you know I charge $1500 an arch for a denture and they'll say, “I’ll go to Denture World get them for $199”. I'm like, “Grandma, I will personally drive you there”.
Howard: I'll call an Uber, I'll call a limo. I'd rather pay a limo to take you to Denture World than do a damn denture for $199. I mean, and those guys when you go in there, I mean, that's all they do. They got their lab man, they take a mush bite, they got it three steps and that's the other thing these young kids got to realize that - that if you are making five dentures a day, you are the best denture maker in all of Arizona. And what I have noticed last 30 that if you don't do a procedure one time a week so I don't care if it's crowns, dentures, implants, Invisalign if you don't do the case once a week you never get faster, easier, higher quality, lower price, and profitable. And furthermore if you need a surgery, let's say you needed a - you know, whatever. Some organ worked done - would you want to go to a guy that does it once a month?
Howard: Or would you want to find the guy who makes five dentures a day at Denture World? And as crazy as that sounds they make really good dentures with a mush bite, the lab man, because God they - they make a gazillion of them. And so if you're going to get passionate about something remember like Shark Tank. How many times does Mark Cuban who I love, who lives in your backyard says, “I'm sorry, Chad. But you're not describing a business, you're describing a hobby, okay? So, go - go play and have fun”. When you're not doing a procedure once a week it is a hobby and you're probably losing money on it and that's all cool if that's what makes you run 20 red lights on the way to work, you know. I don't want you burned out and fried so like when people say should I buy a hard tissue laser or I'd say well, “I - I think a paedodontist would have to. I mean, because the time it takes to give a shot and wait for it to numb up. You could have - you could have done the filling on to that but - but more importantly in anything is does buying a laser sound like the coolest damn thing you could ever do and it make your eyes sparkle and run to work? Then you have to buy a laser. But don't sit there and say that you have to have a laser for any other reason, you know. Try to stick with things that you do once a week.
Chad: I think that's a great. That's great advice for anybody in dentistry especially the new ones coming out. The millennials.
Howard: Yeah, yeah absolutely. And all right well man I can listen to all day long.
Thank you so much for coming on the show. I was so excited when you replied and said you’d come on the show. Love your energy, love your passion. Good luck with Austin and Ava and I'm sure that's the most fun you'll ever have. And on that note I hope you have a rocking hot day.
Chad: Alright man, and thanks Howard.
Howard: And I wanna beg for one request from you.
Howard: One request. My God, that article where you were talking about I mean that – where you were talking about you were working with code diagnostics, Dental wings, Techsource, periodontist yourself. God dang, I wish you'd write that write that up for an article in Dentaltown magazine because it'd be worth your time because they’ll have magazine goes to 125,000 people but we email it digitally to more than that and then on Dentaltown, there's a quarter million dentists and we started the share function where - you know, where these people write the article for Freebo is you read the article and you like it you can just share it to your Facebook, your Twitter, your LinkedIn, and we just started that a few months ago
and it is really taken on me. Sometimes people do an article and it’ll be shared
250 times on Facebook and the average - how many dentists you think the average
dentists on Facebook has following?
Chad: Oh I have no idea.
Howard: I mean I'm sure it's well over a hundred but - so if you wrote it if all you got all those people to write it I mean it'll be read in 220 countries I can guarantee you that.
Chad: I will. I will get you an article.
Howard: Really? That’s - that's a - because that's when you talked about Techsource dental, Dental wings when you talk about the whole thing I bet 99% of the people listening to you never even - even heard of it like that.
Chad: No. I'm happy to. We'll do it.
Howard: Alright, buddy. I'm gonna hold you to it if not I'm gonna have the Arizona Cardinals kick them Cowboys butts every time they meet.
Chad: Hey, I won’t let that happen.
Howard: Speaking about rare things, it's about every 10 years were a starting quarterback in the NFL goes down and the backup is better. How weird was that for the Cowboys to have their all that quarterback. And then he's injured and the backup now no one even wants your starter back.
Chad: Hey, you talk about quarterbacks and backup I'm gonna throw a hot tip out there. Trevor Knight who y'all just signed in Arizona, his dad was my mentor in dental school. He's an incredible dentist, taught at the school in San Antonio. You need to get him on for your podcast and that would like light things up.
Howard: You - you my god, send me an email firstname.lastname@example.org. Email him, I’ll do it. That sounds like a blast. His son is an NFL football player?
Chad: Yeah. His son was the quarterback for Oklahoma then he played for Texas A&M and he just got signed by the Cardinals, He's actually out there right now, Trevor Knight is his name and his dad is George Knight. He's a dentist out of San Antonio.
Chad: Wonderful man and an incredible dentist as well.
Howard: And on that note I don't know if you caught this but we just did a podcast with conquering your adversities by Kenneth J. Polke who was the quarterback for the Cleveland Browns and the Miami Dolphins and says he's the only dentist ever to be the quarterback on two different NFL football teams, the Dolphins and the Cleveland Browns and it was called Conquering your Adversities. He's retired now. He has an - he's quit practicing about two or three years ago and it's now just consulting, speaking, but my God that was a cool story. And – and basically he credits being a dentist - he grew up in a really wrong part of town and was into all kinds of trouble. And you know getting good grades and trying to get into dentistry and football and all that stuff is what kept him out of trouble. But he calls the Conquering your Adversities because he said he was born on the wrong side of the railroad tracks but you got to listen that and send that to that dentist you're talking about and so that'd be a great follow up to Kenneth Polke.
Chad: I will and - and we'll go start eating some glass.
Howard: Alright. Have a rocking hot day buddy, thanks so much.
Chad: Hey, thanks man. I enjoyed it.