Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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865 Digital & Implant Dentistry with Dr. Joseph Field, DDS, FAAID, FICOI, FAGD, DABOI/ID of the Peninsula Center of Cosmetic Dentistry : Dentistry Uncensored with Howard Farran

865 Digital & Implant Dentistry with Dr. Joseph Field, DDS, FAAID, FICOI, FAGD, DABOI/ID of the Peninsula Center of Cosmetic Dentistry : Dentistry Uncensored with Howard Farran

10/19/2017 9:34:54 AM   |   Comments: 0   |   Views: 322

865 Digital & Implant Dentistry with Dr. Joseph Field, DDS, FAAID, FICOI, FAGD, DABOI/ID of the Peninsula Center of Cosmetic Dentistry : Dentistry Uncensored with Howard Farran

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865 Digital & Implant Dentistry with Dr. Joseph Field, DDS, FAAID, FICOI, FAGD, DABOI/ID of the Peninsula Center of Cosmetic Dentistry : Dentistry Uncensored with Howard Farran

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VIDEO - DUwHF #865 - Joseph Field

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AUDIO - DUwHF #865 - Joseph Field

Dr. Joseph Field, DDS is the ideal dental practitioner for anyone who is afraid of the dentist, nervous about dental implant surgery, and adamant about receiving the very best in dental care. 

Dr. Field specializes in dental implants and esthetic restoration, but he’s much more than an implant expert: he’s distinguished for his gentle and caring chair-side manner, his expertise in general and implant dentistry, and his use of advanced dental technology to guarantee the best clinical results. 

Dr. Field is committed to providing a stress-free dental implant placement experience for his patients. Widely recognized for his attentive and personable chair-side manner, Dr. Field is not only adept at putting patients at ease and helping them feel comfortable, but he also offers a variety of additional relaxation options – from aromatherapy and paraffin treatment to IV sedation – to guarantee his patients a calm and relaxing experience. 

Dr. Field has achieved a nearly unmatched level of skill in dentistry: his Diplomate of the American Board of Oral Implantology / Implant Dentistry (DABOI/ID) –signifies the highest level of competence in implant dentistry. He’s also one of the few implant specialists to offer zirconia implant metal allergies. In addition, Dr. Field is an Invisalign Elite Provider (one of a very small number of general dentists to achieve this top designation of Invisalign proficiency), and a certified IV sedation specialist. 

Due to his ability to combine orthodontic cases with implant dentistry, Dr. Field is able to restore patients’ smiles even in the most extreme cases. With a combination of cutting-edge dental implant technology like iTero digital scanning for perfectly fitting restorations and CERAC for same-day dental care, plus state-of-the-art esthetic techniques, Dr. Field helps his patients achieve a natural, healthy, and permanent smile. For patients missing some or all of their teeth, Dr. Field can provide single, multiple, or full-mouth dental implants to help patients restore their smile for good. 

Dr. Field credits his success to his education, both past and present. He completed his B.S. Physiology at Brigham Young University, and then went on to pursue his Doctor of Dental Surgery at the University of Southern California School of Dentistry. His passion for continuing education has driven him to pursue several other designations which have expanded his expertise allowing him to provide the best quality patient care and clinical outcomes:

Fellow of the American Academy (FAIID) of Implant Dentistry after completing the Graduate Maxi Course – only an elite class of dentists hold this designation, making them the top in the industry 

Fellow of the Academy of General Dentistry (FAGD)

Fellow of the International Congress of Oral Implantologists (FICOI)

Diplomate of the American Board of Oral Implantology / Implant Dentistry (DABOI/ID) –  the highest level of competence in implant dentistry 

A Los Altos native, Dr. Field takes pride in getting to know his patients, understanding their needs, and giving back to the community: when he’s not providing his patients with the best, most modern dental implant and Invisalign treatment, Dr. Field makes time to host free dental implant seminars for the local community, or joins up with the entire PCCD team to offer free dental care to Bay Area veterans. 

When he’s not working, Dr. Field enjoys contributing to dental journals and pursuing his interests in photography and website design. Outside the office, you’re most likely to find him golfing, playing basketball, hiking or camping, and attending sporting events with his family. 

Howard: It is just a huge honor for me today to be podcast interviewing Joseph Field all the way from San Francisco, California. He's the ideal dental practitioner for anyone who is afraid of the dentist, nervous about dental implant surgery, and adamant about receiving the very best in dental care. He specializes in dental implants and aesthetic restoration, but he's much more than an implant expert. He's distinguished for his gentle and caring chairside manner, his expertise in general and implant dentistry, and his use of advanced dental technology to guarantee the best clinical results. Dr. Field is committed to providing a stress-free dental implant placement experience for his patients. Widely recognized for his attentive and personal chairside manner, Dr. Field is not only adept at putting patients at ease and helping them feel comfortable, but he also offers a variety of additional relaxation options from aromatherapy and paraffin treatment to IV sedation to guarantee his patients a calm and relaxing experience. Dr. Field has achieved a nearly unmatched level of skill and dentistry with his Diplomate of the American Board of Oral Implantology, signifying the highest level of competence in implant dentistry. He's also one of the few implant specialists to offer zirconia implants for metal allergies. In addition, Dr. Field is an Invisalign elite provider, one of a very small number of general dentists who achieve this top designation of Invisalign proficiency, and a certified IV sedation specialist. Due to his ability to combine orthodontic cases with implant dentistry., Dr. Field is able to restore patients' smiles, even the most extreme cases, with a combination of cutting edge dental implant technology like iTero digital scanning for a perfectly fitting restorations and CEREC for same-day dental care, plus state of the art aesthetic techniques, Dr. Field helps his patients achieve a natural, healthy. and permanent smile. For patients missing some or all of their teeth, Dr. Field can provide single, multiple, or full-mouth dental implants to help patients restore their smile for good. Dr. Field credits his success to his education, both past and present. He completed his B.S. Physiology at Brigham Young University and then went on to pursue his Doctor of Dental Surgery at the University of Southern California's School of Dentistry. His passion for continuing education has driven him to pursue several other designations which have expanded his expertise, allowing him to provide the best quality patient care and clinical outcomes. He's a fellow of the American Academy of Implant Dentistry. After completing the Maxi course, only an elite class of dentists hold this distinction, making them the top in the industry. He's a fellow of the Academy of General Dentistry, fellow of the International Congress of Oral Implantology, diplomat of the American Board of Oral Implantology. A Los Altos native, Dr. Field takes pride in getting to know his patients, understanding their needs, and giving back to the community. When he's not providing his patients with the best, most modern dental implant Invisalign treatment, Dr. Field makes time to host free dental implant seminars to the local community, or joins up with the entire Peninsula Center of Cosmetic Dentistry team to offer free dental care to Bay Area veterans. While he's not working, Dr. Field enjoys contributing to dental journals and pursuing his interest in photography and website design. Outside the office, you're most likely to find him golfing, playing basketball, hiking or camping, attending sport events with his family, and we both have four children. I've already done all my work. My boys are twenty-two, twenty-four, twenty-six, twenty-eight, but your work's just started. Yours are ten, eight, and two three-year-old twins, so you're a very busy man. How are the three-year-old twins doing?

Joseph: They're good. They're very active.

Howard: Are they identical or --?

Joseph: Fraternal, but both girls.

Howard: So, fraternal, which means they're not identical?

Joseph: Correct.

Howard: But they're both girls, so are they best friends?

Joseph: Yeah, they're pretty good friends, actually. They do well together. Better than my boys, we'll put it that way.

Howard: I went all the way through school with these two twins and it was the most amazing thing because they were identical twins and had extremely opposite personalities. One was outgoing and the life of the party and the other one was so painfully shy, she never said a word, and I always thought that was so bizarre that two identical twins could stand out like that. So, I called you. You didn't call me. You're a legend in the field. I never thought about implants and metalology. When they start coming out with those porcelain and ceramic implants, I always thought that was an aesthetic deal. Until I was reading about you, I didn't realize that there could be a metal allergy component to this.

Joseph: Yeah, neither did I until it actually kind of presented in my office with a patient of mine and that's what got me down the path of finding options for patients that have true allergies to these metal implants.

Howard: Wow. So, you always think that titanium and gutta-percha and gold and silver are inert, but you think some people truly have an allergy to titanium or some of the little other metals that might be found in there?

Joseph: Yeah, I've had patients have biologic reactions to this material and really only alleviated once the implant has been removed from their body. They're the minority but they're out there.

Howard: Wow. And it seems like, it was Gordon Christian who told me that this was a far bigger European problem than Asian, African, Latino. He was telling me that the one thing he noticed is that gold, silver doesn't react with carbon, hydrogen, oxygen, nitrogen at room temperature, but if you ever wear a base metal, European people, their skin is more acidic and it'll leech the base metal and they'll get a green tattooing around their finger.

Joseph: Right.

Howard: If you put a non-precious metal crown on especially like Irish, English, Scottish, Scandinavian, they'll get that metal tattooing around the gum line. But he says he just has never seen that in dark-skinned Asians, Africans, Latinos, and he thought there was something with the pH of the skin. So I imagine that was leeching more metal out. So he said he showed all kinds of cases where someone put a porcelain and non-precious metal and tattooed the hell out of someone's gum tissue around it. So, that probably might be more of a problem with Northern Europeans.

Joseph: Yeah, I think you're right. I've seen it on one patient with Indian descent, but that was the only one that was non-Caucasian that I've seen.

Howard: So, just one. So, all the rest were Caucasian but one?

Joseph: The one (inaudible 00:06:47)

Howard: Interesting. And maybe he had generations ago, maybe India was a British empire, maybe he had some.

Joseph: Yeah, could be some British blood there for sure.

Howard: Yeah. Very interesting. So, when you said aromatherapy and paraffin, man, I have to admit I cracked up because I'm from Kansas and I thought, "That's something you'd only find in the Bay Area of California." I don't think anybody would ever walk in Kansas or Arizona and ask for a paraffin, but you're out there in California. Is that a California thing, or did you also see that when you were going to BYU in Utah?

Joseph: No, it's probably here. But again, I'm from here, so I hate the smell of a dental office. I always did growing up and so, the rationale is, "Let's not make it smell like a dental office. Let's make it smell good." And some aromas actually help calm people, relax them, and certainly in a dental environment, that's advantageous.

Howard: Well people joke at aromatherapy, but when you read the stuff by Kroger, the number one distributor in America, number one is Wal-Mart, number two is Kroger, which owns Dillon's in Kansas and Fry, all these grocery store chains. And then, three is Costco, then four is Amazon. Costco and Kroger will tell you that the reason they have a bakery in their grocery stores is because when women walk into a grocery store and they smell a bakery, they spend more money per basket, and they have scientifically figured out that when they increase the cart size 50%, the total volume of sales will follow. And the bakery, a lot of these bakeries don't make any money but they can't take out the bakery because when Mom goes in there and she smells cooking food. So, I would think aromatherapy should be studied extensively in dentistry because you're right, I even walk into my own dental office, and in the winter when it's really nice out, I'll oftentimes leave the door wide open and I'll tell my team, "We've got to air this place out. It smells like a chemical farm." But when it's 118 degrees outside and you got the air conditioners on high, you can't do it, and you get bottled up there in the summer and the place stinks. So what kind of smells do you think relax people?

Joseph: Eucalyptus is a good one. Lavender is a good one. Those are probably our two that we go to most. Citrus is a good one. So, those are the ones that we use most commonly.

Howard: And we had a lady on here just a few days ago from your neck of the woods who does dental office design, and she was showing all this research on how color like light blues relax people, whereas reds and oranges make people aggravated, and some of these airport restaurants like orange and yellow because they want you to grab your food and then leave and make room for someone else. So, I think the proper look and the proper smell would go a long way in a dental office where half the world is afraid of us.

Joseph: Right. Yeah, no one likes to go, and so, I try to be as objective as I can as a patient. I hate being a patient, so anything that makes me feel better, I think it is worthwhile.

Howard: Now, did California vote in medical marijuana on this last --

Joseph: Yep.

Howard: They did? I think Arizona's the only state that turned it down. But I still can't believe there's not some dentist who's made the news of also adding -- obviously, you're not going to smoke marijuana in dental, but they have those edibles they talk about in Colorado. I'm surprised no one's added on their marketing, "Come in and eat a dentist brownie or a dental cookie and take the edge off." Do you think that's around the corner or do you think that's getting -- because you do sedation, too.

Joseph: Right.

Howard: Do you see an edible marijuana as a form of an oral relaxing, like taking a Valium or something?

Joseph: Well, I have patients that admit to me that that's what they do, and it helps them. So, I don't know if I'd ever get to the point where I'm going to prescribe that or recommend that to people, but certainly, patients here in our area are pretty educated on the benefits of marijuana, and so it's used. It's used by my patient population.

Howard: Well, I'll tell you how old I am. When we were in dental school in Kansas City from '83 to '87, there was a dentist there, and he went by Dr. Ace, and that was not his name. But he was friends of mine, and me and Randy Kerwin went over and visited him. He's a dentist in Kansas, and he had a full wet bar in his waiting room, and he swore that at least 10% of all of his patients chose him because they would get there early and make themselves -- He said you could make any drinking at his bars. You could make a White Russian, anything. And he had a full bar, and he thought that was an amazing practice builder. But now, fast forward thirty years later, I don't know if that would be a very good idea.

Joseph: Yeah.

Howard: I wouldn't do it. I wouldn't do it for legal purposes. I won't even let them have alcohol at a staff party, and I've gotten mad at the staff over the years because sometimes they'll bring it in, and I'll say, "Man, if someone leaves a staff party and goes and T-bones in an intersection, we're going to lose everything. We just can't do it.

Joseph: Yep.

Howard: And then they say, "Aw, you're being a stick in the mud," and I'm like, "America has one million attorneys, and I guarantee you I'm not going to be the guy buying the liquor at the team party. That's just pure stupidity."

Joseph: Well, half of them are in California, so I feel you on that one.

Howard: Half of who's in California?

Joseph: The attorneys.

Howard: Oh, the lawyers? Yeah. So, this is Dentistry Uncensored, and I don't want to talk about anything that anyone agrees with. Joseph, you like going by Joseph or Joe, or what do you like to by?

Joseph: Joe's great. Joe.

Howard: Joe? Joe, these kids, you're in San Francisco Bay. You've got two dental schools there. You've got University of Pacific, which is private. You've got the University of California San Francisco. But anyway, I'm in here in Arizona where they have two dental schools, both private. These kids are coming out with a ton of debt, and you're in love with digital dentistry, so I want you to talk slowly and walk through the math on this because a lot of these kids are coming out of school and say, "Well, I want to be a great dentist like Joe someday. I want to get into implants. I want to do all these things, but gosh CAD/CAM, that's a $150, digital impressions, that's at least $30, CBCTs, that's at least $100, $120. Walk through -- a kid can literally double their student loan debt by buying three things. They could buy a LANAP, there's $100. CBCT, there's $100, CAD/CAM, $150. Boom, three good decisions, and now I double my student loan debt. So, do you just have to marry good money? I tell these kids when they get out of school, they should find a eighty-year-old lady who's worth millions and start dating and marrying her first, and then when she passes away, then you'll be debt-free. You'll have all your student loans paid off.

Joseph: Right. Well, it's a huge deal. It's a big problem because they're coming out -- what's the average, $250,000?

Howard: $350.

Joseph: Sheesh, $350... It's just, it's not feasible. My recommendation, I have a lot of friends, their children are in school, dental schools, etc. My recommendation coming out of school is find a practice to link up with, get your feet wet. Start getting the experience. Let them pay the bills on those big ticket items. Get exposure using them. Then, when the time comes, you've paid some debt down, look at maybe buying a practice at that point. I just don't think in today's economy, this kind of debt load, students coming out of school are really in a position to buy a practice out of school or really within the first three years.

Howard: Well, it's really -- the Federal Reserve owns the most PhD economists on earth. I think they have almost four thousands PhD economists working for them, and they said this one trillion dollars of student loan debt is now affecting the housing market because that's the biggest sector of the economy and so many Millennials can't qualify for a house because they're muscling the student loans, and it's so sad because you never hear a conversation from the education community about how they can educate people for less money. They're always expanding, hiring, building. They're still raising tuitions every year. So yeah, these poor dental schools, it's different.

Joseph: Right, And that's where the corporate dental model comes in, and love it or hate it, it's filling a void. Where are these guys going to go? Where are these dentists going to go when they graduate school? And these corporate dental models that have been around since I was in dental school, it's a great attractant to young dentists.

Howard: Yeah, and these dentists that hate it, they're not providing jobs for our colleagues. Six thousand kids come out of school, and they close their office Friday, Saturday, and Sunday, so their own patients in Salina, Kansas are calling with a toothache getting an answering machine when they could have hired an associate from UMKC and had him work Friday, Saturday, and Sunday. They're not providing jobs, then they get mad at corporate who is providing jobs. But take the money away. What do you like about digital dentistry? What are you passionate about that's digital?

Joseph: Well, again, maybe I see things differently growing up here in Silicon Valley, right? We're kind of the epicenter for the Technology Revolution, but for me to be able to provide a digital workflow for a patient where, hey, I don't have to use that goopy stuff, which no one likes the impression material, let's be honest. I can do a digital workup of an implant case, for example, scan the mouth, do a CBCT scan, plan the case out, get a 3D-printed guide, do the surgery, have a crown made ahead of time, install it, all done in a very seamless fashion. It's pretty amazing to think where we've come, even the last ten years with this digital workflow. It's just fun, Howard. It's just darn fun.

Howard: I want you to address the most controversial part of it because you're out there in Silicon Valley, which I assume -- is Silicon Valley basically San Jose?

Joseph: From San Jose to South San Francisco, essentially.

Howard: Did you ever help Dionne Warwick find the way to San Jose?

Joseph: I did not, sorry.

Howard: That was one of my favorites songs growing up, Dionne Warwick. And her sister was -- It was her niece who was... Dionne Warwick. No, no. Who is Dionne Warwick's niece? The biggest famous -- Whitney Houston.

Joseph: Oh, ok.

Howard: Yeah, it was her niece who was Whitney Houston. But -- her cousin? Cousin, niece, whatever. So you have something like Apple, which is a closed system, and you have the Sirona, Dentsply Sirona, where the CAD/CAM, CEREC machine, and the Galileos pretty closed -- it's a very closed system. To me, it seems like the advantage is it's just easier to implement. And then you have open systems, which are more like Google, but it seems like it works pretty good if you're really techie, and you might want to hook up all these different mixing scanners and CAD/CAMs and all that stuff, but I've been into a lot of dental offices where they have a very tight closed system like Dentsply Sirona's CAD/CAM Galileos, and it seems like all the dental assistants know how to use it. They all know how it works. And then you go into other offices that mix-and-matched all the printers and it's open format, great, but man, if you're not born in Silicon Valley and you don't love the ins and outs of technology... I tell people, "If you're one of those guys that you've got to have an I.T. guy come and reboot your computer or help you figure out these things, I don't really think you should be an open format system." So, what's your view on the closed versus open?

Joseph: Yeah. Well, I'll tell you. So I have two CERECs, two OmniCams, I have two Iteros, I have the TRIOS scanner, I have a Planmeca Cone Beams. I have all of these different systems, so I have experience with that.

Howard: Damn, what's your family live under a bridge in a box?

Joseph: Pretty much. But hey, I got cool toys.

Howard: You just listed two CERECs, two OmniCams, a Planmeca what?

Joseph: The Cone Beam, Planmeca Cone.

Howard: CBCT.

Joseph: Yeah.

Howard: And then what else?

Joseph: The TRIOS scanner, and the two Iteros, you got those?

Howard: Yeah.

Joseph: A lot, but --

Howard: Two Iteros, the TRIOS scanner. The TRIOS, that's from Copenhagen. What's that, like a 3Shape?

Joseph: 3Shape.

Howard: One Planmeca CBCT, two OmniCams, two CERECs. Holy crap, that's a million bucks.

Joseph: Yeah. I tried to count that.

Howard: Wow, you might be the most tech-savvy son of a gun, period. But you must not have buyer's remorse, because you went back and doubled down and have two of almost everything.

Joseph: Yeah. Well, I mean, we have the need for it. We use them. So, I would say if you're just getting into the digital systems, finding one system -- I think what you say is accurate. Having a closed system, you don't really get the stuff, you need to have your handheld the whole step of the way. Usually, those closed systems have better support, an easier workflow, but they limit you a little bit, but that might be OK for you. In our practice, we have our own lab that we work with, so having the ability to have open systems and use different things for us is really a necessity.

Howard: So, you have your own lab or -- ?

Joseph: We have our own lab.

Howard: On your dental office premise?

Joseph: It's about 10 miles away from us.

Howard: Wow. So how many operatories and doctors are in your practice?

Joseph: So, we now have three practices, and it's my partner and I, and then we have five associate dentists that work within these three practices.

Howard: So, three practices with two partners and five associates.

Joseph: Right.

Howard: And one lab.

Joseph: One lab.

Howard: Holy moly, you're tearing it up.

Joseph: (inaudible 00:21:32) It's been good.

Howard: And I would imagine that three practices -- I think a solo practicing dentist is getting crushed because they have so many hats to wear. But when I go into these -- I don't like the term corporate, I like big boxes. There's a difference between the thirty-five corporate chains that have fifty or more locations, like Heartland and Pacific. That's huge. But when I go into even very small markets like Sioux Falls, the group that goes from a solo to just a north, west, east, and south, four locations, it just gives them enough scale so they can have one full-time person in HR, marketing, supplies, accounting, bookkeeping, a CPA, then these poor dentists, you've got to learn how to do the dentistry and you got to have the website, and you have HR. It's just too many hats.

Joseph: Yeah. The reality is to keep overhead down, it's it's a huge capital investment. There's a lot more risk involved, but at the end of the day, the numbers work better because just like you said, you can have dedicated people to dedicated needs and really help keep overhead costs down.

Howard: So, will you give us your benchmark overhead goals? The rent, mortgage, equipment, all that stuff?

Joseph: Fifty-five. Yeah, we try to be around fifty-five.

Howard: 55% overhead?

Joseph: Yeah.

Howard: Before you pay your dentists?

Joseph: Including them. Not the partners, but the associates.

Howard: So not the two partners, but the 555 total overhead would include the five associate dentists?

Joseph: Yeah.

Howard: That's the lowest overhead I've heard of after paying associate dentists.

Joseph: That's where we try to be.

Howard: Holy gamoly, that is amazing.

Joseph: Thank you.

Howard: What's your secret to that? If all your costs are a dollar and you do a dollar production, you have 100% overhead. If all your costs are a dollar and you do $2, your overhead just went to 50%. Do you think your overhead is so low, 55%, because the two partners are producing such huge amounts of dentistry?

Joseph: That's the main factor.

Howard: Yeah.

Joseph: I always get asked that, "How do you keep overhead down?" You can't be a miser with most things. There's overhead's overhead, but like you said, you increase production and there goes your percentage.

Howard: Yeah, and that's why the associate model, I just still don't see any evidence of it really working, because when you're lecturing on a seminar, the owner doctor's taking notes in the front room and the associate's on their Facebook, posting on Facebook, doesn't come back after lunch. When you go into an owner-operator and the dentist is married has four kids at home, he does the second molar. The associate refers to an endodontist. When you're an owner and you've got four kids at home, you work that that molar endo in over your lunch break, and if it's 5:00 and it's time to go home, you'll stay there at 6:00. But you go on Dentaltown, the Millennials are posting threads like, "What do you do when there's a toothache comes and at 4:30 and you close at 5:00? How do you temporize that?" And I'm like, "Maybe you should just do your damn job. Maybe you should just do the damn root canal and crown and get home an hour late." But they're single, they're millennial. They just don't have that -- When you don't have skin in the game, I'm not seeing the evidence. Then you go to associates in private and corporate, their turnover -- It's considered awesome if they stay two years.

Joseph: Right.

Howard: So do you see a lot of associate turnover in your California market?

Joseph: Yes. However, we've been pretty lucky. So, our first associate is going on six years now, and then the other associate that's in our main office, she's pushing three years. And then, the other two associates were owners of the practices that we purchased. And then, one of the other associates was in one of those practices that we purchased and she's been there for two years. And so, part of it is we compensate them well. We help them feel like they're part of the game, but the end of the day, like you said, my partner and I do a lot of training with our other doctors and really try to have CE within our group. And yeah, they kind of show up and do their thing, and sometimes it gets implemented and sometimes it doesn't, but I think they understand that we're invested in them and their success and we want them to be successful. So, I think that carries a lot of weight in why they stay around and are part of our group.

Howard: Well, every Ph.D. economist in University of Chicago, which has the most Nobel Prize winning economists, will tell you that incentives really matter.

Joseph: Oh.

Howard: And having an ownership. Hell, that's the difference between the United States and communist Russia that everybody lived through. When everybody's an employee in Russia, everyone shows up drunk and their productivity is pretty low. And then in America, where everybody owned their own farm, their productivity was so much greater. So it's very interesting to see how people will build corporate dental chains where every single dentist is an employee. That is an entirely different beast than competing against dental offices where the dental offices are an owner. And I think the final business model has not been found.

Joseph: I agree.

Howard: And I think the lawyers are ahead of us because they they had these deals with partner, you make partner.

Joseph: Yeah. And that's really the model that we're going to get to. At the end of the day, Howard, people are like, "Hey, what's in it for me?" Right? "Am I fattening your paycheck or mine?" And so, it really is helping people say, "Hey, this is in your best interest to do that second molar endo or to work through your lunch because you're getting compensated for it. You're doing the right thing for the patient, the right thing for the practice, and you get compensated." That's the only way it's going to work.

Howard: OK, so when you expanded in two more locations, you didn't do a de novo startup. You bought a practice.

Joseph: Yes.

Howard: So, why did you want to go from one location to three, and why did you do mergers and acquisitions, which is what Wall Street uses all day long, and set up a de novo build from scratch. How did that unfold?

Joseph: We'll start with the first question first. So, the reason behind it, one is we were running out of space in our main location, and --

Howard: How big was that? How many ops was that?

Joseph: Six ops, and so you can imagine four doctors, two full-time hygienists, it gets tight. And we were already on split shifts, a morning shift, afternoon shift kind of deal, and Friday, Saturday, all that kind of stuff. Anyways, we were out of room. So, that was part of it. And then, the reality of it is, just looking at the numbers, you go into a startup and start building the practice from scratch, and it's going to take you a while to get into the black with that kind of scenario. That may be OK for you. For us, it was a numbers game, so we buy these other practices. The production off those doctors that stayed pays the bills. So no matter what, it's at least breakeven. Now, we've been able to structure things and again, assume other costs and get overhead down so they become somewhat profitable. It just depends on what extent. But it just made total sense just from a numbers standpoint.

Howard: So, the doctors that sold you those two practices stayed on?

Joseph: Yeah, they stayed on.

Howard: So why did they want to sell, then?

Joseph: Both of them were looking to change their schedules, so they wanted to get to working less days, which was great for us because we wanted their space. They wanted to cash out while their practice was that the best value. It was, because they were working full-time. And it was interesting how it came down, actually. We were initially just looking at one practice in particular, and then this other doctor got wind of what we were doing. He was like, "Well, I want in." He was actually in contract with another --

Howard: So are you technically a Baby Boomer?

Joseph: I think I'm Gen X.

Howard: Gen X? So, I'm a Boomer, you're at the tail end of Gen X. When you look at the thirty-five corporate locations that have fifty or more offices, they're two-thirds female dentists.

Joseph: Yeah.

Howard: Do you think the Millennial, and especially the women, are more likely to say, "I don't want to be a owner-operator like my dad, and I would rather just be an employee," or do you think that is a sexist, generational wrong statement?

I think it's a fantastic option. I think it's great.

Howard: But you think it's real, or do you think it's perceived?

Joseph: I think it's real, and it's based on my experience with what I've seen try to find associates, etc. And I don't think that's a bad thing necessarily for our society, right? For dentistry, it creates a challenge, but for our society, I think it's a great thing. I'm kind of a traditionalist in my --

Howard: Because the girls that graduated with me thirty years ago, Lisa Gonzalez, Stephanie (inaudible 00:30:56) those girls, they are owner-operators to this day, and I would say the average girl in our class from thirty years ago had a bigger office than the average guy. Like Stephanie (inaudible 00:31:10) huge. She's like you. She's placed all these implants. She had a million-dollar practice. So does Lisa Gonzalez. They were crushing it. So, the question is, I know the girls thirty years ago used to get really mad in class when these male dentists say, "Well, a lot of these girls are going to get married, and they're going to work part-time. And if they marry, blah blah." And they would just fume, and they didn't do that. They did not do it. Now, it's thirty years later, we can see what they did. They worked their ass off for years. So, the question is, are the girls and guys graduating today, the Millennials, are they different than the Boomers from thirty years ago?

Joseph: I think so. But I will tell you this, I think, just based on my experience and even going back from my female classmates, even if they dropped to part-time, a lot of them are doing as much dentistry part-time as some of us are doing full-time. You know what I mean? They are making it work, there's no question about it. Is it going to be the norm? I don't know. It's tough to say, but I see more of that trend.

Howard: But do you see a lot of the associates when they don't have skin on the game, do you see them a lot of turnover in the Bay Area?

Joseph: Yes. Like I said, we've been fortunate, but in general --

Howard: But in general. Not in your location, but in general, what do you see?

Joseph: Yeah, I'd say, again, if they hit two years, that's pretty good, right?

Howard: Right.

Joseph: But I'll tell you again, interesting enough in Silicon Valley, Howard. So, in tech companies here, if an employee stays at a tech company two years, that's almost too long, right? So, the Millennials are jumping around the tech companies here all the time. I see patients every six months, it seems like they got a new job every time I see them, so that's just the norm of what happens in this society and that culture.

Howard: Interesting. Yeah, because they say the same thing in Japan where their birth rate is down to under one, it's down to point nine, where their Baby Boomer generation, you got a job at Toyota when you were twenty-five, you're retired there at 65. All their parents worked for GM, Ford, Toyota, Honda. They were all lifers, and that whole concept is gone, isn't it?

Joseph: Gone.

Howard: Yeah. And another thing, I've had this pointed out to me. I was lecturing in Sydney and Melbourne last week, and we podcast interviewed -- There's only two publicly traded corporate dental offices on the ASX, and there's one in Singapore, and I had the biggest whale in that market, and he was saying that the Millennials are completely different. He said the baby boomers -- Look at the Ten Commandments. What were the first three commandments? Obey God. Keep the Sabbath holy. Don't take his name in vain. What's the fourth one? Again, obey your parents. The first four out of ten are obey someone else. And he said our generation, you're the doctor, you did what they said. If you said, "I need a root canal and crown," they'd just say, "Well, Doctor Field, you're the doctor. You know best." And the Millennial says, "I am most loyal to me." And he said you look at these corporate dental offices where they were saying -- His publicly traded corporate chain has 20% turnover in dentists per year while they just keep growing by millions and millions and millions. He says, "Look, this is evidence. The Millennials don't care. They say, 'This is my office. It's convenient for me. It's got convenient hours. I assume a filling is a filling is a filling, and a cleaning's a cleaning's a cleaning. I don't really care who does it or who fills my prescription or penicillin.' They're loyal to themselves first." And he says as everybody badmouths his 20% burn and churn of dentists per year, he's got a hundred million dollar valuation on the ASX and he owns 80% of the stock. He says, "I don't care what you say. They're loyal to themselves. They're not loyal to the company." So you say these people that work in a tech stock, they jump every two years. They're not loyal to Facebook or Google or LinkedIn or Twitter. They're loyal to themselves.

Joseph: Yeah. Is it close to their house? What are the stock options? Can they come in late? What's the cafeteria food like? That's kind of what matters.

Howard: Yeah. So, my gosh, so let's walk through these technology purposes. You like CEREC. You have two of them.

Joseph: Two of them.

Howard: Two of them in three locations?

Joseph: No, actually that's a good question. So, we have two in our first location and one in one of the other locations, so three total.

Howard: My gosh, three. So why do you like CEREC, and why not E4D by Planmeca?

Joseph: We've been CEREC a long time. When E4D came out, they just didn't have the same -- They hadn't gone through the same bumps in the road that CEREC had gone through. I think they're better now, and having, again, it be open source is nice, but the CEREC workflow, like you said with a closed system, it just works. It's very predictable. It works really well for us.

Howard: And I think it's going to be a game changer in fifteen days when they lose their exclusive with Patterson and start selling them through Henry Schein and others. Do you think that's going to -- What do you think that's going to do for you as a CEREC user by not having it exclusive with Patterson?

Joseph: I'm hoping costs come down.

Howard: Right, competition.

Joseph: Yeah, that's the big thing. They're pretty expensive. But, as far as the system itself, the results we get for it, no issue. No issue whatsoever. Our associates crank on them. They work very well, and our patients love them. It's funny, even last week, I don't do a ton of them. I'm doing mostly implant surgery and Invisalign type stuff, but I had one last week I was doing and I told the patient, "I don't really have time to do a CEREC today. I'll just do a quick lab crown, you come back for the temporary." He said, "Oh no, I'll wait then till you have time to do it in one visit. I'm not coming back." And so --

Howard: And who does the scan and milling and all that? Is that your doctors or do the assistants doing that?

Joseph: We do it. And so, I know there's different modalities, but I'm a big fan of, hey, I think we should be doing it. It gives us an opportunity to talk to the patient while we're going through the design process. We can show them what we're doing, why we're doing it. I just think that's a service that should be provided. It takes three minutes, it's very quick. I have no problem with that. There are offices that turn and burn and they say, "Hey, you prep and you get out. You let your assistant do the rest." And that works for them. With our patient base, that wouldn't fly.

Howard: Hm. And when you say your patient base, do you think your hours are a competitive advantage. Do you think most of the San Francisco Valley is, most dentists are Monday through Friday, eight to five, and do you do extended hours? You think that's a big part of your secret sauce or not really?

Joseph: No, because that's done all over the place around here, so that's not --

Howard: What's done all over the place?

Joseph: The extended hours and having more availability. There aren't so many of the Friday off guys anymore.

Howard: What are your hours?

Joseph: We're Monday through Friday seven to six, and then one Saturday a month eight to five.

Howard: So one Saturday eight to five, Monday through Friday 7 AM to 6 PM.

Joseph: Yeah.

Howard: And you're still getting those people on the Friday afternoons. Those were (inaudible 00:38:28) kind of fell apart, on Fridays.

Joseph: We were worried about that, too, but it hasn't happened. And even the Saturday thing, we're like, "Well, we'll throw it out there. People --"

Howard: No, I was talking about my employees. By 2 o'clock, they're all at the bar. The patients are sitting there alone in the operatory.

Joseph: Our team's been great about it. That hasn't been an issue.

Howard: Interesting. And then you got the Planmeca CBCT. Which one was that?

Joseph: It's the mid one, so the one that gets not the full head but what we need to see with the oral structures.

Howard: So why did you get that, because you also had two Iteros.

Joseph: Right.

Howard: So the two Itero scanners or CBCTs?

Joseph: Scanners. In oral scanners, so they're analogous to the CEREC and also the TRIOS. So the CEREC was first, then the Planmeca came.

Howard: Why did you get the Planmeca instead of Dentsply Sirona's Galileos?

Joseph: Planmeca was a little nicer at that point, and then also, the Planmeca had the (inaudible 00:39:29) bite wing function, which the other one didn't, which comes in handy for gagging patients, etc. So it was a nice unit.

Howard: Have you ever been to their headquarters in Helsinki, Finland?

Joseph: No, I'd like to go. Sounds nice.

Howard: That's an interesting place because you bought TRIOS, which is a 3Shape out of Copenhagen, Denmark. And here's my belief on those great companies. When you go to Scandinavia like 3Shape in Copenhagen, been there, Planmeca in Helsinki, Finland. Their winters are so brutal that the only way you get through them is everybody just works twelve-hour days. Seven to seven, six days a week. Then Sunday, they just go home and do their laundry and all that stuff. And then, when finally summer breaks out, and then you go there, everybody has taken off like a month and they're all on the Mediterranean, they're all laying out in the park. So when you go to those like Helsinki or Copenhagen in the great tourist time, none of the restaurants are open,. You walk down the street, four out of five restaurants are closed, everyone's gone, they're all laying out in the park. And I think the reason they're such great civilizations and great technology is because during those long, brutal winters that I've had so many dentists tell me. "Look, you've got two options. Either you're going to crawl up in your house with a hundred gallons of vodka and just stay drunk all winter, or you're going to get to work your brains out.

Joseph: Right.

Howard: And he said, "There's nothing else to do but work." And I used to believe that with Creighton because at Creighton, so many times in Omaha, Nebraska, my mind, I wanted to just play on Saturday and we'd look out the window and it was like ten degrees below zero and it's sleeting on the window, and it's gray overcast. I just thought, "Hell, we might as well just stay in and study." Whereas, then when I went to ASU for my MBA and you see this amazing weather and everybody's skateboarding, and I thought, "Man, every college in America should be moved to the Arctic Circle so those kids..." But anyway, it's a interesting place. But you like the Planmeca CBCT.

Joseph: I do. Yeah. Look, Sirona has a new one. We actually need to get one at one of our new offices. I've been looking at that system. It's nice.

Howard: Which one?

Joseph: Not the Galileos, but they have a step down from the Galileos now, I forget the name of it.

Howard: OK. So what's the difference in the scanners? You've got a Copenhagen, Denmark 3Shape TRIOS. You've got two Iteros. What's the pros and cons if someone's listening to you and say, "If you had to buy one, which one would you buy.

Joseph: So, the one that has the nicest interface is the Itero, for sure. The easiest scanner to use is, meaning how quickly it scans and the quality, is going to be the TRIOS. The reason we got the Itero was mostly for Invisalign. That was the initial reason for getting it. We do a lot of Invisalign.

Howard: Because Invisalign bought Itero.

Joseph: And originally that was the --

Howard: Invisalign's right by you.

Joseph: They are. They're in San Jose, just down the road.

Howard: Yeah. Do you know the CEO?

Joseph: He's a patient of mine.

Howard: No way, what's his name? Joe?

Joseph: Joe Hogan.

Howard: Joe Hogan. My biggest fantasy is to get that guy on a podcast.

Joseph: All right.

Howard: You can't get his contact information on the Internet.

Joseph: He lives probably a mile away from me. He's a patient of mine, so I'll put a good word.

Howard: Will you e-mail him and CC me and say I'm begging? Shit, I'd fly to San Fran to do it.

Joseph: He's a great guy.

Howard: Yeah, I've seen him on -- What is that show. It's MSNBC. What's that other bald guy? He kind of looks like me, that crazy bald stock guy on TV. Yeah, the Mad Money guy.

Joseph: Yeah, Mad Money.

Howard: Yeah, he's been on Mad Money. Say, "Hey this is -- what's that Mad Money guy's name?"

Ryan: His name is Jim Cramer.

Howard: Jim Cramer. Tell him that Howard Foran is the Jim Cramer of dentistry. And you say he's already dealt with the craziest bald guy, Jim Cramer, on Mad Money. The reason I want to talk to him is because when I got out of school in '87, all the big brands, Colgate Crest, Listerine, they were all made already. The only consumer brand that I can think of in the last thirty years from Kansas to Kathmandu, I've lectured in Malaysia, Cambodia. You go to a restaurant in Cambodia and tell the waitress you're a dentist, she'll ask you about Invisalign. I mean, it is absolutely around the world. I think it's the biggest. And how they built that brand was just amazing.

Joseph: Yeah.

Howard: And yeah, so I'd love to talk to that dog. But anyway, so let's switch. And the reason implants and Invisalign are so huge is because when you go to so many of these government dental insurance schemes in Tokyo, Paris, London, where the government only gives you $100 for a molar root canal and your costs are going to be $300 if you do it right or $400, the reason Invisalign implants are taking off is because that's the only two procedures where insurance or government doesn't set the fee. So when you go to Tokyo, Paris, and London, where the NIH will only give you $100 for a root canal, well, what do you think the dentists are doing? Do you think they're going to do a molar root canal for $100 US?

Joseph: No.

Howard: What do you think they're going to do?

Joseph: Extract and implant.

Howard: I know. And you just would think, "Well, a doctor would never do that." And I'm like, "Well, incentives matter because they won't tell you that on a podcast, but they'll sure as hell tell you after the podcast, or 'We're not taping now, are we?'" And that's another thing. I've seen a lot of these big welfare Medicaid, Medicare clinics in Asia and Europe, and they say, "Well, we lose money on all the cleanings, exams, x-rays, and fillings, but we pull out an Invisalign case, at least one a week, and we're doing fifty to seventy Invisaligns a year, and same with an implant." And so, that's what puts them in the profit zone. And the reason they have a nice lifestyle is because they are almost using it as a bait and switch where, "OK, I'll lose money on all the cleanings, exams, and x-rays, but hopefully, I'll upgrade one person to Invisalign and one person to an implant per week, and now, I'm profitable. I'm in the profit zone.

Joseph: Yeah. No, it's a great model. It's a great service for patients. And the other interesting thing with Invisalign, in particular, their technology that they use, general dentists who have very little ortho training in dental school, if any, are able to do these orthodontic cases because it's helping us. It's setting these cases up for us. And I do some lecturing for Invisalign. The doctors I work with have a lot of fun with it. They really enjoy it.

Howard: Yeah, that is interesting. So, what would you say -- OK, but I'm going to play devil's advocate. I always tell my guests, "Send me an email,, and tell me how old you are, did you like the show, who'd you like to hear?" But I'm amazed at how many e-mails come in and they're D-2s, they're D-3s. It's amazing. It's at least 20-25%. They're not even dentists yet, and they're all going to get to school and say, "But Joe, we didn't place one implant in all of school, and we didn't do one Invisalign." How do you get out of dental school and you've never placed one implant and you've never done one Invisalign case. How do you go from zero to one?

Joseph: Great question. Let's talk about Invisalign first, and first of all, I was one of those D-2s, D-3s back in the day jumping on Dentaltown and trying to figure out what was going on with my classes, so it's a great resource for dental students.

Howard: So, you were on Dentaltown in dental school?

Joseph: I was, yeah, for sure. It was awesome. And I would use it every time I had questions from the clinic. "Hey, what's going on here? What's this material? (inaudible 00:47:30)" I'd jump on Dentaltown, search it, read the forums, and learn a ton, so yeah. They should be doing that.

Howard: I still think it's Star Wars crap. I cannot believe that on your iPhone, there's a quarter million dentists in your pocket if you have the Dentaltown app. And with that search bar, say you had question on, say, BruxZir. You could just search BruxZir and pull up a gazillion posts on BruxZir or anything instantly. It's pretty damn cool.

Joseph: It's awesome. The danger of it, you've got to filter a little bit of noise, right? And so, some of the dental students, I think, hopefully are smart enough to say, "This guy's a knucklehead," or "This guy knows what he's talking about." So, that's the thing to decipher through. But, with that being said, I'll talk about Invisalign real quick. So, when I was in dental school, I actually met with the head of the ortho department to try to institute some Invisalign training at our school.

Howard: At UCLA.

Joseph: USC.

Howard: USC Trojan.

Joseph: Just kidding, yeah.

Howard: So you're a USC Trojan.

Joseph: I am, yep.

Howard: And UCLA, those are the Bears?

Joseph: Yeah.

Howard: Bruin?

Joseph: Bruin.

Howard: Bruin. And that's a bear, right?

Joseph: We don't talk about them. Just kidding. So, essentially, the head of the ortho department said, "Look..." The message I got was dental students are too stupid to be learning Invisalign. You just need focus on learning how to do a filling and a crown. OK? That was it.

Howard: Yeah, that's what they told us.

Joseph: My first CE course out of dental school was the Invisalign certification course. So, I went and took the course, learned the nuts and bolts of what's involved, and off I went. I always recommend, find a mentor. A lot of the smart orthodontists in the area mentor GPs, and they say, "Hey, look, this is how you do it. I help you with these cases, great. You have cases that you don't want to do that are a little beyond what your comfort level is, I'm happy to help you. I'll do those cases, etc. it's a great symbiotic relationship.

Howard: Yeah, because they think in an abundancy, not fear.

Joseph: Exactly. They're smart. And so, that's the most of the young orthos in my experience. They're smart about it, and they'll mentor and help out, and that's what I did. I got a great mentor and he would help me out on cases and ones that would either take too long or were too hard for me to know how to do, I'd send to him, and he was happy, I was happy. And he's got four kids, too. He's got to put food on the table, so you got to take care of each other. So, that's my recommendation with Invisalign, and then the courses that are out there, their Invisalign Institute that's on their website, their courses are amazing. What you're able to learn about orthodontics, how Invisalign works specifically. If you don't understand it, it's your own fault. The resources are there at your feet, so I think it's a very straightforward thing. Implants are a little bit of a different ballgame. I think it's hard to get in trouble with Invisalign. I think it's really easy to get in trouble with implants. And so, getting, again, CE courses, I did the MaxiCourse through the AAID, which is three hundred hours of (inaudible 00:50:30) on implant-specific dentistry. I really think you've got to get going on that. And then, the same kind of principle holds true, having a mentor to help walk you through your first cases. I did my first implants, I placed four implants on my dad with a buddy of mine basically holding my hands getting through it. And that was after, Howard, I'd done about a hundred hours of CE already on implants and hands-on courses, et cetera.

Howard: The best research primates are always family.

Joseph: Right? Yeah. Because if it goes wrong, whatever. You get what you pay for. So, but hey, they're still in his mouth ten years later, so they're doing good. But I think the resources are out there, resources like Dentaltown. We have mentors. We have guys that are wanting to help younger dentists, thinking, "Hey, when the tide comes in, all the ships rise." It's not looking at it as, you're stealing bread off my table. It's just having that. It's better for everybody, the better we all are.

Howard: So, how is San Francisco? You have two dental schools. How big are the class sizes of UOP and University of California San Francisco, UCSF? How many are you dumping into the city each year?

Joseph: UOP, I think, is around the mid-hundred, hundred fifty, somewhere in that range. UCSF, I want to say, is around sixty to eighty. They're smaller.

Howard: OK, that's the same as my backyard. We got Midwestern in Glendale dumping a hundred and fifty and we've got A.T. Still in Mesa dumping eighty. Do you think of that, economics in three words, supply and demand, Do you think that makes it hard to practice in the Bay Area when you've got two schools that are dumping two hundred and twenty-five? They dump a thousand every four years. Do you think that is a balance to offering liquidity to the older guys retiring and selling their practices, or do you think it makes it for a very hard place to practice?

Joseph: I think it kind of depends on the practice model, so I think insurance-driven practices that really rely on these insurance plans, etc, it's a hard model to compete with, and so a lot of the younger dentists are getting into those models and they're fighting for scraps, so to speak.

Howard: And you say you're not insurance-driven, not that you don't take the insurances, but that you're so concentrated in implants and Invisalign, which aren't insurance set prices?

Joseph: Right. So, we're not necessarily having to succumb to the evil empire, so to speak.

Howard: Do you take all the PPOs? Delta is a PPO because they set the fees, and they claim they have 96% of American dentists participating. They tell that to everyone they're selling insurance to. So, do you take Delta?

Joseph: Two of our practices are fee for service. The third one is a Delta PPO practice.

Howard: So, two of them, you don't take Delta.

Joseph: Right.

Howard: And one of them you do.

Joseph: Yeah.

Howard: Wow. And which --

Joseph: Well, I'll tell you, the third one, we're going to go fee for service as soon as we can on that practice.

Howard: And when you drop being a Delta provider, what happens to all the Delta patients?

Joseph: About a third of them leave. Two-thirds stay.

Howard: Wow. Wow, talk more about that. So, what you just said is everyone's fantasy, but not many people have the testicular fortitude to do it. But you're saying it's worked for you to do it, and you'll lose a third and keep two-thirds.

Joseph: Right. And credit where credit's due, my partner is the one that had the testicular fortitude to do that. It's one of those things where you get to the point where you're like, "Look, I want to work smarter, not harder. I want to do what's right. I want to do what I enjoy doing, what's best for my patients, and I don't want to have an insurance company telling me how I'm supposed to do my job and what I should be doing for my patients." There are just so many ethical issues with insurances and how these practices are run.

Howard: So you don't take any PPOs in two of your practices.

Joseph: Right. So we're fee for service. We bill insurance for patients and they get reimbursed by their insurance according to their insurance plan, but we are fee for service.

Howard: Well, the best thing about lecturing around the world is you see this rodeo being played or not played at various levels of the game. Like, OK, so there's seven and a half billion people, there's only dental insurance covering a billion people.

Joseph: Right.

Howard: There's no dental insurance in China, India, and Russia. They don't even get it. But I watched this rodeo in the NHS when I got out of school thirty years ago. All the twenty thousand dentists in England were the NHS, and they just kept lowering the fees, lowering the fees, increasing the volume, and dentists had to go bankrupt before they dropped the plan. And they'd say, "OK, I went bankrupt, so I think I'm just going to open up." And what I'm seeing is this. This is very bizarre. The insurance model from the 60s and the 70s was this big practice where you delegate all this stuff to the assistants and the hygienists and all these the admin people, and then after they're driven into the ground, they just open up a dental office that was like one chair with like one employee and their phone is their own iPhone, and they just see one person an hour, and they're taking home $150, $180,000 a year and they just say, "Dentistry is not a game of volume." And they used to have nine employees and six ops and running around like a chicken with their head cut off until they went bankrupt. And now you go back to England and now there's about five thousand of the twenty thousand dentists that don't participate with any of that NHS stuff.

Joseph: Yeah, it's a racket. The reality of it is insurance companies are in the business of making money and they don't want your patients to get money. They don't want you to get money. They want the money. It's a total racket, and most of our patients understand it and they get how it works. And so, we have honestly, Howard, very little pushback from our patients.

Howard: Now, of course, I know what my homies are thinking. These boys are listening to you from Louisiana and Mississippi and Oklahoma saying, "OK, OK, Joseph." Are you in really rich Silicon Valley where all your patients have stock options for eBay and Uber, or would you say you're in really rich areas that you're not finding in rural Oklahoma?

Joseph: So, two of our practices are. One of them is not as an affluent area, right? But honestly, it's no different here because incomes are higher, but cost of living is exponentially higher, so the term we use here is house poor. Right? Making $200,000 a year, but they're barely paying their bills because their house costs two and a half million dollars, right?

Howard: Oh my God, I know. I'll never forget, I was in Manhattan and this very famous dentist, maybe I shouldn't share his name. OK, Larry Rosenthal. And he wanted to show me his apartment. This is like thirty years ago, and he'd just bought it, and I think it was back in the late 80s, or maybe it was like 1990, and he had just bought it for like $8 million or something, and it was like a thousand square feet.

Joseph: Right.

Howard: And I'm like, "You paid $8 million for a thousand square feet?" And he's like, "Oh, you can see Central Park." And I'm like, "In Kansas, you couldn't spend $8 million on a house. You could buy a subdivision for $8 million.

Joseph: Right.

Howard: "And kick out the whole cul de sac." I mean, it was just a... So yeah, those houses in San Fran, what are those houses that I always love when you're looking at the bay and you're walking down those hills and there's all these little houses and they can see the Golden Gate Bridge. What were those houses running for/

Joseph: So that's four to six billion depending on what it has.

Howard: If you ever have a patient come in and she's like an eighty-year-old widow and she owns one of those houses, and she's single and lonely, could you fix her up with me?

Joseph: I will.

Howard: Will you? OK. Give her my email. But yeah. So you're making bank but you're house poor?

Joseph: Right, and so, the same problem is universal. Now, granted, there are demographics in different parts of the country where this may not fly. I get that, and I'm first to say, "Yeah, that's probably true." But, once patients are educated, and even if you lower your fees to where they're comfortable, you set up your own insurance plans, there are so many different models to get away from this big insurance-driven dentistry that really benefits the patient and the practitioner. I think people just have to be a little more brave about it.

Howard: So you promised me an hour of your life. I can't believe we went over an hour. Can I hold you just another overtime, just a tad?

Joseph: I've got plenty of time. I'm done for the day, it's just you, man.

Howard: OK, thanks buddy. OK. She's twenty-five-years-old, she didn't place one implant in school. They're all listening this on their commute to work. She's commuting to work. She's working for corporate. How does she go from zero to one implant? With one caveat: In this country, America, so much of the implant education is tied to a manufacturer, and she's telling me in e-mails on Dentaltown that she almost feels like she has to pick an implant because all the training is tied to a system, so she's kind of got paralysis by analysis because she doesn't want to start learning this system and she doesn't know if it's the right system. So, what would you tell her in a peanut butter and jelly world, where most of the education is tied to a system, and how do you dis-intermediate the knowledge from the system? Some people say, "Hey, you're not driving the car that you drove during driver's ed, so it doesn't matter." But what would you tell her?

Joseph: Yeah, well, briefly on the systems, Howard. I have placed probably fifteen, sixteen different implant systems. They all have pluses and minuses. None of them are really bad. My recommendation for these new docs is A, find a mentor. Surgeon, GP, someone that's doing a lot of implants that's willing to mentor you. Use the system that they're using. Use the company they're using and jump on board with some of their CEs. So, companies, manufacturers in the big name implant companies, they invest a lot of money in their continued education. They see it as a benefit for them, too because, like you said, it's getting doctors onboard in their system, but the education's quality. I love it. And so, that's number one. Number two is get involved in organizations like the American Academy of Implant Dentistry. That's very, I believe, non-biased. Go to their conferences, take their CE courses.

Howard: So you like the AAID.

Joseph: I do. They're the most GP, because again, ICOI, AO, all of those. The AAID, I think, is the most GP friendly of the organizations, and what I mean by that is, they're not looking down at you because you're a GP doing implants.

Howard: So, AAID is the most general dentist friendly like AGD.

Joseph: Yep.

Howard: And you're saying ICOI is more specialist centered like the American Dental Association.

Joseph: ICOI and AO, Academy of Osseointegration.

Howard: American?

Joseph: Academy of Osseointegration, AO. Academy of Osseointegration.

Howard: Academy. And that's also specialist driven?

Joseph: Yeah. And I love their conferences, their courses, they're fantastic. But for a new dentist, I think AAID is the way to start.

Howard: The AAID. Yeah, I agree. The bottom line is, you go into the American Dental Association, what percent of all those committees are filled with people that are specialists?

Joseph: Yeah.

Howard: And the AGD is all general dentists. So you're saying the AGD and the AAID are for the general dentists, and the ICOI and the AO is more specialist driven.

Joseph: Generally speaking, yeah.

Howard: And going back to the history because there's a lot of roots in history, a lot of stuff you don't understand unless you understand the history of a country or whatever, and when Branemark came to America, when he first came here, he would only teach it to oral surgeons. And it took a decade of begging to let the periodontists come involved.

Joseph: Right.

Howard: And so now, the young bastard child is the general dentist, and now we're like, "Hey, can we come to this party, too?"

Joseph: We should be the ones driving this ship, man. We're the ones restoring, we're the ones that are responsible for the end product. If we're not placing the implant, we should be telling them how it should be placed. That's BS.

Howard: OK, but she's listening to you right now and she's going, "Bullshit. Come on, you've used fifteen systems, you say they all have plus or minuses, but what if you only had to buy one today?"

Joseph: Oh. Again, I would stick with my mentor, right?

Howard: Right.

Joseph: What they're placing because they're going to be the ones holding your hand and they have all the bits and pieces and if you're doing the case and, crap, that implants the wrong size, I need another one, you call your mentor, "Hey, do you have this inventory?" And they --

Howard: I agree, man. It's everything because when you fly across the country to go learn implants, that guy lecturing on the other side of America isn't going to be there when you screw up. And why don't you just walk across the street and press some flesh? You knock on the door to your periodontal surgeon and he says, "Hey, you want to place implants, go to perio school. Go to oral surgery school," Then great, I'm glad you met him. He thinks (inaudible 01:04:02) You can cross his name off the list and hopefully you'll never run into him again the rest of your life. And then you go to the next door and they say, "Come on in." That's the lowest price, lowest cost. Now you got a friend, you got a buddy, so when you're in the middle of a surgery and you call -- You know how many times in the 80s I had to call up my buddies and say, "Can I send the patient over to you right now? I pulled out the crown but I'm having a hard problem getting the roots out." And your buddy helped you out. I'd rather have that buddy across the street than some fancy instructor in another state.

Joseph: 100% And that's what I had when I started out. I had a periodontist, took me under his wing, helped me out. If I got in trouble, I'd send a case, he'd bail me out, and now I'm paying it forward. I'm doing the same thing for other docs. And they call me, I'm about to leave for the day, like, "Joe, this implant went in the sinus. Can you help me out?" "Send him over. I gotcha." It's a nice thing to have, and so, that's where you want to start.

Howard: Oh yeah. And plus, it's just so much more of a rewarding career when you have buddies and your friends, and in fact, here's my advice for everybody listening right now. You know what you need do? You need to go to breakfast, lunch, and dinner with more of your homies in your zip code, and I'm saying that to all you people spending time on Dentaltown. Why do you spend all day talking to dentists all around the world, and you know how many times I walked into a medical dental building, and I said, "How many dentists are this building?" They say, "Eight." I'll say, "When's the last time you had lunch or dinner or breakfast with all other seven?" And they'll usually say, five, they never have in their whole life after a decade, and two of them, one was like, "Two years ago," and one was four years ago. And dude, your net worth is always equal to your network, and the people that are networking with the dentists in their zip code and doing the most lunches and dinners and friends and all that, you're going to get better great information in your head and that's going to make you explode.

Joseph: Yeah. And at the end of the day, it doesn't hurt you. It makes everybody better. It makes everybody better. The patient benefits, the practitioners benefit. It's the right thing to do.

Howard: So last question. She's been working at Aspen for four years. She so wants to break out and go on her own, but she's just walking around that swimming pool, sticking her toe in the deep end, and she's just afraid to walk up on the high dive and jump. What would you tell her?

Joseph: Jump. Make the jump. Man, at the end of the day, the best way for job satisfaction, profitability, etc, you got to be an owner dentist. You really do. You do not want to work for someone else, so whether you get into a group practice, partnership scenario, some of these models have the ownership potential, you want to have skin in the game. That's where the reward comes from doing what we're doing. Dentistry's hard, Howard. It's not easy work. There's a lot of stuff involved, and being an owner makes it worth it, in my opinion.

Howard: And you're out there in the middle of Silicon Valley. What would you say to an old guy like me? Right now, everybody thinks Facebook's all that and a bag of chips, but I remember when they used to say that about Myspace. Myspace was all that. And I look at the data, and you look at the S&P 500 in 1950, by 2015, 88% of those companies were gone. There's only a 12% survival rate from 1950 to 2015. Ryan, could you find the stat from 2000 to 2017, what percent of the S&P 500? Because I read it's even been more brutal from 2000 to 2017. So my question is this, how are you feeding all those new patients, and you're in a high tech valley? Is direct mail dead? Is the Yellow Pages dead? Is it all Facebook? Is it Google AdWords? Are those the four-hundred-pound gorillas that feed your three locations, or what's feeding three locations?

Joseph: So, Internet's number one. So, your Internet presence. It comes from your patient reviews, all that stuff. That is number one without question because even when we've seen a referral setting, I see patients daily that say, "Oh, my general dentist said I need an implant. They were going to send me somewhere, but I jumped online. I found you" It happens every day, so having that strong Internet presence is number one.

Howard: Wait, wait, say it again. So, half the companies since 1999 are gone, 2009 down 17%, and since 2011, 11% percent are gone. So it's so funny how these companies, they're so arrogant because they think since are all that a bag of chips that they can do anything. Like when Facebook bought Instagram, you post a link to like a 5K for an oral cancer march, and they won't even let your link be activated because they don't want you to leave Instagram. They want to shove more sponsored ads down your throat. You know what I mean?

Joseph: Yeah.

Howard: It's like, "Don't be too cocky, buddy. There's a high mortality rate."

Joseph: Yahoo was king of the hill early 2000, Now they're almost bankrupt, right?

Howard: Yeah. And Google tried to sell to Yahoo, what was it, for like, one billion in like '94? No, I think they offered them one billion and Sergey Brin and Larry Page countered at five billion and Yahoo said, "No way." Now Google's worth half a trillion. But the last thing I want to say, and this is so true, and it's so brutal, but I have four kids. You have four kids. You were talking about some other guy that had four kids. Who were you talking about?

Joseph: My orthodontist buddy.

Howard: Yeah, your orthodontist buddy. When I see these kids for the last thirty years, and I predict who's going to make it. My dad used to always tell me growing up in Kansas, he said, "You see four hungry coyotes walking down a dirt road, something's going to die." And I'll tell you what, when I've been banking on these kids, those kids that had stay at home wives and four kids, they were at work early, they worked through lunch, they stayed after, they crushed it. And you know who did the poorest? The kid whose dad paid for dental school, didn't get married, had no kids, and at 5:00 is wanting to hit the bars and have a little fancy drink with an umbrella in it, and they wouldn't go to online CE, or if you did take them to the CE courses, they were on Facebook the whole time or disappeared to lunch. I'll tell you what, I give almost all of your credit to your four kids, because that's what makes you so hungry and passionate and driven.

Joseph: Oh, I agree, 100%. And I had my first kid right after part one boards. My wife worked at the dental school when we were there, so we commuted in together. So I had to be at school early and stay late because she was working, right? So I'm studying when I'm not in class, and 100%, that anchors you. That motivates you and gets you to work.

Howard: I know. These old guys tell me, they go, "What advice would you give an associate?" And I say, "Just get a hungry kid. Get one with a stay at home wife and four kids and you own a slave.

Joseph: Right.

Howard: But you get someone who's got a cush job, no debt. If they're not hungry, they're kind of lazy.

Joseph: Right.

Howard: So just get someone with 12 kids that lives in a shoe, and you have someone that would work Sundays from 7:00 AM to 7:00 PM. So that's my advice, get incentivized. But hey, Joe, thank you so much, seriously, for coming on the show today. You're a legend in my mind, you're a legend in many minds, and if you could deliver me that guy from Invisalign, I'll tell you what, I'll even give you all four of my kids. That's how grateful I be. You'd go to eight kids overnight.

Joseph: Very nice.

Howard: Ryan, you ready to move to San Fran?

Joseph: Howard, thank you for what you do. You've been a great influence for me starting out early in my career, so I appreciate the efforts and the work that you do to help us. Thank you.

Howard: Thank you, buddy. I hope you have a rocking hot day, and enjoy raising those four kids. One thing I knew with four kids. I had four boys in sixty months, and before the oldest one got a set of car keys, I thought my kids were so good, I should actually write a book on how to raise kids because they were so perfect. And then one by one, you give them a set of car keys, and they'll get in more trouble with those set of car keys. So just enjoy the perfect children at ten, eight, three, and three, and then come talk to me when they're all between sixteen and twenty-two and they all got cars.

Joseph: All of it is you at that point, Howard.

Howard: Alright, buddy, have a rocking hot day.

Joseph: Alright, you too, take care.

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