Dentistry Uncensored with Howard Farran

How to perform dentistry faster, easier, higher in quality and lower in cost. Subscribe to the podcast: https://podcasts.apple.com/us/podcast/dentistry-uncensored-with-howard-farran/id916907356

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howard

http://dentalhygieneboost.com

Karoline Biami is a Brazilian Trained Dentist, former dental assistant, and practicing Dental Hygienist. She coaches and mentors Dental Hygiene teams to maximize production and enhance patient care by implementing a Periodontal Treatment Program. Get started by getting your team on the same page with a written Periodontal Protocol. You can download her One Page Periodontal Protocol for FREE at her website http://dentalhygieneboost.com

Howard Farran: It is going to be a fun hour today. I get to lecture with Karoline Biami, who is a dentist from Sao Paolo, Brazil, which I love Sao Paolo, Brazil. I have lectured there three times in the last 20 years and it was also the largest lecture I ever was honored to give in my life, 4,000 dentists in Sao Paolo. That was the year 2000, at the Aesthetica 2000 Conference. I had a blast. I don’t’ want to say anything mean, but I think I do like Rio a little better. Every time I lecture in Sao Paolo, I would go spend two or three days in Rio before I went back. What is it called, Copacabana Beach?

Karoline Biami:Copacabana, yes.

Howard Farran:Copacabana, like the song. Who sang that song? Copacabana?

Karoline Biami:Jobim. Here in America Frank Sinatra recorded with him.

Howard Farran:Yeah, that beach. I mean, I don’t know how long that walk is along that cove from one end to the other.

Karoline Biami:Actually, the music is not from Copacabana, it is the Girl from Ipanema, it is the beach on the sides of Copacabana.

Howard Farran:And that has got to be, if there is a paradise on Earth, it is Copacabana Beach. And I want to tell all of the men out there watching this video that all of the women on the beach on there are almost as good looking as you are.

Karoline Biami:Oh, thank you.

Howard Farran:It is the biggest collection of beautiful people I have ever seen in my life. And the atmosphere is fun. Brazil is just, compared to America, it is just so more laid back and relaxing and fun and non-judgmental. They just don’t seem to be uptight at all.

Karoline Biami:I think we value a lot the family and good time with friends and family. So for us it is important to work of course, but it is important to also enjoy. It is like work hard to play hard.

Howard Farran:Yeah, and little nuances I picked up, like a lot of the dentists there, they don’t wear watches because they are not obsessed that they have to be back at the office in 3.1 minutes to seat their patient exactly on time. I mean, if they are finishing up lunch then they will just jolly, lazily, stresslessly go back and it just seems to be so much less stress and so much more happiness.

Karoline Biami:Yeah, it is like our lunchtime for example. We sit out with family and eat. It is not like here. I learn here to be like an American girl, but it is definitely a different culture. But you know, Howard, there is no right or wrong. I would say to you that a balance would be the ideal. I love America, I love this country. I am a citizen now and I chose this to be where I am going to be with my life. I do miss Brazil, but here we are doing great stuff, especially when we talk about dentistry. It is awesome.

Howard Farran:Now is your husband from Brazil, too?

Karoline Biami:No, he is from Chicago, Illinois.

Howard Farran:He is from Chicago. So are you losing your Portuguese now that your husband speaks English?

Karoline Biami:I can lose my Portuguese, but my accent seems to get stronger every day.

Howard Farran:So you moved to Florida, which I think is just genius how Florida is the only state that lets a dentist from a foreign country come be a hygienist. You know, we have hygiene shortages in many rural areas. I know dentists in small towns that have had ads out for hygienists for five years and no one has applied. And there are dentists in their city that were trained in India or Brazil or Russia or Czechoslovakia and kudos to Florida for doing the obvious. So then you came to America and you were a dental assistant in Chicago.

Karoline Biami:Yeah.

Howard Farran:And then you became a hygienist in Florida. And now, after seeing all of these offices, you are breaking out into dental office consulting.

Karoline Biami:Exactly.

Howard Farran:So tell us what made you interested in dental office consulting and what are you bringing to the table with that?

Karoline Biami:Okay, well after we start that I am going to tell a little bit about me. I come from a family with two alpha docs; there are two alpha dentists, believe it or not. So I would say that dentistry is in my blood. And you know, I didn’t have a lot of choice what to choose to be my profession. So I have been in dentistry for 13 years now. I have five years as a doctor in Brazil, three years as a dental assistant in Chicago and five years working as a hygienist. And since then I have been out, so like you said, I have been going to a lot of dental offices and helping a lot of doctors and dental hygienists. I quiz their productivity and quiz their lab work and patient care, and profits as well. I feel that I have a 360 view of the dental practice and that gave me a lot of baggage to be able to help hygienists and doctors place systems and protocols in place to, you know, make their hygiene department rise and be very productive.

Howard Farran:Now my thinking on dental consultants is, I have been telling consultants this for years, that a lot of them don’t want to share what they do, because they think the dentist is going to learn it and then not need their services. And I think it is the opposite. I think most dentists when they pick a consultant, I say, “Well, why did you pick this one?” And they say, “Well, this one, here is their menu what they do and here is what this person does.” Like some want to come in and drop all of your insurance and turn you into a cosmetic boutique spa. And they are just like, that could be right or wrong, they just don’t want to do that. And then this one, maybe their area is insurance or HR or whatever. I think the more transparent the consultant is and says, “This is what I do,” then the dentist looks at them. Because what I think the dentist is actually buying is the dentist knows that he or she is not getting it done. So I am not giving you money because you know something that I don’t know or can’t understand, it is just that I can’t get my team to do this. And a lot of times when an outside person comes in, they are more accountable to you than the dentist that they have been working for for five years who they know is easy going and is just going to be a rollover.

Karoline Biami:Exactly.

Howard Farran:So tell us your menu. So if I am a dentist out there in America, what would you do for me? Let’s just say I am in Wichita, Kansas, and my office is flat. Obviously the economy since 2008 has not been, you know, that was the biggest recession we have ever had. My office is flat. It is not going down, it is not growing. Basically, it is malaise, it is apathy.

Karoline Biami:Okay.

Howard Farran:So I want to bring in Karoline for a fresh shot of energy. What would you do for my office?

Karoline Biami:Well first Howard, I am going to talk with you to know what you believe, what is your philosophy, your culture. What do you want for your office? A consultant can go in, but if they don’t work with your desire, what your vision is, it doesn’t work. So I would sit down with you first and ask what are your goals, what you would like to accomplish and what your hygienist and your dental assistant do for you to help you out. So after that, we have got to talk with the team also and make sure that the team and the doctor are on the same page. That, I think, is the bigger trigger. I go to dental offices where the hygienist likes one thing, the doctor likes another thing. I feel like there is a gap between hygienists and doctors where sometimes doctors are ready to start a protocol and implement systems in place, but hygienists don’t really feel like it is the right thing for her. Or vice versa, sometimes the hygienist is ready, she wants to work with the consultant and she wants to provide better care for the patients, but the doctor has some resistance. So I would tell them that the first thing is I would talk with the doctor and the team. I believe that they need to be on the same page. Once we get to a point, a common goal where everybody agrees, then we are going to see what is going on. We are going to see what you are doing right now and how can we improve that.

Howard Farran:And Karolineine, if we were talking in America football or in Brazil soccer, and obviously when you were in Brazil and you were analyzing and you were going to consult a soccer team, you would focus on, do I have the best five soccer players on the field.

Karoline Biami:Right.

Howard Farran:And you wouldn’t be talking about the stadium, the ball, the grass, whether it was natural or turf, or the uniforms. You would go right after the players. And you would go in there and you would say, “We need to get this player from another team and we need to get rid of that player.” When you go into an office, how do you evaluate if I have got the best five soccer players in my office and how do you make these tough calls that, no, this soccer player is never going to – this isn’t a goalie and we need a better goalie? How do you make those calls, because do you believe that the players are the most important part of the office team?

Karoline Biami:Definitely. There is no success for the doctor if we don’t have a good team. The team can make or break the doctor, I say. Definitely I think the first thing, it is analyze numbers. Numbers are extremely important. Numbers don’t lie. So we can go, for example, in the dental hygiene department and analyze the numbers. And also see who is really on board, who is the hygienists that don’t mind if they are a half an hour late if it is necessary, don’t mind skipping the lunch that day if it is necessary and see also who has a good feedback from the patients. If that one has a caring touch, that one is focused on educating and giving information to the patient, all of that is extremely important. But you know, I feel that everybody should have a chance. A consultant can train and develop some excuse in our team that I believe should be the first move. And then of course if you see that you give opportunities, you are investing in your team and they are not giving anything back, then you need to look for other players to be in your team.

Howard Farran:So give some red flags. A lot of dentists tell me, you know, probably the most common question I get is I have had this staff person for five years and I am just not sure if I should keep trying or let her go. How do you come in on the outside versus the dentist who has been with this assistant, receptionist, hygienist for five years? How do you come in the outside? What are you looking for to decide, you know, should I stay or should I go?

Karoline Biami:I like, first, personality. I think you need to have on your team people that believe in what you believe and people that give their blood to make it happen. It doesn’t matter what happens, you need to put all of your office to help the dental office give the best care for your patients. So I would say personality, attitude is extremely important. Other things that I think are important, see how professional that person is. How is your hygienist acting, even outside the office or with your patients? Does she respect you? You know, there is gossip around, so we should not have those things. I always tell, leave your problems outside the door. When you walk in, it is all about be the best you can for your patients, have the best custom service and the best treatment. Focus on doing the right thing for your patients. As far as hygienists also Howard, it is very important for a hygienist to know how to treat, diagnose and treat periodontal disease. I say that because a lot of offices in America are losing opportunities because of that, losing opportunities just to do the best for our patients and opportunities financial also to make profits. So you don’t want to have those hygienists that want to clock in and clock out, be a prophy machine I say, those bloody prophies, and go home. No, you want someone that is interested in learning more, is interested in really diagnosing perio in conjuncture with the doctor and that has a good attitude. You know, help remove the garbage at the end of the day. If there is no patient, go to the phone and do some calls. Help the dental assistant. I don’t like those queen bee hygienists, you know? You really do whatever it takes. And for me actually, that was easy to learn having my experience as a doctor in Brazil that gave me all of the knowledge about the business side of the industry, that we have payrolls, we need to pay people, we pay the rent. And then coming to American and working as an assistant gave me that, okay, I am not a doctor now. I need to follow the doctor. It gave me an understanding on how important it is to be a team player. A dental assistant needs to be the best in the dental office and really follow that command from the doctors and have those systems in place, like what a consulting company can bring to you, help the assistant be able to think one step ahead of the doctor. And as a hygienist, I learned that caring part of dentistry and the education, extremely, extremely important. You inform your patient, educate your patient about what is going on with them, and then I guarantee to you Howard, they will accept more treatment when they notice that you care and really become loyal patients for you and refer more. But before you get to that point, definitely you need to have a team player, someone that gives her blood and soul to the dental office, is not there just to clock in or clock out, but to be serious and remember why she became a healthcare provider.

Howard Farran:Yeah, and you know, dentist’s complaints are a cancellation in the hygiene department and then an emergency patient that needs to be seen today. And don’t those things balance each other? And when I tell dentists, well, if your hygienists had a cancellation at ten and you have got a toothache, well schedule with her. She has four years of college, she can take a PA and a bitewing and diagnose everything and get it all ready for you.

Karoline Biami:Exactly.

Howard Farran:And dentists just routinely tell me, “My hygienist won’t do that.” And I am like, “Well, then why did she go to school for four years?” Like you say, we are a fireman and if you put water on the fire, it doesn’t matter if it is a toothache, periodontal disease, a two year old prophy, I mean, you are a healthcare provider.

Karoline Biami:Exactly, and I like the words a lot, because healthcare provider for me means help bringing back the health for your patient, take them out of pain, bring their confidence back by beautiful smiles, but also the care means take the time to inform, to educate your patient about what is going on. So in the case like you just described, yes, if the hygienist has a chair available, please, why not take the x-rays, start to review the medical history, see if there is any connection between what the patient is having in his mouth with any medication that he is taking or any pre-existent factors that may be causing the problem. And be a bridge. I believe the hygienist should be the bridge between the doctor and the patient. I think it is so awkward for the doctors to walk in the room and the hygienist doesn’t say anything. So the hygienist should warm up everything and tell the doctor what she finds and tell also her opinion what should be done with that. But I feel that there is a lack of communication. And there are two parts on that, Howard. Sometimes the doctors can maybe not explain to the hygienists what they want, so it is very important the doctor be the leader, the doctor leads the conversation and the doctor starts telling the hygienist, I would like this, this and that. And it is very important for the hygienist to understand what the doctor wants. And if she doesn’t know, ask. Explain to the doctor it is that, I am doing it right. And I believe the consultant can open that dialogue between the doctor and the hygienist. And like you said, when we listen from somebody else, it is always more powerful than from the ones that talk with us every day.

Howard Farran:I feel sorry for the hygienist whose doctor keeps her handcuffed by not letting her point things out on the x-ray and say this tooth needs to be extracted, it can’t be saved. This one, you could either do a root canal or extraction. I mean, they have got four years of college and if they were four years of college and became a registered nurse, they are in the hospitals giving shots, starting IVs, dispensing medication. And then they go work in dentistry, and if they work for someone like me, I want them to do all they can, because they are in there for an hour to communicate with the patient. And I would say two-thirds of them are handcuffed by their dentist. They are not allowed to take x-rays unless the doctor diagnoses and says, “Oh yes, you can take an x-ray.” They are not allowed to just look at that and say, “I need an x-ray.” I mean, it is just crazy.

Karoline Biami:Yeah, I think that the hygienist needs to take more, how can I say, empower themselves to really feel confident about doing things, even if it is something that they need to maybe communicate with the doctor before. But the hygienist has a big role in the practice. So I will say, talk to your doctor and tell them, “Look, I can take x-rays and I can make your life easier by maybe anesthetize a patient for you,” if it is a state that allows hygienist to give you local anesthesia, for example Florida , everything happens here so late, but two years ago we are allowed now to give also local anesthesia to the patient. So help the doctor if the doctor is running behind. Do you need anything, or the assistant. And really be proactive on things. I don’t like micromanagement. I don’t think that it is good for any one of us. So I would say that it is all about the open conversation, Howard, and the hygienist tell what she thinks would be the best for the practice and the doctor also, and they come to a conclusion. And remember, we are a team. We are not against each other. We work on the same team to bring good results for our patients.

Howard Farran:Yeah, and I wish all healthcare providers were like that. Like you go to the pharmacy and the pharmacist can give a vaccine and vaccinate grandma for the flu. But here I have got grandpa and he hasn’t been to any healthcare provider in a year and he is in my office. I can’t give him a flu vaccine. You know, a registered nurse can give you an HPV vaccine in the hospital, but I am a doctor and HPV is the cause of oropharyngeal cancer and I am not allowed to discuss the HPV vaccine and give it to the patient in the chair, or the hygienist. So yeah, the government, I mean I know they are trying to regulate and protect the public, but a lot of these regulations cause more harm than good.

Karoline Biami:Yeah, definitely. And I feel that the regulations between professions like hygienists and what hygienists can do or not, because we are such a big country and we end up having different rules for each state. It can become a little difficult for the hygienists as well. But I would say, for example, you just mentioned, if the hygienist is in the office, she is the front line, for example, to fight periodontal disease in my opinion. So she needs to start the conversation with patients about it and don’t just let the doctor come in and see and start to work in a veneer in a bloody gum. You know, it is not going to work. One of the reasons I say that is because I worked in Brazil as a doctor and I remember how it is important the perio health so I could do a veneer so I could do a nice implant, you understand? And I see that there is not a connection. Hygienist, she didn’t dot the point to understand. Connect the dots there. For example Howard, it is epidemic what happened here in America, and in Brazil, too. CDC says that 50% of the Americans over 30 years old has periodontal disease. Academy of General Dentistry says that 80% of the population in America has a type of gum problem. That is included periodontitis and gingivitis. So I feel that the hygienists sometimes close their eyes and start doing those bloody prophies and they need to really start a conversation with the doctor and with the patient and tell, “Look, we need to address that to our patients,” because there is that whole mouth and body connection that we know today that this can affect cardiovascular disease, diabetes, pancreatic cancers and pretty much mothers who are pregnant end up having premature babies, all of that can be aggravated by gum disease, by perio. So definitely I feel that it is an opportunity there to the dental hygiene department to connect the doctor, the patient, the hygienist and not only do the best for our patients, but be more profitable, increase production in the dental hygiene department. And that the hygienists need to understand, that business part of dentistry. She is not there only to clean teeth, but to participate and to engage the patient with the doctor, to find a crown that has an open margin, to find a broken filling and really refer to the doctor so it is a win-win situation.

Howard Farran:I would say, I have said this for years, that if I could just one word of one trait of the most successful, not only dentists, but any business owners, it has always been humility. It has always been humbleness. A company, I don’t care what you make, you make a product and your customer complains. 90% of people don’t want to hear it. If you post a bad review on Google or Yelp or whatever, they want to get an attorney and sue you and take it down and all of this. But the humble ones are the ones that are saying, the humble dentists listen to the hygienists. The humble dentist listens to the assistant. And so many dental labs tell me they can’t call their dentist and say, “This is a horrible impression. You need to retake that and you need to manage the gums better and you should get an ADM laser.” Because if they say that, the dentist is going to tell them to go fly a kite and then he is going to lose a $5,000 a month customer. And it is just humility to just walk in a room and respect your hygienist or your assistant or your front office. And they say, “Here is your new patient. She left her last office because they said she needed a deep cleaning and she just wants a regular cleaning. And I talked to her about that and we talked for 20 minutes on the phone about that. So I want her to see the hygienist.” And you know, just humility. And the worst business owners and the worst dentists are control freaks who don’t let anybody talk, you can’t deliver them any bad news. It is kind of like Saddam Hussein. No general could say, “Well, if you start a war with America, they are going to kill you in 100 hours.” If you said that, he would kill you. He wanted to hear that we are going to kick their butt. And what did it cost him? His life.

Karoline Biami:That is true.

Howard Farran:So yes.

Karoline Biami:You know Howard, being from another country gave me a lot of that humility, to come to America and from a doctor become an assistant. It made me reevaluate a lot of things in my life. And I am going to tell you that you are always going to find people that are more difficult to work and others that are easier, but it important also we give a chance and really try and understand what is behind that control, what is behind that micromanagement. I believe that when we talk and we have opportunities to know each other better, this can end up going away. I am a hygienist and when I go to a dental office, I am straightforward about the type of office I want to work, the type of doctor that I want to work and the type of person that I am. I tell if you want your hygienist to be a machine, be quiet, it is not for me, because I do like to interact, I do like to give my opinion. But some people are not prepared for that. Some doctors may not be prepared for that. And the most important thing I believe is open your mind and you see there is more beyond you, is going for example to Dentaltown. You know, like if you go to the forums of Dentaltown you can meet a lot of professionals that can give you some tips, hey I did that with my hygienist and increased my communication. The other can say I did the other thing. But also, be prepared yourself. Sometimes I believe doctors can have some insecurities because they maybe don’t have that communication so into their soul let’s say. So you know, take classes. I saw the other day; Jamie Butler is speaking with you about stress management. Awesome, I was like, wow. Because, you know, take some extra classes, continue your education, hire a dental consultant that can give you some tips on how to communicate with your team. And I tell the hygienists the same. You know, maybe if you have more knowledge, you are going to feel more secure to address problems with your doctor. I tell them to go to HygieneTown, there are the perio reports that you guys to every edition. It is awesome. Go to continuing education, prepare yourselves more as a professional so you can talk with the doctor on the same level and be able to have that open conversation that will in the end improve your dental office, your team.

Howard Farran:So you said you like numbers, because numbers don’t lie. So talk about numbers. Like when you go into a dental office, like say I was bringing you in to consult in my office. What reports would you want to see before you came in the office? What numbers do you look at? What do you try to do?

Karoline Biami:Yes, I believe that before we improve as a person, that should be me or you, we need to know where we are right now. So for example, I talk about dental consultant and I talk about people having consultants who help to move forward. I tell that because I do have my business code, I do have my English code. I am trying to lower my accent, Howard, believe me I have been working so hard on that. But before I start that, I need to know where I am. So I need to have tactics to know which level I am to be able to improve. So in a dental office, it is the same thing. I always encourage doctors to pull up their reports and really know what is going on in their practice. You can do that from, I would say, any dental software if you have one. And I really recommend you have one that helps you a lot. And pull up reports from the last 30 to 60 days. And there are three reports that are very important, in my opinion. One, know your overall hygiene production. So let’s say if you make $10,000 in a day, your office makes $10,000 in a day, there is a benchmark that says that 33% should come from hygiene. So your hygienist, your department should produce 33%.

Howard Farran:And would that be the office with one hygienist and one dentist?

Karoline Biami:Yes, exactly. If she is producing less than that, it is missing opportunities to do the right thing on treating and diagnosing periodontal disease, because a lot of hygienists doing prophylaxis all of the time when we know the prophy should be done in healthy patients. If that has nothing to do with the numbers, like 50% of the Americans over 30 years old have perio disease. So we cannot do prophylaxis on that patient without being neglected. It would be doing wrong to our patient’s lives. So I would say that when you pull up the report, if you see that 33% of your production that they come from hygiene, you are in a good margin there. Your hygiene department is good. Another thing that you should look is how much your hygienist produces for you per day. So you can run a report and check their hourly rate and then you can multiply it by the number of hours and you have the daily production. There is an easy formula that if you guys want to contact me and I can give it to you or I can talk right now if you prefer. It usually is three times the hourly rate of the hygienist times 1.25. That 1.25 means the taxes and the fees that goes with the hygienist’s salary. So three times her hourly rate time 1.25. What we see as a good benchmark would be your hygienist producing at least $1,200 a day. Of course Howard, it depends on where you are located, where your office is. If you are in New York or you are in Florida, there is a big difference there in terms of fees and salaries also, so you need to be more flexible on that. But that is the benchmark there. And also the third one that is extremely important is see how much of periodontal procedures, how much perio therapy are you doing, how much extra fees, perio maintenance are you doing. So you can pull up a report with those codes, the hygiene codes, like 4341, 4342, the specific codes or 4910, the maintenance code, and you can find a percent of the hygienist is doing a perio therapy code. Usually tell that if your hygienist is doing 40% to 60% in perio therapy codes, you are doing good. You are addressing periodontal disease in a serious manner in your office and you are having profits. So it is not only about the numbers, Howard. The main thing for me is we cannot keep putting patients in our chair and asking them, “So are you taking any medication?” And the patient gives you a list and you don’t connect the medication with what is happening in their mouth. We need to stop. We need to start thinking more and really, “Oh, okay. He is taking anti-depressants.” We know that causes xerostomia. We know that xerostomia can cause problems in the mouth. So we need to think, start to think and connect the dots. And then when you have that, then you are going to sit down the patient in your chair and you are going to take intra-oral pictures, you are doing to do the full mouth prophies. There is no way you can see how the patient is doing, how your hygiene department is doing, if your hygienists don’t have the probe in her hands. She needs to have that. So once you have that, you can see that your patient maybe is not healthy, he is not just for prophylaxis. He needs for something more. And then if you have opportunity to take continuing education, go to Dentaltown, HygieneTown, you end up having a chance to educate the patient and convert the patient from a bloody prophy to periotherapy and you when you are doing that, you are saving lives. We know already, we talk about how gum disease can influence the whole body and we want our patients to have us like someone that is going to educate and provide the best service. So I can’t stand those bloody prophies anymore.

Howard Farran:So you talked about a lot of numbers in the hygiene department. Are there any numbers you look at for non-hygiene departments, like for the dentist or office overhead or any other numbers, collection policy?

Karoline Biami:Well, no Howard. The numbers, I work a lot with the dental hygiene department, consulting more for hygiene department. But I can tell you if the hygiene department is not producing that 33%, she is not sending to you patients, she is not finding more work for the doctor, she is not referring patients to you. And that is extremely important for the overall production. And if you know that also Howard, the hygienist is doing way more than 33% of your overall production, that means that your production as a doctor is lower. So that means the hygienist is not finding work for the doctor. That means that doing the periodic examination, just like, “Oh, you are fine. See you in six months.” So that is not the right way to go.

Howard Farran:So Dr. Karoline, what would you say to a dentist if he says, “Well, I don’t really have a perio program.” So he hired you to come in and set up a perio program in his office. Talk about how you would set up that perio program and what do you like to see.

Karoline Biami:Yes, I would say to you that is very common unfortunately. A perio program, it is doing the right thing for your patients and treating aggressively periodontal disease. And by the perio program, you are doing a lot more profits for the dental office. First thing Howard, about 97% of the offices in America are billing out procedures like prophylaxis. It just doesn’t make sense. If 90% of our patients that sit down in our chair are for prophylaxis, so is the CDC and the Academy of General Dentistry lying? Because the numbers just don’t match. Do you agree with me on that?

Howard Farran:I do agree with you.

Karoline Biami:Yes. So I would say to you that it is important for the protocol to have systems in place. First thing, I would talk to the hygienist. I will observe one day or half a day, observe how a hygienist is doing. I will pull up your reports and know how much you are doing perio therapy codes. If we see that it is just not going well, I will have a talk first with the hygienist and try and understand why she is not doing a full mouth prophy, why she is not taking intra-oral pictures, why she is not educating the patient and making the patient understand the importance of his health and the connection with his mouth health with his body health. A patient Howard, that understands that, will definitely accept treatment. And I tell that there are three big road blocks that stop the office from implementing a perio protocol. One is the team is not in the same place, the same page. So it is so embarrassing, but I have got to tell you. Sometimes in a dental office, you walk in there and the manager tells, “Oh, we recommend that type of electric toothbrush, the type A.” And then the hygienist says, “No, no. Here we recommend the type B.” And the doctors say, “Use a regular brush.” So it is like, the patient gets confused. Do we think the patient will accept treatment? Of course not. And then the hygienists say, “Oh, I think you need a filling here in the #30.” And the doctor says it is a crown, the manager says, “No, let’s just watch.” I mean, patients don’t accept treatment because they don’t understand what is going on. So first, we need to be all on the same page. It is impossible also a hygienist number one produces $800 a day and the other hygienist produces $1,200. I mean, if they both are working in the same dental office, what is missing for one? So everybody should be educated and be on the same page. Number one, that is the number one road block that I found for not having a perio protocol in place. Number two is time. I notice that sometimes doctors don’t give enough time for the hygienist. I will tell, it is impossible. You check the blood pressure at the beginning of the appointment, you do a full mouth prophy on the patient, take intra-oral pictures, take the x-rays, full mouth series, and then you talk with the patient about what the patient has and then you do the cleaning and then the doctor comes in for the exam. You have got to clean up the room for the next patient, you need to write down your notes. If it is less than one hour, it is impossible. So sometimes the hygienist is not implementing a good periodontal protocol and is not paying attention to what your office really needs because of that. They don’t have time. And the third, I would say that is communication and education. Because I come from Brazil and English is my second language, I learned that if I want to communicate well, with my patients back in 2005, I need to have easy and simple terms to talk to the patient. I need to have the patient look at me in the eyes when I talk. I need to ask the patients, “Do you understand what I said? Do you have questions?” And we need to be a little detective and say, “So tell me more here. You said your mother had diabetes. Can you tell me a little more about that?” And communication and education is something that will improve every day if you are doing that. If the team and the doctor don’t make any effortor their hygienists, that protocol is not going to be implemented. Use the analogy, for example Howard, sometimes I tell the patient. The patients says, “Oh, I want a whitening. I want to have my teeth white like yours.” And I see that there are bleeding gums, there is bone loss, there is mobility, I tell them, “Look, imagine if you buy a house. And you see that beautiful chandelier or you see that TV, I don’t even know how many inches is the big TV, but you see that you want something fancy for your house. But the foundation of your house is broke. How can you put that beautiful chandelier in a broke house?” So I tell them that we need to start by taking care of the foundation of your mouth, that is your gums and your bones. Then once we make that stable, we can go to the next level and do your whitening. But you need to sometimes talk with the patient with analogies they can understand. For example, I say, “You know, after all of that investment of time and money that you did in your treatment here with your perio treatment, you need to maintain.” Okay, so by saying that, I want to tell him that he needs to purchase the electric toothbrush that I have in my office. I am telling him that he needs to purchase the rinse that I suggest. Otherwise, he is alone. He does not have what to do to maintain his good oral health at home. And then I tell them, imagine you buy a Lamborghini and you have the fancy car, but guess what? You don’t put oil, you don’t put gas, you don’t take care of your car. The car is not going in their full potential, right? They are like, “Oh yes.” Because that is important. I am doing, I am playing the team here like a soccer team, I am doing my best. But you need to do your best in your home as well. So sometimes hygienists don’t have that, and that is part of my consultant job. I really talk about communications and analogies that can really touch the patient and make them like, “Oh, because of that I need to fix this, this and that.” And make it personal. It is not about your doctor, it is not about your hygienist, it is about the patient. What is good for them? Talk about them and, you know, make it personal. Make them feel like you care. And if they feel like you care, they trust you more, they refer more and here it goes. You are increasing your profits.

Howard Farran:So a big question every dentist has, a lot of patients, Dr. Karoline, call us up and say, “I want to make an appointment to get my teeth cleaned.” And we don’t know who this person is from Adam. We don’t know if they have perfect teeth. We just don’t know. How do you schedule a new patient who just wants to come in and get their teeth cleaned?

Karoline Biami:Well, I would say in my experience, a new patient needs to have at least 90 minutes, an hour and a half. If you say, “It is impossible Karoline. I don’t want to give that time for a new patient,” then I would tell you, you need to have in your schedule pre-blocks. What is pre-blocks? Let’s say Howard, you can in to me and you are thinking you are going to have a prophylaxis, a simple cleaning, get in and get out, but you have gum disease. You have periodontitis. So I would explain to you what you need and by making it personal to you, by taking my time, and once you accept the treatment, I need to have the time to start at least one quadrant. But I would never let you go without starting something, okay? So we want the money there. Money is important for us, also. So we are going to start one quadrant there. So I need to have that 90 minutes. If I have an hour and a half, it is enough to collect all of the data and x-rays and the pictures and exam and then I can start the treatment, the procedure. If I don’t have, it is important to have some blocks in your schedule. A lot of offices are so busy that if I need like an SRP, I just can get in your schedule two or three weeks after. I mean, really? Your hygienist has spent more than 20 minutes telling how important it is treating gum disease, it is serious, you cannot let it go. And then when you go to reschedule, you cannot get to the patient because you don’t have time. So I would say making two or three blocks a day to start is a good thing. Or give the hygienist the 90 minutes with the new patient. But time is important. There is no way that we can do the right thing if we don’t have the time.

Howard Farran:You mentioned an electric toothbrush or a mouthwash. Are these part of your protocol? Do you recommend electric over manual and why is that and mouthwash? Go over that.

Karoline Biami:Yes, definitely. I think it is not only what you do there once you diagnose what the patient has, it is not only what you do as a procedure, but how you are going to leave the patient alone without any support? No, he needs to have an electric toothbrush, definitely. You know, there is no doubt about that, especially if he is not being very good with his oral hygiene. There are rinses, yes, that can help lower the level of inflammation in their gums. There are antibiotics that I would apply also in the office to help the patient. So all of this will help the patient to get to a good health state and will increase the profits. One perio patient, Howard, is three times more valuable than one prophylactic patient. Let me tell why. A prophy patient comes to our office two a year, every six months. A patient that has perio problems, he needs to be there every three months. So once your hygienist takes the time and explains why it is important, the patient will be four times a year in your office. So here you go, you increase your profits already. Then you are going to tell him that he cannot, once he invests all of that time and money during the treatment, he needs certain tools that are going to help them taking care of their gums in their house. So then you are going to get from your closet that toothbrush as part of the package, you are going to get the rinse, you are going to get anything, the tongue cleaner, the tongue scraper that the patient needs and that is part of your therapy. So you are not selling procedures. You actually recommend therapy. So what they need is like a home therapy that includes your visits there, but also includes things that you need to use at home to be successful.

Howard Farran: And give them name brands. So you are mentioning electric toothbrushes and mouth rinses, but what brands have you grown to like?

Karoline Biami:Oh Howard, you are putting me in a situation here that is difficult now.

Howard Farran:Is that not good? I mean, because you have thought about this a lot more than a lot of other people, so a lot of people would want your recommendation.

Karoline Biami:Well, I would say I work with the three main ones in the market in my opinion are Sonicare, Oral-B, and it used to be ZILA, now it is DenteMax that is the Rotadent. I think those are the three that I work and I can recommend. They are all equally good for the patient.

Howard Farran:Rotadent, you said ZILA? ZILA bought Rotadent?

Karoline Biami:No, ZILA used to manufacture Rotadent.

Howard Farran:Really?

Karoline Biami:Yes, but ZILA was bought by DenteMax.

Howard Farran:Denmat? Really?

Karoline Biami:Yeah, they just purchased them.

Howard Farran:Denmat bought ZILA, I did not know that. My buddy is the CEO there, Steve Semmelmayer. So they bought ZILA, which makes Rotadent.

Karoline Biami:Exactly.

Howard Farran:And that is one of your three favorites, Rotadent?

Karoline Biami:Those are my three favorites, Sonicare, Oral-B and Rotadent. I would say that if you have one of them, you are good. The patients will have a good care. The other thing, Howard, that is part of my protocol, definitely oral cancer screening in the patients. We can no longer, put your tongue here in the gauze, look to your right, look to your left. No, please. We have other tools that help us. We have Velscope, that is awesome. We have Identify, that is the other oral cancer screening system. We have Visilight, we have now the Oral ID is one that just came out. It is awesome, it is excellent.

Howard Farran:Didn’t ZILA have a light? What was ZILA’s?

Karoline Biami:ZILA is Visilight, but now they incorporate Velscope also in their products.

Howard Farran:So ZILA got bought by Denmat and ZILA has Visilight and now they incorporated Velscope, too?

Karoline Biami:Yes.

Howard Farran:Those were two separate companies and now they are all owned by Denmat?

Karoline Biami:Yes.

Howard Farran:Okay.

Karoline Biami:And now there is one new company, I don’t know the new one, I know they are from Texas. It is called Oral ID. It is a light system to help you with screening also for any abnormal lesion in the mouth of our patient. Also we have the Identify, that is a very good also light system. So I would tell you part of my protocol is also telling the patient the importance of oral cancer screening. And for that you charge extra for your patient. Okay, so you are going to be making money also.

Howard Farran:And what do you charge? Does insurance, like does Delta Dental pay for these?

Karoline Biami:No, the majority of them don’t. There are some insurances that do, the majority don’t. I can tell you here in Florida, okay I don’t know New York or Arizona, but I would say Florida is about, you can charge up to $60 for oral cancer screening in your patient.

Howard Farran:In Arizona we don’t do oral cancer screening, because we are all going to die of skin cancer. I have probably got a melanoma on my head right now and I am not even worried. I want to ask you another thing about oral cancer. We are seeing an explosion of oral and pharyngeal cancer because of HPV.

Karoline Biami:Yes.

Howard Farran:I think, what are your thoughts? Is it a dentist’s and is it a hygienist’s role since we deal with oral and pharyngeal cancer to talk to patients about HPV vaccines?

Karoline Biami:Yes.

Howard Farran:Do you talk about this or is that…?

Karoline Biami:I do. I think all of the team should talk since they walk in the door, the front desk, office manager, doctors and hygienists. But I take the responsibility. I don’t mind. You know, bring it to me. I will take it. I talk with them. I make comparisons, especially with the women. I tell them, oral cancer being increasing a lot in our country, one person dies every hour from oral cancer. So that needs to be stopped. We cannot keep doing that. And they look at me and they say, “Really? I never thought about that.” And I say, yes. So we have here in our office a new technology that we can, by a light, a spectrum of light, we can diagnose any lesion that can be suspicious, not necessarily cancer I tell them, because they start freaking out. So I say not necessarily cancer, but any abnormal cells that we can end up finding in your mouth. And then I tell them that is not covered by your insurance and the price is $50, for example. They are like, “Oh, I don’t want it. No.” I say, “Look, you are a woman like me. We go every year to the gynecologist and we do our Pap smear, right?” Yes. I would say, “Do you know what is the Pap smear?” And they are like, “Well, no.” And I say, “In the Pap smear, they gynecologist removes some cells and she is going to test those cells and see if there is any abnormal cells. What I am doing is the same, but I am taking the cells from your mouth and we are going to test and see if everything is okay. It is very important. If your gynecologist tells you that she is going to charge you $30 to $50 to do the exam, would you say yes or no?” Oh no, yes because that is important. Here it is the same. We are here, we are healthcare providers and it is the same. I am telling you that we need to test for those to see if you are okay or if you have abnormal cells that can lead to oral cancer and that is the price. It is your health. So I think that is not even an option for you. Am I right? And then the patient says, “Yes, you are right.” But if you just tell them, “Look, you need to be tested for oral cancer,” they are not going to accept it. Of course not. But if you are a hygienist, take the time to explain why it is important. Compare, make analogies. The patient will say yes. So that is what I work a lot of when I go to dental office consulting. I work a lot of on how to communicate to the patients, how to educate the patients and also how much this increases your profits. It is like it is night and day, Howard, I would tell you. There is no way that I team can work without having the right verbiage, the right information to give to our patients.

Howard Farran:Karoline, I am a man so I have never had a Pap smear. But do they use those lights downstairs? I mean, some men have told me that Visilight and Velscope, a lot of this technology was all pioneered from women in a Pap smear. Are they just taking a swab and putting it on a Petrie dish out or do they actually stain the tissue, look with a light?

Karoline Biami:I don’t know all gynecologists, I can tell by mine, mine take a sample of course, but also use the light.

Howard Farran:So they are using light down there.

Karoline Biami:Yes, down there, yes.

Howard Farran:I have heard men say that, but then I am always wondering, I am pretty sure that man telling me has never had a Pap smear.

Karoline Biami:Yeah, but if you have a male patient, you are going to tell, you know how important it is the prostate cancer and prostate cancer killing people. So you know, we need to do the same. We need to examine you to make sure that you don’t have any problems and we are healthcare providers. We are here to educate and to bring you back to health, to maintain your health.

Howard Farran:And you know what, there is no accountability either, because there are a lot of girls in Phoenix who are having massive oral cancer at 22 years old that were seen every six months at a dentist right here in my back yard and no one ever said to the little girl and the mom and dad, “Have you considered getting an HPV vaccine for your daughter?” And then at 22 the mom is livid that she has had a six month recall for the last six years, nobody told her about this. And then the dentists are always telling me that they get mad when people say, “Oh, you are a dentist. You are not a real doctor.” And I always want to come back and say, “Well you know, by your actions, you are not a real doctor. You are a molar mechanic, because you had a little girl come in your office every six months for 15 years and now she is dropping dead of oral cancer and you never once mentioned the HPV vaccine.” And then the state boards, I am not even allowed to give the HPV vaccine, but a registered nurse can or a PA can. And my pharmacist can give you a flu vaccine. It is very confusing and we need to get, dentists and hygienists need to become, like I say, it is like when I see a house on fire on fire, every fireman is putting water on that house. And I am the healthcare provider and I feel like 90% of my job is putting water on a fire from two gram negative anaerobes, P. gingivalis and Streptococcus mutans, two bugs that can’t live in oxygen. But this HPV virus is rearing its head and I am in a big town. I am ten minutes from Arizona State University and there is a lot of oral cancer from ASU and it is mostly girls.

Karoline Biami:Yes, I just knew that two weeks ago a girl here in Florida, here in my city in Fort Lauderdale, she passed from oral cancer, a young girl, 18, 19 years old. And yes, you know, this cannot happen. And it is very important that we communicate. And if the doctor doesn’t feel comfortable, the hygienist needs to say, “It is on my. I need to talk.” I mean, you cannot really pretend that it is not there. We are, yes, you are a doctor and you are as capable as a physician is to help the person to understand their problem. And sometimes, Howard, the patient will march to us, to our dental office, then they go to their physicians. At least twice a year we see them, and then we cannot close our eyes from that.

Howard Farran:Karoline, do you know what it reminds me of since I am 52 and I graduated in ’87? In ’87, everyone was embarrassed to talk about HIV because it was gay people and homosexuality back then was in the closet, it didn’t come out of the closet, it wasn’t legalized. People didn’t want to mention it. I remember older instructors would call it gay cancer, you know? And now, here I am 52, 27 years later and dentists and hygienists say, “Well I am not going to mention HPV. That comes from oral sex and I can’t say oral sex in front of the patient.” And I am like, “If you can’t say oral sex in front of the patient, you shouldn’t be a doctor.” I mean, it doesn’t mean you condone it or you recommend it. I mean, you are a doctor and this little girl has died of that because she caught HPV from oral sex at 19 years old and you just saw her on six month recall since she was two years old.

Karoline Biami:That is sad.

Howard Farran:It is very sad.

Karoline Biami:Yes, we need, sometimes I tell if the hygienists don’t feel secure or don’t feel that she is capable to communicate, take continuing education classes, go to a seminar. Just get more information. The more information you have, the more secure and able you feel to talk with other people. There is nothing to be embarrassing to talk about oral sex and how much this can cause problems like oral cancer because of the HPV virus, embarrassing is you don’t talk, embarrassing is those kids die. So I would tell hygienists, doctors, assistants, we all need to be together to do the best we can for our patient’s lives, no doubt.

Howard Farran:Yeah, and I want to end on this one note, is that if you could say anything good came out of AIDs, which is hard to say, I mean that was one of the worst viruses that ever hit Earth, at least now the entire planet knows that you can pass a sexually transmitted disease and die. The whole planet knows that and condoms and abstinence are taking over and we see HIV rates plummeting. But we still see mouth, it is like a totally different deal. There is no difference between a mouth and an STD. And you see, I can give you the names of 25 patients of mine that are just livid because they have been fighting three month recalls and perio disease their whole life and no dentist ever said, “Well yeah, but then you go home and kiss your husband and he hasn’t been seen by a dentist for ten years.” And then I get the husband in there and he has got three molars rotted off to the gumline, six and eight millimeter pockets and a lingual tartar bridge, and she is saying, “So you are saying that when I am kissing him that I am getting gum disease from him?” And it is like, well if he had gonorrhea and you had gonorrhea, I can’t give you penicillin every six months for the rest of your life. I have got to treat your husband’s gonorrhea. Everybody knows that below the belt, but they don’t understand it in the mouth. They are not talking about HPV. They are not telling every single person with periodontal disease, “I need to see who you are making out with.” If you are kissing your husband and Frank has got a full mouth of this, I can’t treat you without Frank. So we have got a long way to go. Hey, our hour is up. Man, that was a fast hour.

Karoline Biami:It was fun.

Howard Farran:And thank you, Dr. Karoline, for all that you do for dentistry, for your patients and for all of your posts on Dentaltown. And thank you so much for sharing an hour with me today.

Karoline Biami:Yes, and Howard, you said about implementing a perio protocol, if you go to my website, you can get a free first step that helps implement a periodontal protocol in your office. It is just the first step. It is taking more than just download the protocol, but that is to help you and your team start communication.

Howard Farran:And what is that website?

Karoline Biami:I don’t know if there is a W actually, I always put it directly. KarolineineBiamiRDH.com. There you can get a lot of good tips from me and also you can have for free a free offer of my periodontal protocol that you can download and start to talk with your team about gum disease, about oral cancer and how can you make better for the health of your patients.

Howard Farran:And Karoline, I would like to ask you a favor. We have a section on Dentaltown called downloads. Like I have a lot of forms, speakers put up their seminar handouts of whatever. But I wish you could also put that on Dentaltown downloads. You could have your contact information, too, but it would be one more place where dentists could find you.

Karoline Biami:Yes, definitely I will do that. And I want to tell just one thing, Howard. My first dental seminar ever here in America was Dentaltown in 2008 in the RioHotel and I was three years in America at the time. And it was wow, I worked for a doctor in Arlington Heights, Illinois, Dr. Gilbert Mendez. That was a blessing in my life. And he was always on Dentaltown, he loved it. And he said, “Let’s go the whole team,” and he paid for everybody and we went to Las Vegas. It was my first time in Las Vegas and my first dental seminar here in America. I loved it. I was like, “Wow, look how things are here in this country.” And I never thought I would be here talking with you. So thank you for the opportunity, Howard.

Howard Farran:Well, I am going to put you on the spot. You have got to come to a Dentaltown meeting and actually speak next time you come.

Karoline Biami:I will, next year I want to be speaking there.

Howard Farran:Next year you are speaking, you are already planned?

Karoline Biami:Let’s do it.

Howard Farran:Alright, let’s do it. Karolineine, thank you so much for an amazing hour.

Karoline Biami:Thank you, Howard. Bye.