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 Farran:

It is just a huge honor for me today to be podcast-interviewing Dr. Irfan Atcha DDS, DICOI, which is a Diplomat in the International Congress of Oral Implantology. He's with NewTeethChicago.com, and, my gosh, he is amazing. Dr. Irfan Atcha graduated in 1996 from UIC College of Dentistry. Which UIC, University of Illinois?

Irfan Atcha:

University of Illinois, Chicago, correct.

Howard Farran:

Chicago. Dr. Atcha's been in private practice in Chicago, Illinois since 1996. He is licensed to practice in Illinois, Florida, and California. His practice is focused on dental implants, bone grafting, cosmetic dentistry, and sedation dentistry. He has preformed over 1,000 arches, surgically and prosthetically, of All-On-Four, five, six, teeth, in a day, TeethXpress, full-arch dental implant cases.

He is trained and certified to perform IV sedation of the ultra high-fear patients, for their comfort. Dr. Atcha has conducted lectures and hands-on courses for Nobel Biocare, BioHorizons, in 2009, '10, '11, '12, '14, and '15. He is a Diplomat of the International Congress of Oral Implantologists and has been awarded first place for a table clinic award at the ICOI, for the immediately loading of Zygomatic implants. He has published several articles on full-arch, All-On-Four dental implant concept with guided and skilled approach. Dr. Atcha is a member of the ADA, Illinois State Dental Society, Chicago Dental Society, ICOI, and American Society of Dental Anesthesiology. He and his wife love to travel, spend time with family, and fitness.

My gosh, I love your YouTube videos. You sit there and interview patients afterwards, and I mean they're just hitting every buzzword. "I was 98 pounds and I'd gotten down to 81 pounds because I couldn't eat, and now I've gotten back to my normal weight", "I was afraid." I mean you watch those YouTube videos of some consumer, anywhere really in the United States because with websites like yours, I bet you get people flying in from all over the country.

Irfan Atcha:

We do, we do actually, we do draw people from ... I have drawn people from Minnesota, from Ohio, from Wisconsin, and even as far as Florida. So we do, we do get people from different parts of the country.

Howard Farran:

And you know it's weird because, you know, we both have our diplomat in the International Congress of Oral Implantology and so many times you meet so many amazing implantologists and then you go to their website and it just says like "Dental Implants". And then you go to your website and there's video testimony and one lady said she saw you on TV, so you're doing television advertising.

Irfan Atcha:

I have done some television advertising in the past, on local Chicago news channels. It's all about creating awareness and letting people know what you can do to help them. That's the biggest thing when it comes to what we do, for patients there that have missing teeth, or are about to lose their teeth, it's a big need that we're trying to fulfill in the dental community.

Howard Farran:

So I really love it. There was a man on there about my age who said "You know, every time I look in the mirror and smile, it was worth it." And another lady said, "It was costly, but now I can eat and now I'm not afraid of getting my pictures taken," and I mean you just must feel ... You're just changing people's lives on a daily basis.

Irfan Atcha:

Absolutely, dentistry is a great profession, and as you know. I've been a big follower of you on Dentaltown and your MBA courses, so you know it's been a good eye opener. Basically we're transforming lives. People come in with self-esteem issues, people come in with broken teeth, missing teeth, and they want to know what you can do then, what we can do to help them. And when you really take care of someone at that level, they're really appreciative. They're really appreciative of the fact that they can eat with their spouse. A lot of them their husband had never seem them without teeth, they were wearing dentures, so it's a very private thing for the patients and it's something that they're really reconnecting them to something that they have lost, or that they're about to lose. So it's really, really changing and as you said, transforming lives.

Howard Farran:

I've had a patient a decade. I've practiced 30 years, about one lady a decade will say to me that when she got her dentures, she couldn't sleep with them in at night, and she couldn't take them out in front of her husband, so she kicked her husband out of her bedroom and locked herself in there and he was sleeping on the couch. And after a year or two he went away, and she basically equates losing her teeth to losing the love of their life, and they cried. I mean, it's a very big self-esteem deal.

I've given every denture patient ... And I like that in another one of your testimonies said where, "When it was all over, he gave me his personal cell phone number." And I know, with women dentures, I always give them my card. I always tell them this is my cell phone number, I say, "If you ever get in a cosmetic emergency, this thing breaks or whatever," and one lady called me, and it was actually on a Thanksgiving evening, and she went in the bathroom to clean her dentures and she dropped it the sink and busted it. And she called me, hysterical, and I said "Well, we're both in Ahwatukee," I said "Just cover your mouth, run to your car, and I bet I'll beat you to the office." And I hung up. And I jumped in my car and I drove straight down there and I unlocked the front door and left it open and went in there and started getting out my stuff and she came in, she was crying, but I mean, mental health is more important than oral health-

Irfan Atcha:

Right.

Howard Farran:

And a lot of these oral rehabs are not fixing their oral rehab, they're repairing their mental health.

Irfan Atcha:

Absolutely, absolutely. When you give somebody ... If they know they can get a hold of the doctor, it's a very personalized and individualized care. You know, each patient you become near and dear to, you get to know their family members, you get to know their other loved ones, and a patient wants to know that after the amount of time that they've spent with the clinician, and you know, the time involved, the investment involved, you know they want to know that they can access the doctor. And so you know we're available, we also have 24/7 emergency service, our office call center that can get a hold of me or my associate if we need to. But I do with patients, do give my cell number because I want to make sure that they're ... sometimes, they may have a question if we do surgery on a Friday, over the weekend, if they have any questions or concerns, they can reach out to me.

Howard Farran:

I wouldn't call you that top 1%. You've got to be that top 0.0001%. I mean, a thousand arches. There's not a hundred people who've done a thousand arches. So, walk these kids through the journey. Podcasters tend to be younger. You just had 6,000 kids walk out of dental school, and they graduated, and they think that they learned everything, and they're going to realize that they just left kindergarten class, and they're going to start their journey across the street.

How do you go from, "I graduated from dental school, I never placed one implant," to being what you've accomplished? How does that journey work? How did it work for you?

Irfan Atcha:

I've been practicing since '96. For the first ten years, I did [DLVI 00:07:23], did a lot of cosmetic dentistry, I've done some Dawson courses, so I did a lot of restorative dentistry.

Then I realized, I had family members, like my grandparents. They had dentures. I made dentures for them. One set, two sets, and then realized that there was something they were not happy with. They couldn't do anything. In fact, then, when I first graduated, I wasn't doing implants, I was just restoring them.

Then I started learning about dental implants, I started taking continuum, I started taking residency, I started taking courses to really, really help patients that are missing teeth. By even simple things, simple things like, we can take our denture patients, put two implants in the lower jaw, and make a denture that snaps on. That is a big thing for a patient so that it doesn't slip and slide.

You've got to learn the full arch rehabilitation with All-On-Four, five, and six. It's sort of just with taking some advanced courses, after taking advanced courses, doing some mini-residencies, after doing mini-residency, getting a fellowship in the [inaudible 00:08:26], after the fellowship, I want to do the diplomat, just go all out. Then, just seeing out individual high-level courses, or hands-on that suited what I wanted to do, and I wanted to do full arch when I saw my family members suffering through what they went through with their dentures.

Howard Farran:

So, in America, and around the world, so much of the courses are tied into the manufacturers, and a lot of the young kids ask, on Dentaltown, they almost feel like they need to pick the system before they sign up for the course, because all the courses are tied to a system. What would you say to that young kid on that journey? Do they need to pick a system first, or a residency first? How do you make sense when you can go to the ADA convention and see 175 different dental implants for sale?

Irfan Atcha:

That is so true. I would advise them not to pick the system. I would advise them to learn from the leaders. There are lots of leaders out there that are conducting residencies, continuums, learn the basics, learn everything about implantology, from zero- from A through Z.

You can experiment different systems. There are, just like you said, 175 different systems. I've gone through at least four, five different ones. Narrowed it down to two that works in my practice.

So, there's no right or wrong about which system works. It's what do you want to do? What do you want to accomplish? Do you want to do single teeth? Do you want to do multiple teeth? Do you want to do implant bridges, do you want to do overdentures? You want to do full reconstruction?

But don't pick the system. You cannot go and learn having implants over the weekend and come back on Monday morning and start placing implants. No, you go through a proper continuum. You have people that have had years and years and decades of experience on teaching these courses. Take that, and from there, that's as good a starting point, then you can spin off in however way you want it.

Then you can go to a manufacture course and say, "Hey, what do I like about this system, or what do I like about-" It's not really about the system. I mean, we use the best systems out there. But patients don't know what systems I'm using. I know I'm using a good system because for what I need to do.

But for a young dentist graduating, go pick a mentor. Pick people that have conducted residencies, people that have conducted continuums and go with that first. That's a good starting point.

Howard Farran:

Well, do these analogies hold true: It wouldn't matter which clubs Tiger Woods was using, he would beat you and me in golf?

Irfan Atcha:

You know, there are so many different implant systems out there. Yes, you gotta' have to use the one that has the clinical research, the background, the materials science behind it. Do you like the TiUnite surface, do you like the Laser-lok surface? What does it do for your patients?

You kind of have to do little research and background yourself. If the implant company doesn't have a lot of research and development behind it, I'm sure it works. Titanium integrates. All titanium integrates.

But what are you trying to do? Are you trying immediate load, are you trying to delay load? So you kind of have to do your research before you pick a system.

Howard Farran:

So, a lot of them are hearing mixed reviews about implant hands-on courses because there's advantages if you go to non-US countries where they don't have lawyers and you can go place a bunch of implants in Mexico or Dominican Republic, but then you don't get to see the follow-up. You don't get to see that person three months later, a year later, whatever. You recommend they do mini-residencies. Do you have any that you can recommend?

Irfan Atcha:

I know there's a couple of them in the Dominican Republic. I know Dr. Garg ...

Howard Farran:

Arun Garg.

Irfan Atcha:

Arun Garg. He does, and from what I know, he puts on a pretty good residency. I've known people that've gone to his residency. I think it's in the Dominican Republic, and I'm sure it's pretty good. I don't know if there's any hands-on here.

But you're right, there's no follow-up. You don't know what the patient looks like a year, two years. But I say start somewhere. I say you've got to start somewhere.

One of the advantages of the hands-on courses that you're able to either, A) place, you're able to, and obviously under their certification, and you're able to get a lot of experience.

Howard Farran:

Any you recommend?

Irfan Atcha:

I think, Garg is a really good one. There are a couple. I don't know their names, but there are a couple of them out on the west coast. I know that they also do some. I don't know offhand. I've kind of been away from the educational world. But, I'm right now, the first thing that comes to mind is Arum Garg's training.

Howard Farran:

Well, you set yourself up for this question. You said you tried five or six systems but you're down to two. So, I know there's a thousand kids driving to work right now, listening to this podcast saying, "Well, tell us which two." Which two are you down to?

Irfan Atcha:

I'm down to BioHorizons as my main one. BioHorizons, and I'm also using Zimmer, so that's two. Third one, on certain cases, I'll use Nobel BioCare. Those are the three that I've narrowed it down to.

Howard Farran:

So, BioHorizons. That was started by the late Carl Misch, correct?

Irfan Atcha:

Correct.

Howard Farran:

Was that hard to see him pass for you?

Irfan Atcha:

It was very heartbreaking. Dr Misch has been a good mentor. I did his courses as well, and heard him speak. It was. We lost a good leader in our community. It was. The implant system that was developed, especially the Laser-lok system. It's a very good system. We've seen some great tissue regeneration around the neck of the implants, great primary stability. I use that pretty much for all my full-arch cases. It's pretty much our work-course is BioHorizons Laser-lok system. And they have different prosthetic components for different things that you want to do. I also use that for my single-unit implant cases as well. Yeah, it's a great system.

Howard Farran:

My gosh, I would give anything if you'd make an online seat course on that system on Dentaltown. These millennials, they have $350,000 in debt, and we've put up 411 online seat courses, and the views are coming up on a million.

Irfan Atcha:

That's fantastic.

Howard Farran:

I know. You would be ... if you ever want to write an article on that for Dentaltown Magazine, or do an online seat course, whatever. You're an amazing man. Not only are you delivering the goods, but your business acumen is off the charts. Your website, patient testimonials, just everything. I can't find an A- or B+ in anything you're doing.

Irfan Atcha:

Well thank you. Thank you. Thank you for the compliment. I appreciate that, coming from you. Appreciate that.

Howard Farran:

Yeah, it's world-class. So, again, any advice? If you were giving a commencement speech. You just had 6,000 kids graduate this week. They're throwing their hat up in the air. They're so glad to be out of dental prison. They're ready to start the world. A lot of them are afraid. When I graduated, I had my office open in four months. I just walked out and opened it up.

A lot of them think they have to work in corporate or that when you and I graduated it was a lot easier. It was the Golden Era. You and I are lucky because we were born at the right time. I doubt they'll say that at my funeral. They'll probably say I should've been born 30 years later.

Is the Golden Era gone? What would you tell these kids? Can they walk out, open their own practice, and go for it?

Irfan Atcha:

That's a phenomenal topic because ... you know, The Golden Era ... everything is a matter of perspective, Howard. Everything is a matter of perspective.

It's a business. We've taken courses, we went to four-year dental school. We've gone through residencies, we've gone through fellowships ... At the end of the day, it's a business. Opening up a practice from scratch is definitely a daunting task, because nobody knows about you. You need to get your marketing in place, you need to get your staff in place. Should I sign up with insurance? All that stuff.

My recommendation would be, first time around, buy an existing practice. That is my recommendation. From day one, you'll have cash flow. Sure, you'll pay more. Sure, you may not have all the bells and whistles, but so what? What's the most important thing in the office? Revenue. Patients. Patients coming in. You have patients coming in, [inaudible 00:17:14] you can generate dentistry from it. You can bring your own reality into it, especially if a dentist is retiring.

I would hands-down advise to not set up a scratch practice from the beginning. I'm not saying that nobody can take a scratch practice and take it up to $500,000 a year right away. It takes time. But, buy a practice and then build upon it. Nurture it. You've got to work hard. There's no substitute for ... you've got to put your sweat-equity into it. Whether it's marketing, whether it's proper training of the staff. Clinical staff, administrative staff, business systems, how to answer phone calls, how to do treatment planning, how to present cases. How to get case acceptance.

How do you take somebody that is resistant towards dentistry and to educate them and motivate them to get it done? Those are the things that a new grad should invest in, instead of learning about should I buy this new gadget, or should I buy this?

That doesn't make you do dentistry. That doesn't do anything for you. That's just all shiny-shiny, and all you do is incur debt. I would say you buy a decent-sized practice with good equipment, with good will, and with lots of patients. You'll do well, because it'll pay for itself. The revenue from that practice will service the debt. And not only that, you'll have some income too, as well. That's my recommendation.

Howard Farran:

I know how my homies think. I've been on Dentaltown several hours a day since 1998. A lot of them are going to listen to you and say, "Well, dude. You live in rich Chicago. I'm out here in Parsons, Kansas, and you're lucky. You were born in the right place. You're born in New York, LA, Chicago. I'm out here in Bumblebutt, Iowa. Nobody's going to pay for a full-arch of implants in the middle of Iowa." What would you say to that?

Irfan Atcha:

Well, that's not true, because there are people that come from small towns. My average patient comes from 30-40 miles away. Thirty to 40 miles away is a lot of farmland around Chicago. So, they're willing to drive up here, and they're willing to pay.

I have some colleagues that are in small towns. It's how you position yourself, and it's how you present yourself. It doesn't matter where you are. It doesn't matter if you're in small town in Ohio or if you're in New York City, or Chicago or Los Angeles. That's a myth. Being in a big metropolis, yeah, you have a lot more people. But, you can be in a mid-sized town or a small town and position yourself as the go-to person for this and you can do it and charge the fee that you want to charge.

People have to find value. People have to exchange value. If they find value in what you do, you're the person, because you have the track record, you have the patients, you can back yourself up. They'll come to you. They'll come to you from everywhere, and they're willing to pay for your fees.

It doesn't really matter if you're in a smaller town or if you're in a big metropolis. Being in a big metropolis, yeah, people have a lot more dentists to choose from, but again, it doesn't really matter. If people don't know about you, whether you're in a big city, or in a small town, they'll never come to you. They've got to know about you.

Howard Farran:

When I walked out of dental school, only rich people flew in airplanes, and they were usually being paid by the Fortune 500. Back in the day, it was Eastern and TWA, and Braniff, and all these expensive ... but Southwest Airlines is now the number one carrier, 27% of all sea miles flown, and I can't tell you how many dentists I've talked to that developed elaborate websites like yours with patient testimonials and all that stuff, and people just jump on an airplane and fly to that office because they don't have the faith and the trust that the dentist in their small town can do these skills. So, not only are you a great chef, you've got a great restaurant website. You're making the food, and you're getting the information out there.

A lot of people might be wondering around the country. "Well, is there not a ClearChoice in your area? Did big corporate come in there and did that hurt you?" How many ClearChoices are around Chicago Area?

Irfan Atcha:

Chicago's got a ClearChoice. Chicago has a ClearChoice. Been around for the last seven, eight, nine years. They've created a lot of marketing campaigns, so a lot more people are aware of what the full-arch construction, All-On-Four, Teeth in a Day, all that's available. They've done a great job of creating awareness.

I look at it this way. It doesn't matter if you have one ClearChoice or two ClearChoices. Everybody is different. Everybody has a different position. You position yourself differently. I'm sure ClearChoice does a phenomenal job in delivering their services. We do a phenomenal job of delivering our services.

You know, with us, everything is in one office. I'm the doctor who does the procedure, and I also do the follow-up, and people want that one-on-one connection with their doctor. It really didn't do anything to our business, our message in marketing and our message in getting the word out has always been consistent. I'm sure ClearChoice is very busy with what they do, and we're busy with what we do. There's enough patients to go around for everybody. That's the way I look at it.

Howard Farran:

You know, I always look at ClearChoice as ... and John F. Kennedy would always say, "A rising tide lifts all boats." I can't tell you how much these dentists in Phoenix that advertise on TV about LANAP or ClearChoice, or any of these deals. Then your patients are coming in saying, "Well, I saw on TV ..." They're getting information, doesn't matter if it's you, Wikipedia, Facebook, or TV. But they're coming in to the one they trust.

Irfan Atcha:

Right. Absolutely. Who are people going to trust, Howard? People are going to trust who they see the most. If your message is consistent, whether it's internet, social media, your email blasts to the patients. Whatever it is. If your message is consistent and persistent your brand becomes more aware. They see you on whether it's your Facebook page, or whether it's YouTube, they see you more and more and more. They see you more and more, trust. Everything about what we do is trust. You don't need years and years to create trust. You can create trust in an instant. It's all about creating the expert status in what you do and also getting your other patients to say, "I went here, this is what they've done for me. My life has changed." It takes all the uncertainty out of the equation when patients can already see what your other patients have done.

You've got to start from somewhere. Again, I keep saying that. There are enough patients in every metropolis, anywhere, to go around, for everybody. People will trust you. People will come to you if they see your message consistently, over and over again.

Howard Farran:

That's a great message, because in some of your YouTube testimonials, a lady said, "I wouldn't have done this if I didn't trust you, if it wouldn't have been you, and that you were a big part of her deciding to get over the fear and the cost and get it done."

I look at the physicians. There's 211,000 dentists, there's over a million MDs, and they work trust so much more. Mayo Clinic, Cleveland, Sloan, Scripps. Because they know, if you go to the store, and you want to buy a bottle of water, that any American knows, this is a bottled water. But, when someone says, "Well, you've got cancer and we've got to cut off ... we've got to do this surgery on you." It's like, "Well, how do you know that's ..."

You hear people just in your own personal life say, "Well, someone told me I need to get this cancer treatment. I think I'll get three opinions." Well, they don't get three opinions when they walk into the Cleveland Clinic, the Mayo Clinic. They walk into the Mayo Clinic and they have trust.

The whole deal in dentistry, when you tell someone they have four cavities, they're just looking at you like ... you might as well say "You need to have your transmission re-done." You might as well, there's just a lot of things invisible to a lot of peoples' experience.

When the plumber comes to my house and says I need a whole new toilet or the dishwasher repairman says I can fix it or you need a whole new dishwasher, it all comes down to trust. How would I know if the dishwasher could be fixed? I've never even used the thing.

So, the bottom line is that you just have an aura of trust. Like, when I talk to you and when I see on your videos, I mean, you just really got trust down.

By the way, my homies are driving, so what I do is I retweet. I guess last twitter so they can go to my Twitter @howardfarran, my last retweet was you. @implantschicago, so I just retweeted that and it's amazing. One of them is, "Use a bone-reduction guide in All-On-Four dental implant surgery. A concept misunderstood by the masses." Oh my god is that the actual blood and guts gory detail. I mean, you can call that a dental war.

And then another one, classic moment with you. "Bring the family, your patients to see the new teeth afterwards." I mean, you're just hitting all the hot buttons. You've got people for [cleanse 00:26:47], you've got people crying. It's a husband, his wife's all excited. God dang dude. You just nail it. You should've gone into marketing. What made you go into dentistry instead of marketing? You should have an advertising firm in Manhattan right now. No, really, you're just crushing it.

Irfan Atcha:

Thank you. Thank you. Aside from what I love to do with dentistry and changing lives, I'm a student of art. I am. I like to study marketing. What is marketing? Marketing is something that you need to let your audience know about your product, services and solution. If your target audience know about your product, services, and solution ... If you have inner conviction about your product, services, and solution, why wouldn't you want to let that message be aware to others? That's been my thing, and I think that's been kind of like ... that's not something that you did that you learn in dental school or during CE courses. That's something that you innate have to have it.

You worked so hard in dental school. You spent so much in dental education. You went out and did all these advanced courses, and residencies, and education. You invest in a dental practice. Well, why wouldn't you want to let your patients know, or the public, or the community, or the world know?

That's why social media's so good. Your pool is the world wide. There's seven billion people you're attracting. You're not just attracting to 1,000 or 2,000 or 3,000 people in your town, or 20,000 people in your town.

Marketing is very important. Marketing and promotion of what you do is very important. Not only from your aspect but what other people are saying about you.

Howard Farran:

What would you tell a young kid who just spent eight years learning math, calculus, physics, geometry, the Kreb's cycle, and will never use any of it the rest of their life. Yet, they'll open up their dental office, and they won't know how to use Quickbooks Online, they won't know how to do payroll, and they sure as hell won't know how to do marketing.

What would you tell a young kid? What would be your shortlist of how to learn, how to market?

Irfan Atcha:

I would say, you know, look at different businesses, how they promote. It could be other dental offices, or it could be some other businesses that's very successful. If they're successful businesses that are growing, that are profitable, that have the message up, just look at them and learn a few things from them.

What do the telephone company, like Verizon or T-Mobile, what are they using? How are they marketing themselves? How are other verticals, whether it's in healthcare or not healthcare, how are they marketing? Look at their marketing strategies, and see if you can make it real to your practice. Every practice is different. Some people just want to go for the veneer, some people just want to go for the PPOs, and if you belong to an office that you have to sign up, that's great. I did that for the first eight, nine years of my career.

The insurance company market's for you. People come in in droves, and it's a different type of a dentistry, and it's good. Now, my model's a little different. Mine's more about awareness, more about education, it's more about branding what I do myself and what the office is about.

So, definitely learning different marketing strategies and promotion to get your practice from somebody who doesn't know about you to even doing postcards in your backyard. Even creating a Twitter handle, and then just tweeting it, or outsourcing the tweeting to your staff. Make sure they constantly keep the feed alive so people are connected to you.

People have to be connected. People have to be connected online and offline, and that's how they'll remember you.

Howard Farran:

So you don't think any PPOs?

Irfan Atcha:

I take certain PPOs, and my associate takes them. There's only three PPOs that we take. But, rest of them we don't. We only take three of them on a very limited basis.

Howard Farran:

On your marketing, do you still do any old-school direct mail, or is it all digital, Facebook ads, Google ads, ...

Irfan Atcha:

A little bit of both. I think you hae to hit both. You have to hit online and you have to hit offline too. You have to hit some targeted zip codes with mailers and you can do some postcards to new residents. I do a little bit of both. I think it kind of balances out.

But a lot more people are online now. A lot more people are with pay-per-clicks, Facebook ads, sponsored ads, I think that seems to be where people are glued to nowadays.

Everybody lives in a virtual world, so everybody's on their phone or their iPad or iPhones or Galaxy, and this is how they find you, especially if they're looking for high-end services. They're gonna Google the services, but there're still a group of people who'll pick up a Sunday newspaper and may respond to your ad, or may respond to your postcard use.

It's both. A little bit of both, but it's more going towards digital, that's for sure.

Howard Farran:

You know it's weird because our whole childhood, Americans were steady at four hours a day on television. And then, when the smartphone come out, the 25 and under basically fell off the television screen completely. And they actually fired Jay Leno and replaced him with that, that new kid, what's his name, Jimmy Fallon, because they were trying to get the young kids to come back to TV, but they're gone.

Basically, television's over 50 now, but what I find interesting is that, for all my life, Americans held steady at four hours a day television time, and now they've switched it to "screen time," and it's five hours. So, it must be much more engaging.

What was the complaint of our whole childhood? You had three channels, ABC, NBC, CBS, and there was nothing on. And then cable came out and it was weird, 'cause now you had a thousand channels. What was the complaint? "There was still nothing on." But now when you have a smartphone, you have 300 million websites.

Irfan Atcha:

It's incredible.

Howard Farran:

... and with 300 million websites, they've upped their screen time 20%.

I want to go to treatment plan presentation. When you go into the general dentist's, the biggest offices, the top 10%, all have someone who presents the treatment and the finance. But, when you go into orthodontist's office, they're like, 95% of orthodontists have for two years out have a treatment plan presenter, financial coordinator.

Some dentists think the doctor's the doctor. You're the one doing the surgery. You should present the treatment. Do you present the treatment, or do you have a treatment plan presenter, or do you present the treatment and then you have a financial coordinator do the finance? How do you divvy up those skills?

Irfan Atcha:

Another great topic to discuss. When I am with a patient, after the evaluation, examination, if I have time, I present the same day. If I don't have time, then they come back. I do everything. I present everything to the patient, from going over the clinical part of it, going over the steps, and I also the fees. I present the fees. I feel like fees, and how the sequence of treatment, the steps that comes from me, it just has a higher impact. Because at that time, patients may objections, some patients may have a lot of questions that I'm well-versed to discuss, and handle any objections.

Once they're committed, once they say, "Yes, Dr Atcha, we want to move forward, I want to go ahead." Then, I get my treatment coordinator. Then the details of how it's going to be financed, paid, or whatever, it's worked out with them. I'm there until the patient is saying, "Yes, I want to move forward," or "I want to think about it," or "I want to go home, I need to discuss certain things with my spouse." Then we have a second or third consultation scheduled for them.

But I do all of it. I present it. I like to present fees, and case presentation is not about case presentation, it's about listening. It's more about what the patient wants, not about what I want. It's about what they're telling me. What their personality is. Are they bottom-line, are they very direct, and they somebody to take very slowly.

I want to make sure that when I present my treatment, I try not to use a lot of dental jargon. I try to use words that they can comprehend, and I try to keep it very simple. Let's see how it's going to change their life and how it's going to impact them. I try to make it very simple. I try to make my treatment presentation no more than 15-20 minutes. If you're doing more than that, then the patient gets confused, and they walk out and do nothing.

But, when it comes to fees, I'll go over the fees, but then I'll have my staff go over exactly different payment options and so forth, and then we schedule for whatever the next phase is.

Howard Farran:

You know, every amazing treatment plan presenter I've ever met in my life has always told me "If the doctor states the fees before he calls me in, and the doctor owns it and says it, it just gets rid of the issue so much." Every treatment plan ... some of them might've worked for one office for seven years, one worked in another office- they'll always tell you that when the doctor states the fee with confidence, that helps them close the deal so much.

Irfan Atcha:

Absolutely.

Howard Farran:

A lot of times a patient will come in and need a bridge or a case or this or that, and then they say, "Well, I'm going to go home and think about it. I'll call you back." And so many doctors never ever try to get them back.

When people say, you have a hundred people, after you did your whole presentation, everything, and they say, "Well, I'm going to go home and think about it," and they don't call back. They don't come back. Do you follow up on those leads to try to get them again, or not?

Irfan Atcha:

The whole "Let me think about it." Let me dissect that a little bit.

We are presenting. We are selling. I'm going to use the word. A lot of doctors don't like to use the word. Our services are a solution. Whether it's hygiene, whether it's recall, whether it's full-mouth, All-in-four reconstruction veneers. It's our services that changes their life.

If a patient says, "Let me think about it." It means either, the patient didn't understood, there's a misunderstood word in your presentation, or you went too fast, too steep, and they completely zonk out, or the patient is very fearful about dentistry. Majority of the people are very fearful about dentistry.

So, "I want to think about it." I need to know a little bit more. I always ask the patients, "Did I do my job properly explaining the treatment?" If they say, "Yes, yes, yes" because they want to get away, then I just say, "No problem. I'm glad I did. If you want to go and think about it, by all means, go and think about it, I'll give you all the time in the world. But, if you think about it too much, your problems will worsen." Usually a week later, I'll have a staff member follow up with them.

I will tell you how many times that we ended in a very nice, high note, we give the patients a treatment plan. A week later, we did a simple phone call, maybe an email, and that patient appreciates it. That, "I'm glad that you actually called back. Let me come back for a second consultation, or a third consultation."

I had a patient today. Patient came back for the third time. She came in first time, came in, did the paperwork, had a scan taken, X-rays, boom, left. 'Cause she was afraid. Half of these people are afraid. She couldn't stay, and I'm like, "Can we move to the next step, can I go over ..." "No, no no. I've got to go."

Came back. Okay. Staff followed up with her, got her back the second time. Went over everything with them, wanted to see if they wanted to take the next step, "No no no, I gotta go. I just can't handle it. I'm hyperventilating." Left.

Staff followed up with them. Finally she came back, the third time, and we're starting her case in the next couple weeks. So, you have to follow up. Your staff has to learn how to follow up with the patient. It's very important.

Howard Farran:

One of the things that doctors are scared about in full-mouth rehab is that when a patient spends a big amount of money, some of them want you to warranty it or take care of it, or whatever. Because if I go out and buy an F-150 pickup truck, it's going to come with a warranty. Do you have an express, written warranty? How do you do warranty on people who are spending this kind of money?

Irfan Atcha:

Well, you can look at it ... the mouth is a very harsh environment. You look at a medical procedure. None of the people in the medical world warranty anything, whether it's a heart transplant, whether it's a liver transplant. Something happened, they're going to need another one. There's a revision surgery. They never call it "failure." The word "failure" is very, very, very loosely used in our profession, in dentistry.

I personally like to call it revision. There's times where an implant wouldn't take. Okay, we have to do a revision surgery. If a revision surgery's needed, we don't charge a patient. We just take the old implant out, put a new one in. Patient is very happy about that.

In terms of written warranty. The mouth is a very harsh environment. Yes, patient can spend a good amount of money, and time, and investment into what they're doing. But, at the same time, they have to own the problem. They have to make sure that they have to follow the oral hygiene instructions, they have to follow the diet instructions. All the other instructions.

My commitment is, "Hey look, if something happens, I'm going to fix it. No problem asked. But if you're a smoker, you're noncompliant, and you get this care done, and you come back three years later and things have fallen apart, how do I know what you're doing?" There's never any written warranty to anybody.

One of their contingencies is they have to come in every six months for their follow-up and checkup and cleaning. There's something that can be fixed, we fix it. We give away so many services at no charge to our patients. It has worked well. It's about direct and honest communication with the patients.

Patients ask me, "Do I give-" I say, "No, I don't give a written warranty because the mouth is a very harsh environment." You have bacteria, saliva, food. I mean, a million things can happen. We can do a good surgery. We can place beautiful teeth, but the other half, and I can use the best slab and they can use the best material, but the other half of this is also patient.

Are they wearing the night guard? Are they compliant, are they non-compliant? So, I don't know if that answered your question.

Howard Farran:

It did. Some of the younger kids ask on Dentaltown, "Does All-On-Four mean All-On-Three if one of the implants fails, and what do you do if local television people are saying, All-On-Four, All-On-Four," and you want to convert them. Maybe you want to do it All-On-Six. I mean, brand market All-On-Six before Paulo Malo came out and [inaudible 00:42:00] with All-On-Four.

So, let me just start specifically. Is All-On-Four done on three? Do you put spare tires in? Would you rather go six like Bryn Mawr in case one of the implants failed you don't lose the whole case? What are your thoughts on that?

Irfan Atcha:

That's a good question. See, again, it's a misunderstood concept. Basically what All-On-Four states is to do a full arch or rehabilitation, and there is peer reviews and there is scientific articles published over and over again that all you need is four implants throughout the upper jaw and the lower jaw, properly spread with anterior-posterior spread with proper stability to load the teeth. All you need is four.

Now, do I just do All-On-Four? No, I do more than All-On-Four. I've done All-On-Five, I've done All-On-Six. I've done, I call it, "All-On-Four, plus." If somebody needs an additional implant, I do it.

All-On-Four is just a term. If someone needs a fifth implant, or sixth implant, absolutely we place it. But, I would say, the majority of these cases I get, they have no bone in the back part of the jaw. They have no bone between the sinus. The sinuses are completely pneumatized. So, I have a very minimal amount of bone left that I can really place good implants with good primary stability and load a temporary prosthesis on the day of the surgery.

So, I think this whole All-On-Four, none of three, I think it's more of whim than anything. If you have done 100+ and if you don't have the surgical experience, then where are you getting the data? Where are you getting that information? But if somebody has full-blown volume, if you can add a fifth implant or a sixth implant, by all means, do it. There's nothing wrong with that. I still do, I still place five, I still place six.

You have to do what's best for the patient. All-On-Four is just the minimum that you need, especially if they don't have a lot of bone, instead of doing bone grafting, sinus lift, again, which you can.

You can avoid all of that, do a good All-On-Four surgery and give them all their teeth.

Howard Farran:

Everyone listening should check out his website, NewTeethChicago. Just an amazing website. Another thing that confuses the kids is they go to these courses and they hear all this stuff about the medial health history, taking a medical health history, and one of the things that really stuns them is, they say, "Well, you don't want smokers, you don't want drinkers, you don't want all this stuff like that." Well, those are usually the people that ... The people who lose all their teeth usually aren't yoga instructors eating tofu.

Irfan Atcha:

That's very true.

Howard Farran:

In Phoenix, we have a joke, like, anyway I don't want to throw anybody under a bridge, but there's a section of town called, "Apache Junction" where it's known for all the meth labs and the trailer parks, and all that. So, a lot of these kids are like, they want to do their first implant, but this lady does everything wrong. She's 60 years old, she smokes a pack a day, she's probably an alcoholic, she's ... she probably hasn't had a vegetable and last time she got it was at McDonald's ... Do you do smokers? What do you do when people are doing everything wrong, but they want new teeth?

Irfan Atcha:

Sure. So, a lot of our patients are what we call a "dental cripple." They have been away from the dental office for 10, 15, 20, 30 years. They've had a very very fearful, very bad experience as a child or in adulthood, so they've neglected their teeth. So, their teeth have really, really gone down.

Either they've lost all their teeth and they're wearing dentures and they hate it, or they're about to lose their teeth because every single tooth is either perio or caries or a combination of both.

And a lot of them are smokers. With smokers, we try to have some agreements. "Look, you're investing time and money and energy into this." We go over smoke cessation. We go over prescribing medication. We talk to their physician to make sure they're going to ... and a lot of them we have converted them away from smoking, especially if they're going to change their mouth and their health.

So, that's a big plus.

Now, there's some people that do smoke, and you know, if they're careful. Smoking is going to cause problems. It's not only going to cause problems with implants placement. You're going to have more bone loss, you're going to have more infection, more inflammation. A majority of our patients ... there's some patients who've said, "I'm not going to give up smoking." So, at that point, I'm going to make a decision, if you're smoking a pack or two packs a day, do I want to take you on as a patient? What if there are factors that didn't go right, and you lose implants? I don't want that on my hands.

So, there are patients that I've literally not taken and turned away, because they refuse to change their lifestyle. Part of our treatment plan and protocol is to do lifestyle modifications for our patients so they are healthy overall. Not just getting your mouth healthy, but they eat better, they give up smoking. They, a lot of them lose weight. Fitness. It's an amazing thing, because we're not just fixing teeth.

Howard Farran:

So, if they're smoking a pack or two a day, you won't treat them?

Irfan Atcha:

No, because I go through what are the consequences that could go wrong if you smoke. Maybe nothing might go wrong, but what if there is? And if there's something that goes wrong, then if implants fail, then what happens?

If somebody's not willing to eliminate smoking or at least cut back, and somebody's really adamant, "No, I'm not going to change my- I'm still going to smoke two packs a day," I might consider saying, "Maybe we're better off with a denture. Maybe we're better off maybe with an implant locator." Let's try that out a little bit and see how it is and take it from there.

Howard Farran:

You know, when I got my fellowship in the Misch Institute. Carl Misch and his brother Craig Misch, that was pretty much the main thing they didn't agree on. Carl would treat a smoker, his brother Craig wouldn't.

Irfan Atcha:

Oh, really?

Howard Farran:

You know what? I know so many patients that, over the years, quit smoking that were women. I said, "Well, why'd you quit smoking?" "Well, I wanted to have the eyelid surgery done, or I wanted to have a tummy tuck, or a breast augmentation. The doctor said I could not smoke one cigarette six weeks before the surgery or he wouldn't do it." Usually after three or four days, then it's just a mental addiction, there's no physical addition, but quitting six weeks so they could get their cosmetic surgery, and now they're non-smokers.

Irfan Atcha:

That's incredible. A lot of our patients have gone on Chantix prior to the surgery, and they quit. It's a great thing, and they're very happy that they quit.

Howard Farran:

This is Dentistry Uncensored, so I only like to talk about things that are controversial, not what everybody already knows. Pretty much every hype dentist will say that if they had to pick between a fixed arch implants or removable, snapping on fixed, they want the removable. They say, "I want grandma or grandpa to go out and pop out that denture and brush around the implants." But, when it's fixed you need a water pick, it's tough. Peri-implantitis is a big issue. What do you think the size of the market is for fixed and their mental health wants it fixed and it'll never come out, versus converting them to where, "Well, this is a denture snap-on. It's a lot easier to brush and clean."

Irfan Atcha:

Yeah, at the end of the day, patients want teeth, Howard. Patients want teeth and majority of the patients want teeth that stay in their mouths. Yes, from a hygiene perspective I can agree that when you take the snap-on overdentures out, you can clean the locators or clean the bar and put them back in. And that works for a good amount of patients.

There are some patients who want teeth that don't come out. They don't want to ever take them out. So, from a hygiene perspective, yeah, people can use water pick, people can use hygiene aids, and when they come in for their re-care, we take them out. We take the teeth out. We clean the the abutments, we change the prosthetic screws. It's part of the service that we give them when they come in for the six months.

So, cleaning them is really not an issue. As long as the patient is able ... if you design the prosthesis that is self-cleansible, you're not going to have a lot of these patients when they come in, when we take their hybrids out, you don't see a fun gray little plaque if any.

It's all about educating the patients on how to clean them.

Howard Farran:

Everybody's talking about peri-implantitis. How significant is peri-implantitis? What are you doing to treat it? What's your views on peri-implantitis?

Irfan Atcha:

So, the peri-implantitis can happen from even a single-tooth implant or a full-arch. The most important part is how well are they maintaining their plaque? The kind of implants that you use, if they have better collars, better surfaces, like Laser-Lok, it's so nice that you get nice soft-tissue growth around the implants. The abutments are so nice and polished. [inaudible 00:51:08] even people that accumulate a lot of plaque.

I've had some cases where there's some bone loss around the implant, especially anterior, a patient's not cleaning them. A lot of times, you can just clean out the defects, bone-graft it, put the bone back in there, and the implant doesn't have to be removed. So, I don't see a lot of peri-implantitis.

That can happen from whether you're doing a surgical and a prosthetic part properly, proper oral hygiene, using the proper ... it's all about the design, the prosthetic design, it's about the ending result. Are you doing platform switching? What kind of implant are you using for what case?

Also, what are you and your team doing about hygiene and educating your patients about hygiene? So, we don't get a lot of peri-implantitis in our office.

Howard Farran:

I just walked into a wall when you said, "platform switching," because I know there's a lot of homies listening who don't know what that means. Explain what you meant by "platform switching."

Irfan Atcha:

What I meant by platform switching is if you're putting a wide-diameter implant, say, a regular-diameter implant in the front, but you need to have the prosthetic ... prosthetic is what the patient sees. Prosthetic is the tooth, the abutment of the tooth.

So, a lot of implant companies will have an implant that you can switch to a narrower diameter abutment fixture. For example, if you're putting an implant in number 7-10, you put a [inaudible 00:52:43] diameter, but you make sure there's enough adequate tissue height, there's enough soft tissue. If you put a wide-platform abutment and a crown, you might not have proper soft tissue aesthetics.

Some of these implant companies have platform switching where you can switch to a lower platform prosthetic connection to have a better prosthetic outcome and aesthetic outcome as well.

Howard Farran:

You've been so amazing by giving so much time. What would you tell a kid who's stressing out? They're starting with single implants, and they see a patient that needs a sinus lift and implant? What advice would you give on sinus lifts? There's all kinds of sinus lift procedures? What would you tell about sinus lifts?

Irfan Atcha:

I would learn to go to either their ... a clinician that has done quite a few, a specialist who's has done quite a few, an implantologist that has done quite a few. Learn from them. Go to their office. See one. Look at one. Look at the instrumentation they use. Look at how they do the flap design, look how they do the oval window. Look at it. Don't just go to a weekend course on sinus lifts and come back and lifting sinuses and placing implants and membranes.

I would say, go to an experienced clinician, and just shadow them or learn from them a little bit. And then, take on there. Maybe bring your patients to their office, maybe for a first case or two ... just to kind of work together. That's what I would do.

Howard Farran:

Podcast with Carl Misch. He thought that drawing blood and spinning blood was not necessary, and that created a big controversy. Do you draw blood? Do you spin blood? Is that part of your regular protocol?

Irfan Atcha:

I've done both ways. I used to do lots of PRP, which is taking out blood from the patient's hand, spinning it, and using the PRP for proper soft-tissue regeneration, angiogenesis, and better healing. It'll work both ways, Howard.

Is it ultimately necessary? You have to look at your cases. I've done so many cases without it. Nowadays, everything's about PRF. Everybody wants to do PRF. Now, I have cases where there's very deficient bone. We're going to do simultaneous bone grafting and implant placement. Somebody that's a little bit old and frail, vascularity's an issue. Absolutely. Drawing out blood, using some PRP and PRF is going to be a great adjunct. They'll heal really well. Why not?

Somebody that's young, somebody has very vascular, they're losing their teeth but they're healthy. I really don't think it's necessary. It's dependent upon cases. Case selection is everything.

Howard Farran:

So, you're saying on a 55-year old young grandpa like me, you wouldn't do it?

Irfan Atcha:

If you're healthy? Your bone is vascular? No, I probably won't.

Howard Farran:

My job is to predict what my homies are thinking. They're all alone, they're driving to work, this is a commute thing or an hour on a treadmill. You said "PRP, PRF" and someone's out there saying "What's the difference? What's that?"

Irfan Atcha:

The only difference is PRP is "platelet-rich plasma" so you're only restricted to using "platelet rich and platelet poor" and a lot of times we just put the implant, coat the implant with it, place the implant, put it inside osteotomies, and have angiogenesis, soft-tissue healing.

"PRF" this is what it's going towards. A lot of people are doing courses. It's actually clot. It's platelet-rich fibrin, it's sticky bone. That's what they're using, and it really helps with a lot of soft-tissue regeneration. It helps with getting that really nice tissue around your implants, especially when you're doing a full rehab, when you have a very, very narrow resort maxilla or mandible. It's very thin biotype. You want to grow a little bit of that, use a little PRF with some membrane, and when you close everything up, you get a really nice attachment to soft tissue. That's the difference between the two.

Howard Farran:

I can't believe we've already gone one hour, but I have to ask you one last, very controversial question.

Irfan Atcha:

Sure. Okay.

Howard Farran:

A lot of these kids come out, and they get an associate. They're working for an older man who's 55-70. Every 55-year old to 75-year old that has placed a thousand implants never used a surgical guide one time in their life. And these young kids say, "Well, I want to make a surgical guide." And he says, "Well, why don't you go home and put training wheels on your bicycle? You need to learn how to lay a flap and blah blah"

So, the old guys, no surgical guides, the young guys, they read about it all the time. What's your view of surgical guides? What percentage of your cases are you using a surgical guide?

Irfan Atcha:

Howard, I don't use a lot of surgical guides.

Howard Farran:

See what I mean? Yeah, the guy who did a thousand arches, of course. I saw that coming.

Irfan Atcha:

I don't use a lot of surgical guide. I like to flap, I like to see the bone, I just came from a BioHorizons symposium in Miami last month, and there's ... we can do it both ways. Ultimately, what is your result? Result is patient [inaudible 00:58:10]. Okay, when I've done guided cases, I've done guided cases when patients are fully dentureless. It's a lot easier. It's more predictable.

A lot of my cases, the teeth have to be removed, you have to do bone reduction, then you have to place the implants. You can do that now. Now you have end-sequence. You might have heard of ... end-sequence technology has really come up with a great way for people that want to employ surgical guides, bone-reduction guides, surgical guides, especially with these full-arch cases.

So, you can do that. I just like to reflect the flap, I like to see the bone, I like to feel the bone. That's just me. No right, no wrong. There's a lot of group discussions on Facebook on this and guided surgery's the best way to do it.

I wouldn't say it's the best way to do it. Sure, it could be. But, there's so many times where if the guide is in the place properly, how do you know where the implant is going if you don't have a flap? At least I can see the bone, I can see the [dehiscence 00:59:12], I can see the fenestration. I can make changes to my implant. If my implant doesn't go all the way I want, and my abutment, is too facial, well, I can turn my implant a quarter-turn and rotate my abutment.

That's just me. That's just how I like to see it. Somebody right out of school, may want to just do all cases guided, and there's nothing wrong with that. I personally would say, before you do, especially full-arch guided cases, do a hundred of free-hand.

You've got to learn how to cut, you've got to learn how to flap, you've got to learn how to feel the bone. You have to do it conventionally. Then you can take on some guided cases. Jumping into guided cases, it's like, "Are you afraid to pick up a scalpel and reflect? I don't understand. Why would not somebody want to do that? You're learning a skill. Why don't you want to learn it? Then you can employ the guided cases." So, there's both ways you can do it.

Howard Farran:

Last question, last question, last question, I promise to let you go. Someone might be wondering, what CBCT do you use?

Irfan Atcha:

I use the i-CAT. I use the i-CAT 3, yeah.

Howard Farran:

And when you're at a DI, a Diplomat International Congress of Oral Implantology course, does it seem to you that that is the leader among all the people who've placed a thousand implants?

Irfan Atcha:

I mean, the diplomat is the highest distinction in the ICOI. There's also more certifications, ABUI. I'm working on that right now. And, if you get beyond the fellowship and masterships and diplomats, I mean, diplomat's the highest distinction. Again, materials change. Protocols change. Different methodologies change. Always, always trying to learn something better way of delivering my surgeries, and also my prosthetics. Every single time. Every single day.

Even though you become a diplomat, the learning never stops. I make sure I keep on learning more and more and more, whether it's through articles, whether it's through a symposium, whether it's through even traveling abroad, wherever. It just doesn't stop.

Howard Farran:

I hope someday you honor us with an article in Dentaltown magazine or an online seat course, because I can't think of a finer person these young kids should learn from than you.

Irfan Atcha:

Thank you, sir. I'd be glad to. It would be my pleasure. We would definitely coordinate that very soon. I would love to. I've done one article, you and I talked about it back in 2010, but I would love to do another one. I have a lot of content that I can share with the audience.

Howard Farran:

Well, thank you so much for all that you do for your patients and for dentistry.

Irfan Atcha:

Thank you very much. Thank you for having me.