Dr. Sonia Chopra is a Board Certified Endodontist and founder of Ballantyne Endodontics in Charlotte, NC. When she opened her practice in 2008, her goal was to help patients understand the “why” and “how” of their procedure. She works with her local dental community to host seminars and learning events, and has recently launched an online education forum at soniachopradds.com, for general dentists worldwide. Her mission is to share knowledge on perfecting endodontic skills, focusing on thorough diagnoses, delivering compassionate solutions and considering whole patient care. Dr. Chopra is a Director for the College of Diplomates of the American Board of Endodontics, and on the CE Committee of the American Association of Endodontists.
VIDEO-DUwHF #1084 Sonia Chopra
AUDIO-DUwHF #1084 Sonia Chopra
Howard: It's just a huge honor for me today to be podcast interviewing Sean Thompson all the way from the United Kingdom, Sean would refer to himself as a slow starter but eventually he went on to gain his post graduate diploma and maxillofacial prosthetics and technology at Manchester University while working in the orthodontic & Maxillofacial laboratory as Sunderland royal hospital. In 2003 he achieved the only highest possible grade pass with distinction to date and especially earning him a coveted award from his national body in the process. Prior to this Sean had studied for four years to gain his dental technology qualification and a further four years at Newcastle for his advanced certificates and orthodontic technology and also prosthetic technology. Sean gave you a reputation that is second to none in the field of orthodontic technology and he was appointed to the National Council of orthodontic technicians Association in 2012 in recognition of this. Sean established Ashford Orthodontics in 2001 due to specialist clinicians needing a laboratory specializing in orthodontic technology rather than having to send their work to general laboratories which simply dabble in the specialty. Two new directors in Craig Stevens and Graham Wenyard joined in 2005 when Ashford became a limited company and between them they have over 75 years worth of experience in this field. Ashford employs over 50 highly skilled members of staff and basis of success on the quality of the work they produce being directly linked to the quality and train of the staff they employ. Sean has been instrumental in steering the company through its recent successes seeing Ashford invest heavily as an early implementer in digital technology forming the retainer world brand in the process allowing Ashford to create and secure diverse income streams into lab. This deliberate business model has resulted in rapid but sustainable growth last few years and it's firmly established Ashford as a leading light in the field. Ashford is now the technical strength behind various other companies allowing it to expand in the field of 3d scanning and printing which it turnouts allowed to export to Scandinavia, Belgium, Netherlands, Australia and New Zealand. I don't see the United States on that have you got any United States customers yet?
Sean: We are actually in the process in the process constant so much.
Howard: Well we're gonna get you one today we just will just be somewhere between Kansas and Missouri. The company continues to expand following its 17 years of continuous growth inception and it's currently in discussion to increase its income streams further. So where work basically the same age we graduated from school the same time basically gosh Invisalign has really changed orthodontics. I mean I can't when I look at orthodontics I mean that has to be the single greatest factor that's happened to orthodontics since I got out of school three decades ago would you agree or disagree?
Sean: I would totally agree with that and I think it's actually been the leading light for other people to change the way they work so everybody's been trying to play catch-up and I think it's one of those ones where everybody's doing that now, wear all kinds of using similar technology and just not on the same scale as Invisalign but pretty much the way Align Tech is they're the hub behind Invisalign that's kind of what we're starting to be and we're starting to deal with smaller clients but basically deal with the same type of thing. We're all using the same technology it's just trying to make it what we found was making affordable and available to ordinary people particularly as in the u.s. you don't have something called our national health service where you get free treatment and everything's done kind of insurance in the US and we have a similar type of system where we call them private patients but primarily orthodontics in the UK is mainly funded through our National Health Service and it can sometimes be seen as a second-tier service compared to private you get what you're given and we don't really have a great choice and we decided that we would do something different about that we would try and make it affordable and available to everybody even on the National Health Service, so yeah Invisalign has been great in that because it's actually set the bar to be raised to.
Howard: I always hold up my hand when some guy tells me they got an idea, it's got to be faster, easier, higher quality, lower cost and miniature. I mean the first steam engine was in your country but it was so damn big all I can do is take water out of flooded coal mines but as I got faster easier higher quality lower costs and smaller eventually that thing fit on a ship and then you had the whole ship the transatlantic shipping business then I got to America they had to build canals. So everything is about doing it faster easier higher quality lower costs and more miniature and health care has a hundred year tradition of every time the earth goes around the Sun to raise all your prices 5% and so it's interesting to see how you're admitting and realizing that if you can bring down the cost of this it will reach more people.
Sean: Absolutely right and you know that's more prevalent in the UK with the NHS their National Health Service but the whole ethos behind this is exactly what you've just said Howard, if you can make it affordable then you'll make it available to more people and therefore if it's a benefit to those people you don't want to put a financial barrier in there and the way it works in the UK is the clinicians who we deal with the orthodontists they have a budget they have a price to work within and that's being squeezed.
Howard: and what is that price?
Howard: and what is that price?
Sean: It's varies we have something called units of orthodontic activity and each clinician will apply to the National Health Service for a contract to see X number of patients for X number of years at X number of pounds and they get given that in the form of units of orthodontic activity. So the contract can range from a few hundred units of orthodontic activity up to many thousands but equally this times of austerity worldwide and it's not a bottomless pit with the NHS everybody has to justify what they're doing now so essentially everybody gets given a pie it's not like you have to bake your own pie with ingredients you're given that pie you have to actually cut it up slice it up wisely and eat it at a measure that's going to last you one to three years so we're trying to make sure that that pie lasts a bit longer so that's what we decided to do yeah.
Howard: and are you doing clear aligners are you doing bracket systems too?
Sean: We do all of them yeah we do all of them.
Howard: So what is it about 80% brackets and wires and 20% clear aligners?
Sean: Yeah on the NHS it's virtually all brackets and it tends to be stainless steel brackets and you still get exactly the same treatment you'll get exactly the same result into some fantastic results and the difference is with the NHS the clinicians have to be governed by what they can spend per patient to fulfil their contracts and so they have to look for the most cost effective alginate or impression material so rubber base isn't going to happen and so they're trying to find ways of servicing this contract to a very good standard but in it also it has to be affordable for everybody they have to make a living, everybody has to make a living but nobody wants to say a second-class service to the NHS patients.
Howard: How much money would the average dentist and the UK get for an ortho case so about how many pounds would it be?
Sean: I'm not sure because they keep that finger very close to their chest so I'm not really sure it depends again on the size of the practice and how many patients have got and but I know this measures in place now where it's down to how many children and intends to be under the age of 19 so there's around about a million patients per year in the UK qualifying for free NHS treatment
Howard: Free what treatment?
Sean: Free for free NHS treatment so they don't pay for it, it's free
Howard: So one million children under the age of 19 qualify for free NCH treatment in the UK?
Sean: That's correct yeah how you qualify that varies in different areas down to oral health and the severity of the malocclusion so it really depends on which level they come in at but if they qualify its some of the clinicians then to be to service that contract and get a really good result after 18 months two years and then keep the teeth looking nice as well. So they've got a duty of care that they don't just get the teeth straight and then they disappear and that child isn't where the retainers so all of that is the aftercare as well and they have to have a financial provision in place to make that happen and so they're being squeezed you know it is hard for them at present so that they're trying to make ends meet and we came along to try and fill a gap for that really.
Howard: So what technologies have you adopted that you think is making orthodontic treatment for the NHS faster easier higher quality lower cost?
Sean: At present we probably do around about eighty five percent of all of our orthodontic cases the retention and everything at the end of it and via the traditional alginate impression material route and we do now we do about 15 percent digitally and we do around about 8,000 orthodontic retainers per month which is quite a few. What we've done is we've tried to provide the technology digitally to make it affordable and available so instead of having to send us via courier or post these traditional alginate impressions will receive the scans you've seen them out of the iTero and I don't find a lot of them iTero, Carestream, Trios they're all out there and the clinicians now are investing in these because they know the accuracy is better but can we then combine that into they don't want to pay more to have that service so could we combine the service that we can provide to them digitally for the same cost as it would cost them to send it via traditional algenets and that's what we've tried to do by implementing digital technology on a large scale.
Howard: So when you talk about the scans when you talk about a iTero Carestream Trios those are big investments. So iTero is owned by a line and trios so if some dentist was listening to you right now from around the world and said knew these are expensive which what they will know which one you recommend?
Sean: We don't actually have a preference or we're going to take scans from all of them any scanner out there we can receive them the vast majority of the ones that we get at present or the three that you've just named but primarily Itero being the most popular one and I think it's because of the connection with Invisalign. So a lot of the National Health Service orthodontists have a fulfillment to treat the patient's under that contract but then they also have an obligation to treat patients who want to go privately and maybe miss waiting lists out so the iTero scanner takes both boxes and but what we're finding now and this is kinda really the basis of what we're doing is we've now got three large orthodontic practices who don't have any impression material in their practices. So which was unheard of the thought of that actually happening to do everything digitally was just a year ago probably wouldn't have happened and now we've gone from one to two to three practices and more people trying it now. So they've invested in the scanner which is the expensive bits they can in need their for their private patients to do Invisalign and stuff like that and but actually can they implement that to the National Health Service as well and give every patient that opportunity they could only do that if they could find a laboratory such as ourselves that could provide that technology for the same cost as it would cost them to do in via traditional routes and that's where we've kind of made a breakthrough.
Howard: I want to go back to the big dollar question about buying a scanner because you know it is a lot of money for the dentists and we don't want dentaltown that when you're thinking about buying a CAD cam or a CBCT they spend hours and hours just on that one topic reading everything. I know Itero and Trios, iTero is owned by Align Technology in America and Trios is a by 3Shape in Copenhagen Denmark those two have been kind of arguing and fighting amongst themselves and in courts does any that matter to the dentist or the lab person, I mean are they open systems does it not matter. Again I'm trying to help this dentist decide which system we go to.
Sean: Yeah I mean the iTero one is a closed system you have to sign up to it and you have to be and pay a fee it will cost you every month to kind of have an iTero and but it also allows you to use Invisalign and the other systems as you well know like if you said there with the Trios system and it was in it was out this is also what's going on with that so other systems haven't been accredited by Invisalign. So when you come to pay that money for the investment you want one that's going to tick all the boxes and at the minute court cases pending the iTero one ticks the boxes because although you pay for your file system and your monthly phase it does open all the doors for you whereas you know you're taking a bit of a gamble with the other ones because they're excellent scanners and open file systems with Care stream and everything but actually if you want to send them to Invisalign then it becomes difficult although you could always send it to a lab to print a model and send the models to Invisalign I think that's a way around it.
Howard: So your saying iTero is a closed system and it's owned by Align Technology and they only want to support Invisalign.
Howard: and so then what is Trios trying to go to court to force them to take 3Shape scans or what is the court dilemma about?
Sean: I think you've hit the nail on the head there I think that's what it is they want to open up their users to be allowed to send their scans via the Trio's to align tech to it to use the Invisalign system and you know there's connections in there with the incognito system as well the lingual systems. So there was a little bit of you scratch ours our back wheel scratch yours and I think that's gone a little bit sour with payments and things so there's a whole minefield and I think that's what they're trying to do is if you allow our files we allow your files and everybody lives happily ever after but there's actually lots going on out there which is beyond us.
Howard: You know I dont look at things as right, wrong, up, down, left, right I mean an engineer looks at everything is a trade off. I mean you know like Apple is a very closed system but it's very easy to work in all Google and Microsoft a very open system so there's all advantages of that but you get more bugs and viruses and and I've seen dentists who bought the the the closed system CBCT at a Dentsply Seriona where it's all closed but everybody in the office knows how to use it because it's all one system it's real easy and then other people want to open system say by a CBC from one company a CAD from another come they have all this open technology but then when you walk in the office you ask your asistant well do this, well I don't know how so then so then if you're number one cost is labor and you have this open system but then you're you know so the bottom line is are you just getting it done are you getting it done and you're getting it done faster easier higher quality lower cost cheaper, so you know everything's is the trade-off it will be interesting to watch how these court cases play out but I certainly don't know why how a government can force Invisalign to use another company's scanner I mean I don't know if that's the place for government but I hate I hate talking religion politics sex or violence. So you're saying if you're gonna do a lot of Invisalign get the its owned by Align Technology get the iTero, you're having no problems with the care stream or the trio's from 3Shape either?
Howard: What about 3M's True Def scanner you see that much?
Sean: Yeah we do scans it's probably about six or seven different types of scanners and you have to pay sometimes a fee to one to accept their files, you have to you have to upgrade your software that will accept another file so there's different ways that you have to pay to receive these even though they're in kind of open systems you have to have the technology within the lab to do that and most people have signed up the word and you accept that it's kind of part and parcel of what you've got to do and but from our side of it we're not really bothered at all what scanner you've got and if you want to send it and use the technology and then we can receive it and that's kind of what we've based our business around yeah.
Howard: Money is the answer what's the question I mean I could listen all the philosophical arguments yeah yeah yeah yeah but I mean look at the x-ray machine was out forever and dentists weren't using it until Delta Dental came on it's called the long sermons on dental insurance plan in the northeast Oregon Washington California which really turned into the first Delta about 1948 they covered x-rays at a hundred percent Oh the dentist were like dominos I mean from coast to coast all the sudden who's this Renkin guy really I need that machine. So at the end of the day money is the answer what's question or what I don't understand what some of these systems like take true death it's like okay you're owned by 3M so I'm supposed to buy a $17,000 scanner to avoid having to buy impre gum which I've been using since 1984 and they say oh but you have to have a $200 month license well shit am I even buying $200 a month of empergum and you know so at what point so money is the answer so as it gets faster easier higher quality lower price but you're obviously you need some volume. So you have three orthodontic practices so they're totally digital but they must have great volume it's not like a dentist where five or 10% their revenue is ortho, I mean this is an orthodontic practice so it's it's a hundred percent ortho.
Sean: That's exactly what it is.
Howard: So are you see in the future of the all-digital practice just with orthodontist?
Sean: Yeah and we just have specialist practices just doing orthodontics and obviously because they've got the contract with our National Health Service and that's what their speciality is they don't do anything else the refer outwards for everything else and you know some from their side of things that they literally do 100% ortho and they need to get patients into treatment they need to be do and empergum is absolutely fine it's it which is not broken don't fix it but what they are seeing the benefits of is that you get a more accurate scan and a more accurate model to work on given the scan that you're using, plus the speed of treatment we haven't got a ship compression materials in it comes in instantly the Canada geographic boundaries have gone it's not a case of we've got to get something from Scotland down to anywhere in the UK it can come in instantly so there's an immediate benefit there that you saving at least 24 hours on that you don't have to travel with the empergum the alternative it's pretty much stable these days but you don't have that issue with the scans so if you've been particularly for retention the quicker you can get the retainers into the mouth at the end of treatment the better it is for everybody you know because all the hard works gonna fit the teeth drift.
Howard: Now how are you making your money in these orthodontic practices, are you selling the clear aligners are you selling the retainers or your business model?
Sean: Yeah it tends to be the retainers the retention element plus refinement aligners at the end.
Howard: So their using Invisalign for the clear aligners?
Sean: No we use actually 3Shapes software and the ortho analyze a product we use their software to do the manipulation on the models so we can use their software to move the teeth on the STL file and then we can print a series of models which will create the sequential aligner system which is very similar to Invisalign.
Howard: Okay so the orthodontic practices your using are using Invisalign, these three that you're talking about that are all digital?
Sean: Yeah using Invisalign for their private patients but for the prime for the NHS patients they tend to use brackets but then when it comes to the end of the treatment if they have some kind of refinement aligners you've got one or two stubborn teeth which just won't move and then they can use the software that we do just to do a little mini series of aligners at the end of the treatment if they wish yeah.
Howard: and when it comes to money orthodontics is a game about retention not straightening I mean straightening up some teeth it's pretty damn easy but when you take those wires and brackets off if you know if everything relapses that's the problem well I mean do you agree that orthodontics is a game of retention?
Sean: Oh absolutely when I first started then this may be 35 years ago there used to be where the retainers just for kind of a couple of months and you'll be fine and now as it's gone on retention is for life you know so it doesn't really matter if you're using Invisalign or if you're using fixed brackets you still need retention at the end of it and I think quickly you can get retention onto the patient's mouth then they've been through a lot of time and a lot of treatment time to get the nice straight teeth that the real thing like you've just said is keeping them there keeping the patient motivated to keep wearing the retainers and provide the best quality retainers. If you've got a retainer which is just an immovable retainer and it costs X number of pounds if you can go out there and provide two types for the same prices one type for example you can put a fixed wire bonded retainer and a removable retainer for the same price what traditionally people paid for one retainer you've got what we call the belt and braces approach you've got much more chance of getting a compliant patient if they lose their removable retainer if they've got a fixed wire on the back then they have time we can print another STL file get them another model made send the retainer directly out of them but in the meantime they've got the wire retention on the back. So if we can make that affordable so practices start using both types of retention then actually you've got a much better chance of keeping the teeth straight for the longer term and that's what we decided to do, we decided to use digital technology in order to produce a very cost-effective model so we could provide all types of retention at a much more affordable price to encourage clinicians to use that and that's where we've been successful like you said if you're going to make a little bit of something you need a lot and that's kind of where we've set it up we make a lot a little bit off a lot.
Howard: You know another thing I want to tell you young kids, most people listening to podcasts are millennials but you know if you go back you know I'm 56 so if you go back to when I was little all those big post World War two families five six five nine kids were family you can only afford the most serious malocclusion on a woman to get your orthodontics was you got seven kids and one daughter is so messed up no one's ever gonna marry her you know so we're just gonna fix up Suzy and now with birth control families going from five and a half kids to under two, orthodontics is just it's the everybody wants it and so when people what I'm looking to these wall street us on Invisalign and I'm looking at their projections what they need to focus on is a trend line between orthodontics in the 60s being very expensive and needs base done to just the ugliest kid in high school to now it's ortho for life I mean I see people coming in all day long she's 40 years old she just got this slightly crooked tooth and she and I mean you would never have done ortho for that in 1960. So I see I think these Invisalign trays these clear aligners people I think the ortho demand is even about and the most shocking for me was I you know I've done these podcasts from I don't know 20 30 countries but even in very very Portage I mean I was in Cambodia, Indonesia, Malaysia, South Africa and the girls the waitresses at the bar when they found out we were dentists that's all they want to know about was Invisalign and then she did this other girl she pointed to her so I brought over here anyway long story short I started doing the math this woman was probably 18 she paid $1,000 for clear aligners and I'm figuring her yearly income was probably 3,000 a year I mean she's putting a third of her money for so this orthodontic this cosmetic market which really was started by I think Ivoclar I think is Bob Ganley I would clearly just they just went from CEO to chairman of the board with Ivoclar he's stepping down and turning the reins over but I think this cosmetic revolution that he started in the early 90s it's still going going going going going and I'm even and now it's also transcending more into men. I mean 30 years ago you would have never had a 70 year old man wanting to bleach his teeth and now now they're they're talking about it. So do you think continued growth?
Sean: Oh absolutely you know our NHS service our National Health Service is for children under the age of 19 if they're in full-time education but we're doing as many now privately with adult patients wanting exactly what you've just said there you know tiny little tweaks a little tooth crossed over another one we're seeing lots and lots of that adult orthodontics and but we just made the decision that it doesn't really matter if it's adults or children you still need good retention and if we can do really good retention we can make it affordable doesn't matter if you've used if you've used Invisalign if you use any of the system's out they are a fixed system if you can kind of help the people out there who have had the treatment like my lady who just said she's paying $1000 out of a three thousand salary to get her teeth straightened she also has to be able for the retention at the end of it otherwise she looked really good for a short period of time when she read about the wish it was so we've got to make sure that everybody can get that best retention out there that's why we said a blue retainer will brand it was to make it affordable to everybody so if you're using Invisalign what why don't you just you obviously sending things to these states to get made but with now with digital technology you've removed the geographic boundaries. So if we've got any clinicians in Europe or in the UK they were using other systems like that then you know if we can speed up their options for retention and be able to provide them with a more cost-effective method to keep the teeth straight then it's a win-win for everybody and that's what we've kind of decided to do.
Howard: So what website should they go to find out about your retainer brand? Is that ashfordorthodontics.co.uk?
Sean: That's the one yeah retainer world is now a wholly owned subsidiary of Ashford orthodontics and it was growing so much we basically brought it back in-house and we made sure it belonged to us so Ashford orthodontics has its retainer world brand which is a value-based system. We wanted to make sure that everybody has that option if it's a better form of retention to have a wire bonded retainer as well as a removable one we didn't just want that to be offered to private patients we wanted that to be able to be offered to NHS patients as well and that's kind of where we based our business around that. It's the way forward I think but you've just said the popularity has never been as great and it's only continuing so we've got to make sure that we have a responsible attitude to that that we don't just take the money straight in the teeth and then you know see them for six months and then what happens after that is up to them we've got to basically make sure that retention is for life and we've got to provide them with the best options at the best price that we can do it.
Howard: Well Twitter is my homies are listening to me they're driving to work so I retweet your website on Twitter. Thank you for the 23,000 dentists following me on twitter that's pretty damn cool. So the website is a Ashfordorthodontics.co.uk and I you also need to get an Instagram picture on this only though you have a Facebook, Twitter, Linkedin, YouTube, that is great but the Millennials man they're on they're on Instagram they're they're running away with it.
Sean: I think we have an Instagram.
Howard: It's not on the site.
Sean: All right so well we do have one, we have the guy who looks after the Instagram accounts do that.
Howard: If your a grandpa like me you're on Linkedin and if you're under 30 you're on Instagram. So I also notice you have a picture on your website of formlabs, why is that picture there what are your thoughts on formlabs?
Sean: We have the largest bank of formlabs printers in the UK and there's so much technology out there what we started with this technology kind of five six years ago we can what we think was a mistake we went after the biggest the best printers with the biggest build platforms that we could build everything on in one go and get them on and off quickly but that ticks the boxes on certain ways but equally you can't just have one of these big beasts you have to have to because if one goes down you need a backup. So you have to have these big beastie printers and you have to have them and run them at 50 percent knowing that if one goes you've got cover and the way we run our business Howard is that and scan that we receive up till 3 p.m. in the afternoon will be printed that night we will print it that night we will manufacture the retainer the next day and send it out. So then we decided how can we get a more cost-effective model and 3d printer model and that's where formlabs came in they're not the fastest printers they're probably not the most accurate printers but they are very very affordable and then make a very good model for the costs. What that allowed us to do was it allowed us to produce the 3d printed model from the STL file at half the cost of the bigger brands out there with the huge printers and from our point of view it doesn't really matter if the printers build a build platform in one hour till hours three hours we close at about 8:00 p.m. at night and we open again 6 p.m. 6 a.m. in the morning so as long as those printers have printed everything reliably for us to start work again at 6 a.m. then it doesn't really matter how long how quickly it was printed they'll just lie on the build platform for kind of you know one hour two hours three hours. So the formlabs printers came along the virtually plug-and-play you know we have a very very high success rate we very rarely have any failures with them but it allowed us to produce a 3d printer model at half the cost of the other systems. So that's what we do so we started off with one for large printer then we bought two and then three and then four and we currently have 12. So we run these every night we were in them during the day if we have to and we we print all of the models at an affordable price. So what we the way it works in the National Health Service is and probably the same in the US is you have to have a start treatment model so you have to know what the crooked teeth look like beforehand and then you have to do the treatment and then then you have to have a study model digital of what the teeth look like nice and straight. So what we decided to do was if you've got a scanner whichever scanner it is then you don't need the study tests and pre and post-treatment. So if you can substitute the cost the laboratory cost of having those plaster models into the cost of the printed models then you have exactly the same lab bill. So we used to charge whatever price it was for the study models that's how much we charge for the printer model then the clinicians lab bill digitally is exactly the same as it was doing it via the impression material. The only way we could do that was to find a more cost-effective printer which was reliable and that's where we got into Formlabs and they've been fantastic and we just keep growing and keep up the virtually plug-and-play. So you plug them in you if you know what you're doing with them which we do now they're very very reliable and we can keep getting 14 60 and 80 in a big bank of these printers and that's kind of why we have it on our website because I'm very good there very reliable for us.
Howard: Now Formlabs that's right up the street from Boston does they're a bunch of MIT boys, so they're headquartered in Brighton not so who do you work with there?
Sean: No we don't we don't work directly with Formlabs in Boston because they have UK what's called on sellers so we work with their we work with John Winter and they're in the UK and the dental directory and we buy our printers from them and they're the on sellers but we do have an we do have connections with formlabs obviously because they've just sent a Boston film crew over to our place and Sunderland in the UK and they spent two lovely days filming with us and I think the video is just about to come out on their website and so we show them the sights of Sunderland and how we've grown a small lab from started in my garage kind of eighteen years ago how we've now turned it into a huge laboratory 12,000 square feet with them over 50 staff and it was no doubt that probably three four years ago we were doing around about two percent of our work digitally now we're up to 15 percent and it's the fastest growing area within the orthodontic laboratories.
Howard: So tell me the dates on those, when were the dates on thoughts? What year?
Sean: Probably two years ago yeah
Howard: So 2016 it was 2%
Howard: and 2018 is
Sean: 15 percent.
Howard: I mean that that's crazy growth.
Sean: Yeah it is.
Howard: I mean that's crazy where do you think it's gonna be in 2020?
Sean: I think it's going to be at least 50/50 and I think the way that they're training the dentists as well is probably going to change in the next you know a 2 to 3 years a lot of the dentists are trained via traditional methods and they enhance their training normally postgraduate with digital techniques tends to be via continual professional development. I think within a very short space of time what's the teaching establishments have got the money to invest in this digital technology it will end up being digital teaching with a little bit of traditional this is how we used to do it and whereas I think of the minute it's this is how we do it but these are the options going forward and I do feel that you know within a very short space of time then the training will have a dictate by the digital technologies. I think it's gonna be 50/50 within a very short space of time and maybe even more to the way.
Howard: So England so the UK has 65 million people so how many how many dentists and how many orthodontists do they have?
Sean: I think was around about 25,000 dentists if don't quote me on these figures is around about that and I think there's about three and a half thousand orthodontic specialists orthodontists.
Howard: DO the orthodontist and the general dentist do they do they play nicely together in the playground or is their a lot of animal spirits?
Sean: They used to play very nicely there was a good referral process in place between kind of dentists and orthodontists if it was a very simple case there would maybe think about doing it in-house if it was more complex they would have no problem in referring to an orthodontist to do and I think with the onset of better training more available training there are more and more general dentists and branching out into offering orthodontics to adult patients. In the UK you have to be specialist to get an NHS contract so that tends not to be the case but with adult patients there are more and more dentists now actually taking onboard training where they can offer the easier cases. I think there's a gray area in between of you know do you do that do you do this slightly more complex ones or do you refer and I think what you just touched on there there used to be a general referral process now there's more and more dentists saying you know what I think I can do this myself with some training and mentoring I think I can do it so they've realized that there is an adult market out there so that the lot more doing it themselves very successfully I've seen some very good cases so there's an argument between the two dentists and orthodontist that should who should be straightening teeth who shouldn't be straightening teeth and I think really that there's no definitive answer you should only act within the realms of your competence. If you treated 50 simple cases with adult orthodontics and you know you should you be told you can't do that briefly if you've got a dentist coming out who's had no experience wants to take on right at the very top of what they should be treating on the first case then yes there's an argument that you should refer as well but I think if you've got a system in place where there's a good communication between them some definite mentoring some definite teaching and there's a lot of orthodontist now taking that stance that you know what I think these guys are doing a great job in certain cases and if we can help them choose the right cases and everybody else a nicely again.
Howard: You know that kind of reminds me MacAruthers island hopping strategy in the world war two were the Japanese ago fortifying Island they'd be all ready for the attack and MacArthur would just sail around him an attack their supply line behind them and until they ran out of food and water and ammo and he you know he said starvation why these orthodontists have been fighting with general dentist Invisalign went right around them and said you know we don't need either idea they're opening up scanning bars in Manhattan right next to these Apple genius bars and there's little cute two girls in skirts and high heels taking oral scanners and they're sending that scan to Costa Rica and they're making trays and that they own 17 percent of Smiles Direct Club and what gives it worked it on as I'm sorry as a general dentists I mean I see it's dysfunctional. I mean when you're in a dental school and you're working on a child any pediatric dentist will help you if you're working on a root canal any endodontist will help you, trying to pull teeth every oral surgeon out there, every specialist bends over their back trying to help you except the orthodontist and they think in fear and scarcity why they're sitting there thinking and fear and scarcity with the general dentist that if he gets an Invisalign case then the orthodontist will get one less not realizing that the overall orthodontic market is skyrocketing and then number two while the orthodontist is all worried about the general dentist referral Invisalign says screw both you I don't need either guys. Is their smiles direct going on in the UK?
Sean: Yeah I think it's starting to already of in the capital and a couple of cities around the UK there's a these rumors that they're opening there as well the same thing direct to the public and it's a difficult one you know from our side of the fence it's we don't really have an opinion on whether it's right or it's wrong it's not really our field it's one of those ones that let them fight it out in court and let them do those things but if you can get more people from our point of view if you can get more people into treatment would you have a method it comes from then they all need to retainers at the end of the day and if you can provide that you know then that's the main thing keep the teeth straight let them argue between themselves which is the right or the wrong way, personally I would always go and see an orthodontist if I wanted my teeth straightened.
Howard: Yeah I mean if you had the money to buy a car you only want to buy it from Japan or Germany and then if you don't have that much money then you consider buying a car from the UK America or Korea so yeah I mean you got the money yeah I would only I would only buy only two countries know how to make a car its Germany and Japan but then if you don't have the money sometimes you gotta buy a Chevy or a Ford or Chrysler or a Hyundai and so and then some people are gonna take the bus and I it will be interesting to see how this smiles direct plays out because I know it's ruffling all kinds of feathers but I do know this this is what that this is what the dentist and the orthodontist wants to hear the only historical trend for a hundred and fifty years it helps everyone it's intense competition and if you start passing laws and putting protectionism in place and not let like the NHS contract only letting orthodontists deliver it and not general dentist. Anything you do to make it the environment less competitive then everybody gets less stuff for more money and it's just not good. I mean other time out all these trade deals and then aft and all that stuff in the United States to get out of every single deal they just said we have zero tariffs coming in or coming out we don't care how stupid your country is no regulation no import oh my god you know how many companies would move here tomorrow from around the world and set up their factories if you would just have playing those games. So explain to the young millennial she's 25 she just got out of school and she didn't learn any ortho in school because the orthodontist department thought in fear and scarcity but she learned endo and oral surgery and all that stuff and she sees a case she's gonna do it but she's thinking of straining these teeth tell her the importance of retention because she's not even at that party she's doing she's never even seen a case relapse what would she what would be the top three things to be thinking about on retention and finishing that case?/
Sean: Yeah I think retention for me personally it's the most important part of any tooth straightening process it has to be you have to get that end result and then you have to keep it if you can't keep it it's like having a house that looks great but then you know the falls down a few years times. So you've got to make sure that whatever she's treatment planning the retention elements has to be taken in right to the start and she's got to think how can I offer this to a patient but actually I don't want to offer that patient something which you know like you went back to the car scenario it's alright saying yes you could have this one but you know she might be at the top of the patient may be at the top end of the budget so therefore you can have this one because it does a pretty good job but this one is okay you really need to be thinking how can i stabilize those teeth long-term what would I do to stabilize them and for me it comes down to a white board retainer on the back of the teeth my wife's at hers on for probably 25 years now.
Howard: Upper and lower?
Sean: All upper and lower.
Howard: So your wife has you recommend a fixed wire on the mandible and maxilla on the upper and lower a fixed wire?
Sean: Absolutely yes on both arches and then also a removable retainer which you can it's your choice which you want personally I love the old fashioned wire and acrylic ones but the patients don't so ultimately it comes down to whatever we thinks the right one I know for a fact that I couldn't get my wife to wear a pallet and the wire even though would probably last longer and it would give a lot of adjustment to where it was needed she simply wouldn't wear it so it could be the best retainer in my mind if she doesn't wear it it's the worst retainer. So we have to find something that's visibly aesthetically pleasing which there's nothing better than a clear type Invisalign retainer but you want the strength of a wire on the back no depend on which way you choose there's different options there as well and but if you can combine a wire on the back of the teeth of mandible and maxilla you have a removable retainer of choice of the patient that they have actually got a physically where as opposed to keeping the top draw you've got much more chance then of keeping the teeth straight. So from my point of view you don't want to make the patient choose which is the most affordable retainer they have to have their option of the best retainer at the affordable price and that to me is where I feel we can bring our product to the market and there's no geographic boundaries there's no reason why anybody shouldn't send scans to the UK you know it's the same time scales as whether you send it from you know ten miles away or a hundred miles away. So I think for us it's about doing the morally right thing which is everybody thought we were crazy when we half the price of our retainers.
Howard: So you're recommending these for the fixed wire retainers they come in as the scan and then you make it in a deal so it's easy faster easier to cement?
Howard: Do you do that for brackets as well?
Sean: Oh yeah we deal an awful lot with brackets and I think one of the key questions we were always asked is if I take the brackets off the teeth how soon can you get my retainers back and it used to be I have to use a local lab because they're just around the corner and they can get them next day for me and we don't want the teeth drifting but with the technology they can use now three shape the ortho analyzer one we can digitally remove the brackets you can scan the patient with brackets on and remove the arch wires and the modules scan it with the brackets on send it to lab we can digitally remove those brackets we can 3d print the model as if there was no brackets there and in that we can make a wire bonded retainer we'll make a removable retainer whitening trays all of those things and all back in the surgery before you've removed the bracket from the patient so how quick do you need them before the patient's debonded absolutely you can't get better than that zero chance of relapse and if you can do all of those things and not charge a premium price then surely that's the way to go in my opinion is the way forward so have you retainers before you finish treatment.
Howard: How do you deliver the retainer, do you deliver so it's in a seating device? So you take out the brackets...
Howard: What do you call that delivery system?
Sean: We do we've got a retainer that we use them to the hardest bit when you're fitting the wire bonded retainer from everybody says to me is you need three hands it's very difficult to try and hold it in place and bond it and stop the bond from flowing everywhere so we invented our own system called the silicon stent bonded retainer SSBR and essentially what we do is we position the wire on the back of the teeth particularly that the upper one is very important to do this because you need to check the occlusion so we will bend the wire we'll position it where it should be on the teeth so it doesn't interfere with occlusion how do you check that it's very difficult to check that if you're making some form of Korean jig so what we do is we actually wax the wire onto the back of the 3d printer model we use the exact size shaped saucer pads and then we close the Arctic down and you can see if it's touching and then what we do is we actually have a flowable clear silicon which we then inject over the teeth to make a very thin mouthguards type of carrying tray we boil the wax out the wire is held in the silicon and you've got a little saucer shaped indentations which means that you literally etch the teeth a little bit of composites plus it into the mouth like you peel the tray off and there you go a little bit clean up and you're done.
Howard: Are these videos on your website?
Sean: We're just in the process of getting those finished off we've got some that will be coming out on the formlabs website.
Howard: Now on the Formlabs do you put that into a YouTube file and then give it to formlabs or what file do they go to?
Sean: They did their own film of filming of it so it will be coming out via their website and then once they've released it because obviously we can't steal their thunder was they've released it will then be uploaded to our YouTube channel yeah.
Howard: You know yeah again that's in fear and scarcity so many of these companies they put their videos on their website and you know though they'll use a format where it only plays on their website so now the world has two million dentists that would gladly share this on Facebook Twitter or dentaltown othotown, I don't know how they can do that but I wish you would on dentaltown there's fifty categories and one is orthodontics I wish you would load those videos on under orthodontics. Now see again back to the specialist all this was some of the greatest oral surgeons pediatric dentists and they're all in dentaltown I mean like that many 25,000 of them regularly I mean regularly and but don't work it on us we had to set up a whole different site and it's called orthotown and I can't even go on it and I own the damn website and what's sad is as an orthodontic lab you can't go on there and I tell them I'm like well you gotta have communication with your vendors you gotta work the value team and I have all these orthodontic companies always ask me well do you know what they say on orthotown about this or that or this that I'm like well why don't you ask the damn orthodontist to let you on and they're like no we don't want anybody on. I mean you're either a board certified orthodontist or I guess you're a Neanderthal cro-magnon man knuckle dragger you know it's just they're a hard tribe they really are they're extremely tribal but I think these dentists get out of school I see two types of dentists they come out of school they're either like me what I call an an apical barbarian blood and guts we do a root canal we want to get all the way the end and have a puff of sealer out at the apex we love pulling teeth we love layin flaps we love pareo implant we love we love blood and then there's this other group of dentist I call them pulp lowers when they get to the end of the root canal they want to say a half a millimeter from the apex and get it all nice and pretty and they like bleaching bonding veneers they like all this stuff and they're just just - probably the two main categories of dentists apical barbarian blood guts are pulp loving fluffy white and if they like that fluffy white stuff what you're telling them is they need to start getting into orthodontics. I mean it's one of the fastest-growing orthodontics and implants are the only two sectors of the economy in dentistry that's growing two to three times the rate of the dental economy I mean if the dental the economy is growing three percent the implants an orthros growing six eight nine percent I mean it's just it's it's explosive growth and it all comes down to anthropology at the end of the day all animals just want to eat drink and reproduce have offspring and I know when we were little they thought all the scales along those dinosaurs was that so they can catch the Morning Sun when it was perpendicular to it and it's going to be some evolutionary advantage to warm up their blood faster and that given them as they find out all that stuff is just sexual it's all like the peacock it's all for mating I think that's why it's huge I mean makeup lipstick I mean it's crazy and Asia it's really neat going to another tribe and when you start looking at their beauty to make you realize how all beauty is just so silly. I mean it's like a peacock I mean if the peacock spanned his feathers in front of you would that do it with that do anything to you but they do that in front of a female and she's like paralyzed I mean she just likes you know what's do and I just still think the bizarre thing in orthodontics is that when you go to Asia you see that girl making $3,000 a year or spending a thousand on Invisalign and why because when she takes your finger from her nose search and the lip can't touch and she's trying to pull it back and then when you go to the Western world all the women are taking derma Phil and puffing their lips off like Donald doc and it's like and the bottom line is the men in both villages no man in America wants to be married to that Donald Duck's you know derma Phil leip and nobody in China gives a crap for that woman's lip is in proportion to her nose and her chin. They just perceive this so they got a high heel they gotta wear the shoe they gotta wear the so Invisalign bleaching bonding veneers I mean it's going to be huge till the end of time as long as there's a species wanting to reproduce and have offspring they're gonna want to look younger better all that kind of stuff so it's fast growth. So what will my homies find if they go to your website?
Sean: Yeah they'll see a little bit about us they'll see about where we've grown from and where we go to and let's see a little bit about the retainer world brand about what we tried to do with that image and make an affordable people and see a little bit about the history of the company how we started from a garage and now with the largest ortho lab in the UK. So I think what also is well what you touched on there Howard what we tried to do is when you've just said orthodontics is the fastest thing the fastest-growing thing what we've also got to remember in this is that we need to train the people who can provide the services to fulfill this at this marketplace. So it's a skill and the skills now are changing from traditional skills to digital skills and what we can't ever forget the traditional route we need to have a good blend because like you've just said about there people want Invisalign there's still people need the functional appliances they need to correct the mandible there's still all of that and that's a dying breed out there and if we just turn our attention to purely digital then this is going to be forgotten about there's only gonna be old dinosaurs like me and Graeme who can actually Bend these appliances like by a neighbor's and Franko's and things. So we need to be able to sustain this market by training people and what are the things that we like to do is to bring people in as dental technicians but then give them the opportunity to train to become orthodontic technicians and I think we mustn't forget that and what you know it's easy to think digital is the future which it is we haven't going to forget traditional as well.
Howard: and I just want to say you look mighty dapper and charming in that photo, you shine up very bright. Tell me why you're looking all handsome and pretty in your tuxedo?
Sean: Well that nights that particular night we actually we won the award in our region for business of the year for medium business of the year and because you know we've got less than 50 50 employees but then they all went into the overall business and there was about 25 winners went into the pot and they chose the overall business and unbelievably Ashford orthodontics won that as well so we got two trophies instead of one so we particularly were pleased that night.
Howard: and two trophies from whom?
Sean: It's our regional business we have the portfolio Awards in our area in our region so they voted for us you have to submit your applications the first time we've ever done it and what we what we don't like doing is actually applying for dental industry awards because I think there's a little bit of you know you scratch my back I'll scratch yours and I might be wrong there we prefer to go into business categories because ultimately if you're gonna have a business it doesn't matter if you make widgets it doesn't really matter you've got to do what you do very well you've got to keep a good team you've got to have a good business model and I say to many dental technicians working in the business rather than over the business. Wo we took it as a particular compliment that we run a good business you know we know how to look after customers we know how to make really good widgets we know how to price them well we know how to sell those widgets and we know after look after the customers who buy those widgets and I think for us it was a bigger pat on the back to receive the Business Awards than it is to go down the dental awards about me not that did you know devalue that the dental wards at all but I think we were particularly pleased as you can see from that photograph that we actually made a stand for orthodontics within the business community so it's a business rather than an orthodontic lab and I think that's what we were most proud of that night.
Howard: That's tribal like even the Oscars I mean it's always a certain type of movie that wins the Oscars. I'll never forget when I when Gandhi bet okay one's an autobiography how creative genius is an autobiography you know and the other one is this complete innovation story you know what one was genius and one was a third-grade autobiography well guess which one won because you can't have ET win over Mohammed Gandhi and me is one of you know most important leaders and they in that time period. Last thing on and I hope you get with Formlabs and I hope make a post on dentaltown. When you go to make a post on dentaltown there's a little YouTube button so when you have a youtube video you know you can share it it has a link and that's something you might post on Facebook but it also has a button called embed and you click embed and you copy that code you can put it in the whole YouTube video and a lot of you guys out there that are podcasters there's about 60 dental podcasts now on dentaltown we're word hardly any of them the reason we film this even though I have a face for radio the reason I do YouTube is because YouTube and Google are the two biggest search engines in the world and the views I mean we're up to 8,500 dentist subscribe to this podcast just on YouTube and that one's growing very very fast and whenever a dentist make a YouTube video if they post it on dental town people subscribe to their channel and it really explode it's free marketing and explodes your youtube channel. I want to ask one final question just because I would say at least half of our viewers or from the United States Canada Australia New Zealand and in America. I'm going to last this last so we cut off in but I know they're all sitting here thinking what's up with brexit and I don't like talking about politics but there's two questions well we don't get a lot of solid news coverage on 220 countries I mean you just get rid some pieces but the two questions that most Americans ask about the United Kingdom is number one is brexit are you or is brexit good or bad do you think they'll go back to EU you and number two is EU still gonna be there in ten years?
Sean: Personally my personal opinion on this brexit is bad for the UK I think we are part of Europe, I think it's the unknown nobody will really know what it's gonna I think a lot of Europe when you ask the second part of the question waiting to see what happens with the UK because I think there's a lot of people if it works well for us then I think a lot of people are saying well actually we don't want to be part of the EU but I see I think there was a lot of misinformation given when people decided to vote for breakfast pretty sure if you had the same vote now without the lies that were told then I think you'll find a different vote and we wouldn't be leaving the EU. So I think there was a lot of misinformation given there was a lot of people used it for particular agendas rather than looking at the overall picture there was some bad advertising which was how much money was wasted and proves to be a lie afterwards and nobody's held accountable for that and I think if you had that vote now I think personally although they say there's not gonna be a second vote I think the way it's going now the way it's been handled because nobody knows what to do about it I think it's heading that way I think it's heading for a second vote even though everyone says it won't but I think if there was a second vote now you wouldn't get the same result I honestly wouldn't. I think there's a there's a lot of companies out there where we are in Sutherland and we have the big Nissan Plant it's a huge employee something like 25,000 people in our area and probably about the same again in in add-on companies and I think they are watching very closely and I think it comes down and it they still stay in the UK and do trade deals with the likes in the US and other companies nobody knows nobody really knows but I think it's one of those ones. Brexit to me isn't good I would sooner have the devil I know than the devil I don't just from business points of view because business creates jobs and jobs creates income and everyone lives happily ever after and I think once you've upset the applecart you don't really know what's going to happen. So they're all watching the UK I don't think the government's handled it very well at all, I don't think anybody knows what's going on properly there's no definitive answers to anything so I think it's a case of ask us again in a year's time and I'll probably have a better idea.
Howard: (inaudible 1:02:16) has been celebrating brexit since 1776 India has been celebrating brexit since 1949 but here's my take because I have lectured in a dozen of those European countries several times each and you know when EU came along it was really nice not to have to change your money when you went from France to Italy and all the money changers and all that stuff like that but that was all solved by the credit card my American Express doesn't care what country I'm in and the volumes and the trades of the transactions but when I looked at last year's number from The Economist's were who pays net contributions to the EU Netherland is Netherlands Sweden Germany Denmark Finland Austria France UK Italy and Ireland pay in pretty much paying greatly more than they than they receive and then look at the list who gets more cash coming back than they paid in Spain Croatia Cyprus Belgium Slovakia Romania Bulgaria Czech Republic Portugal Poland Estonia Sylvania with Divya Malta Greece Lithuania Hungary Luxembourg and when I go lecture up there I'm up in those northern Denmark Sweden Switzerland Germany the dentists don't have to drink too many beers at dinner to start really getting very upset about countries like Greece just running colossally insane policies and so the question is how long are the hard-working men and Denmark and Switzerland and Sweden and Norway and Germany gonna subsidize Greece and Lithuania and hungry I mean I just I don't know.
Sean: I agree with you
Howard: and as an outsider I mean I'm sitting here keep my mouth shut sensing a lot of hostility I mean every time I go it's not a pleasant conversation and it seems I'd be getting worse though it's so I don't know but anyway hey I just wanna share your videos you can't log on to orthotown because we have to be a spiritual leader or an orthodontist or God you have to be a bug gondii and to Buddha but I hope you share those videos on dentaltown and tell Formlabs that they're there best marketing isn't on their own website. Google says there's 1.6 billion websites and half of them are active so putting a video on your own website I mean that's why Facebook is so powerful because you're sharing it so to put that to put that video on dentaltown when there's a quarter million dentists on that thing it would be great marketing but hey thank you so much, what time is it there 7 o'clock what are you getting ready to go to bed?
Sean: No I've got a couple hours to do. Thanks very much Howard it has been a pleasure thanks very much.