Howard: And it’s just a huge honor for me today to be podcast interviewing David Gane all the way from Vancouver, British Columbia. He is a graduate of the University of Western Ontario with an Honors Degree in Physiology and Pharmacology, and a Doctorate Degree in Dental Surgery. David has authored many publications and technique videos on digital dental imaging, and has lectured nationally and internationally on this topic. He is a recognized leader in the dental profession, and is also a corporate executive with extensive experience in dental technology.
He is the former vice president of Dental Imaging for Carestream Dental, and has served in executive capacities with a number of dental companies, including PracticeWorks and Kodak Dental Systems, and is the founder of Orbit Imaging Inc., a company that owns and operates dental imaging centers in Vancouver. Doctor Gane currently serves as CEO of LED Medical Diagnostics, the manufacturer of the VELscope and the parent company of LED Dental, and Apteryx? Is that how you say it? Apteryx Inc.?
David: Apteryx. Yeah. That’s an Australian bird.
Howard: And seriously, God dang, David, you’re amazing. I mean you’re an amazing dentist, and when you were with Carestream and Kodak, I mean those were some of the… you were the former vice president of Dental Imaging for Carestream, which used to be Kodak, I mean that’s… God dang, they could have gotten any dentist in the world for that position, and you scored that. I mean, that is amazing. And PracticeWorks… so, Kodak bought PracticeWorks, which owns SoftDent, which I’ve been on for thirty years.
David: Right.
Howard: And a bunch of others. And then they sold it to CareStream, which is in Canada. Right?
David: CareStream? Yes, private equity. CareStream was the Kodak Health Imaging division. Of course, dentistry was a part of that, but that’s a private equity group out of Toronto called Onyx.
Howard: Onyx. How do you spell that? O-N-Y…?
David: O-N—oh, that’s a tough question. O-N-Y-X, I believe?
Howard: Yeah?
David: And they just recently divested, about a month ago, to two other private equity firms. So CareStream Dental was just sold.
Howard: So it’s really weird, because usually, the exit strategy of a venture capitalist is take a public, but I notice this is a whole different strategy. It’s kind of like a hot potato, like you see with DSOs.
David: Yes.
Howard: There’s not one DSO in America that’s publicly traded, and I don’t think Wall Street would take any of it. I don’t think Heartland, Pacific, Aspen… I don’t think any of them will go public, but what you’ll see is they’ll give venture capital, in say the five million range, and their goal is to flip it to ten million, to a venture capital in the ten-million range.
David: Yeah.
Howard: And then that guy buys it, and his goal is to flip it to someone in the twenty million range, and the forty million. It’s like the hot potato. It’s like nobody keep it. Everybody wants to just flip it.
David: Yeah.
Howard: And so… interesting deal. So Gosh darn. We could talk about so much. I want to start with something completely off the deep end. You’re the manufacturer of the VELscope.
David: Yes, absolutely.
Howard: And you make that now?
David: We do. We manufacture in Burnaby, British Columbia.
Howard: So, I mean what I’ve never understood for thirty years is that dental insurance, like Delta is the big dog… I mean they’re the biggest… they’re the four hundred-pound grout. They don’t cover oral cancer exams. I bet you… because VELscope is very similar in technology to the cervical uterine cancer technology. I mean they were… 30 years ago, I mean I remember seeing that, where they swab the tissue with toluidine blue, they were looking at the same… it was the same thing, especially in the ‘80s. And I imagine if medical insurance companies said, ‘You know what? We’re going to quit covering vaginal cervical cancer exams and women’. Oh, my god.
David: There’d be an uprising.
Howard: I bet the CEO would have to resign. He’d be written off as some sexist, animal, crazy nutjob, yet here we have… now, it’s 2017, and insurance companies don’t cover it, medical insurance companies don’t cover it, and fifty thousand Americans a year die from it. Why is that?
David: It’s a good question, Howard. Actually more people die from oral cancer than they do from cervical cancer, and we all know that most ladies, they get screened annually. And in dentistry, opportunistically, we’re right in the right position to be able to screen these patients, and it’s not happening. And as you say, the carriers don’t reimburse it, and reimbursement does drive adoption of the technology.
We all know that. Dentists… we’re in a business, and they need a clear path on an ROI. Delta Dental, I would guess, they don’t play on the medical side. That’s why they don’t cover it, because early detection saves lives, it also reduces morbidity. And I think, I haven’t done a full analysis, but I think there are some dental insurers that do cover it, and they also play, coincidentally, on the health side. So, I’m sure their strategy is if we create some reimbursement… and we’re seeing in our customer base, about $30 about a third of the time. But I’m thinking that those dental carriers that do reimburse are also playing on the health insurance side, and they’ll figure out that we’re going to have to pay now or pay later much more. So, I’m sure that’s just a business decision, but… yeah, it’s…
Howard: It’s kind of interesting what you’re saying, because the doctor… the big buzz word is the Oral Systemic Link.
David: Absolutely.
Howard: And all my other physician friends say that the same concept is coming to them, like the internists are starting to realize that they’re connected, the cardiologists. So that oral systemic link is being played out with every other body part of all fifty-eight medical specialties, all nine dental specialties. But it looks like it should be in the insurance. It sounds like a stand alone dental insurance company is not as holistic…
David: Right.
Howard: As someone part-medical. Because I remember listening to the past executive director, I think, of the ADA. I think his name was Brenner. And do you know Brenner? Do you know who he’s with? I think it’s Connecticut General or whatever, but they were… I think it’s Connecticut General, is it? Will you look up Brenner on…? But anyway, they were talking about how the medical side was most interested in the dental side covering pregnant women, because if they had gingivitis, periodontitis, and dropped a preemie, their average preemie cost was a million, and the number one thing they could relate it to, besides smoking, was gum disease.
David: Periodontal disease.
Howard: So if you’re smoking and have gum disease… I mean they want you to see a hygienist and someone to talk you out of smoking, because they have a million dollars at stake if you drop a one pound frog.
David: Yeah. It’s interesting, because we know that patients want to be screened. There’s good data out here from the Head and Neck Cancer Alliance, and there’s a lot of information out there. But dentistry has not done a good job, organized dentistry, in screening patients, and if I could just read a little data point here that I think is interesting. ‘Fifty-eight percent of U.S. consumers know little or nothing about oral cancer. Sixty-five percent of American consumers are not aware that HPV is a risk factor for oral cancer.’
Howard: What percent? Sixty-five?
David: Sixty-five percent. ‘Eighty-three percent want to be screened. The patients want to be screened at every check-up. Only thirty-seven percent of U.S. patients report ever being screened at their last check-up.’ And it just goes on and on. So we did an interesting little experiment where we know that pharmacies have now got rid of the tobacco, and they’re all about health and wellness, and they’re doing screenings. Right. They’re doing blood pressure…
Howard: You mean CVS quit selling cigarettes?
David: Yeah. And up here just overall pharmacies are more health-conscious and more into well-being. And so we approached an AD change store up here in Vancouver market and said, ‘Hey, your pharmacists are doing injections for flu vaccine, they’re doing blood pressure screening. How about doing some oral cancer screenings?’ And they thought about it, and it didn’t take much, and they said yes, and they’ve been doing them now for the last three years. They love the demographic that’s coming in. Of course, they advertise it, they charge for it, and they charge an average of $25 per screening, and…
Howard: Is that Canadian or U.S.?
David: That’s Canadian. We’re up to 80 cents today.
Howard: So $25 Canadian, and what would that be in U.S.?
David: Yeah, I would say $22. Twenty bucks.
Howard: Twenty bucks.
David: Anyway patients are willing to drive to the pharmacy to get a screening. We use the VELscope. We’re putting dentists and hygienists in there, because the pharmacy college is kind of a little unsure about their scope of practice in this regard. Any findings or triage, right to oral medicine or back to the dentist of record, and it’s been working great. So my point here is dentists shouldn’t be afraid to either give it away, and incorporate it into their comprehensive oral examination, or don’t be afraid to charge for it, if that’s your thing. Because people are more than willing to pay a fair fee for that service.
Howard: Well the reason I was asking how much that was in U.S., what are the disposable costs? What do the sundries and supplies cost in a VELscope oral cancer screening?
David: With our device, it’s around just over a dollar would be the disposable cost, and we’ve made those disposables very robust, and I wouldn’t be surprised if people were reusing them, but it’s about a dollar… just over a dollar per use.
Howard: Do you have a good YouTube video that shows the VELscope oral cancer exam?
David: I did, and I thought, ‘I’m a dentist, I’m still licensed, I don’t practice anymore,’ but I thought it’s probably embarrassing for a dentist to say, ‘I forgot how to do that’. And so, I contracted with a buddy who’s a very famous oral medicine doctor here locally, Samson Ng, and I did create a YouTube video, and I’ve asked him to do it. And it’s him doing an oral cancer exam, tactile, comprehensive…
Howard: How long… how long is that video?
David: It’s about six minutes. Doesn’t take long to do…
Howard: Do you mind emailing it to me? And then right now we’ll splice that six minute video in, so everybody who watches on YouTube downtown or listening to it can hear that exam now?
David: Absolutely. And…
Howard: I think that would be a very good deal.
David: It’d be a great service to the profession, because it’s simple once you know how, but until you know how. People, I think, are tentative to do it properly.
Samson: Hello, my name is Doctor Samson Ng. I’m a board certified specialist in oral medicine and oral and maxillofacial technology. In this video, I would like to show you a straightforward exam that helps your dentist, not only to develop an idea of the overall health of your oral cavity, but also screen for signs of a potentially deadly disease, oral cancer.
During the procedure your dentist examines both the inside and the outside part of the mouth, looking and feeling for anything abnormal. Most findings usually represent infection, inflammation, or some sort of trauma. However, there are also situations that could represent precancerous, or even cancerous changes. All of these abnormalities benefit from early discovery, allowing your dentist to manage the conditions before it becomes a more serious issue. Finding oral cancer early is absolutely critical, and may even save your life. Let’s get started.
Now today we are going to complete a full oral health assessment.
Patient: Okay.
Samson: In the history you indicated you have a sore in your mouth.
Patient: Yeah. I’ve got a bit of a sore patch, it’s on the right side of my tongue, a bit near the back.
Samson: How long have you had it now?
Patient: Two or three weeks.
Samson: What have you done so far?
Patient: Nothing too much. It’s sort of been coming and going, so I’ve sort of been hoping it’s just going to go away.
Samson: I see. So we’ll be having to look into it as well.
Patient: Okay, great.
Samson: Now, how’s your health otherwise?
Patient: Oh, it’s good. Thanks.
Samson: Good. Do you smoke?
Patient: No.
Samson: Do you drink?
Patient: Occasionally, maybe. Wine with dinner, something like that.
Samson: Before I look inside your mouth, I’m going to look outside, around your head and neck. Can you rest at the back? Thank you. Great. I just want to make sure there’s no lumps and bumps on the skin. Great. Can you open your mouth? Can you close? What I’m doing now is to make sure there’s no swelling gland around your jawbone area and around your neck regions. Great. Can you swallow? And do it one more time, please. Great, thank you.
Okay, so to start off, I’m going to look into the lip, you close a little bit. Great. Perfect. I’m going to look into the mouth. You open? I start off with the side of the cheek. Look into the lower lip, and also the other side of the cheek. And then go to the upper gum, on both sides. The palate looks absolutely healthy for me. Thank you. Now you close and swallow. You open, and you say ‘Ah’.
Patient: Ah.
Samson: Perfect. Thank you. I’m going to look into your tongue. Can you stick out your tongue, please? Great. The side of the tongue look good, the other side of the tongue is good as well. You close and swallow. I’m going to feel around the bottom surface of your mouth to make sure there’s no lumps and bumps. Great. You open again, I’m going to feel around the palate and the jawbone region, as well, to make sure there’s nothing else. Great. You bite together, and thank you.
So, right now, I’m going to use another light to look into your mouth again. Okay?
Patient: Okay.
Samson: Before we do that, I’d like for you to put these eyeglasses on, please. You open your mouth, please. Again, I’m going to do the same thing using. I’m this light to look into both sides of your cheek, the roof of the mouth, and the core of the mouth. Can you roll your tongue back, please? Thank you. Great. Can you close and swallow. Great. I then look into your tongue again. Can you stick out your tongue, please? Great. Look at the side of the tongue, then the other side of the tongue. Great. Thank you.
Good. Now you can take off your eyeglasses now. Good. I’m going to take a picture of the sore area that you talk about. Now, you open your mouth, and I need your help to help me to hold onto this cheek retractor for me. Great. Can you stick out your tongue, please? And to that side. Great. Good. Can you stick out your tongue again? Great. Good.
When this oral exam is conducted regularly, particularly with a device that helps your dentist to see things which might otherwise have been overlooked. You have a better chance of discovering an abnormality sooner, and treating it with a better outcome. From time to time, your dentist or your hygienist will ask you to come back for another checkup, or even refer you to a specialist for additional care. They are routine, and an essential part of the process. I hope you can see why an oral exam is a very important part of your routine dental check-up. Remember to ask your dentist about it on your next visit.
Howard: Well, how many Americans do you think die each year from oral cancer?
David: I got the facts here, Howard. So there’s six hundred thousand new cases a year. That’s worldwide. In the U.S., ten thousand, with about forty thousand new cases growing annually.
Howard: So ten thousand Americans… ten thousand what? New cases in America, or ten thousand die?
David: Ten thousand die. Nine thousand five hundred and seventy will die of oral cancer, pharyngeal cancer, this year.
Howard: Of oral pharyngeal?
David: Yes. Oral and oropharyngeal.
Howard: Oral cancer and oropharyngeal.
David: Correct.
Howard: And then how many cases… so ninety-five seventy will die from oral cancer and oropharyngeal cancer, and there was how many new cases?
David: Forty-eight thousand new cases in the U.S. this year… expected this year.
Howard: And what do you think early diagnosis as opposed to late diagnosis would do that ninety-five seventy, if they were all treat… caught in stage one, as opposed to stage two, or three, or four?
David: Well stage shifts are huge, as you know. So, again, I’m just quoting data from the Head and Neck Cancer Alliance. Forty percent of those diagnosed with oral cancer die within five years, and that’s due to the late-stage finding. And early diagnosis, they say, will more than double the chance of patients’ survival.
Howard: Yeah. That’s what’s weird about dentistry, because people always tease and they’ll say, ‘well dentist, that’s not a real doctor’, and I always say, ‘well Doctor Pepper is not a real doctor. Doctor Seuss wasn’t a real doctor. Doctor Dray’s not a real doctor’. But when you look at dentists, they kind of act like they don’t want to be a doctor.
David: They don’t.
Howard: Because when they look at the… almost ten thousand Americans die of oral cancer, and that’s the one thing they don’t do, and their insurance doesn’t cover. And then what I can’t believe is when you look at the flu, eight thousand is like the least number of deaths in America in, like, the last ten years, and it will soar all the way to forty-eight thousand, and when they look at those forty-eight thousand people that died.
The last top three points of entry into the healthcare system always includes the dental office. And so, here’s a hygienist with a four year’s degree, and if she was at a… grandma would have went to the hospital, or physician, the nurse would have given her a flu shot. And here’s the hygienist trying to see if she has gingivitis. Grandma ain’t going to die from gingivitis, but she might not see her six months later from the flu, and then when the board’s vote on whether or not the dentist can give a flu shot. The dental boards are the ones that vote it down. I mean can you believe that? I mean you would think that someone else was doing this to us. It’s like…
David: Yeah.
Howard: It’s like the guy living under the bridge is the one smoking the meth. And the only state out of fifty where they finally allowed dentists and hygienists to give flu shots was Tennessee. And it’s like…
David: There’s a total disconnect. And you’re right. Dentistry is driving it, and it started right at the beginning. There’s… I forgot the name of the book, but I’ll send you a link. There’s a great little book. There’s a Washington lobbyist. I was writing about the disconnect between the oral cavity and the rest of the body and how it started. It’s a wonderful read, and I go to the dentist they don’t ask me if I’ve been exercising, and kind of working out and taking care of myself. And if I go to the doctor, they don’t say, ‘have you been flossing lately?’
So, there’s a real disconnect there, and I think you’re right dentists don’t want to own it. Again they don’t see a reimbursement model for it. But it’s right in their wheelhouse, and it’s unfortunate that periodontal disease is now being found through all these new amplification techniques, and new knowledge to be causing everything from rheumatoid arthritis, to breast cancer, to heart disease, but that’s the portal. That’s our world. That’s where we live, and hopefully, that will change. But we’re doing a bad job for screening, for sure, and if we could just identify these oral mucosal diseases, if it’s pre-malignant or not and we could make a big impact.
Howard: Man it’s been a long time since I heard wheelhouse. Wheelhouse. Baseball, the pitch, within the zone.
David: That’s not Northern term either. I’ve got a Southern partner and I picked up a few from him.
Howard: It’s baseball within the zone that is most advantageous for a batter to hit a homerun, within one’s area of expertise or interest. There are some subjects that are in your wheelhouse. I don’t think I’ve heard that term since I was ten. I’m actually… yeah, that’s a… So, yeah, I mean the… So, what are you most passionate about now? VELscope’s been out… I mean that’s about for thirty years.
David: No…
Howard: Not thirty?
David: Seven… eight? Fluorescent visualization technology for other parts of the body, like the lung, have been around.
Howard: Well what was the one in Phoenix, where I live? That’s Phoenix, Arizona. There was an oral cancer screening company.
David: ViziLite?
Howard: Yeah, ViziLite.
David: ViziLite has been around longer. It is… yeah, it had the light stick and the astringent rinse.
Howard: Right.
David: Yeah. Similar technology.
Howard: And are they still in business, or are they gone?
David: I think they’re still there in some form, and I don’t want to misspeak, but it may have been DenMat that picked up the assets of that, ViziLite. But we’re the largest player right now. We’ve got about… and what the largest player has in terms of user base is about sixteen thousand globally, units. So, it’s pretty sad, in terms of…
Howard: Sixteen thousand units globally, and how many of those sixteen thousand are on the United States?
David: I’d say ninety percent of them.
Howard: Ninety percent.
David: Ninety percent of them. We just picked up… in Southeast Asia and China there’s carcinogenic foodstuffs that they like to chew, stimulants, rakan nut, betel nut, so they’ve got a big risk factor over there. So recently, we did sign with a large distributor over there. So we’re making some inroads in China, same thing in India, similar type of dietary habits that really drive much higher findings of pre-malignant and late-stage tumors.
But it’s handheld. It’s easy to use. Howard, the big news on the VELscope is that we just finished a five year double-blind clinical randomize at nine oncology centers, and what they were doing is they were using the VELscope to guide the surgeon for surgical removal of the cancers. So four hundred plus oral cancer patients, and they divided them into two groups, and the experimental arm, they used the VELscope oncology surgeons to remove the lesion, and just in the control arm, they just use traditional methods of palpation and incandescent light.
Then they measured recurrence of the disease over five years, and now we’re in year six. Most of these are oral cancers, they recurred about forty percent by year three. And so that’s why it’s such an aggressive surgery. They take a large rim of healthy tissue in hope of excising the lesion in total. We did a retrospective study that showed that the recurrence of the disease goes down from thirty-five percent, down to about six percent, if we’re using visualization technology to guide the surgeon’s approach, and a more conservative approach at that.
So this data will be published in the next sixty days on a five year trial. So we’re really excited about that, and we think the prospect of study, that these nine oncology centers will mirror our retrospective studies. So that could be big for moving our VELscope from screening to actual treatment.
Howard: What do you see in the difference in oral cancer and oropharyngeal cancer? Is that the terminology you’re using? Oral cancer?
David: Yeah, or oropharyngeal. So…
Howard: Oropharyngeal?
David: Yeah. So the risk factors… traditional risk factors of tobacco, whether you chew or you vape or you smoke, smoking… of course, smoking and drinking is double bad, and then alcohol used by itself, and the new risk factor, of course, is HPV. HPV-16.
Howard: But is that oral cancer, or HPV for oropharyngeal cancer?
David: Both, but mostly oropharyngeal.
Howard: Okay, and that’s HPV-16?
David: Sixteen and some of eighteen, I believe, but mostly sixteen. And I just read on Flipboard the other day that fifty percent of the men in America have or are infected with HPV. So that’s a pretty big number. Of course, Gardasil will change that over time.
Howard: Okay, but there’s…
David: But here’s a step for you that is really, really troubling is the largest rising group of oropharyngeal cancer patients is non-smoking, non-drinking, and it’s totally due to a sexually transmitted disease of oral sexual activity, and it’s in the adolescent group. So the whole demographic is changing, which mean dentists now have to be more aware and not just screen, if they’re screening at all, in that elderly at risk group of drinking and smoking, but the entire population over the age of sexual consent.
Howard: But again our dentists, doctors… I mean what percent of the doctors have ever, ever had Gardasil conversation with their patients, regarding their pediatric patients under ten years old?
David: I would say very low, they’re uncomfortable with that.
Howard: Well I mean… so they’re uncomfortable with the conversation, but they’re okay with ten thousand deaths a year?
David: Apparently.
Howard: And the other thing is when they’re talking about oral sex and HPV and all that stuff, it seems like they… do they really… I mean it could just be kissing, right?
David: It could be. It could be. Again, I’m not an expert, but I think the vast majority of these infections are from oral sexual activity.
Howard: So not just kissing.
David: Not just kissing. No.
Howard: I wonder if that’s because no one just kisses, they all… but anyway, to me, it seems like when I look at the research where a standard kiss will transfer eighty million microorganisms, bacteria, fungi and viruses. I mean if somebody’s infected with something, I don’t think it really matters if the fluid was coming from the mouth, or downstairs, or whatever.
David: Yeah.
Howard: I mean you’re trading fluid with some other member of your herd.
David: Yeah. Yeah. Exactly, and this fluid, which has largely been a nuisance to us as dentists, I think, is going to prove to be the new superfluid. Again, with all these amplification techniques and these new biomarkers and these proteins. Saliva is pretty much a real-time fluid, so there’s a lot going on and you can tell in the moment. And you can correlate some of these biomarkers, whether they’re proteomic, or your proteins that the body is excreting, or actually viral particles or even cancer cells.
At the point of care, to be able to facilitate or bolster… VELscope’s a very sensitive device. It’s not very specific, but then when you start adding these biomarkers and these point of care tests, in conjunction with it, it can get much more higher specificity. So that’s kind of where I see it going, and there’s some really great dental companies, and Dr. Wong’s doing good work in California, Vigilant Biosciences, and there’s a few of them now coming to market with these point of care tests. I was surprised… point of care Zika test, $2, spit, and a positive. It’s very binary you have it or you don’t $2, and you know in ten minutes. HPV, HIV spit tests, and that’s really…
Howard: Are you guys selling those too?
David: No, I have a professional interest in that, because it’s tied into early diagnosis of oral cancer lesions, but I think it’s going to take the profession by storm pretty soon, because where do you harvest spit? At the dental office.
Howard: You should create an online CE course on dental town about this. We’ve put up some four hundred courses on dental town since 2004, and they’re coming up on a million views. Old guys like you and I read textbooks and go to conventions, and there’s a quarter million people on dental town. But when we came out with the app, fifty thousand people downloaded the app, and those were all the millennials.
David: Yeah.
Howard: And when you and I read textbooks and go to conventions, the millennials are on these apps, and oral cancer is everything. You should create an online CE course on dental town. I think that would be…
David: Well I just did a program on salivary diagnostics for my own professional interest, and I just delivered it to my study club. So I’ve got a fresh program, it’s about an hour and I’d be happy to do that.
Howard: Perfect.
David: I leverage the material.
Howard: So I’m Howard@dentaltown.com, and the guy that does online CE is Howard Goldstein. So he’s Hogo, H-O-G-O@dentaltown.com. And Ryan, will you email David, and I’ll go… yeah, that would be amazing, because I’m trying to a leader, and stir these doctors up. It’s not all about gingivitis I mean there’s oral cancer. How do you say that vaccine? Gardasil?
David: Gardasil
Howard: Yeah, it’s just… I think it’s just… how do you spell it? G-U-A-R-D.
David: G-A-R-D-I-S-I-L. Gardasil. That’s the trade name.
Howard: G-A-R-D-I-S-A-L.
David: S-I-L, I believe.
Howard: Gardasil 9. To me, it’s just so sad that nobody in dentistry… I mean, we have…. There’s two hundred and eleven thousand American who have an active license to do dentistry, and a hundred and fifty thousand of those are general dentists, thirty-two hours a week or more, and thirty thousand are specialist, thirty-two hours a week or more and this is their damn cancer.
David: Yeah.
Howard: And they need to own it…
David: Or somebody else (inaudible 31:01).
Howard: The primary care? And let’s talk about primary care. I mean I almost try not to laugh every year I get a physical, and my doctor I’ve been going to forever. When it gets to my mouth he says ‘open up’ and he takes a popsicle stick, and a light and he says ‘say ah’, and I say ‘ah’ and then he’s done, and he throws the stick away and I’m like… okay I’ve been a dentist for thirty years, what the hell did you just do? I mean shed some light on your homie here. I mean I don’t know…
David: Yeah.
Howard: I couldn’t have done anything. And so what’s a doctor going to do? The dentists says ‘oh I’m really a doctor but the primary care physician owns oral cancer’. I mean give me a break. I mean they really… and I think an online CE course to help that. But dentists should be given a gardasil 9 talk, they should be giving brochures to all the patients. If they can’t have a conversation about oral sex, they should actually go back and turn in their dental degree and go live in a bubble under the basement of their mom’s house. And at least give hand-out or have your dental assistant or hygienist talk about it. And they should give a flu shot.
David: I think…
Howard: And I think dentist should just start giving the flu shot. I mean what is the government really going to do? Are they really going to come arrest a dentist and put him in jail for giving grandma a flu shot when you can go to Walgreen’s or CVC and the pharmacy tech…
David: Yeah.
Howard: Who went to school for nine months can give grandma the flu shot but doctor and hygienist can’t? I mean it’s insanity.
David: Ridiculous. But you brought up a point there about the hygienist. I think the big opportunity, in the short term, is to leverage the hygienist. Because they have a pretty tough job, they’re with the patient for a long time, and I think most of them do care about the patient’s health, holistically. And they’re looking at the soft tissues, they do like technology to be able to help them, and bring it to the attention of the clinician. So I think probably the secret weapon in the short-term would be to leverage that hygienist base.
Howard: Absolutely. Yeah, and I almost think it’ll think some lawsuits before the dentist will react. I almost think someone has to get sued because she took her daughter to this dentist every six months from birth to eighteen then she went to freshmen year to ASU and died of oropharyngeal cancer and nobody told her anything.
David: Yeah.
Howard: I almost… I almost think…
David: You know who’s doing good work in this regard is Brian Hill at the oral cancer foundation.
Howard: I do not.
David: Brian is a stage four survivor. He was in the dental trade, in the business, and he’s pretty much devoted his life at this point to oral cancer awareness.
Howard: What’s his name?
David: His name is Brian Hill
Howard: Oh. Is he at the oral cancer foundation?
David: Yeah, he is.
Howard: Yeah, I do, I know.
David: He’s doing some really incredible things in marketing, low-cost marketing, sponsoring a rodeo rider, doing oral cancer screenings, among the beer and the smoke at the rodeos. Sponsored the rider, doing great things at surf competitions, and all young people and just creating that awareness of HPV as a risk factor. One of the soap box… or soap opera actresses actually did get oral cancer, and was able to convince the producer to keep her on the show and let America see what this disease is all about, and so he’s a very, very creative and he’s doing some fabulous work about education the public on this disease
Howard: That is amazing.
David: We like to support the Oral Cancer Foundation wherever we can.
Howard: Nice. So what else are you passionate about?
David: You know i'm an imaging guy, and velscope is an imaging device. It was time for me to leave Atlanta. I was there with my wife. I said we’d be there for two years, and after thirteen, she said ‘I'm leaving’. So it was time to get back to Vancouver but I've always been an imaging guy. It was… you remember Dick Barnes?
Howard: Oh yeah.
David: Remember Dick and his five slides?
Howard: I was Barnesified.
David: I was Barnesified. That turned me on so much. I started practice, I bought a camera and I made my own five slides, and I took pictures of everybody because I had time to do it. There was not a lot of patients, starting from ground zero and I quickly found out that I could really sell a lot of dentistry, that I didn’t really know how to do and the slides worked. That got me going and then, of course, I took Homer’s course on case presentation and how to close them. Then I had to go learn how to do the dentistry and I became such a passionate person about imaging.
I started an imaging software company, and I don’t know if you remember Image Effects or Picture Perfect, and DICOM imaging systems. Those were foundational products that we created. I got into the software business. Dentistry, you only make money when your fingers are wet. So that kinda sounds like an Homerism but I thought ‘well software’s better because you could just print in on discs and it’ll be easier’. So I did that, of course, I end up selling my company to PracticeWorks in 2002, and at that point they were doing the consolidation. They were buying SoftDENT and they bought north of thirty companies in about a two year period, it was pretty intense and I was one of those acquisitions, and then...
Howard: And then sold it for how much? How much did Kodak pay for it? Was it…
David: Five hundred million cash.
Howard: It was half a billion.
David: In ’04.
Howard: And my jaw is still on the floor about that. Nobody could believe Kodak wrote half a billion dollars those days. That was crazy. But they did it.
David: Just before Kodak brought it, we acquired Trophy Radiologies. So this was a real thrill for me being an imaging guy. So we went to France and we bought Trophy and, of course, Francois Moirin was a big hero of mine. And he had the original IP, and so we had all of these… I would think it’d be SoftDENT, to PracticeWorks, Computer Age Dentists, OrthoTrac, WinOMS, eventually had sixty thousand user base. Then we went and bought Trophy, they were divesting. Then Eastman Kodak, that was messing with their business because they had ninety percent market share in film, and I bet you that hadn’t closed, but we brought it for one times revenue, it was a great deal.
So we grew from early stage to about hundred and twenty million through acquisition, and a little bit of organic growth. As soon as we bought Trophy they were on it, and I bet you a year didn’t go by and our leadership sold for half a billion in cash. They only held it for two years, and they sold it. Private acuity, so we all know that kodak story, it’s a sad story of not being able to make the transition in a timely way, or at all. And liked the digital. So it was exciting.
Howard: Tell the millennials. Tell the under thirty the Kodak story. Why do you think… they owned film, why do you think they missed digital?
David: Imagine if they had one tenth of a cent of every picture that was ever taken by a smartphone right now. It’d be like… it’d be the biggest company on the planet but they missed it. I think it was their senior leadership. They just missed it, they were too focused… so kodak had three business units. They had the movies, they had consumer photography, and they had health care. And the first thing that jettisoned was healthcare, because they couldn’t be a major player because they were running into problems. So they had the movies, they were still shooting on celluloid probably, and they never… in the consumer photography, they never made the jump from film. Film is high margin. I don’t know if they got greedy. Dental films, super high margin. They stuck with it too long.
And, once digital radiography came along, and they started losing market share. Us just consolidating these practices and now solving their back end digital problem. We became a perfect target. And of course, my partner and I, and other leaders on the team, we knew exactly that was going to happen. Probably before they did. They had to do it. But it was too little too late, and the rest is history. Right.
Howard: Sad.
David: It blew.
Howard: And then xerox...
David: One of the most iconic names in the planet or brands right?
Howard: And Xerox basically invented all the stuff that was in Steve Jobs’ deal. I mean steve jobs tried to make it a legend that he and Wozniak invented all that shit in their garage. But that was all Xerox technology and Park Research Lab.
David: Yeah.
Howard: And every time they brought the technology back to xerox, they said ‘well what does this have to do with the copier?’ I mean they just could not see that there could be another company in there.
David: Yeah. Yeah. No, it’s good to look back and see what happens to all those mistakes that are…
Howard: So you’ve gone from film, to 2D, to now 3D. That means we must be getting old.
David: Yeah.
Howard: When you practice in film, 2d, 3d. I still remember the greatest invention on the 2D panel was when they did the upgrade, to where they put an R on one side and the L on the other. I thought that was absolutely the greatest radiographic invention of all time. I did not see the 3D coming.
David: Now, do you remember and again this is… I had the good fortune to meet Francois Duris recently. He came out of retirement to do another 3D imaging project in dentistry. But back in the 80s Francois, at the Chicago mid-winter, probably about eighty-eight or something like that. Mechanically digitized a prepped tooth with a little wand, that he had to touch every surface, created this digital pattern, and then designed and milled a crown and seated it on the floor of the trade show.
We were in 3D in the 80’s, he was so way ahead of his time. It was not funny. So I’ve always become interested in 3D, and at Carestream they made the 9000 which is the small field 3D, I remember being the VP and I remember pulling on the thing is like three centimeters by four centimeters. and I’m coming from comprehensive care, it’s just you'll never sell that. Nobody will ever buy that, like [inaudible 41:41] or two. Right. I was so wrong. We sold thousands, and thousands, and thousands of those. Mostly the Andonis. Right?
Howard: Right.
David: Became the standard of care real quickly. And, that machine sold… it opened the market for 3D, and at an affordable price point. It was just a great little machine, I still have a couple at my imaging center. But yeah, 3D now is so exciting, really what’s happened is it’s just transitioned… imaging in dentistry from the realm of just pure diagnostics to image guided treatments. Look at invisalign, look at image guided implant placements, and it’s just getting going. Image guided snoring appliance. Just using all this data.
Optical impression scanning in full color, merge consolidated with DICOM sets. Merge with photogrammetry in full color of the face. It’s just amazing to the point now we’re so close to a patient specific virtual model, that we can diagnose a treatment plan and almost treat the patient in simulation, like they’re right there when they’re not. So I still have as much passion for imaging as I ever had, and I think it’s getting more exciting, and more fun than ever.
Howard: So you talk about the commoditization of intraoral sensor technologies, what do you mean by that?
David: I bought one of the first sensors, you can barely get it in your mouth, and it was like more than $10,000. I know what these things cost to make, and so does everybody else in the industry, and it’s been very expensive for clinicians to buy these. To be frank, to this point they’ve been somewhat fragile. So that’s really slowed down adoption, and right now, all the patents of Francois Moirin are away. So everybody has access to the simulator and the optical fiber, and getting a nice clean diagnostic image with not a lot of dose, not a lot of noise.
So any factory can make these now. So what I mean by that is probably sensors right now are due for a price correction. They won't be able to substantiate these high margins, and these high costs which I think, at a lower price point with a product that’s as good or better. I think that’ll drive further adoption to digital which is good for the patient, and good for the practice. So that’s really the focus of our company is we’re a unique little imaging company. We’re public but we’re small.
Howard: Where’re you trading?
David: The Toronto Venture Exchange. We’re looking to uplist in the near future to, hopefully, to the Nasdaq but now we’re on a lot of people’s radar. We just closed an acquisition in February of Apteryx. Apteryx is a wonderful little company. My partner and I have tried to buy them a couple of times before. We’ve known Kevin, the single shareholder owner, for twenty years. He’s built a wonderful company, he’s got tens of thousands of dentist customers. He’s got the…
Howard: Now that’s Aperturix?
David: Apteryx, it’s actually… Apteryx is an Australian bird maybe you'll see one there next week.
Howard: After I talking with you I’m going to the airport, and flying to New Zealand. I mean to…
David: Australia, yeah.
Howard: Melbourne in Australia with Ryan. So A-P-T-E-R-Y-X, and what is Apteryx?
David: Apteryx is a dental software house, they make dental imaging software. They are suppliers to the US military, the navy, the air force, all of their user base… all of their naval and army bases, and sub-bases worldwide. They’ve got a very large user base because they’re basically… their secret sauce to their software is it’s open software. That means it’s diagnostic to hardware devices. It’s full DICOM, it’s full open, and if you look at many companies in dentistry and imaging like Serona, or Carestream, or the Dentaire products. They’re closed proprietary ecosystems.
So this approach of having an open architected software system allows, for instance, the US army to use their entire inventory of sensors globally and not have to refresh their sensors by using the Apteryx software. So a common platform. DSO is another great example. We’re very popular in the DSO market, because these closed proprietary systems, something fails, like a sensor, you’re pretty much captive to that manufacturer. You don’t like their pricing, you don’t lie their support. Too bad. You can’t afford to leave because you’ll have to refresh your entire inventory of hardware.
Apteryx over top allows you to continue to leverage your existing inventory of imaging hardware, pens, septs, sensors, while adding the new sensor of your choice. Which I believe we’re going to be in the running, because we have this new sensor line that’s as good or better than anything out there, at much different price point, value point.
Howard: And you said Apteryx is named after an Australian bird but is it an Australian company? Cause the address on the website says Akron, Ohio.
David: Based on Akron, Ohio. I forgot to ask Kevin where he got the name but he liked that name. But I did look it up and it is an Australian bird. The other thing that is every unique about Apteryx, they’ve got a very large user base. We’re very happy with that, and of course, Howard, they're all digital dentists cause they’re using digital software but Apteryx also has forty patents in the dental imaging space. A lot of them are surrounding their software IP. So at the same time their software is diagnostic to hardware. They integrate well with all the dental practice management softwares. So it’s a great solution, and many dentists have found it. It’s very well priced, supports very reasonable. That’s how they got such a large user base.
Howard: And what’s the owner’s name? Kevin?
David: His name is Kevin. He’s a son of a dentist how he got into dentistry.
Howard: What’s his last name?
David: Cruz. C-R-U-C-S. Kevin Crucs. C-R-U-C-S. Great guy.
Howard: C-R-U-C-S out of Akron, Ohio.
David: Akron, Ohio. Lives down the street from Lebron, great guy, very smart.
Howard: Do you think he’ll do a good podcast?
David: He’d be an awesome podcast.
Howard: Can you fix us up?
David: Absolutely.
Howard: Email. Have email him, and cc me and Ryan, and we can have him follow you. So you think…
David: He’s got a great story to tell. He's been in the business for twenty years, and he’s seen it. And we’re happy now he’s on the team.
Howard: And right now you're in the midst of buying him right?
David: We closed the acquisition in February, so we're done. He's integrated into our team.
Howard: And is he your stay on?
David: Yeah, absolutely.
Howard: Nice. Nice, nice, nice, very, very good.
David: So it’s a nice little… it transformational to our company for sure. We’re excited because he’s a profitable company, he adds revenue, he adds earnings, he adds users, he adds IP, and he gives us this really unique piece of software, that allows us to really tailor our products to the enterprise groups and DSOs. So we’re really pleased with that acquisition.
Howard: Nice, nice, nice. So what else has got your passionate? What else are you excited about?
David: I’m excited about so many things. Right now, we’re growing the business, it’s a relatively new venture. When I joined the business, right at the beginning of 2014, we had one product. Now we have a whole portfolio of imaging products. So we’re a full on imaging company. I’ve been in the imaging business…. it’s a big fish in a small pond and my own company with PracticeWorks but real excited about LED medical, and the transformation that we’re making. Be nice to get on some more radars and have people out there know kind of what we’re up to, because I really think that when people look under our hood they're really going to like what they're going to see about what we’re trying to do.
Howard: Talk about intraoral CAT scanners, and CAD/CAM chairside milling. What are your thoughts on that?
David: The old days, if you believe the powers that be, the Cerac and the E4D’s of the world, we’re going to kind of take over. But it seems they capped out at about twenty percent market share, and I think that’s going to be dropping down. I think dentists are kind of control freaks, a lot of them. They want to control the whole process from scan, the plan, and even do the lab work which never made any sense to me. But now with these intraoral scanners being optimized and refined with next gen technology. These optical scanners can take an impression much faster than impression material, much more accurate, full living color. What you're seeing now, I think in the global market, is no more chairside milling but just these scans go up and it’s like priceline.com on a design, priceline.com on an open mill. So it’s really going to drive the lab deliverable cost down in my estimation. And of course a lot of these mills and design teams are off-shore so they can be done during the night.
So I think, my vision of the future is, we’re not going to see too many mills in offices going forward but we’re going to see scanners in every office, and we're not going to be scanning for impressioning, we’re going to be scanning for modelling the patient, for empirical data, accurate data in all three dimension in full color. You’re automatically charting restoration, you're charting accurate color on gingival inflammation, you can turn and twist these things. You can mount them virtually.
So no more articulators, no more impression materials trace, all these skews, autoclaving stuff. It’s really going to change everything. So I am so excited I ran out and bought a 3Shape scanner soon as they came out just like I did early on with the sensor. We’re using it in our imaging centers, and I really think two minutes to scan a patient upper and lower arch, that saves you ten minutes chairside just charting the patient, what restorations, what teeth are missing, and all of that.
So I don’t think people understand yet the true value of this technology but they’re going to real quick. 4D, we’re talking about 2D, 3D, 4D. Where occlusion, overlying occlusal data on these models. It’s just going to be amazing what imaging is going to do for the profession.
Howard: Couple of things. I think the lowest hanging fruit on being a better dentist has always been microfiche. I mean you can go from naked homosapien eyes to loops two point five…
David: Yeah.
Howard: To three point five, you’re a better dentist.
David: Yeah. Absolutely.
Howard: Scanning. Scanning. No dentist has ever scanned a prep and seen their prep the size of the screen and not put their tail between their legs, and went back to that prep and cleaned it up…
David: Cleaned it up. Yeah.
Howard: And did some more stuff. I like that. But I want to challenge your numbers. You said CAD/CAM chairside milling, the adoption rate was twenty percent. There’s a hundred and fifty thousand general dentists in the United States, twenty percent would be thirty thousand. I almost think it’s half that amount.
David: Yeah. I’m saying it’s going to cap out at the very most that, and these aren’t my numbers but this is good research.
Howard: So you think it’s going to cap at 30,000?
David: I think it’ll cap maximum twenty percent of market. I’m kind of buying into good data.
Howard: Which would be thirty thousand units.
David: If that. Yeah.
Howard: Yeah. Where do you think it is now?
David: I would say it’s much less than that, I'm not sure.
Howard: I’d say is half that amount.
David: Yeah, I’d say it’s about half that.
Howard: The point I'm making is my homies are smart. I mean all my friends have eight years of college and are a Doctor of Dentistry and what do you think the adoption rate is right now in 2017 of digital X-rays?
David: I knew I was going to be asked that I haven't bought the latest paper or research yet but I would guestimate it in the US right?
Howard: Right.
David: Sixty-five, seventy.
Howard: Okay. So if sixty-five percent bought digital x ray, and twenty percent bought chairside milling that’s a huge red flag. That it must not be faster, easier, higher quality and lower cost.
David: Yeah.
Howard: A lot of people bought that chairside milling, and now it the most expensive coat rack you’ve ever seen.
David: Yeah.
Howard: Because what you said earlier, you never thought ‘why does a doctor digress and to become a lab tech?’ All these people in the lectures saying ‘oh yeah, he can do this in an hour’. But out in the real world that hour is two to three hours.
David: Yeah.
Howard: And you're saying that thing that I'd rather just prep , scan, and send that to the lab, temporize and leave. In fact the people I know that are… my friends are using the chairside milling the most, they're not even milling chairs anymore. They’re just storing all the impressions, then they have a lady who works at a dental laboratory Monday through Friday to five. She comes one night a week on a Wednesday and mills out all the crowns that they’ve impressed the last week. So yeah doing lab work chairside, well I think it is proved by the adoption rate.
David: Yeah. I agree.
Howard: I think the adoption… same thing when I got out of school with lasers. When they came out with those lasers in ‘87 I think the first one was. But it was fifty thousand, and I noticed every time a laser came out for fifty thousand in the ‘80’s, one thousand dentists would buy it. I’m convinced that one thousand dentists would buy anything. But it always stopped at about a thousand you know what I mean? And the true, between bleeding edge and leading edge and all that is the adoption rate. But, yeah, the…
David: The greatest companies in the world right now in dentistry is 3Shape out of Copenhagen. They are killing it. They’re growing so quickly. Their products are amazing, they’re fast, they’re accurate, and they’re pricey. They’re at the top end of the price scale but I really think that is an amazing, out of nowhere kind of company, that is really going to dominate our profession going forward.
Howard: Well it’s so expensive because the US dollar is at an all time low against the Euro. So as the dollars crashing.
David: Yeah.
Howard: And the Euros… that’s why export is always on a weak dollar for that exact reason.
David: Yeah.
Howard: I mean nobody at 3Shape wants a strong Euro.
David: Yeah.
Howard: They wish the Euro would crash.
David: Yeah.
Howard: So when the dollar crashes and the Euro gets strong. Everybody in Liechtenstein and Germany and all those companies are cringing. But it’s ok.
David: But it’s a product line the 3Shape, it’s a distributed product for us but we really think the best of breed out there right now across the board. Crown and bridge, and implant dentistry, ortho, now they’ve got a direct link to the Formlabs printer. That is a killer little printer for those who want to do some in office printing at a very good price point.
That is disruptive to all of the envision techs and all these other higher price printers. They got biocompatible materials, provisionals, splints, guides very, very cost effective. They did the deal with Align Technologies, not sure how that’s going. So align opened up 3Shape, so that will continue to fuel their growth I’m sure.
Howard: That is definitely a company to watch, isn't it?
David: Yeah, I’d say.
Howard: Yeah. So anything else you want to talk about?
David: No, Howard that’s it. Our paths haven’t crossed. I never sat down with you like this so I do thanks for the opportunity. It’s been a pleasure to sit down with you and chat.
Howard: The honor is all mine. I love technology but like I say I always hold up four fingers. Is it faster? Easier? Higher quality? Lower cost?
David: Yeah.
Howard: People always come up to me… they always come to me with all these ideas and products and I always ask them those four things.
David: Yeah.
Howard: And when you answer yes to all those things, it’s amazing. But I really hope you do the online CE course, because I really want dentists to go from being molar mechanics…
David: Yeah.
Howard: To physicians of the mouth. And I really want them to take this oral cancer, Gardasil. I mean I just think you would feel horrible if some little girl came to you every six months then goes to college and gets oropharyngeal cancer, because you never even had a vaccine shot with her. You never even had the talk.
David: Yeah.
Howard: The oral cancer that’s our deal. I hope we make that on… so what was your lecture on?
David: Yeah.
Howard: What was your online CE course could be on?
David: It’s going to be on… I’ll have to change a little bit to make it a little bit more pertinent to oral cancer, but it’s just going to be on salivary diagnostics and introduction salivary diagnostics. I think the profession needs to know what’s happening out there, and what’s coming, and what’s already there in some places, and tie it back into oral cancer screening. So yeah, I'll come up with something there and I’ll be happy to do that.
And maybe just a parting word. You mentioned that your audience is of the younger crowd. My advice to the younger crowd, the younger dentists and students would be, it’s really important for them to embrace technology. Patients expect it, they almost demand it, and it takes a lifetime to be a good dentist but it only takes like five or six minutes to look like one. But technology will really allow you to leverage so many parts of your practice in terms of workflow efficiencies, and reduction in lab fees, and all of that.
Unfortunately a lot of these new dentists I think are ending up in practices that don’t have technology, as associates, and so they’re going to have to be a bit pushy and get some adoption there. The other thing of course which is not novel is that it’s a lifelong learning experience, and I was able to sell dentistry using imaging and not being able to deliver it, and I had some bad failures. So it’s always important to never stop learning and join a study club, sales study club or your local study club. Kind of get switched on and plugged in to your community that way, to your mentors.
Howard: You’re right. First impressions and that like when it comes to sterilization. Every complaint I’ve heard about a dirty dental office. I mean, the patient doesn’t know what an Autoclave is, they don’t know a Tandem Sterilizer. They don’t know anything about Autoclave sterilization, but these ladies tell me ‘well there was dust on the baseboards, and there was… and the bathroom didn’t have any toilet paper’, and she converts a stain on the seats in the waiting room, dust on the baseboard, and no toilet paper, as you probably don’t clean your instruments.
David: Yeah.
Howard: I also read a deal that when you walk into an operatory and you have a pad, you know on wifi, and you do their patient chart on a wifi deal, the millennials think you’re the highest tech guy in the world because you got a little stick pen and you’re doing it on the pad. I’ve seen dental offices where instead of saying ‘here fill out these forms’ the receptionist will get up, walk out there and sit next to you with the tablet and fill it out with you, and people just think you’re Star Wars.
David: Yeah. Yeah.
Howard: Yeah. Okay. Well hey, yeah. We were talking before this show that we both did 23andme, and I was jealous because I turned out to be four percent Neanderthal and you're only…
David: I”m only one and a half.
Howard: One percent Neanderthal. I always wondered because my knuckles do drag when walk. That is really going to be state of the art someday isn't it?
David: Yeah. No, and I think it will be a point at care test in dental offices for risk assessment pretty soon.
Howard: Yeah. Alright…
David: Those type of tests. Yeah.
Howard: Alright well thank you so much for coming on the show.