Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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925 Interpreting Radiographs with Dr. Philip R. Eckman, Jr. & Dr. Kevin A. Criscitiello : Dentistry Uncensored with Howard Farran

925 Interpreting Radiographs with Dr. Philip R. Eckman, Jr. & Dr. Kevin A. Criscitiello : Dentistry Uncensored with Howard Farran

1/19/2018 11:35:23 AM   |   Comments: 0   |   Views: 291

925 Interpreting Radiographs with Dr. Philip R. Eckman, Jr. & Dr. Kevin A. Criscitiello : Dentistry Uncensored with Howard Farran

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925 Interpreting Radiographs with Dr. Philip R. Eckman, Jr. & Dr. Kevin A. Criscitiello : Dentistry Uncensored with Howard Farran

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VIDEO - DUwHF #925 - Xray Upload

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AUDIO - DUwHF #925 - Xray Upload

Phil Eckman and Kevin Criscitiello are two past dental school roommates from the University of Maryland.  They both have been in private practice for 8 years and have decided it is time to give back to more patients.  In 2017 they invented to help people across the globe.

HOWARD: It's just a huge honor for me today to be podcast interviewing Dr. Philip R. Eckman and Dr. Kevin A. Criscitiello.

PHILIP: It's an honor to be on the show, Howard.

HOWARD: Thank you. It's an honor to be talking to Randy Eckman's son. Your father is a dentist and you were telling me there are five dentists in your family?

PHILIP: Yes, five licensed practicing dentists in Pennsylvania.

HOWARD: Wow! You guys should all do that 23andMe Genetic Testing and see if they find some gene. There might be a dental gene.

PHILIP: There definitely might be. (inaudible 00:39) all this family.

HOWARD: So, Philip's the one on the left. Raise your hand Phil so they see.  He's been practicing for eight years, graduated from University of Maryland Dental School which was the first dental school in the world. I think it's something like 1840. He graduated there in 2009. He's a third generation dentist, lives in hometown of Kennett Square, Pennsylvania, 25 miles west of Philadelphia, and practiced with his father Dr. Randy Eckman, MAGD; beautiful wife, Kelly; and then son, Zach, age 2 and daughter, Julie.

And Kevin, on the right there. Hello Kevin. He's been practicing for eight years, also grew up at North Carolina, graduated from University of North Carolina at Chapel Hill in 2005. Isn’t that where Michael Jordan went?

KEVIN: It sure is.

HOWARD: It sure is. He didn't make the team freshman year?

KEVIN: High school, he got cut.

HOWARD: That is so hilarious. He graduated from University of Maryland Dental School in 2009. He currently practices in a group practice in Pasadena, Maryland located approximately 50 miles south of Baltimore, Maryland; his beautiful wife, Veronica, with his first child due in November. Equally excited and scared of fatherhood. Guys, thank you so much for coming on the show today.

KEVIN: Thanks for having us, Howard. We're excited to be on.

HOWARD: All right. Well,I when I heard what you were doing, I just thought, “My god that is so cool.” This year, you invented to help people across the globe. Damn! I just think that's such a cool damn mission. I was so excited to get you on the show. So, tell all my homies what they'll find if they go to

PHILIP: Well, the service is pretty simple, Howard. As you go to the upload page, all the person will have to enter is the patient's gender and then their age group-- the standard groupings you know 18 to 24, 25 to 34, 35 to 44 etc and then you need to upload an image of your X-ray. Most images now are just transmitted across e-mail. It's essentially a JPEG as if you took it with your cell phone. In fact, we've had people take a picture of the computer screen on their way out of the operatory after cleaning or something and submit a photo. We can tell is a photograph but honestly that's enough for us to give some basic free X-ray interpretation. That's what we are we're for informational purposes only and we're an organization designed to help all people.

KEVIN: Yes, absolutely. Phil's kind of summed it up right there but it's very straightforward. If you're a consumer from any different background or market and you have something that you want to have a group of dentists look at for you, you can submit it to us and we'll give you feedback pretty quickly.

PHILIP: We promise to have your results to you within 48 hours of submission.

HOWARD: How much does it cost the consumer to get it looked at?


KEVIN: Free of charge.

HOWARD: And how-- so this is a charity? Or... explain that. Explain your business model.

KEVIN: Yes. So initially right now, we are kind of exploring a few different pathways to profitability but we're also-- we're okay providing this, I hate to say, niche service but I'm getting into this market where there's not really, other big player in there and kind of seeing where it goes, I guess for lack of a better a better answer.

PHILIP: We're happy to do it for free for a while, Howard. We have other friends from University of Maryland that are ready willing and can help do responses and replies over e-mail. We basically share one inbox. All the doctors don't have their own log in or anything. And eventually we're up to compensate people but right now, we are just giving back a little bit.

HOWARD: I'm looking at and how you upload. So, when I take a picture on my iPhone that's a JPEG?


HOWARD: I never knew that. Never thought about it but that sounds pretty cool.

PHILIP: Even if you export your image to your desktop, whether it was sent to you over e-mail or just off your practice management software, that's usually a JPEG. When you attach it in an e-mail you know all these transfer e-mails you get. You know I want to be a patient of your practice, Howard. Here is my e-mail's being X-rayed from my old office. Think how many images are already sitting in inboxes across the country.

HOWARD: Right. I'm just curious, explain to my homies, when you're looking, is it going to be a photo or an X-ray? It could be either one, right? A photo--

KEVIN: Absolutely, could be either one. I mean, ideally, I think it might be a little easier for us if you actually got a copy of your digital X-ray and upload it to us. Obviously, it's going to help with the evaluation, make it a little easier for us. But again, as Phil is elaborating on, if you took a picture of your X-ray or for those offices that have traditional film, if you took a picture of a traditional film X-ray, we would also interpret that for you as well.

PHILIP: It blows our mind, Howard, that only 65 percent of dental offices are digital.

HOWARD: What percent?

KEVIN: We saw statistics that as of 2016, we still 65 percent are digital.

HOWARD: Two-thirds.

PHILIP: Yeah, and granted that's up 10, I'm sorry, that's up--

KEVIN: That's double from about a decade ago. We saw stats that in 2007 it was around 35, 36 percent. So, it's definitely trending that way, right? Technology is making it easier to go digital. I mean that's just the future, no other way around it.

HOWARD: Explain why you need to know the age and the gender.

PHILIP: So, Howard, we think that that's very important to advertisers. When we do have to monetize to be able to pay our doctors, we want to be able to say to Invisalign or I don't know if you guys have Smile Direct out there who Invisalign acquired last July in 2016. Their stocks going up 125 percent since that acquisition. Basically for-- in order to monetize, we want to say we have X number of females age 18 to 34 that visit our site once a month and it's a free service. So, as long as they can pay us a little bit more for the click than what we're have to pay on Google AdWords, we can deliver a margin that way.

KEVIN: Yeah, there could be a way to monetize also when we're evaluating certain images, it will help to see a PA of a tooth for someone who is 65 versus someone who's 18. That helps give us some information as to what the prognosis might be for that person and what they should be expecting. But as Phil is saying, yes, knowing the age brackets is just-- it will be good information for us to have both to interpret the films or any images that you're submitting, but to also give us some data so we understand what we're finding out, what the market is out there.

PHILIP: Bone density can differ between men and females.

KEVIN: Yeah, absolutely there's just a lot. That's just one other piece of evidence that will help and it's something that we like the users to include.

HOWARD: And when did this go live?

PHILIP: We're a two-month old company. My little sister helped design the website and she took the lock off the homepage on July 26th. We got a little bit of feedback so far on data. The first month, there is over a thousand page views, 600, 700 unique visitors but we haven't started our SEO or online advertising yet. Now we're learning a little bit about Instagram and Facebook and what it takes to have a sponsored ad on there. For $10 a day in the L.A. market, for example, where there's tons of people, for a ten-dollar ad you can have 2000 people view your post and 25 of them probably will click on the website based on what we've seen. So, I mean at that, that's roughly 50 cents per click. That's pretty inexpensive.

HOWARD: Wow. So, have you started a thread about this on Dentaltown?

KEVIN: We have not yet. We need to work--

PHILIP: We want to get your approval first.

HOWARD: No, everybody is allowed one promotional thread. Say you lecture every weekend and you have a course for money, you can have one thread and you just can't post it in 20 different places. Every company like if you're-- any dental company, you can have one thread that's always posting your stuff. Have you talked to the editor of a Dentaltown magazine about doing a story on this?

PHILIP: We've mostly been in contact with Ryan.

HOWARD: Can my homies, how can they contact you?

PHILIP, Well Howard, we're an organization to help all people: consumers, dental school students, residents even practicing dentists. I think I heard from your previous podcast that 25, 30 percent of your listeners are juniors or seniors in dental school. I'd say I wish I had a service like X-ray Upload when we were entering the clinic.

KEVIN: Doing treatment plans and-- Yeah absolutely, so we're open to anybody. We've actually had people abroad, other practicing clinicians in other countries contact us and submit films for us to evaluate and some feedback as to what they might want to do.

PHILIP: Even just curious dentists or colleagues like we're kind of afraid what image we're going to open. You know what I mean Howard. But listen, we really are... we just want to help. We're happy to confirm treatment plans. I mean it adds a whole extra level of validation. Could you imagine having a X-ray upload certified doctor in your area?

HOWARD: Do you give out your e-mail?

PHILIP: Yeah. On the website, it is possible to e-mail--

HOWARD: I mean on the show right now.

PHILIP: Our e-mail address is

HOWARD: I just sent you an e-mail to I cc'd Tom Jacoby who is the editor in Dentaltown magazine and Howard Goldstein who's the head of the message boards. And I think your SEO will explode if all these dentists are checking it out. Google, these people that tell you how SEO works always makes me laugh my head off because you know Bing is owned by Microsoft they can't figure out how Google's doing it. Yahoo can't figure out how Google's doing it. But the guy at the Holiday Inn you know, he knows. Microsoft doesn't know it either as Yahoo. But there's obviously something to-- a ton of activity, part of that algorithm. It's not a dark side, all these people. And if they start clicking it, Dentaltown's got dentists from all 200 countries so they if start clicking it from around the world, they'll start showing it around the world.

PHILIP: Yeah, you've built an amazing media company. We used to fill in our CE in '08, '09 we're dating our self now. We would mail it in to Dentaltown for free, we photocopy. Then went up to $35 but we had to wait till we've got jobs to submit them.

HOWARD: Well that's a good point you guys got to remember because when you're in dental school all those 450 courses are free. So, if you're out there listing that stuff in dental school... I'm sure your dental school instructor is great but it's it's great to hear instructors from around the world.

PHILIP: When I graduated I had 16 credits from Dentaltown. I did eight classes. And those were free. You would have had to pay for those. I started out my career with 16 units of CE and I didn’t even graduate yet.

HOWARD: Nice, nice. And I'm so proud of your dad for getting his MAGD. Is that something he is encouraging you to do?

PHILIP: Yes. And he was recognized in 2015 with the Lifelong Servicing Award, LLSR. It's a level of achievement even past MAGD. So, he's really proud of it and he's meticulous about submitting every single thing he does.

HOWARD: It's called LLSR?

PHILIP: Yes, it's a Lifelong Service Recognition, I believe. It's one level past, I don't know, MAGD. It's not a formal suffix but there might be two or three of them in Pennsylvania.

HOWARD: Now have you guys both joined the AGD?


HOWARD: Both of you? Tell us why you joined the AGD?

PHILIP: Because I wanted to keep track of my CE for me.

HOWARD: Right--

KEVIN: I would just say that being the best clinician that you can be is important. I would tell the homies out there, the dental students, any young practitioner-- I feel like I'm still a young practitioner, but you could always learn and get better and it's important. You got to be a master of your craft.

HOWARD: So yeah, I mean, if you're going to spend your whole life being a cook and own a restaurant, why don't you just be a good chef? I mean that just seems-- it just seems so like a no brainer. I mean sometimes I watch those silly shows when I'm going to sleep. I don't know, whether they're making the best cupcake or the best-- some cooking show. What is it?

PHILIP: Cake Wars?

HOWARD: Yeah Cake Wars and they were doing Halloween things the other night. I mean what was so cool is that these guys were  building a Halloween cake or a muffin or a treat, more serious than many dentists take a root canal. You know what I mean? I mean they were just, it's so cool. So, it's kind of a humanitarian thing but you're hoping you can monetize this someday?

KEVIN: Yeah absolutely. It's one of those things-- we've actually been in contact with a couple of people who have actually reached out to us with questions as to whether we'd be interested in partnering with a couple of people who might be able to help us. We see a few different pathways as to--

HOWARD: Who are you thinking about partnering with?

PHILIP: Well it's early talks with a small venture capital firm that funnels money mostly from physicians into different areas but we're not ready for Shark Tank yet, Howard. They're very humble numbers. But some numbers we do want you to hear are that in the United States ages 18 to 64, there's 200 million people according to and 64 percent of the people in that age group had a dental visit in the past year. That's from the CDC. So, most patients in that age group get X-rays once a year. You know a minimum X-ray frequency for patients even with the lowest risk is every 24 months according to ADA. So conservatively, Kevin and I estimate that, a hundred million people had X-rays during the past 12 months. That's taking into account the low risk criteria and X-ray refusal, all that.

KEVIN: Yes. So, there is a market there, there's a lot of people going in for check-ups, going in for emergency exams and the dental consumer, from their perspective, it's hard for them to understand what needs to be done when they have no pain and they can't see something that's going on. So again, a lot of times, we're just going to be validating what our peers are telling consumers, but it is nice to know and there's a lot of that in other industries. It's how do you know what the right price is to buy a car or whether the car has a bad history or wreck history. There's all types of services and other industries that exist. And so, there is a market there for consumers on the dental side.

HOWARD: What's kind of funny with dentists is they often say things, but their actions don't fall. I mean I guess all humans. Like for instance, when they're young and they're your age they're all against holistic dentists and alternative medicine and natural paths. And then when they get old, fat, and bald like me in their 55 and their doctor says, “you need to take high blood pressure pill and a statin to lower your cholesterol.” They're like I don't know want to do the traditional medicine I want-- I want to lose weight, exercise and do it naturally. It's like dude you've been slamming alternative medicine and you always reject what your M.D. tells you. And the other thing is with second opinions. If you go back on that site. I've been on  (inaudible 17:16) four hours a day minimum since 1998. And dentists get emotionally thrown off their horse when someone gets a second opinion. But when Doc gets prostate cancer, guess how many opinions he gets. It goes to his local hospital he might go to Mayo or Scripps or Houston, Cleveland Center. It's going to be so funny, you're going to see this so many times where a patient, Doctor Good with his MAGD is going to say, “you have two cavities” but a smart consumer is going to sit there and talk, “Well, hell if I can upload that for free. I want to see if he's right.” (inaudible 17:57) funny how they are. Dentists are emotionally hurt when their patients get a second opinion, yet they always get a second opinion for themselves.

KEVIN: Absolutely. You don't always know that there should be a market for something. There's all types of things that we didn't know we needed certain things until the market kind of popped up and it's there. We kicked around this idea for quite a while. It's something that, Howard, I'm sure you've seen it, listeners have seen it, you're in your practice, you're working every day, once a week, twice a week, three times a week. Someone comes in and they want a second opinion, they say “hey I saw someone a week ago they told and told me I needed XYZ. I didn't feel comfortable for some reason.” It doesn't mean what they were told was wrong, but they want to explore their options. And again, there's a need there and if we can get the word out that we're available--

PHILIP: Or what if you used up your two exams for the year already? You know most people have PPOs. Come November, December what if you'd have to pay out of pocket for a consultation. We're there. We want to stay in our space and we want to be an X-ray service. We are the nice guy fact-checkers. We just are an organization to help right now.

HOWARD: Yeah. Even I've got a second opinion. I got a physical last week and my doctor told me I was short, fat and bald so I got another opinion. He said, “You're short, fat, bald, and ugly.” He missed one.

PHILIP: You need a third opinion.

HOWARD: Yeah, I think the confusing thing for I think people that don't live in the United States, when you talk about the health care for like Canada or Australia or New Zealand, it's one system for the whole country. But if you're talking about the United States, Medicare is a federal program for all seniors. But Medicaid is different in all 50 states and a lot of those state Medicaid programs they don't-- the exam might not only be covered one time a year. So, it's so confusing to talk about Medicaid for the poor when you're talking to anybody from another country because I got it, it varies so much between Arizona and California that you'd have to be a lawyer to understand the differences.

KEVIN: Absolutely. There's also-- there's a component of access to care maybe, I don't know if that's the right phrase or terminology. But direct to consumer maybe, all those things kind of apply to what we're doing: providing a service that just-- we're trying to make it as easy as possible for people to get more information about what they've got going on.

HOWARD: Well I think you should start a thread on it in Dentaltown and get a bunch of feedback on that. And then I think you should e-mail Tom Jacoby and write a story on this because I think what you're doing, it's so damn innovative, it's high tech, it's something you'd have to be-- Are you guys technically millennials? I mean you're both 34.

KEVIN: We're getting there. This is forced us to really step up our game.

HOWARD: What are you-- Millennials are born in 1980 and after. What year were you guys born?

KEVIN: '83.

PHILIP: '83.

HOWARD: So, you're both millennials, I mean this is up that only young, high tech and innovative millennial. Your dad and me would've never have thought of this. So, what's your dad think of it?

PHILIP: He thinks it's a great idea. He says it's long overdue.

HOWARD: Nice, nice.

PHILIP: And you don't have to charge. I mean people-- you never get off the ground if you charge. That's the way we feel, and it doesn't really cost us much to do it. And if we get too busy we're going to, there's probably going to be advertisers that want to help pay our costs. So, we're going to write our replies, look at a film give you our gosh,(inaudible 21:35) darn honest opinion. We're careful not to say a tooth should be extracted, we'll say ‘has a hopeless prognosis’ because we don't know their medical history. No medical advice can be given (inaudible 21:50) in an exam and history. There is going to be stuff-- there's going to be clinical findings that we can as an X-ray interpretation service for informational purposes only. If one percent of the people who have dental records in a year use X-ray Upload, that equates to 85, 000 users per month, Howard.

HOWARD: Yeah. So, did you have a really, really, really good lawyer look over your terms and conditions?

PHILIP: Yeah, malpractice lawyer in Philadelphia, a patient of mine. I restored an implant for him that was in his jaw for 20 years. I uncovered it and everything. So, he's a great guy and he's happy to be on my side.

HOWARD: Yes, there is no doctor-patient relationship with X-ray Upload. Film interpretations are for informational purposes only. The information provided on this website should not replace the medical advice given by your doctor or qualified healthcare provider. Any recommendations for treatment are not the legal responsibilities of the doctor. The essential findings are discovered during an exam that will not be demonstrated on film. Medical advice cannot be given absent the exam and history. All replies are based strictly off radiographic evidence and do not take into consideration patients symptoms or clinical evidence, information submitted on a voluntary basis, thus giving consent to its collection use and disclosure. You will receive notice within 48 hours if your X-ray is inadequate or radiograph interpretation cannot be made by our doctors. How many pictures can they upload for this?

KEVIN: Multiple. I think it's already at 4 or 6 right now.

PHILIP: I think it's 6.

KEVIN: It's at 6. So, I mean, I guess maybe we're a little limited there with regards to, if someone had for example a full mouth series or something but--

PHILIP: We prefer one X-ray and then you know of a photo if you had. We will do a couple, but it isn't... We don't really want it to be abused, if you know what I mean.

KEVIN: It's not exactly a--

HOWARD: No, Ryan and I are going to abuse it. We'll think of some way to make them blush.

KEVIN: It's not meant to be a full exam. One of the issues that we talked about for a long time was is this something we should do because we're doing a clinical exam, right? There's going to be limitations to what we can do. But ultimately, we decided that yeah there are some limitations but there's still, again there's a service that can be given and there are going to be users who want to use it.

HOWARD: I love your name also X-ray Upload. I mean it's clear, it's concise, it's succinct. It's just X-ray Upload.

PHILIP: Thank you. We were happy to see it was available when we tried to buy the domain name. We kind of wanted to stay general. What happens if a hand surgeon or spine surgeon, they use a 2D film still too. What if we need to branch off into medicine? We want to be able to stay on top of the X-ray Upload search because Howard it’s not getting any smaller. What did we say, 35 percent of the dentists still aren't even using digital. So, we're trying to position ourselves in the field and everything is going direct to consumer. I'm not sure if you guys have SmileDirect out there but it's a company that was acquired by Invisalign. It's pretty much east of the Mississippi and last July they bought them for $46 million for 17 percent of the company.

KEVIN: People are, for whatever reason they want to access to care, they want things to be easy and we're just trying to leverage the technology that is available. You get an exam, your (inaudible 25:15) can e-mail you the films and you get a second opinion pretty easy.

PHILIP: People don't want to get in their car to drive to appointments. They want access remotely and instantaneously.

HOWARD: Yeah and you know what, it's amazing because Invisalign-- What's the name of the CEO, Ryan? Joe Hogan. And who's the MMA fighter guy? Joe Rogan? Well we'll have to see if they'll ever square up-- I've seen Joe Rogan-- Joe Hogan, CEO of Invisalign on Mad Money with Kramer and it's pretty cool because some... I have seen this (inaudible 25:48) so many times. 

I remember when Interplak came out with an electric toothbrush. They were selling through dentists. I mean by that time I'd already sold 15 or 20 or 30. The next day I noticed they were selling them at Walgreens for $20 cheaper than they were selling them to me. God damn! And then the words in-office bleaching and then that was making bank. The next thing you know Crest came out with their Creststrips for 50 bucks in a box and it just killed that business. 

And now the orthodontists are acting like they can't believe this happened. Like what do you mean you can't believe? Invisalign found a way to go, to bypass the orthodontists, I mean they did it with Crest did it with bleaching. All the electric toothbrush companies no longer-- I mean now you can even get a toothpaste company to give you samples. Even if you're going to go to some missionary deal. So yeah, so that Smile's Direct club. Have you guys see anybody who's done it?

PHILIP: There's a location in Philadelphia, there's a location in Baltimore, but basically all you do is you walk in and have a digital impression in your mouth. And of course, they're using Invisalign's iTero scanner and if you qualify, not that I'm preaching for them or anything, but they mail you your trays it's pretty remarkable. It's for cases of 20 aligners or less and there can't be any stripping or no attachments. But they really cut out the dot and ‘cause I'm sure they have guys on there, signing off on it remotely but pretty big acquisition and you know what happened since July of 2016, Invisalign’s stock is up 125 percent. They went from $84 in July 2016, I saw it $189 last week.

HOWARD: When dentists were upset when Crest started selling bleach directly to the patient, not going to the dentist, again, instead of the dentist being emotionally upset that this is a fact of life. They should know about the stock. When people come to me, this makes people-- it makes me crazy because they'll say, one thing about spending $150 thousand in buying a CEREC machine. I say why don't you spend $150 thousand and buy their stock. It's called X-ray and it's on Nasdaq, my God, that would be such a better move. And same thing on social media. You have to get Facebook money to boost your ads and that stock's going crazy good. Twitter, I’ve never give them a dime and there's stock came out of 40 and it's down to 20. These companies that you don't give them any money-- I mean you're a dentist. I mean when you saw all the orthodontists upset and you knew that is going to be faster, easier, lower costs you should be buying the stock. And if anybody out there knows Joe Hogan who's the CEO of Invisalign, come on dude you went on Kramer. How can't you come on Howard. We both look the same, same height, both bald, I mean you've already practiced with Cramer being on Mad Money. Come on this show--

PHILIP: He needs a second opinion, Howard. He needs you.

HOWARD: Yeah. I mean I think business is business and dentists, that's another thing they say in their action (inaudible 28:54). They say they're always for the consumer. It's like, okay what are your hours? Monday through Friday to five? Okay, the Federal Reserve owns more economists than anybody on earth. I think they have like 3, 000 Ph.D. economists for them. Every time they do the health care, they say 1 in every 3 Americans cannot go to the doctor Monday through Friday from eight to five. The same guys are saying that at the hospitals, eight out of every 100 are emergency room visits is odontogenic in origin. And then the dentist will say I'm patient-centric. It's like dude, you're dentist centric.

PHILIP: We see a big opportunity for urgent care as relating to dental too. But anyway, we've heard you say before that the DSO’s actually deserve some credit because they hire young students, they are open until 8:00 or 9:00 at night—

KEVIN: Saturdays.

PHILIP: And so, there are friends...

HOWARD: And Aspen, to me, of all the big boys, you got the very, very large, maybe 35 companies at 50 or more locations. You got the very, very small where it’s just one doctor by himself. And then, you got the very middle, and that could be anywhere from two docs to a group practice to two or three locations. And Aspen, their mission is they go where the dentist won't do Medicare or Medicaid. Not Medicare, that's a federal program for Grandma. Medicaid. And the fact that they're going in to where the other dentist said, “Well, I'm not going to do dentistry for that fee,” and then they're providing jobs to six thousand graduates who have a ton of student loan debt and need a job.

The bottom line is when you get out of school, there's no way getting around it. It takes you three or four years of the basic filling, crown prep, endo. You just have to do your basics for years before you can get out.

KEVIN: Absolutely. It's supply and demand. I've heard you talk before in the past, mid-level providers and things of that nature. If you're in a rural community, put a clinic there and pay off some student loans for somebody and pay them a good enough salary. And guess what? They'll come there and they'll work for two, three, four or five years. Maybe they’ll move, maybe not.

PHILIP: And pick the location where all the adjacent dentists are retiring or getting close to that age, because we've also heard you say that the cheapest charts you can buy or the lowest patient acquisition is purchasing a retiring dentist charts. It's pennies on the dollar.

KEVIN: There's a lot of things that when you sit back and think about them they kind of make sense. Everybody wants to be in suburbia or close to a city or a major metropolitan area but that's not always going to be financially your best move.

PHILIP: And people that are in remote areas, middle of the country, they might not have access to a dentist for 20 miles or more, but they have access to the Internet. And we're happy to look at their X-ray remotely for free.

HOWARD: Yeah and when you talk about everyday activity, I mean it's all you talk about on Wall Street. I mean it's just all the movers and shakers. And then you go into dentistry and every time I meet a dentist who's got a three or four million dollar practice, he sat there for 30, 40 years and every time old man McGregor said I'm done, he just bought the charts, moved them in. They're already within five, seven, eight miles of the practice. The old man said, “you know what, that's where I want you to go.” You've got the third person endorsement. I mean like 1800-Dentist that's $100 a head. Google AdWord in my practice or a Facebook ad is $100 a head. You start doing direct mail, maybe $100. You start doing other things, it could be $350 a head land and if you can buy an entire practice for a $100 a head. Furthermore, when you use advertising and that person walks in and doesn't know you from Adam, they only spend $1. But when they're referred in and they have trust, if they just come in to me and I say you've got four cavities and they're $250 each. Wow, I just met you and you want me to give you a thousand dollars, I don't know. But my Uncle Larry sent me in here or my dentist retired and said out of all the people in the world, “I want Philip Eckman to be your dentist. He's taken all my charts.” And then Philip tells me with this third party endorsed that I got four cavities. Then you buy $3. So, when they come in referred they buy $3, when they come in from naked advertising with no trust issues, I mean-- I was talking, I had lunch yesterday with the auto mechanic across the street from me-- And you know and that's a good point. There were dentists and friends of mine that have businesses here. Their last name is 14 letters long. I mean you know (inaudible 33:54) was not a name... This should have been G's Automotive or something. But anyway, he was, we always joke around that we're in the same exact business because he fixes about 450 cars a week. It's a big deal but everyone comes in and if he says you need a new alternator. I mean how many people know how to decide if you need an alternator or not. And if I say you need a cavity, how the hell-- what are you supposed to do? I grew with five sisters playing Barbie dolls. I don't know what a transmission is versus an alternator, I've never change a spark plug. I bet if you put a gun to my head I couldn't change my oil. So, it's totally trust deal , and he knows that. So, what does he do? He's big into the community, he's at sports teams and drag racing, and he's lived right by his office and tried to stay real visible in the schools, in the churches and all that stuff because he knows his entire unbelievable business is completely based on trust. So, I think what's going to start change in that is a piece of technology that when that engine light comes on, instead of just having a little engine light, I'm seeing now the up and coming cars are going to send your iPhone a text saying what it read or an e-mail. And then they'll probably be forwarding that text or e-mail to a company like you guys.

KEVIN: Yeah absolutely. Technology's making everything easier. There's no other way to say it. It's just continued to advance and we're trying to leverage that and be a part of that.

HOWARD: So, what else do you think everyone should know?

PHILIP: Well speaking of the car business, do you remember TrueCar going public in 2014? They had a billion-dollar valuation at their IPO and their formula is very simple. All they really do dominate the car search, a car buying search. So just for example let's say they can spend $5 on a Google AdWord. They get-- to take two people go to their site to 50 percent click conversion. So, 50 percent or so there's been $10 cost of acquisition. But when they get on their site, they click on an ad of a local dealership, but the dealerships are willing to pay $12, right. So that's $2 profit times millions of leads per year. We hope to attract users (inaudible 36:28) for less than what someone will pay us for their click.

KEVIN: Yeah absolutely. And that's what we talked about earlier. There's a lot of pathways for us to try to turn a profit down the road when we have to, we get to that point. And that's just one easy example of another market that didn't reinvent the wheel they just invented a car search company.

PHILIP: And 17.5 million cars were sold in 2016, which is a record. But 100 million people had dental X-rays.

HOWARD: Yeah, well another monetization deal, if they're taking photos with iPhones, any dentist has a Facebook page. Every month somebody's private message you an iPhone picture of their tooth. And if you knew their location and if you ask them their zip code-- that's what I would add, you got their gender, you got their age, put in their zip code. And then you could say “I think you have a cavity. I think the tooth is hopeless. But you might want to go see Howie in 85044.”

PHILIP: We would love to have a link on the reply e-mail that said, “click here to see an X-ray Upload certified doctor in your area.” And maybe dentists would want to pay us to be listed on those.

KEVIN: Yeah absolutely. There are lot of pathways.

HOWARD: Yeah. So why don't you ask for their zip code right out of the gate?

PHILIP: Too much personal information, we're not ready to do that yet. People don't want to give that up until they're comfortable with the brand and we want to prove ourselves as the nice guy fact-checkers. If you understand the freemium service, or you can charge for her upgraded consult which is a little more secure that you wouldn't be able to provide your zip code.

HOWARD: I think the easiest way to monetize is sit there and get the results and say, “and if you have any questions, there is a licensed qualified dentist in your zip code 85044” and then charge that guy 100 bucks a head.

KEVIN: Yeah absolutely and that is probably the most likely route that we're going to end up taking. Right now, we're still up and running and we're excited every time someone comes to the site and submits an image for us to interpret.

PHILIP: We'd love to get to dental school students from all over the country to use our free resource. Now we're in talks with some third year students at Temple Dental School in Philadelphia and we'd like to get back to Maryland and speak there. All the students that listen to your show, feel to try us out once.

HOWARD: Well another way to get into those schools, I do it all the time is, you know for 30 years, I always speak free in schools but, man it just beats you up. Flying all the way from Phoenix to Fort Lauderdale and then lecturing in class for two or three hours then back. I mean you're almost gone 48 hours door to door. Now these students like, I'm in one tomorrow, they Skype you in the class. So, all you got to do is send an e-mail to those deans and say, “I'd like to Skype in to your class,” and that way you don't have to get out of bed. You don't have to shower, bathe, or brush your teeth, or floss, or do any of those things that those traveling people have to do. Yeah, it's amazing what technology does. I think this is really, really exciting. So, are you going to call Invisalign and try to talk to Joe Hogan or you're going to prove your concept more first?

KEVIN: Right now, we're still proving the concept a little bit. But again, we're already starting to see-- we're eight weeks old and we're still very young, but we're already seeing an increase in, again, people coming to the site, amount of users, people submitting images. So yeah, if things continue to progress, which knock on wood, they're going to continue to go that route, we're going to absolutely have to contact some bigger players for lack of a better rate.

HOWARD: Well do you have any protective moat around your business as Warren Buffett always talks about? Do you have any intellectual property or anything patentable?

PHILIP: The reality is there's no unique... There's no ground-breaking technology that we utilizing, we just want to be first on the scene and best and build the brand.

HOWARD: But have you talked to an intellectual property lawyer?

PHILIP: All you can do is trademark the name. We're not doing a patentable process.

KEVIN: Yeah. We reached out to one patent attorney and got some feedback but with limited suggestions on how to move forward.

HOWARD: That's what I would do. I would go on Dentaltown and I would say, “can you think of any unique feature I could add to this which should make it patentable?” Because Warren Buffett I mean that's why he owns a third of Coca-Cola because he said if you give me a billion dollars and I started Warren Buffett's Cola, he goes-- You can't compete against Coca-Cola. The brand is  (inaudible 41:31) a protective moat. There's trademark. Any type of intellectual property makes the margin, the S&P average profit margin is five percent. But you go into those companies that got a lot of intellectual property and their margins are like 38 percent. And I bet it'd be a blast to start a thread on Dentaltown trying to get all these damn older dentists and millennials, and everybody trying to brainstorm with you to find something patentable.

PHILIP: If somebody can come up with a good solution, we're happy to have him on board and offer them a...

KEVIN: Yeah. Jump in and help us out I mean we'll talk to him for sure.

HOWARD: Yeah, I actually think you don't need them to do that because it's like Wikipedia. I mean Wikipedia, when they saw Microsoft starting to get an encyclopedia business. It was Encarta, it scared the shit out of everybody. The last guy you want controlling the world's history would be Bill Gates who had a class action lawsuit with America, another one with 22 states, another one with the EU. Now he's re rebuilding his image as this humanitarian going around the world stamping out polio. But he's got a lot of work to do. There's a lot of burned bridges there.Where was I going with that... . Oh so Wikipedia thought, people after work, they like to come home and do the L.A. Times crossword or the New York Times crossword or they like to do board games, or they like to play cards or something. They like to watch Wheel of Fortune and try to get stuff out. So, Wikipedia started this, they have no employees don't pay anybody. They're all volunteers. They have 30, 000 people, mostly women who come home and their way of unwinding, instead of go and do yoga or drink a bottle of beer or wine or whatever, they send in one fact and they just sit there and say, “Philip Eckman says he won the heavyweight lifting championship of the world all three years of college. And is that true?”

PHILIP: Second opinion, Howard, second opinion.

HOWARD: Yeah, and then they'll look at that and they'll say-- Kevin will get on the Wikipedia and say, “I can find zero evidence of this,” and they'll e-mail you and say, “I need a link or paper... Give me some evidence.” And if they can't find the evidence, they'll edit it. And then if you go back and put it back in, they'll take away your rights to it. In fact, they just took away all the rights for the entire Church of Scientology because they were spending so much time editing all the stuff that they were saying. Look at AA, instead of after work, look at AA, well you got hundreds of thousands of volunteers that aren't paid a dime, that an hour before work or after work they go in there and help somebody quit drinking and tell him “dude I haven't had a drink for 12 years.” You should build an email group of your daily crossword puzzle and where you just sit there and say sign up for this deal. Every night after work, come home from work, do your thing, feed the dog, get your glass of wine and we're going to text you or e-mail you one Wikipedia-ish type deal. And it's just a way to unwind. 

I know people that when they finish that New York Times crossword in under an hour, you would think they just threw the Hail Mary pass that won the Super Bowl, I mean they're just like I mean their timing, you know what I mean? Same thing with chess. They're just like games. I build up a Wikipedia cult an AA cult where that is their daily crossword.

KEVIN: No, absolutely. I mean we want to build a brand building following 100 percent.

HOWARD: And you want to build all that labor like Zuckerberg. Zuckerberg has the largest media company in the world and he doesn't have any writers. It's all user-generated content. So, you want to get all the dental oral radiologists diagnosis of the world, around the world without paying him a penny, and they'll do it just because it will make them feel better. And you have to monetize it somehow because if Wikipedia didn't have enough money for servers and all that stuff then the service is gone. Every time they throw a banner ad says: “Wikipedia needs your money,” I always click there and give them their money, what they're asking for because I sure as hell don't want Bill Gates or Fox News or CNN to be the ones telling the 7 and a half billion people what happened 100 years ago. They can't even get the story right today. They sure as shit can't be in charge of what happened 100 years ago.

KEVIN: I totally agree.

PHILIP: They're fact-checkers just like we are, Howard.

HOWARD: Yeah and I'm convinced that there’s not too many facts out of mathematics. Doesn't mean you can have seven dentists looking at the same X-ray on Dentaltown. I saw a case posted and it was this beautiful cosmetic deal and I said well, I think for my four-bicuspid extraction, the ortho, I think it ruined the whole case. And Gordon said to me, he goes “it's just amazing how everybody sees something different.” Some people were looking at the bleaching of the teeth and the some are looking at the midlines, some are looking at the straightness. You were looking at the four-bicuspid extraction, he said, “there's not two dentists in the world who would look at X-ray and see the same thing.”

PHILIP: It really gives that sunken cheekbone appearance, it takes away from the aesthetic.

HOWARD: And that was all the rage, when I got to school, I mean most of the orthodontists, half their patients just routine four bicuspid extraction.

PHILIP: We're seeing lots of it, I agree.

HOWARD: It's gone from about 50 percent to 25 percent. It's gone from 1 out of 2 to 1 out of 4. Well is there anything else you want to tell my homies?

KEVIN: Yeah, I would just add that piggy backin on what we said earlier, be the best clinician you can. If you're doing root canals, crowns, whatever you're doing in early practice or still in school, get as good as you can at your craft. The only thing I would say is, it is never too early to start knowing finance, knowing business. At some point you're probably going to own your own business. You need to understand this stuff inside and out. You need to understand overhead, insurance. You understand how to pay your staff. You need to understand interest rates. This is stuff you got to know. I guess at the end of the day, you can try to pay people to help you do this stuff. If you're going to lead your business and your practice, you've got know this stuff, you've got to be the most knowledgeable person.

PHILIP: And if it's not something you're passionate about, it's okay to just be an employee dentist. We need those too. The DSO’s are very nice opportunity for that. 

HOWARD: When you get out of school you need time. You're not going to win a marathon in the time it takes to do 100-yard dash. You need mentors.

KEVIN: I would encourage all the listeners out there, go to Dentaltown, learn as much as you can. Read Dental Economics-- whatever it is, that's information, that's going to help you a lot. And like Howard said it's a marathon. If you can find a way to shave a quarter percent off your student loans or whatever it is, you don't think it's a big deal, but it is. All those things really add up in the long run.

PHILIP: That'll allow you to maybe open a location and help more people. And that's what you want to do.

HOWARD: My consensus after 55 laps around the sun  is that, entrepreneurism comes from empathy. Some people look at someone having a hard time doing something and they just say, “it is what it is.” But the heart of entrepreneurism is say, surely there's got to be a better way, grandma can get up those steps, or a patient can brush her teeth with rheumatism. They're always looking at their fellow social humans and an empathetic, sympathetic way and then trying to monetize it because if I need to get, build grandma ramp or a wheelchair, I can't do it with pixel fairy dust. And I also feel sorry for the rich guys because they're always guilt-shamed and always giving money to charities. It's like dude, the Fortune 500 is solving more solutions and for them to take their seed capital and give it over here to-- for whoever doing what, I don't really even know if that's the most -- I think if your product is making everything faster or easier or higher quality, lower costs and helping more people, and they're buying it, and they're feeling that growth, that's probably the most impactful charity. If you look at the gains of how people lived 100 years ago to today, most of that came from capitalism.

KEVIN: It comes from capitalism, you took the words right out my mouth. I could not agree more-- 100 percent capitalism has done more to lift more people out of poverty and to raise standards, SES standards and throughout the world, this country specifically, have improved vastly. Still areas where we can improve but capitalism will solve a lot of problems that government or other agencies cannot solve.

PHILIP: And what is Dr. Christenson always say: faster, easier, better, and less expensive.

HOWARD: Yeah and that's why this country is so divided on health care. Because when you talk to my good friend, they go to Lifetime and swim when they're in Canada they said, “Yeah it was the best health care ever.” But sometimes I had to wait six months for that. My father one time had to wait two years for this and all that. That's the... They got access. But that's where America slipped because what you did as a high-tech procedure and they're just afraid that if you take the free enterprise capitalism out of health care, you're going to get the post office and the Department of Motor Vehicles. They want some kind of hybrid.

PHILIP: Well, do you know where the best doctors in Canada are, Dr. Farran? They're in the US right over the border.

HOWARD: Yeah, the health care is so much, it makes me the maddest. I don't want to say anything too much chip away, but I've had patients of mine for 30 years that worked and paid taxes and all that stuff. And then when they got their brain cancer, and the only thing they find on the Internet, it's made in America but the only place they could go get it would be like Denmark or Sweden or Switzerland. I'm not talking about crazy stuff in poor places in Asia, Africa and Central in South America. I'm talking about first class, like Copenhagen, Denmark. That's 3Shape. Finland, I mean they made Plan Mecca. And they had to sell their house and move to Scandinavia because they couldn't get the treatment here and it's like dude, I get it if you want to say that it's not approved and that since it’s not approved or won't be covered by Medicare or Medicare insurance. But for a government official tell me I'm dying of brain cancer and there are some scientists in this country says this is your only chance to stop that. I mean I think that is just over the top criminal.

KEVIN: Yeah absolutely. I 100 percent agree, and you know I personally believe in a lot of patient autonomy. Like you said it gets more complex when the government gets involved in who's paying and what's going on. But I agree, very, very challenging for a lot of people who want to sign up for a health care system where the government has the final say--

HOWARD: For 25 years, I've been writing to Senator John McCain and his wife Cindy that in Arizona we've got a bunch of retirees, we've got the Mayo Clinic, and we've got these big, Indian reservation on the west side and on the south side. And there, they have gambling and casinos. And I would say why don't you make that a free FDA zone instead of a free trade zone. Why can't there just be two areas where the FDA can go screw themselves. And if you're sitting there and you're a red blooded American, you don't want them to-- Who wants to move to Helsinki, Finland or Copenhagen, if your whole family, culture, church and friends are right here. There's so many-- I mean Phoenix is the largest state capital, that's one point four million, there's no state capital that is big as Phoenix. And every time I send that letter or talk to them or their people they say, “oh my god you could never get that pass.” and I say why?

KEVIN: Yeah, I agree. It makes sense--

HOWARD: And it is also research-- why would you want to do research on monkeys and apes when they're not the same DNA as you? I mean if grandma wants to be a volunteer lab rat for a new chemotherapy, I mean she's going to die anyway, if that's how she wants to go out, being lab tested be better on a human with the exact cancer than trying to extrapolate from mice and rats and pigs--

KEVIN: Again, patient autonomy. At the end of the day, that's the problem you're going to run into. The government is going to say yes or no to what you're allowed to do and it's going to create conflict. There's no doubt about it.

HOWARD: And by the way if you ever do decide to get money and you don't want to get in bed with the venture capitalist, or you'd rather get in bed with someone who has a lot of money in their dentist, every one of those CEOs. I mean you could just name Rick Workman of Heartland and Stephen Thorne of Pacific, Fontana at Aspen. Those guys are venture capitalists, seed fund. They'll really look at it and say, like shark tank. They'll either look at it like a Mark Cuban or Mr. Wonderful and tell you what they see wrong with it and then you can go fix it, or they might say no. I have six hundred locations. I see how this works. There is a lot smarter investor than a venture capital guy whose last deal was in consumer clothing or something.

PHILIP: You get the strategic partner.

HOWARD: Yeah. When you own 600 dental offices with a billion a year cash flow, they have so much access to so much more information and resource, whatever. But if you ever need VC money, I’ll go hit those guys up.

KEVIN: Yeah.

PHILIP: Thank you.

KEVIN: Thanks.

HOWARD: All right, guys. Well, tell your story on Dentaltown. Tell it to Tom Jacoby. He might cover it in Dentaltown magazine. That goes to a hundred twenty-five thousand dentists every month and Orthotown goes to ten thousand orthodontists, and then it's digitally sent all over the world. Tell your story and best of luck to you. And my God, I'll be cheerleading on the side here.

KEVIN: Thanks, Howard. You’re the man. Appreciate it.

HOWARD: And let me know if you need anything.

KEVIN: We'll do. Thanks Howard.

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