Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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1178 Orthodontist Evan G. Rubensteen DMD, MS of Miami Beach Orthodontics : Dentistry Uncensored with Howard Farran

1178 Orthodontist Evan G. Rubensteen DMD, MS of Miami Beach Orthodontics : Dentistry Uncensored with Howard Farran

4/22/2019 6:08:59 PM   |   Comments: 0   |   Views: 161

Dr. Evan Rubensteen grew up in South Florida, graduating from MAST Academy in Key Biscayne. After high school, Dr. Rubensteen attended NYU for college, double majoring in Political Science and Religious Studies while serving multiple terms as class president. 

VIDEO - DUwHF #1178 - Evan Rubensteen

AUDIO - DUwHF #1178 - Evan Rubensteen

From there he went to Harvard University and obtained a fellowship to help impoverished children in Guatemala. Enjoying his work with children (and the warmer climate!), he decided to pursue a career in orthodontics and completed his residency and a Master's degree at the University of Florida. 

Howard: It's just a huge honor for me today to be podcast interviewing Dr. Evan G Rubensteen DMD, MS. He grew up in South Florida graduating for a Mast Academy in Key Biscayne after high school he attended NYU for college double majoring in political science and religious studies while serving multiple terms as class president. From there he went to Harvard University and obtained a fellowship to help impoverished children in Guatemala, enjoying his work with children in the warmer climate he decided to pursue a career in orthodontics and completed his residency and a master's degree at the University of Florida. When he's not at the office you can find Dr. Rubensteen in or next to the water running sailing surfing scuba diving paddle boarding or sitting on the beach a book in one hand and a cup of tea in the other, he's 35 years old. My gosh how did you go well first of all to be a political science and studying religion you really had a curious mind I mean you were really trying to but what were you searching for getting a degree in political science and religious studies?

Evan: All the answers of life right, which you can only find in the dental office.

Howard: Yeah I mean my two oldest sisters went into the nunnery straight out of high school my old I've been a dentist 32 years my older sister has been a Catholic nun 35 years so was it a fun intellectual journey studying political science and religious studies?

Evan: I think a lot of it was how to understand people from coming from different walks of life interacting with them trying to understand what they believe how they lived their lives and how they make decisions that govern what they do.

Howard: I also think that one of the things that educated me and my four boys the most is you know I've lectured in 50 countries and I drug my boys at least three or four of them to you know 25 to 50 countries and seeing how other people live it's kind of like the common denominator you have this complex life in Miami and then you go to Guatemala and you say well what's the you know what's the denominator the numerator did you find that equally intellectually challenging?

Evan: Of course it's kind of like I don't know if you ever seen the movie It's a Wonderful Life like real wealth is there real wealth is having family friends and spending time with those people and you know those are the things that are important. You know you can amass a ton of money you can amass a ton of stress you have a fancy house a fancy car Taj Mahal dental practice but at the end of the day you got to find what makes you happy what makes what you determined to be wealthy.

Howard: You know I always wanted to write a book but it's out of my wheelhouse I wouldn't call it the giggle factor because I noticed when you went to the most advanced countries who had the most material stuff they were the most uptight and hardly laughed and then you go to like on Nepal Kathmandu, Nepal and everything's funny everybody's giggling everybody's laughing and you know I remember I'll never forget at night you know they turned off the country's electricity because they have to import all their coal and oil so you just turn it off and you just saw the whole city of Kathmandu turn off and then everybody walks out into the street and they start playing soccer and giggling and laughing. I thought my god these people are ten times more happy than Seoul, Korea I mean my god you go to Seoul Korea and get knocked down just trying to get into the subway. I mean it's like why are you guys all so stressed out and dentists have this problem I want to always stay on this tune just for a minute a lot of dentists are stressed out and they're burned out and on dentaltown in orthotown there's all these threads like I want to retire when I'm before I'm 50 what do you think of the dentists that are listening to you on the way to work tonight that are all stressed out like a bunch of Americans Germans Japanese Koreans and they're not laughing and giggling like they are in Katmandu what advice would you give them?

Evan: I mean I think you and I would give them the same advice based on what you were just saying but you know this whole principle today I'm alone together, you know we might be together but we're still alone we have a lot of social media we're connected on all our devices or we're constantly you know even whatever have our devices we take them out public places stuff like that you need I just unplug disconnect and spend some time interacting with people. Which i think is one of the good things I get to do as an orthodontist you know I have a ton of people coming to office every day I get to interact with them face-to-face person-to-person a lot of them get to talk to me more than if I was you know a normal dentist and doing all that stuff you know what I'm saying yeah you know that's what I find to be one of the most rewarding aspects of what I do you know I get to interact with people all day you know they have to shut off their devices for five minutes and talk to me I find that rewarding you know and some of them I have a big impact on their life someone have a little impact you know they're still on Instagram or their snapchat while I'm talking to them so I'm including me in their Instagram and snapchat you know what you know we have that moment during the day where you know exactly what you're saying you know they don't necessarily feel you know separated and stressed out and you know I don't think I'm hilarious I used to make good fun that I became a dentist than not a comedian because I don't have a captive audience you know they'd have to have this didn't listen to my jokes about how bad they would be. So you know sometimes I get a giggle here and there but you know you gotta do what you can it's funny you actually said that I haven't caught I have a friend from college and he actually just published a book and it came in the mail this morning I open the book maybe an hour and a half before I talk to you. So I actually did recently read the book that he did publish but you should publish the giggle factor too.

Howard: Well you know every dental office consultant that I've ever talked you said that when they walk into the dental office they can tell in one second that it's successful cuz you just it just feels fun and inviting and everybody's happy and then you walked into the other 90% of the offices and you think you're in a library you can just feel stress and you can tell the hygienist and not you know there there's tension in the office. So it's funny how your outlook I'm just having a fun you know where assistants aren't don't live in fear they can ask the dentist questions. I mean I've been in dental offices with my friends where the assistant asked him a question about an x-ray and his response was well if you want to learn that go to dental school and I thought holy moley I mean that is wrong on so many levels, just relaxing having fun enjoying what you do. You're in one of the most controversial specialties there is, I mean you know there the ADA just announced their 10th specialty with anesthesiology so there's 10 now but yours with Invisalign, Smiles Direct Club, straight to the consumer orthodontics. What is your outlook on that cuz you're in Miami which is extremely progressive I'm sure Smiles Direct Club what we'll do well down there what are your thoughts on that you do you think of that as fear or is that a non-issue or what are your thoughts?

Evan: I have one of those Smiles Direct Club scan centers not too far for me you know and in a supersaturated area you know probably one of the more saturated in the country when it comes to orthodontist, dentist too but I do think that that segment is probably going to grow to be honest most of my colleagues down here we know you me talk shop ortho shop we're not saying that too much one class one crowded cases you know it's usually the GPS that are doing those. So I think that to you know to our benefit that I'm this benefit I think as more and more of these cases the general dentists aren't doing them as much they're gonna try to fight kind of what's happening with Smiles Direct Club and all these come all these other companies a lot better than we would be able to because obviously they have more numbers and a lot more vocal than a bunch of you know orthodontists that might seem a little bit more self-serving. You know I do I know there's plenty of cases and I'm sure you've seen some cases to where people are doing these do-it-yourself aligners and they're not getting the results that they want and they're causing you know periodontal damage you know other problems all that stuff and I think it's just like everything else a lot of stuff in dentistry and orthodontics is very cyclical I think that it's probably gonna be here to stay in some degree but exactly to what extent you know I don't necessarily have the answer. You know you got to have a choice right you can stay in the maze and keep going through the maze trying to find the end or you can kind of just give up. So you know you got a you got if you're gonna be in the rat race and you're trying to find the cheese at the end if the cheese gets moved you got to keep finding that cheese you're gonna kind of starve there. So you know it's something else is another obstacle you don't really expect to see when you go to dental school or residency but you gotta adapt you know you got to do what you got to do and keep moving forward.

Howard: So you know the the macro numbers that I keep reading is you know you know States has 200 and you know basically 230 million people and four and a half million of them are currently in ortho so there's got to be tremendous upside I mean what would it would is four and a half divided by you know 324 million people I mean it it said did you know don't you think there's a lot of up growth in ortho?

Evan: Oh yeah I don't necessarily think that the number of cases we do is going to substantially change I think they're complex if I'm kind of hitting on the complexity of the cases that I do is a very different from like the bread and butter of orthodontics maybe 10 15 years ago. I don't have a lot of simple class one crowding I do a lot of work though perio I do a lot of you know prepped for prosthetics I do a lot of you know severe classes to severe class threes you know I you know if one or two a month the simple class one case find their way in my door I'm surprised you know.

Howard: The cases you just saw mention were a lot of adult cases do you see downward pressures on the adolescent cases?

Evan: For sure there's downward pressure I mean a lot of it has to do with there's not a lot of you know I mean there are but a lot more of orthodontists are kind of going into the corporate model or they're going into one day a week or two day or three days a month in a GP practice so standing on ortho office have to differentiate itself a lot. You know my honestly my practice is about 60% of dots 40% kids so I said my practice just trying to tends to be more towards adult like you kind of hinted on we have a fun office we have a pretty fun office we definitely have a kid-friendly office but you know you don't walk into my office and there's not like you know barny the dinosaur or spongebob all over the place you know you can feel comfortable here if you're a teenager or if you're if you're an adult you know I kind of think that kind of sets us apart a little bit too. The other thing else is if you look at a lot of the demographic reports you know you're making your living a little bit too early over in charting that I'm just a child at 35 but you know a lot of people my age are putting off having children and they're putting off buying the home they're putting off doing a lot of those you know normal things that would happen in their mid to late 20s so the amount of kids if you look at the demographic reports that are being born it's also going to decrease. So the amount of children seeking orthodontics I think is going to decrease over time know the number may stay the same but as a proportion of the population I think that there's gonna be a huge huge push in adult orthodontics huge.

Howard: Yeah and matters of you know that they always say that if you make the economic decision with your brain on the s&p 500 it's about a five percent profit margin if it's a decision maker your heart like choosy mothers one Jiff for their children it's about a 15 percent profit margin but if it's below the belt about Beauty reproducing having offspring you know it's like thirty five percent profit margins and I just see I just see the the beauty market just I mean it's just growing hand over fist I don't see it slowing down and you're right about the kids some you know they when they talk about a student loan debt the ADEA is saying that the average graduate comes out with two hundred eighty five thousand one hundred eighty four dollars but held the price of raising a kid in America from birth to seventeen not including college is higher than that so they're just gonna have lot less kids and the most advanced society that I've ever seen Japan their birth rate is less than one percent it's point nine and you need two point two five just to maintain the population of the herd. So every morning in Japan there's less people than the day before so it's a weird market. So your relationship with a line technology some people some were that honest didn't like the fact that they started their own stores some of them you align technology owns Invisalign and iTero some of them have the iTero and only do align technology some of them wanted a more open system like biolace or 3shape with their oral scanner are you doing Invisalign do you use the iTero do you use a different intraoral scanner?

Evan: Yes I live in the Invisalign world the same way some people have been a Mac versus PC world you know. The thing about a good line is they have you know they have a great product their product works you know as long as the patient wears the trays. The other you know the other type of aligner systems they're great for more simple movements and stuff like that but if you have a lot of case complexity unless you're sitting there doing the setups yourself and you know have either an in-house lab or someone who's really gonna do those you know trays for you they really have the product at these other companies that are you know our AAO is coming up in them at the beginning of May they're supposed to be a lot more aligner companies releasing products and stuff like that but right now you know they're trying to the people who have you know the product to beat. You know the other products just just aren't out there yet I can do what they can do you know and everybody I mean they've also treated what do they say millions upon millions of people you know so they have a consistent product and the product is consistent. I mean you can love it or hate it you know but if you want to consist in so if you go to McDonald's you know what kind of hamburger you're gonna get you know you know what you're gonna get out of Invisalign. So I think I think you know I think there'll be a lot more on the field I think a lot of that's gonna change I think a lot of people are buying the 3d printers and trying to do stuff in-house but my cases are a little bit too complex for that at this point unless I'm gonna spend a lot more of my I guess I could say leisure time or personal time setting up a lot of this stuff myself and this the Invisalign product it works in my hands you know just like there's some things that work in other people's hands better it's just kind of where we are right now.

Howard: What do you think about Invisalign versus ClearCorrect and others do you feel that the technology in the Invisalign in the polymer and making the clear aligner is just really like a mercedes-benz and a lot of these other clear aligners or more like Chevy's Chrysler's and Ford's or what do you think about that?

Evan: For me I kind of draw the line at twenty eight twenty eleven or less nobody draws the line at large okay you know I'm making a random number but if I think your case is gonna be like twenty liners or less I think that serve as well for people who are doing like in-house aligners or using a dental lab or using some of these other systems you know what I'd like you know Moeller up righting  or I'm trying to fix the roots you're closing some space you're doing those type of things Invisalign product and just the way it works with I can have as many requirements as I want and all that stuff, it's just the case is just finished with the least aggravation for me. You know I'm saying it's it's not um it's not the other the other I don't necessarily know if I agree that it's the plastic or it's this or that cuz obviously like I don't necessarily always use the optimized attachments they would recommend in certain places I used my own you know clinical protocols and stuff like that but overall as a product you know it just it just serves its purpose.

Howard: A lot of the other clear aligners like clear correct are probably gonna try to be lower price point than Invisalign I assume Invisalign is gonna say where the mercedes-benz and all these other ones are gonna be less cost is does that play into your mind about what using or is the aligner tray cost not significant enough to overcome the attributes you just mentioned?

Evan: Basically the cost for me happens at about 20 trays and of my if my dental lab does it or if let's I use Clear if I use a different one aligner company other than Invisalign pretty much of 20 trays is kind of where it differentiates because at 20 trays I know I'm gonna have it at least one if not two refinements which are gonna be another 14 to 20 trays but at that point if I'm paying per tray it's worth it for me to pay a little bit more on the front end to have the peace of mind that have to keyboarding more trays and do more refinements I have it all in one package.

Howard: and when you when you say you're 60% adult 40% kids does that mean that you're 60% adult and they're all doing clear aligners and 40% kids you're doing a fix ortho?

Evan: I would say I'd be adults it's probably 50/50 clear aligners versus traditional braces.

Howard: Wow and what about for kids?

Evan: For kids I would say maybe five to ten percent clear aligners if that it's much less for kids.

Howard: Much less for kids huh and when and are you when you're doing Invisalign are you using the iTero scanner?

Evan: Yeah iTero scanner.

Howard: Like Patterson they have a brand new Sirona prime scanner but Invisalign doesn't accept it do you think Invisalign is only going to accept iTero scans and say on iTero or do you think their format will open up and start taking scans from all kinds of companies?

Evan: Well considering it opened once and then closed, I don't know if I think it's gonna open again. You know they we're accepting the scans and the Trios for a while and a lot of people bought the Trio's 3shape scanner and then they have to buy the iTero's. You know so I'm not you know I don't don't get insider information from Invisalign on that end but you know they sell a product it's in their interest not to open it up to other liners if they want to move their product. You know I don't know necessarily what their margin is on each of these iTeros but I'm sure it's pretty good.

Howard: Yeah well they well Invisalign started opening up their own stores and then that got in a lawsuit with them Smiles Direct Club. I wonder if down the road they'll try to revisit their own stores by redoing their contracts with Smiles Direct Club.

Evan: I don't exactly know the final decision on the arbitration but I think that it's they're locked into like 2022 I think so I would say probably some point after that if not sooner they would do it.

Howard: So with no so when you have Smiles Direct having their own stores Smiles direct, Invisalign tried it they had to close them down they'll probably revisit it. Is it harder for you to market to attract new patients when you have such sophisticated DSO's advertising and with full time people doing this?

Evan: To be honest I'm I'm more concerned with SDC and Smile Direct Club and invisaligns marketing power than the DSOs I mean you like to talk about this too but a lot of this dsl stuff is cyclical you know like a lot of people come in they put all this money to it they go this hedge fund money they try to do really well then they have to manage dentists which is like one of the most difficult things to do in the entire world and then they slowly start to fall apart. I got a giggle they start to fall apart because you know you can manage people but managing dentists that you know dentists are the subset of people that have think they know everything about everything they're dealing in a profession of millimeters and are you gonna talk back and forth with them over this net so I think that's very cyclical. I think the marketing behind you know Invisalign and smile direct Club that's much more much much much more difficult for me to compete with and not even my Google keywords have skyrocketed in my area for certain things you know even over the past year and a half and that for me you know it's always a trade-off of what's my acquisition cost per patient, you know is it worth it for me to compete against these cases. So the problem is is you know when I look at the cases that were coming for certain of these keywords right these were simple class 1 cases that would then the price that people wanted to pay for that type of treatment was either Smile Direct Club prices or you know less than what I would normally charge for that case because that would be a slot my schedule that wasn't filled with a more complex case even if I could finish that case in slightly less time. So the cases that we're coming in from that model were a little bit more you know the cost per acquisition was much higher as a percentage of my collections. So I don't necessarily have an answer because I'm actually figuring that stuff right now with my marketing of where to put those dollars more on I mean I'm still doing it but I can steadily see my acquisition costs per patient from those from those mediums going up and going up and going up you know.

Howard: Yeah so do you have a full-time marketing director is that something in the wheelhouse of the independent orthodontist in Miami or do you have to wear multiple hats and become a great clinician and a great marketer yourself.

Evan: I wear all the hats.

Howard: I love how succinct you summarize the DSOs how they're cyclical because when I was your age I was I already lived past the orthodontic Centers of America implosion and if you want to manage a lot of people hopefully none of them graduated from high school Walmart the army they'll do what they're told but once you enter dentist, physicians, lawyers, oh my god it's like herding cats every one of them is smart enough to rule the world you know they just they don't agree with anybody and you're right I totally believe the DSOs are cyclical because in this second round that I've observed nobody can like like you mentioned at the beginning of the show you throughout Instagram and snapchat you said we are alone together but Instagram and snapchat can go public but a dental office doing root canals fillings and crowns can't. I mean does society you're a political science religious major does society need dentist and physicians or Instagram and snapchat yet are our financial markets of Wall Street they don't want to touch these guys. So you're right it is very cyclical the only thing these private equities can do they buy they put a bunch of money in and then they got to flip it to someone bigger, they're just there it's like the greater fool theory no matter they buy the stock at they think someone else will buy it yeah I could call it the DSOs or the Bitcoin of dentistry you know as long as you know everybody's believing that everybody will go along with it but they're not gonna get Wall Street. My gosh I can't tell you from LinkedIn how many Wall Street analysts and brokers have called me because they're trying to get their head around this and I always take the phone call and just to see what I'm gonna learn and when they're telling me what they're confused about I'm just like yeah that's it any other questions. I mean they totally get it and a DSOs weren't cyclical then Heartland and Aspen and Pacific Dental they'd all be publicly traded on the Nasdaq and none of them are. Speaking of the people though you gotta wear many hats when I ask orthodontists and dentists what is their most stressful part of their office they always say it's the people whether it's your staff or your patients. Do you think you just have a natural leg up on the game since you sound like just a complete natural people person?

Evan: I would love to say yes but the answer to that is no. I mean honestly my biggest headaches day-in day-out is front desk.

Howard: Is from what?

Evan: Is front desk, you know I joked when I tell people that I'm gonna fire them if they don't pick up the phone by the second ring you know that's a gateway to my office. So I'm here in Miami Beach it's sunny outside it's beautiful weather I'm like six blocks from the beach would you want to come to work and answer my phone for eight hours a day you know. So it's tough it's tough to find people who want to come to work and show up to work and kind of do what they're supposed to do my clinical staff is amazing you know they're great you know they like what they do they're happy to be here but front desk is a continual adventure you know I learned something every day from them.

Howard: Yeah and it's amazing how you already have even on the phone I mean they do in direct bonding or bonding of their their brackets and all this stuff like that and then you just reach over and ask them how many people called your office last month they have no idea and they'll be talking about some ad they're doing on Facebook and I'll say well you know this is April 8th so in the first quarter how many incoming calls did you have the first quarter 2019 versus 2018 they don't know how many I went to voicemail they don't know and that is the one thing I like watching about the DSO is because if there's anything they figured out is to have a call center that after the third ring it's got to come over to a call center that but what are you trying to do to increase your phone game?

Evan: Basically get more people, you know it's it you know you just you just gotta have people who can do the job then it needs to be done you know it's a much more efficient or much more efficient much more effective for me to hire another person to answer the phone and have someone sitting here in the office that can do things then just spend the same amount of money on marketing. That doesn't mean no minute to spray-and-pray was Direct Mail or Google or Facebook or whatnot and then no one's here to answer the phone because they're called it 5:35 and everyone wanted to walk out the door 5:30 you know so it's much better for me to have someone here enter the phone during times people want to call you know lunch after work stuff like that I think I think you know that helps time you know just having people here. I'd love to have a call center you know but I just have my one little office here it's kind of it kind of does it in the bill you know it's not gonna pay the bill of having a super efficient call center.

Howard: So what software are you running your dental office on?

Evan: I use Dolphin.

Howard: Say it again.

Evan: Dolphin management we have like uh now we have a server and all that stuff we're not in the cloud yet I'd love to go up to the cloud in the foreseeable future but I think that type of stuff makes sense when you have more offices and it also has kind of a pro and con for me because I do like to disconnect from the office and if I could log in remotely even easier than I do now with you know like a remote login I would do a lot more stuff out of the office as well and wouldn't disconnect as much as I probably should just you know. Well so  it has its pros and cons is a little bit in that decision to keep server-based versus going to the cloud more than kind of just a functional thing for the office then it's also I mean there's also limits in Miami Beach I mean the internet speeds here and stuff like that is also more limited but you know in the future you know obviously gonna be like everyone else will be in the cloud and all that fun stuff.

Howard: So you're running your software and your patients go to your website and schedule a plate and direct or do they have to talk to you human?

Evan: No no they can they can schedule an appointment directly through a website and they can schedule like a normal wire change appointment but any new patient that wants to come in can schedule appointment.

Howard: and do all this stuff they need to do through the website it links me involved and stuff like that and is that because the your website can link because dolphin management software allows that to happen I mean they got some plug-in then?

Evan: So they do have some plugin that allows us to exercise I mean you were making fun of me that I wear many hats so I also built the website for our office it's if any listeners want to check it out but I also built that myself and I kind of just have the schedule template on there so it doesn't actually doesn't integrate with my practice management software but we have overflow slots in the schedule where we know these people are gonna get scheduled and if they decide to come at that time they come at that time if they need another appointment time they can also you know obviously call us directly cuz there anything also we found is that with people who are making appointments online if you don't have availability for them within 24 to 72 hours they're going to someone else. You know if you know I'm saying like even if there's no slot in our schedule for 48 hours we're still just trying to see that person for a consultation you know with a new visit exam because if we push them out of week they're just gonna go another website where they can schedule something sooner.

Howard: Wow that is amazing. Now I notice on your website you have that chat I'm Bob you have that live hi welcome to our practice who do I have the pleasure is speaking with today and I'll just type in a Howard for Ann do you think I'm that what what do you think that does to the overall effectiveness of your site like you didn't have that live chat streaming and a hundred people land on your website how many do you think would convert and call your office and what do you think this live chat does to your website conversion rate?

Evan: So I don't personally I don't think it makes a big difference to our conversion rate. What it does is it actually helps my SEO right so the longer someone spends on my web page the more that they know like the stickiness of my web page that's more that helps my ranking and the more it helps me kind of move up the Google ranking and you know kind of is circular kind of thing you know it just basis the more time people start on your website the more the algorithm thinks your websites helpful and the more times you're gonna be consistently ranked so there's that and there's just the other thing that everyone has a chat function on their website today you know so not having one kind of different would differentiate yourself more than you kind of want to be differentiated because you've got a you know you guys stay on pace with technology. You know it keeps costing you more and more and more money but you've got to look like you're kind of on top of what's going on. You know if someone's going to another website and they see a chat function when they come to your website and they don't see a chat bone shown even talking about their dentist you know it could be you know going to the Starbucks website or you know any type of website that might have some type of chat function and you don't have it you know you're gonna be playing a little bit of catch-up if you're billing yourself as state-of-the-art office and keeping up the pace of Technology and you know all that stuff.

Howard: So before you know I started talking my marketing but I didn't and yet underneath that first underneath it what percent of your new patient flow as dentist general dentists referral versus a direct-to-consumer from your SEO website social media?

Evan: I'm kind of in an interesting position here in Miami Beach because I'm obviously super saturated and I'm a younger guy and a lot of you know the older guys have their referral patterns and you know people have been here for a while. I took this office over from another orthodontist that was here a few days a month and then you know now I'm here you know four or five days a week so it's kind of turned over quite a bit we do actually I know a lot of orthodontists say that a lot of general dentists don't send them referrals, we do actually still get a lot of general dentists referrals. I would say that's probably about 20 to 25 percent, I would say 50% that was due to my marketing efforts and I would say at this point 25% is due to internal marketing obviously I would love that internal marketing and those referrals to increase because those are obviously a lot less expensive than my Springfree marketing that's making up 50% right now but it kind of just what it is you know we're young practice we're growing you got to spend money on marketing if you want to get people in the door you know you're just kind of sitting there you know on your knees with your hands together and pray or hoping some of calls.

Howard: So you're saying about 25 percent comes from GPS 25 percent internal referrals and then 50 percent directions to consumer?

Evan: Correct

Howard: and a lot of it a lot of the dentists I talk to you know podcasting is is a young behavior you know old guys like me you know we read books and when we get on dentaltown and orthotown it's on the desktop and then it's the young kids on the social media and all that kind of stuff like that but a lot of the young kids that they're like they see you at an orthodontist at a study club and they're afraid to go you know talk to you because they're doing Invisalign and they think you're gonna think they're naughty and bad and not like them anymore but I don't see this issue with endodontists as much or oral surgeons or not but it seems to be a real issue among orthodontists. Do you think that's a true or false?

Evan: I think it depends on the person. So I saw I actually just recently lectured to my local you know Dental Society on 2019 orthodontic trends and tips and stuff like that like 60 percent of their presentation was how to improve your clinch X and let's do with Invisalign to get better results. So I think that you know I think our rising tide raises all ships. If I'm not doing the class one cases I think it helps for the dentist to know what's in it within their scope of what they're comfortable with you know I think I think most general dentists can easily treat a class one case with Invisalign you know I think they can also finish that case in six months versus a year you know increase their profitability there's things that they can do to improve it, so if they can see well I can finish this case in six months and do this why am I wasting my time with this class two case when I can send it to the orthodontist and I'll just keep all the classical cases for myself which is kind of what I'm seeing you know. So I'd rather be the guy that they call when they have a problem with their class one case sure if they tried to do a slightly class two you know they throw me a bone here or there and send me a couple cases you know versus all this guy doesn't want to help me I'm just gonna do as much as I can myself and you know he doesn't he doesn't care about the other dentists here we just ending on my case isn't true like I said I think that it's important to educate other people and you know I'm sure you feel to you're in your practice too there's things that you feel very comfortable doing and you could get more education to do those things but there's some things you like to do in your practice more than others you know and say the same thing for most people across the board so if people like ortho you know I have plenty of gp's that come over you know we'll get lunch go over some clin checks do stuff like that you know I have other worked on these buddies that would never do that you know but that's kind of why you know a lot of people say they don't get as much referrals from their general dentist is that used to I think that it's because a lot of those relationships have been you know continually been felt and there's kind of not as le butting heads but there seems a little bit more kind of concern or control over the patient's you know.

Howard: Right so you think obviously I mean you're you're extremely mentally healthy so you think and hope growths that abundancy a rising tide let's grow the pie as opposed to thinking and fear and scarcity that the general dentist does Invisalign you'll have less food to eat.

Evan: So I mean I have a fun thing that I like to say about this I think it's like I think it all says like I'm an oldest child you know.

Howard: Of how many?

Evan: Of three

Howard: Okay

Evan: I have a brother and sister. I've lived in a world of abundance I lived in a world of less abundance you know you know versus my brother who's lived within a world of scarcity and more scarcity you know and I have a sister who's the only known abundance right. So I think like you have you have to weigh the pros and cons so like of course yes you know I have a mindset that I think that there's plenty of patience to go around but there's only there's also only so many patients you know so I think it's kind of an idea that as long as kind of what you're hinting it I think there's gonna be a lot more adults getting you know orthodontic treatment be it with Invisalign or Smile direct club or even lingual a lot of people now are doing more lingual orthodontics again you know I think there's gonna be more of a push for more cosmetic stuff and obviously as you can probably pick up on I'm kind of positioning myself be the go-to guy for that and I think it's something like that if you can find your niche you know if you're gonna be the guy that does this you're gonna be okay you know. If you're kind of the guy you know like you were saying in the kind of the back corner somewhere you're not not really interacting with people not kind of really on the pulse of what's going on you're gonna have a difficult time and I think honestly that difficult time is getting more and more stressful because kids are coming out with more and more debt it's becoming more and more difficult you know to hang your own shingle and you know all that stuff that concerns a lot of new graduates today.

Howard: So beginning to show you that you basically think the Invisalign material the aligner something about the technology that it's better than generics correct?

Evan: So one of the favorite things that you've done that I like to listen to we actually listen to it on the way to Burning Man with another orthodontist was you a 30-day dental MBA and one of the things you talked about in that you know is I think that came out of 99 originally?

Howard: Right

Evan: When you're first and you talked about investing in warehouse spaces but if you had a ton of money you would invest in warehouse spaces in the inner cities right. So I think of another movie the graduate right where the guy comes over and he's talking to Benjamin after he graduated he's like plastics plastics put your money in plastics right. So I don't have a marketing budget of hundreds of millions of dollars right kind of your work are kind of living that too with Google so if Invisalign is gonna put hundreds upon hundreds of millions of dollars into this type of thing I might as well feed off of that. You know because I mean I know you talk about this to a lot of dentist don't another patient acquisition costs I know my patient acquisition cost right so what I rather put money out of my pocket to pay for a new patient or what I'll either let Invisalign front that for me. Right so as long as Invisalign is fronting that money for me I might as well take as much benefit from that as I can. The other you know the other liner systems no one's coming to my office and asking you know for clear correct or aligned five or something like that so yeah I can still offer that I'll offer that as nice discount you know if people want to pay a premium price you know you're alluding to Mercedes yeah they're gonna position themselves maybe I'd been Mercedes they're gonna position themselves as the Rolls Royce you know who was treated I don't know what they say not ten million smiles or five million was that really Street as many smiles as they had you know so it's like the I think the other ones eventually will catch up I think they have a quite a bit of a running start.

Howard: Yeah I think it's the biggest brand in my 32 years after graduation I mean when I graduated they already had Colgate, Crest, Listerine, all that but Invisalign I mean no matter what country I lecture in as soon as the waitress finds out you're a dentist first question out of her mouth is Invisalign and you're talking about Cambodia, Malaysia I mean just just these you know places all over the world that their brand is amazing but so then the same question about fixed brackets is the bracket a bracket bracket or do you think some of these brackets actually can make you do ortho faster easier higher quality lower in price and more succinct?

Evan: So it's kind of the same response I gave earlier it really just depends on the case complexity there's some cases that I know normal twin brackets you know prescription I like they're gonna finish beautifully in a certain amount of time and I know other cases that they're just other brackets in my hands that are just gonna finish a little bit nicer. You know I don't think it has to do with drinking the kool-aid with like this or that but I do think some bracket systems you know if you can use a self ligating bracket or something that just some for some reason they just finished a little bit better.

Howard: So what brand do you use?

Evan: I use different types I use I do a lot of normal Justin twin brackets I use an eighteen slot system and then I you do a lot of Damon and I'm starting to use a lot of the Pits brackets also.

Howard: A lot of the what brackets?

Evan:  Tom Pits are you familiar with Tom Pits the orthodontist?

Howard: No

Evan: He just to used he used to do a lot of daemon work and he's basically just released the bracket system of his own.

Howard: and where's he out of?

Evan: I want to say he's out of Las Vegas Las Vegas , he's been in business for a long time, Tom Pits.

Howard: One of the one of the controversies on dentistry uncensored has been by oral radiologists that are kinda cringing at the routine use of CBCT while other people are saying there's an Adonis who will say that a CBCT a 3d picture of a molar root canal was standard of care some are starting to say that in ortho. Do you think CBCT workups or the standard of care in orthodontics or do you think that's overkill?

Evan: I think standard of care is a is a kind of sometimes a good term to use and sometimes that's not a good term to use because it can get you into a lot of legal battles. I do think that the imaging and basically just the diagnostic information from a CBCT, CBCT is lightyears ahead of what you would get from a pen set but you just you just can't argue that now there's just not much to argue with that a lot of our that on just aren't doing a lot more stuff now for regard to airway and things like that and think if they'd continue to go on that path you know just because another reason to a pallet expander or another reason to address you know I recruited mandible or all this stuff I think CB CT is gonna play a lot more of a role in that. I do think eventually I know you asking me about scanners I do think eventually we're all gonna have CBCT's so that the scanner companies either if it's in-house or through a big corporation is gonna want our route information to better move our teeth. I mean the funniest thing to me is we take a scan of the teeth and we forget everything underneath the bone you know everything under underneath the crown of the tooth and the bone you know which obviously has a huge point and how we move the teeth in orthodontics you know we're not we're not giving them any information on we send them a pano but we're not really telling them the route looks like this the routes like this how are we moving the routes so I think the aligner companies are getting a lot more diagnostic information from CBCT. I think we'll eventually get there they're real honestly the real problem with them for come for taking a part of standard of care is if you take a  CBCT you have to read the whole film right and a lot of I mean I'm trying to read the whole film but it takes me a long time you know I can look at a pano for five minutes and I'm good to go if I have to look through a CBC T it's not five minutes you know it's a huge chunk of my time and when you actually take for some reason the state of Florida and when you take a CBCT if you send it out to someone else and they read the film for you they can have the immunity if they miss something it's still your fault. So until that stuff gets kind of resolved in the courts it's just an additional liability for my office and I'd rather just refer that out to the patient's you know with an impacted canine or with an airway or something where I'd want the CBCT.

Howard: So I'm let's talk sleep apnea that was something when I was your age you know no one ever mentioned it one time and then out of nowhere it was just became it became so huge that a lot of people started wondering if it's a fad. I mean for a while there I mean you know if you fix your sleep you wouldn't be short fat and bald anymore and you'd look younger and I mean so where do you see obstructive sleep apnoea now? Is it a big part of your practice you're diagnosing treatment planning?

Evan: So actually my master's thesis is on CBCT and kind of coming up with a criteria from a CBCT if you can diagnose from it and the patient's not in a supine position right. So they may look great when they're standing straight in the machine but ii may lie down they have a problem so unless you're kind of gonna start taking CBCT's with the place patient lying down I don't if it's super severe yeah you can get quite a bit of the high agnostic information from it but most people that you would have come in your practice like you know run-of-the-mill people that would benefit if that happen undiagnosed right now it's not giving you a ton of information. I do think with the growing obesity and other problems stuff like that I think though obstructive sleep apnea is going to be more of a moral concern. You know I definitely see a lot more I can foresee a lot in our kids being you know overweight and having problems and stuff like that but you know the literature kind of is supportive but I don't think it's supportive enough that it's changing the way I practice right now.

Howard: Same with this new huge fad of laser snipping the lingual tongue-tied I mean it's just like you know pediatricians say they say you know they just look in the mouth for one second so you need to snip that and it's really taking off faster than I I think the research. What do you think of the lingual tongue tied in the pediatric patient?

Evan: I mean I think it's kind of exactly what you said I think it's becoming a fad now so it's been getting done a lot more but you know I look I know a parent to ask me I say when I was a kid you know I had a class in my class 125 kids and not one of them were tongue tied you know. So statistically it doesn't make sense that all of a sudden everyone's being tongue-tied unless there's some radiation on the water that we don't know about then we've got bigger problems than tongue-tied you know. So you know it's kind of like we're talking before like everything has its fad everything kind of goes this cyclical nature and the hard part about practicing is kind of knowing what's actual reality and which is kind of this like circle you're treading water in so.

Howard: Yeah you know and the thing about the tank is funny when you when you hear people talking about humans it's like they forget how robust of a species it is I mean Homo Sapien is basically 50,000 years old and a hundred and eight billion of them have come and gone and there's seven and a half billion alive on the planet I mean what were we're in the same level as cockroaches and ants as far as durability, I mean it is amazing. It's Dentistry Uncensored so I don't like talking about anything everyone agrees on something to go right to one of the most controversial areas period its extractions.

Evan: Nothing so far has been controversial? We've been talking about Invisalign, Smile Direct club...

Howard: Well the extraction deal I mean and you don't when you're my age you start you don't ever understand so much why but you do recognize patterns like in stock markets like I don't care if you don't know anything about the economy but you know I graduate school in 1980 when interest rates are 21% it crashed in 87 it crashed in 2000 and crashed in 2008 and I smell it crashing again. Now I can't see around the corner but you recognize patterns and one of the patterns that scares me with dentists is when they're extremists like when they do not believe in extractions and if their orthodontists recommended four by extraction they would just think you know they would just put a spell on his practice and never talk to him again. You know you see the same thing with amalgam like when I talk to a dentist I get it if you just your your market doesn't want amalgams but if you look me in the eyes and tell me that your posterior composites last as long as amalgam I want a urine sample because you're completely stoned or something we're on a head injury a concussion. I mean amalgams last twice as long as composites and if you only want to do composites I want you to tell me well yeah the market only wants tooth colored yeah amalgam are twice as long they're not toxic the Mercury's and an insoluble salt and so it's the same thing. You know it's that fanatic mind which I'm sure you learned a lot of in the religious studies my sisters have very fanatical thoughts about Catholicism but there are a ton of dentist who are fanatically against any form of bicuspid extraction what are your thoughts on that?

Evan: I think it goes back to that colleagues not competitors mindset you know that I was kind of alluding to earlier, you know if you if you go to someone's practice and they're extracting you know four bicuspids and everyone well they mean yeah you might not want to have a conversation with that guy you know but if you have one case that you sent them over and if you know if a dentist calls me to ask me why it's very different than just saying I'm never signing that guy another patient and I think I think it's important to have that type of dialogue and be open to that dialogue right and it kind of goes back to what you're asking before too about the Invisalign you know it's not when someone asks me there's there's obviously a way to ask it because that you were making fun that I was a little bit on the younger side versus some of my you know colleagues might be a little bit on I don't want to say older because I didn't this they might be offended but they might have more experience or more wisdom than I do you know but I'm saying is a big if they come to me they say look can you explain to me why you decided to do this versus why the hell are you doing this you know we have a very different conversation. You know and if I can explain to them why in this specific case it's better for the patient to take out some teeth when I tell them well you know I treated X number of cases last year and this is the one case I decided to extract teeth in it might come across as better you know because you know there are some you know there's some practice where people just decide okay you've got crowding I'm extracting you know and that kind of goes to what you were asking before why do I use certain bracket systems you know if I have an adult patient and I want some expansion just the expansion is gonna happen a little quicker be a little bit less painful if I'm using some of those different self ligating passive systems you know sure could I do surgical expansion and put in a high rack sure but you know the patient's not gonna go for that you know and I got to make the clinical decision of what I think I can do what's the best result I can get you know. So if I can get to three millimeters here and I can get to three millimeters there yeah I get a much better result in extracting but in some cases you still have to take teeth out you know you have to yeah the shoe has to fit you know.

Howard: So are you direct bonding your fixed or or do you do in direct bonding?

Evan: No I do direct I do direct bonding.

Howard: You just like to mystical II look at it and see it and feel it?

Evan: No I honestly I would love to do in direct bonding but the cost associated with it and the time associated with it, it's just more efficient I know that does necessarily make sense but in my practice it's more efficient for me to do it and the type of clientele that I have for the most part wants me to sit there and place the brackets.

Howard: Yeah

Evan: You know I up some patients who come in it or upset the v-system edge to teeth you know so it's like it's not necessarily a battle worth fighting and for me to go and put the brackets on the teeth is a lot more efficient for me to do it sitting chair side than to do it on a model and then have someone do a suck down and hope it comes up properly then happen there's just too many possibilities for error in the entire process in my office you know if I had if I had a dental lab doing in and all this stuff then yeah it would make more sense but then it also increased my overhead. So you gotta you gotta weigh the pros and cons.

Howard: So are you thinking about any printing your clear liners in the futures is that something on your radar?

Evan: Yeah it's for sure on my radar honestly if you were asking what I think the future is going to be is I think words you're gonna all have 3d printers in our office and either license the printers from Invisalign or someone else and they'll spit out the aligners and then take it from there. To be honest a lot of my you know other orthodontists in my area or the big differentiate things a lot of people are starting to tell people they'll get their aligners today. You know the big one of the big concern with Invisalign is it takes four to six weeks you know if you prove the Clinch act sooner or whatever whatever but it's even if you X but it's still taking three to four weeks to get these trays back and a lot of adult patients changes their mind to three to four weeks you know they're a lot more concerned versus it's really you're saying before it's a beauty impulse purchase you know they come to their office they've been thinking about it and then they do it and they're like well you know this and that versus did they left the office with three aligners and a couple of attachments you know they're kind of locked into the system. So I think eventually we're just gonna license printers and the technology and they're just gonna get printed in the office or we will have our own printers and stuff like that. For me in my office it just it can't become the same thing as everything else it's just the time cost and it's my time cost at this point of setting up the systems to do this it isn't efficient enough from my it's not really even a price amount it's just like my value analysis to get me to where I need to be.

Howard: So the the the scanners you know 3Shape, CERAC, iTero, Carestream, 3M you know there's all these scanners and there's all kinds of design software's 3Shape, Bluesky Bio, XO CAD, Arch Form, OrthoSelect, XC Ortho. Is there any type of printer you think that's going to be dominant the 3d printer? I mean who's got who you looking at now at the printers that you think are gonna be major players?

Evan: I think it comes down to just speed you know I think  you know the ones that are kind of using the like the projections the ones that are using I think it's like the DLP printing there's one type that fits a lot faster than the SLS that one I think will become more of the norm just because of the speed you know. The for making aligners the quality you could argue microns back and forth but they'll all have a bench is the same type of quality it's we're just going to come down to the speed and efficiency of printing and obviously cost.

Howard: Any name brands of the printer that you thinks going to be...

Evan: I mean you know there's people who have the jule printer they have the form formlabs printer they have the moon ray printer, a lot of people have started so looking at that chief or the any cubic front printer you know for ortho the problem to any cubic one of the the build platform is a little bit small I'm kind of don't really have much to say on this because the oh there's supposed to be two but actually already came out but I haven't seen her them yet but formlabs and Spin Tray I have both released two new printers with a much bigger build platforms and they both claim to have a lot quicker print times but I haven't seen either of them in action yet you know so I can't really say which one would be better but like I said you know it's kind of I'm gonna come down to whatevers obviously most cost-efficient and the fastest.

Howard: What is your you know I'm you know our big audiences are dentaltown and orthotown on these podcast, what would you what advice would you give you just seemed like a natural people person politics studied religion you really seem like a really cool guy what advice would you give to general dentists and orthodontists to try to have a more healthy functional relationship?

Evan: With each other or?

Howard: Yeah

Evan: I think it's really important to disconnect you know I think that you got a you got to realize that that you're office you know your office is going to be there you know you have things you within your control things without your control you know this myth of a stable dental office where like everything is going and all this distance work everyday is non-existent. You know the day my office the day my office runs exactly as I wanted to I'm gonna buy a lottery ticket because if I run the lottery once I'll probably win the lottery a second time. You know you can't you can't you kind of just gotta find a way to you know pick your battles and kind of what's important and I think it's a very easy when you don't have to speak all day when you're working to not think before you speak to other people. You know when you're working on patience you're kind of talking to them they're not really talking back you know you're kind of doing what you got to do it you're kind of in a grove of things then when things don't go your way you got to realize or you should at least try to have a team that you know is trying their best. Now if you have a team member you know they're not trying your best their best you have obviously have a completely different problem we gotta just gotta realize that most of the people around you are trying to do their best and if there isn't good enough for you then you have a different problem. You know you guys I kind of figure out why their best isn't good enough for you and manage your expectations otherwise you're gonna be perpetually disappointed and everything else is it's just important to disconnect and it's obvious as you were talking about earlier it's become more and more and more difficult to disconnect in today's world and you know just turn off your cell phone sit outside if you know if you're not in sunny Florida you can't always sit outside but you know find someplace you can go to that's quiet and just like zone out for you know an hour half an hour if you can go to the gym hit the treadmills just something so you're not thinking about dentistry and a lot of, I listen to your podcast sometimes in the gym and other podcast so that might not be the best way to disconnect from dentistry not the best message for your podcast but at the same time you know kind of just do something and don't and don't you know don't listen to music don't listen to a podcast just have quiet, quiet peace and then you'll be more able to have time with other people and realize the value of that. You know versus being on all the time.

Howard: So you know Miami Beach it's kind of like a peninsula I mean it's it's almost science it's not quite an isle is Key Biscayne an island dodge Islands an island but what are you on a big peninsula?

Evan: I'm on the causeway so you know when you come off of the 95 and you're heading towards you know where the Fountainbleu in Iraq is I'm like right on that causeway.

Howard: and do patients and or all your patients kind of on that Miami Beach Peninsula or do some of your patients drive the i-95 to the mainland?

Evan: I actually have patients from all over the place actually a lot of patients from Europe and there's actually another reason I use some of those different bracket systems you know because we use a normal twin bracket and you have an elastic pieon it you got to see that patient you know every four to eight weeks if you have some type of self ligating brackets you can have these patients cook for three to four months between appointments and so I have some people who fly to see me from Paris and parts of Spain which is always nice but not have patients come to me from Fort Lauderdale and South Miami and stuff like that too. I always said I would say probably actually I know I'd have to say 65 percent of my patients do live within five to ten miles of the office and about 35 percent don't live within them the zip codes that we talk I know because the zip codes we target with our direct mail and stuff like that.

Howard: I have about a dozen patients that fly between a thousand and two thousand miles to see me but they're all family members and I have to even by their plane ticket and give them free dentistry so I know I don't like those traveling nests. So you must not believe in global warming if you're so young and you bought in Miami Beach I mean if you believed Al Gore who also bought a house in that area we wouldn't your practice be underwater before you're my age?

Evan: I'm on the third floor, I got a good 27 feet.

Howard: Well do you see people concerned about it down there I mean you see wall to wall construction of condos on the beach so there's so Wall Street is obviously loaning the money they wouldn't loan money to build a condo if they thought the ocean was gonna rise a meter and they'd lose her investment.

Evan: So that I mean honestly the big thing down here is that I know you I don't I know you guys don't really need hurricane insurance out there in Phoenix but obviously my wind insurance here is astronomical and the flood insurance in a couple years is supposedly no longer gonna be federally subsidized. So in the federal federal government or basing the state government stop subsidizing this insurance it's gonna be a nightmare for people who have low leveling property in flood zones so if you're looking for time to buy a place in Florida it may not be the time to do it yet wait to see what happens with all that stuff. I think I mean it's obviously gonna be a problem but like you said there's no way people are gonna invest tens of billions of dollars here and there's not going to be some type of solution that gets developed. Do you know why you know why the buildings in Manhattan are called brownstones?

Howard: Cause the stones are brown?

Evan: At the turn of the century there was a huge problem right well what were people using for temptation to turn the century they were using horses now these horses that were going out of town in downtown we're you know going number two all over the place and they used to basically broom all that stuff at the side of the buildings that would turn them brown or they would paint them brown to kind of hide some of that staining and then the automobile came out right and now with the automobile at the turn at this entry we have another problem. So it's gonna be there has to be some type of development it's gonna solve it because I can say there's just too much money sitting here, you know no one no one's gonna let a trillion dollars go underwater I don't believe it.

Howard: Right

Evan: You know if you do you shouldnt be shorting all that stuff because it's just you know there's no there's no financial instrument that doesn't have its tentacles in these low in this Miami Beach area you know there's just more and more money coming so I mean yeah they're building up the stem walls they're gonna raise the streets they're gonna do all this stuff we actually had a day where one of the storm pumps failed and the flooding was pretty bad here in Miami Beach but you know it's like everything else people adapt people will do what they need to do and you know I do I mean obviously it's going to be a serious problem but I think things will develop and things will change so that we can better compensate for what's going on.

Howard: So I only got to you for a few more minutes you have to you have to run around you're looking at your schedule, fastbraces what comes your my new fast braces really work?

Evan: I mean in what sense?

Howard: That they're faster, have you checked out fastbraces?

Evan: Yeah I mean I've never clinically done kind of fast brace to case you know I you can tell patients you have fast braces it just it's just case choice you know you could choose a case that should take you about two months to finish and it finishes and kept six months is that still fast? So it just kind of depends what you're using for your criteria. You know even like some of these clear aligner companies in their advertisements they'll say we finish you know three times faster than braces or ten times faster than braces are you really finishing ten times faster on a case-by-case basis where it's been your study design where you've actually tested this. You know I've been seen any longer not even long-term I haven't seen any no randomized control studies going on with these different systems versus traditional systems and seen a big result.

Howard: Final a lot last question, again looking at the ten specialties I mean when you go into any of these dental schools they got endodontists teaching you everything they know about endo and molar endo and all that kind stuff I got but the general dentists they come out of dental school they really weren't taught ortho and then they end up going to a lot of and a lot of orthodontists don't cater to educating dentists on ortho like the only one the only board-certified orthodontist I know of in America that teaches general dentists is Richard Litt out of Detroit and Harry Green right here out of the great state of Arizona. So they end up taking a lot of things like six month smiles first of all why do you think or why do you think endodontists every weekend in America or lecturing the general dentists on how to do molar endo, periodontist neurosurgeons are teaching them how to place implants but there's no orthodontist teaching general dentists in America. In fact they almost actively talk to meeting planners because I've lectured at a ton of meetings they they have to get orthodontist outside of America you know to come from Canada or Australia or New Zealand because local orthodontist just won't do it what why do you think that is and then and then you think that's good for the patient when they have to go learn from non orthodontist?

Evan: I think there's a bunch of different reasons why I mean I I may think of a few, I may forget a few I'm going through kind of the list in my head but I think the first thing was what you said is that they have very little training in it in dental school you know so I kind of dip it depends a lot where you went to dental school if you were even exposed to it. I think for a long time dentist shied away from doing it. I think in in Florida one of the main reasons people would get sued I don't remember up until what year it was just because they were doing orthodontics and messing up cases you know and that I'm not saying that those people did something wrong I was just they weren't trained to do it but one of the main reasons to get sued was because you did something wrong with orthodontics so that also I would say scared some people away. Something else is that it's kind of a big ticket item you know there's just some dentists who are much more comfortable discussing you know $2,000 dental treatment that was not a dental treatment you know most people and I think you talked about it - about selling big cases they're just not comfortable selling something for $6,000 you know and a lot of the systems in place to pay for that the payment plan stuff like that you know like people walking in that type of money didn't happen. I think a lot of that has changed though over the past 10-15 years I think that's why a lot of people have beginning into it. I will tell you a lot of the general dentists that send me they send me patients that were the ones I described before as you know a little bit wiser and supposed a little bit older because they just don't have the experience doing it you know and I think that I think it goes back to what you were saying is just a lot of orthodontists don't do it. In orthodontics you know was pretty much the first dental subspecialty they almost even thought of taking themselves away from dental school to begin with and I think that and to begin with you know kind of you know siloed themselves off or separated themselves from the rest of the general dentist from the get-go.

Howard: So if someone's listening to you right now and they're a gentleman she's 25 she just got out of Nova she's fourteen million dollars in debt she wants to learn ortho what were would you recommend her where would you recommend that she should go?

Evan: What type of ortho does she want to do?

Howard: Invisalign, Invisalign on adult.

Evan: Invisalign has plenty of courses on their website I've honestly gone through a lot of them. Invisalign has masters courses for dentists too that are good that are a lot there are a orthodontist teaching some of those courses there are orthodontist that are mad at those orthodontist teaching those courses but there are orthodontists that are teaching some of those masters courses for GPS to do Invisalign more efficiently more effectively all that stuff and there actually is a there's a ton of stuff on your orthotown website too, I mean know about treating cases and stuff like that. You know you can some you know I've also stepped up my Invisalign game a lot there's plenty of books on Amazon you can get stuff like that learning invisible learning clear aligner biomechanics and stuff like that I mean the important thing is it's difficult to learn because like you said no one's kind of handing it to you and it's something you have to be a lot more proactive about but a lot of that is is because it's a very recent thing. You know there's a lot of orthodontists your Brighton orthodontist for 15 20 years you know who may not have as much exposure to complex clear aligner treatment at this point either.

Howard: Is there, you said something so profound about reading books like I can believe how many times you go to a course and the questions people are answering it's like okay you flew all the way across the country you dropped a ton of money on this weekend course and you just answered a question that you should have known I mean that you so these textbooks I mean you buy Pathways to the Paul by Stephen Cohen I mean I think he's honest fourteen hundred edition I mean it's a implantology books by Misch I mean there's just got all leaders are readers and you can get a book and those like well that looks like two hundred and seventy five dollars I'm like your plane fare to this course was four hundred. Is there a clear aligner book that you like that you recommend?

Evan: I wouldn't say a specific book per se, I mean Barry Glazier has some good stuff there I don't know what his exact title of his book is there's another book clear aligner biomechanical principles. I would say honestly just do a literature search there's a lot of good stuff by Jonathan Nicosia and Maslul Shiri also in the dental literature they published articles and stuff like that of good things to improve your clinical effectiveness with Invisalign. You know just kind of do that stuff you would do in dental school you know you got to just kind of put your head out there and kind of find something that's gonna talk to you. You know you might buy it you might I might recommend a book and it seems not dry to me cuz I'm an orthodontist and I understand the biomechanics and like where the force is pushing and another person might pick up that book and be like man I got a C in AP Physics I can't do this ortho you know so you know kind of get your feet a little bit wet in the shallow end and then dive a little deeper.

Howard: You're right you're right the orthodontic specialty was the first specialty and Dr. Edward H Angle MD DDS from 1855 to 1930 is the father of American orthodontics final question what do you think Edward Engel would say about the orthodontic specialty today if he was alive and well?

Evan: The best is yet to come

Howard: Nice and what would you say to someone at Nova we get this question on dentaltown all the time they're a senior and they don't know if they should graduate and start going or go on to graduate school, what would you say to that young lady if she was 24 and thinking about going into an ortho residency?

Evan: So that's a very complex question because the amount of debt these students are coming out with today. You know I used to I did a couple seminars at the University of Florida on transitioning from residency to clinical practice so you know there's a big difference between doing what you love and learning to love what you do right. So a lot of these like talking points people today will talk a lot about only do what you love only do what you love you know is the guy in the grocery store who's bagging my groceries making minimum wage doing what he loves all day? You know I think that a lot of people would find out a lot more happiness and learning to love what they do you know you got to be happy in what you're doing every day you know you you know it gets my dream to play you know basketball for the Miami Heat I'm a short Jewish guy in Miami you know that's not that's not happening you know.

Howard: How many Jewish people are in the NBA today I assume the same number is Irish. I'm still mad at my mom for being a five five foot one and Irish there's that kind of rules out the NBA and the NFL but I love that you started off profound we are alone together with social media and everybody's telling you to follow your heart and dreams and it's like come on we're a two-million-year-old species where they were locked up in the winters hiding in a cave trying not to die living off eating Mastodon crap and now all the Millennials believe that life's just gonna be this fairy party and they got to find their passion and their love and they're gonna find the ultimate job and be rich and happy it's like no man it's a brutal world you have a job and what you just finished with this learn to love what you do and that's an attitude.

Evan: I don't think it and there are plenty of people who I know would have been great orthodontists and I didn't get into an orthodontic residency program you know what's the end of the world for them you know like some of them reapply you know a few years later and you know they get into programs they wanted to get to but you know that's that's super hard when you begin study as your whole life and then you miss getting to residency program because you scored two points less on one exam that you took your junior year of dental school you know is that you know is that really fair to them I think everything...

Howard: They didn't get in because they had bad parents who didn't bribe the faculty get a and you hear about that dentist in UCLA that was given all this money to get his daughter, I mean can you imagine what it's come to I and I'm sure if you ask a hundred percent of kids would your other dad give a hundred grand a bribe UCLA to let you in or would you just want the hundred grand and say screw College, what would every kid take?

Evan: A hundred grand, I would still take it from my dad today.

Howard: Hey man I love your energy I called you to come on this show you didn't call me, I'm a big fan of a lot of the stuffs that have you've done. I know it's busy it's on a Monday morning Evan G. Rubensteen DMD, he's an orthodontist on Miami Beach Florida. If you're one of my homies and you're in that Miami Beach Florida area go over there and start referring patients and be as friend I don't think you're gonna find a more fun guy to chill with. Thank you Evan so much for coming on the show today.

Evan: Thanks for having me as well. 

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