Dentistry Uncensored with Howard Farran

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

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Howard: It's just a huge honor for me today to be podcast interviewing Dr. Mohtashami, he is the founder of the forum Institute a postgraduate dental specialties intensive learning institution advancing dentistry through specialized intensive training designed to give dentists the cutting edge skills needed to help restore the human spirit with every smile. In 1998 Sean opened Albright dental in Las Vegas Nevada it thrived as a general dentist practice he wanted more and more and so he dove headfirst in a dental implant dentistry. Upon seeing the remarkable change both emotional as well as physical that had on his patients he instantly fell in love with the process. He began became the leading dental implant expert in the Las Vegas Valley looking to expand he began traveling to Southern California as a dental implant expert placing implants as an associate for other dentists. Dr. Sean is the artist and authority behind the 4M dental implant solution and an expert in cosmetic dentistry he knows how to design a beautiful personalized smile and says the road to excellence is endless this is the motto which has inspired him throughout his entire dental career it was only a matter of time before he opened his own dental implant practices in Southern California 4M dental implant center was opened in Newport Beach with 4M dental implants Center Long Beach opening soon after both practices handle all specs of Dentistry would they focus on the life-changing 4M dental implant solution. He has a BS in chemistry from UCLA a DDS from USC progressive orthodontics continue education Las Vegas Institute for Advanced Dental Studies the California implant studies Loma Linda implant specialty. So you got into USC so my first question is how much did your mom and dad have to pay to get your picture on the soccer team to get accepted in the USC?

Sean: Thats a good question.

Howard: Does that does that there your rep, I actually feel sorry for the kids when I hear that their mom paid 500 grand again USC I don't even care about anything other than man I feel sorry for that kid could you imagine being a child who was had a helicopter parent so bad that she paid a half million dollars to get you into her college but so the one that I think first of all thank you so much for coming on the show when I look across dental industry sure people say there's 211,000 dentists, the United States it did 108 billion last year but the United States only four and a half percent of the eight billion humans when you look at the almost seven point seven billion humans there's two million dentists. Dentistry is a very mature industry that's only growing one or two maybe three percent a year except for two areas the only two areas growing in double-digit clear aligners and implant dentistry and these are the hotbeds of Dentistry and a big reason when we were taping shows from Tokyo and Paris in London they were saying well the government sets your fee on molar endo and you can only and they only set the fee in Tokyo at $100 or more so nobody does molar endo because you go bankrupt doing it so a lot of things that they love about implants and clear aligners is insurance companies and governments aren't setting the fee right they can set their own fee so you're crushing it and the implant market would be where do you think dental implants is that and where is it going?

Sean: You know Howard I think first of all thank you for having me I appreciate it, it's an honor to be here but implant dentistry we're just scratching the surface there is such a vast majority of population that is in need of dental care and when I say dental care I mean implant dentistry not filling and crowns that we haven't even gotten to because these patients either don't know about their options number two they can't possibly afford going to the dentist and million different appointments for root canals for crowns for every tooth and number three and most importantly they're just scared of going to the dentist they want to go in there they want a quick solution that looks good feels good and it's economically affordable to them. So that's why implant dentistry is so big today it's going to get bigger.

Howard: So what is the difference I see two insights to websites for 4M Institute and 4M dental implants which is one of them B to C for patients and ones B to B for dentist?

Sean: Correct so the dental implant center 4M dental implant center is for patients before and 4M Institute is for other doctors or dentists that will participate in learning this procedure of all on four that we teach.

Howard: So what would you about 1/4 of our viewers are still in dental kindergarten school and the rest of them are pretty much 30 and under and I want you to put your dad hat on because when they come out of school half of them have already decided I don't want to do doctor bloody stuff I want to do bleaching bonding veneers I want to do Invisalign, I don't know if you know they just they're afraid of blood and even if they do a root canal there like a pulp lover that wants to stay a half millimeter from the apex then there's guys like me who are an apical barbarian want a puff of sealer at the apex and would rather pull a wisdom tooth and do a MOD composite any day of the week or these people that want to be fluffy composite bleaching bonding veneer dentists do is there have you seen any of them migrate over to blood-and-guts dentistry?

Sean: Well let me give you my own personal experience when I got out of dental school I wanted to be that cosmetic dentist that does the most beautiful crowns and fillings I hated blood in fact I might actually saw blood I fainted so it's because that's what we learn in dental school that's what the focus the dental school is all about how to you know have perfect margins and how to save every single tooth that we possibly can but once I went through all that I went through my cosmetics and orthodontics and I'll you know all the good stuff I still there was something missing and that's when I got into surgery and I realize how simple it is and how gratifying it is to replace a tooth in 15 minutes it doesn't have to be that bloody with today's technology we can do guided surgery you don't even see the side of the Glide you only need two characters anymore you know obviously if you do bigger cases full arch cases then you will get into some bloody stuff but but to start off with you know I recommend getting to the implant dentistry you know all these dentists complain about there's so much competition out there every dentist is doing whitening every other dentist is doing you know Invisalign or aligners or whatever, every dentist calls themselves a cosmetic dentist so if you really want to be different then you got to do something different you can't just sit there and do the same thing in complain about it.

Howard: So when you when I look at your your website 4M Institute that's your b2b dentist dentists website where's your 4M dental implants is your b2c dentist to patient deal but when the dentist goes to the 4M Institute website what does the 4M mean I'm thinking your last names got to be one of them, is Mohtashami one of them?

Sean: Correct so the 4M doesn't have a particular name but it would stand for we focus on all on four so the four stands for that and I've done some redesigning in the whole process of the all on four especially in the restorative part so we've kind of created our own name of 4M procedure or 4M prosthetics.

Howard: I think I'm all on four, it scares a lot of the kids because then they think that's like the most advanced surgery and they don't want start all on four they they really want to start on one tooth how do you how do you start on one tooth I mean yes okay so someone's gonna get to the top of the mountain and do it all on four one day but most but the journey of a thousand miles starts with a single step where is the 4M Institute in that journey is it step one place one implant one missing tooth?

Sean: No so 4M is this boutique Institute that's going to teach other dentists how to do advanced implant dentistry so yes we do actually offer a couple of courses for single implant for the basically baby steps when our focus is not that our focus is how to teach experienced dentist whether it's a few years out of dental school or ten years out of dental school to teach those experienced dentist to how to take their practices from this level to a higher level by introducing all on four into the practice and so we don't just teach them how to do the procedure we also teach them how to approach their team at market how to restore so there's a whole package of things that they learn.

Howard: Wow and so we had back in the day we had a gentleman on Paulo Malo who is the inventor of all on for and how long is that procedure out and do you like it and has it really changed since Paulo Malo started that procedure?

Sean: So the procedure initially came out in early 2000 but it was until 2006 I believed that it actually hit the market and since 2012 it's become a bigger hit. It's changed my life and it changes every patients life on a daily basis I mean I change patient life on a daily basis your question was how has it changed since it came out I don't think the actual procedure surgical procedure part of it hasn't really changed much it's just the instrumentation the product has obviously improved. Now in some cases we can be a hundred percent guided surgery with those as well and I think the most important part is the prosthetic that has improved the back then it just used to be just a bar and a denture teeth where patients will you know denture teeth pretty much what fixed but now it's way more over way more than that we've got so many different options, I think the most the biggest improvement is in the prosthetic part of it not so much in the surgical part of it.

Howard: and our your is your Institute implant agnostic or do you prefer working with one type of implant?

Sean: Well we partner with different implant companies so depending on which implant company is partnered with us that's the one we use at that moment but we're open to you know as long as the implants has been producing well and they're well known we're willing to work with them.

Howard: and what about software and a lot of them a lot of high tech CB CT are you is there any Seabees the same question for CBCT do you like are you agnostic or is your one you like more than others or what about the surgical software?

Sean: Actually because being an institute we are exposed to a few different ones I don't want to name a particular one at this point as we're going through some changes with do different software but there are a lot of good ones out there honestly, we use a couple of different ones one from nobel biocare here but there's definitely more than one software out there that you can use and they all work.

Howard: and that's really a game changer, I mean when I got a dental school in 87 we thought we were so lucky because they were installing computers for the class you know behind us and we were high-fiving like we got out of there before he had to deal with any of this computer baloney and little do it okay that computers would completely change the world back then but do you think that what surgical guides CB CTs have made placing the implant a lot easier and requiring less surgical skills than say back in 2000?

Sean: Oh absolutely, absolutely you know what it's like it's like I would compare it to today's cars with all the cameras you know 20 years ago you only had one way to park parallel park your car right you have to look over your shoulder and you have to look around and figure out how you're gonna do your parallel park but today you can either do that or you can use all your camera on the car and that camera will help you ten times more to be able to park your car. So it's the same thing you my recommendation would be to learn how to do everything surgically just in case you get to a point where you need you can't use your surgical guide which it happens once in awhile then you know how to proceed and do the surgery the way it's supposed to be when surgical guide is done a long ways and most of the specialty with single or double implant surgeries we can just do a guided no problem.

Howard: What would you say to the 1,000 prosthodontist who never know if they should start placing implants or not because it's called channel conflict they're afraid if they learn how to place an implant that maybe their referrals are gonna stop sending to them but what advice would you would you give to prosthodontist should they learn or not?

Sean: 100% I mean I believe that every prosthodontist she learned how to do the surgery every oral surgeon should know how to do how to restore implants only because it helps you to see the final product or vice versa if you prosthodontist if you know how to surgery or communicate even if you decide not to do the surgery you can see things so much more clear one of the advantages that I think I have is I can do both you know I've done all the prosthetics now I do all the surgeries I can just put the two together. I used to refer to oral surgeons and the cases would come back not that the implants were done wrong but the angulation in certain prosthetic parts were not being looked for or taken into consideration and that would make my job a little more difficult. The same thing goes for a prosthodontist if they know how to do the surgery they can communicate better they can treat the patient just all-around way better.

Howard: and what is on dentaltown I always want to get this other way I don't know if you're gonna laugh at this question or take me seriously under implantology it's one of the forms it's one of the most visited volume forums it's all over but we had to separate implantology from mini implants because they just they just my gosh anytime you know they they don't respect each other and I don't like that I mean I think we should all get along somehow but what is your view on mini implants is there any place in dentistry for mini implants or no?

Sean: I mean there's definitely a place for it but it shouldn't be a big place for mini implants you know if you have a really really tiny space limited bone what I use I see the mini implant being overused a little bit, I've seen cases where you could place maybe you know he's an edentilous arch you can place two real implants versus they've used five or six mini implants and I kind of relate it to even to put a big TV up on the wall do you want ten nails on there or do you want two big screws which one works better. So there is definitely some cases for mini implants but I think sometimes it's being overused for no reason where which use actual implants that works way better.

Howard: Is Dr. Ben Javid is a prosthodontist, he's a lead educator at 4M Institute, is her partner in all this?

Sean: Yes he is.

Howard: So how so talk about him for a second.

Sean: He's a prosthodontist, he's been doing all on four he does also the surgery so here's a prosthodontist that does the surgery and the prosthetic part. We met a couple years ago, we both have the same vision we both really practice very similar which was great and that's when we started the 4M Institute in Long Beach so we can teach other dentists how to change lives just like the way we do. He is he's very book smart and I'm a little bit more clinical smart so the two of us together actually really wealthy and when we teach the courses the comments we'll get is that you guys really put a good show together I mean it's really nice to work with him.

Howard: So when you know i-i've been done I think I graduated school in 87 a lot of you know back then it was it was really bizarre because the early implantology were really not respected in 87 I remember at UMKC dental school the one oral surgeon he placed implants was always called the butcher I know when they when I came out the early implantology were doing all these great subperiosteal ramos frames they would take dental cripples and rehabilitate him but the first time they had a major case fail the boards would take their license away and it was so cruel to watch some of these really successful implantologists and go end up lose everything they have and go drinking a trailer until they died I mean I saw this and now when it's mainstream I always want to whenever someone's argue someone I always say you know settle down the jury's still out but back in the day the implant used to be the goal the implant was to have the longest implant possible I mean you wanted it to go all the way out of the head around the moon three times and back down now you see shorter fatter implants and you know I think everything should be shorter and fatter but that's just me personally are you seeing a lot less sinus lifts now that shorter and fatter implants is more common or is your procedure all on four it isn't that the main reason people like all on four because there is no sinus lifts or anything explain explain what all on four is and why there would never be a sinus lift for these shorter fatter implants?

Sean: So alright so all on four is when we place four implants in an edentulous arch to support complete prosthetics, prosthesis these four implants the front two implants are placed pretty straight forward and pretty straight up and down but the back two implants are tilted posteriorly or distally to where we can skip the sinus but yeah we use very long implants actually they're not short implants, they're long implants to where they we can maximize the amount of the bone that's there the anterior part of the implant is more anterior to the jaw where that's where the strongest part of the bone is as you know as we go further back into the jaw the bone gets softer especially an upper arch so what we do is we tilt those implants so we can get an anchor of the better bone more anteriorly and yet the posterior part of the implant will be further back distally so this gives us a nice ap spread anterior posterior spread for a nice prosthetics to be restored.

Howard: and this is the patient I mean you're out there and in highest setting I mean you're out there in Southern California I mean that would have to be the highest patient expectation for  beauty obviously every hygienist is going to want that to be a all on four to be a removable so you can take it to the kitchen sink and clean it and brush it and snap it back in but I know patients psychologically when they're paying all that money that they want it fixed. So how do you how do you judge they easy to clean with having it snap out and versus that psychological it's like me I won't wear a wig because I'm so afraid it will blow off when I'm walking that I just go without it so how do you balance that the hygiene needs versus the psychological needs?

Sean: The hygiene need of all on four is actually very simple obviously the outer surface of the teeth you just brushed normal like you would but if you can imagine what a contact on a bridge looks like imagine that across the whole arch so the amount of contact between the prosthesis and your tissue is almost like a contact on a bridge it's not huge it's pretty minimal and with using what we call a hydro flosser or some kind of that that's water pick they can easily clean under it once a day that's all they need out of the thousands of cases arches I've done honestly I've had a single patient complain that they're afraid they can't clean it no one else was ever complained and that one patient was wearing dentures for probably 40 years and the fact that he couldn't remove it it kind of bothers him but nobody else ever complains.

Howard: So what so if you do a hundred units of all on four how many of them are fixed versus removable?

Sean: Alright so when you say all on four you are talking about it fixed prosthesis we're not talking about removable.

Howard: You can't make any removable all on four?

Sean: Well you've gone for all that all on for you call that over denture or snap-on denture or you know there are other names for them removable supported denture but when we're talking about the term all on four the procedure all on four is a fixed prosthesis that's all done in one day patient walks in with no teeth or with teeth that need to be removed the same day leaves with fixed prosthesis so that's what you call all on four.

Howard: So that includes all done in one day.

Sean: Correct, so we also call it teeth in a day or all time one day yes some people call done one day.

Howard:So then you compete with a clear choice?

Sean: Exactly

Howard: and how does that go and what is your unique selling proposition to go against clear choice?

Sean: I mean clear choice has done a great job to market this procedure for all of us so we can't take any credit away from them they've done a fantastic job they've helped all dentist around but what sets us apart is not so much in the surgical part of it but all but in the final prosthetic part of it. Like I said earlier the material huge you know they're different, different things that can be used to to give patient that beautiful smile you could go from denture teeth to all zirconia teeth or there are all these different things in between. I think our product is superior to what all on four users and I can get into more detail if you wanted?

Howard: Sure is it the teeth is it because I always think a Southern Cal for some reason whenever I'm talking to a dentists from Southern Cal I always think it's a higher aesthetic need. I mean Bob Ibson and started Denmat in Santa Maria because I mean it was just beauty was first I mean he wrote the first book on adhesive dentistry because no one wanted to hear how long amalgams last they wanted it tooth colored and then when he started making Denmat composite fillings he was shocked that the patients noticed that crust and Colgate dulled the look the luster and they'd old it because the toothpaste wasn't abrasive enough so he made it with a titanium dioxide and came out with Rembrandt. So I assume that your advantage on clear choice is something to do with the aesthetics of the teeth.

Sean: So there are two major products, yeah you're absolutely right.

Howard: Was I close?

Sean: There are two two major products that are being used for the final t, one is titanium bar with denture teeth which most of the time is what clear choice uses and the second option is full zirconium bridges now each have advantages and disadvantages the titanium bar with denture teeth it's light it's not strong enough so a lot of these teeth keep popping up or breaking off after a year or two and there's a lot of fixing that needs to be done for repairs I mean so that's one option the other option is the full zirconia, the advantage is that it doesn't break that easy so you have this really heavy piece of bridge that's screwed into or implants now there is a lot of wear and tear that happens when you have such heavy east of zirconia and patients when they talk and they chew then you get that top down or that noise loud noise when they do so overall the disadvantages of the zirconia is that it's too heavy I mean it wears down the implants to quick. We brought these two together we took advantage of the lightness or the flexibility of adventure team and the strength and the aesthetic of the zirconium teeth and we combined the two together so we use the material called Zirpeek. Zirpeek, this material in as the strength of the zirconia like I said but it's still very light you don't feel the patient doesn't feel like they have something heavy in there mouth and on top of that we do individual round it's just like you having sixteen crowns in your mouth so for whatever reason if one breaks we can just replace that one crown as if literally if there was a crown friend and it's just that easy as that so that's the advantages of what we have and aesthetically it's just amazing, each tooth you can almost floss between each one it's beautiful, you got to see it.

Howard: and why do you why do you think clear choice Holdings is up for sale why would you guess?

Sean: Well clear choice is I believe that's their model the model is to build and then to sell it to a private equity I think that's that's their model that's what they do they've sold it three times already.

Howard: Yeah it's on the block again I'm they're saying that on the projected EBITDA offer is north of fifty million dollars so it's a weird game because none of them want to go public I mean you're out there in California why can snapchat go public when you know I could live another fifty seven years without even knowing what snapchat is I still don't know what it is but how come these big health care providing companies why aren't they publicly traded on NASDAQ?

Sean: I'm a great implant dentist but I'm not good at this correct me if I'm wrong, I don't think you can go public with service companies when you're giving patients or whoever a service I doubted if you can go public on that am I right or wrong?

Howard: You can go public if you get the revenue I mean if you're...

Sean: It could be that, that's a good question.

Howard: but it is it is well like like Kevin Mosier started the company in 2005 and like you say it's been flipped three times that's uh it's just a weird game that you have these major dental players and their only goal is to sell it to a private equity whose only goal is to sell it to someone else, it's kind of like what was that game on the chairs we go around the chair and those music stops everybody had to find a chair that is just. So is there an aesthetic health compromise in doing this all in one day I mean if if you were doing this for your own mom or your own dad would you say you know what the burden of doing this all in a day and I mean yes there's a huge market for that I mean that's the American Way I mean I I couldn't think of another country to start this in than an America I mean you know teeth in a day but do you think it would be better if it was spread out over more days or weeks or months?

Sean: Not this particular procedure I mean if you want to spread it out I mean so let me backup for a second this procedure is designed for patients that want quick results patients that don't have a lot of bone issues that don't want to go through sinus lift and six months of healing patients that don't want to spend $70,000 or more in their mouth I mean there's definitely a reason why this was designed so yes you could there are definitely patients out there and there's definitely candidates that would benefit from six to eight implants sinus lifts waiting six months you know wearing your denture for four to six months initially but that's going to rule out about 2/3 of the population. So what we're doing we're serving that two-thirds of the population that doesn't want to do all that, that doesn't want to go to the dentist a hundred million times doesn't they want teeth today, they don't want to wear removable for six months. A lot of patients are hanging on to their infected teeth to their done disease teeth because they're afraid of what's going to happen what they think once they take their teeth out as sure that you tell them nothing is going and the only thing that's gonna be great is you're gonna walk out of here with healthy fixed teeth that same day and that's what they're looking for when they hear that they get excited so would I do that same thing for my family absolutely after doing this procedure for so many years and seeing the benefits for every single patient I would do it for my family 100%.

Howard: So implant you know implant forms is big on dentistry it's one of the most busy ones and I post on an implantology all on four with clicking joints he's currently working up a case with the periodontist that everybody wants to do all on four and says she has noticeable clicking of her joints bilaterally but it's currently asymptomatic what goes through your amazing mind when you hear that?

Sean: The first thing that goes through my mind is why does it have to do with the all-on-four how do we know it's from the procedure of all on four why...

Howard: No he hasn't done the all on four he's working it up that the teeth are trapped the patient wants the all on four but she has clicking she has noticeable clicking of her joints bilaterally but it's asymptomatic.

Sean: I've treated many patients even with tmd disorder or TMJ disorder who've had pain discomfort and we were able actually to treat them and resolve their issues maybe not 100% but 70% I can think of a couple of patients actually right now as we speak. You know you have so what would you do it if we were to restore this patient without any kind of implants or without the all on four we would still want to correct the patient's bite place their bite in the right position to where their TMJ is comfortable whatever system we're going to use we're not going to get into that whether it's near muscular or whatever this we would do that with placing the patient in a splint in an orthotic monitor for three to six months adjust their bite until they're comfortable then we would either orthodontically move teeth or crown and bridge their key to place them in that position right that would be that the restorative way now we can do that same exact thing with all on four so that shouldn't stop us. If someone has the talent the knowledge to be the patient for their TMD it doesn't matter whether they're doing it from the all-on-four perspective or a percent crown and bridge or orthodontist it should all be the same the final result should be to same.

Howard: One of the problems that people worry about all on four is you know the person that needs an on for that that's not gonna be your vegan yoga instructor who eats kale three times a day I mean that's the most likely gonna be you're drinkin smokin Irish guy and so a lot of people say what I'm worried about all on four is the reason they need it all on fours they didn't have home care to begin with and now they've had all this all on four I know that my hygienist they when patients come in with all on four they want to have the whole thing removed clean and put back on but that that's an extensive cleaning appointment and clear choice doesn't really want to do they don't have a hygiene department for those do they?

Sean: I'm not sure about clear choice but we do.

Howard: Yeah because that's one of the major complaints about clear choices they do all the teeth in a day but they really don't then they want you to go back to a regular dentist but so specifically the question if you're a hygienist and they come in do you always remove the prosthesis at the six month cleaning is that on six month recall, four months recall how does that work?

Sean: Our protocol is after we deliver the final prosthesis we want the patient back in six months so we can evaluate and see how their hygiene is if they're doing a pretty good job and things are good then we put them on a one year recall. So once a year they come into our hygiene department we remove it the prosthesis we clean make sure all the screws are nice and tight nothing is moved that is basically loose and then they go on their way and it's a very simple procedure it's way easier to unscrew four little screws and clean a prosthesis and put it back on then cleaning 16 teeth in an arch and you have even not only for us it's easier for the hygienists but also for patients so imagine the patient that has gum disease or has hygiene issues in one arch you have let's say 14 key 14 teeth that have circumferential pockets that this patient needs to worry about right brushing flossing if they have 5 or 6 millimeter pockets that's a lot of pockets for plack to sit in there and cause more gun there's even more issues now you take 14 teeth away you put four implants and these implants are obviously a lot smaller than a molar now all of a sudden you cut their work in 1/16 or one I'm sorry whatever the math comes out too right so they're by gene maintenance is a lot easier I see patients that have older teeth removed because of advanced perio disease and two or three years later they come to me and they're healthy still because it's so much easier for them to keep the all-on-four clean then they're natural teeth.

Howard: and what I really like is like say back in the day nobody liked a Waterpik because it made a mess in the bathroom there's water on the mirror was crazy but now they make these water picks that you can take into the shower and so when you water pick in the shower it's just a lot more easy and they start out with the shower floss remember the shower floss where you would take off the head of the shower need screw that was a great so that's a very interesting protocol is what about peri-implantitis so again this is the most people who lose all their teeth enjoy smoking drinking and you know Smirnoff. Do you have what what is your failure rate of these implants from peri-implantitis excerta?

Sean: So peri-implantitis doesn't cause failure it may cause some issue you may cause some bone loss and so on but it doesn't cause failure the only thing that really causes in fact failure is in the first three to six months if it doesn't heal properly or get movements of the implant or too much pressure but our failure rate our let me put let me tell you about our success rate is that 97% and we kind of keep track of that as we go all the time. We have a really really high success rate when implants are placed and they're splint together and we never have to unscrew and screw back an abutment or a healing cap that tissue heals really nice around those abutments so at the time of the surgery we place the implant we put a final abutment which is called multi-unit abutment and we never remove it it's done so that first primary healing that you get around that in plan around that abutment it has never bothered again and that's really a big success versus single implants where you place the implant four months later you remove the healing cap and then you put another impression coat and then two weeks later you remove that and then you put another abutment so every time you do that you're interrupting that periodontal healing, the periodontal pocket or tissue so that's another success.

Howard: So you're saying that if implants are gonna fail they're gonna fail right out of the gate in the first three months?

Sean: The first three months we would know yes very seldom six months a year later but most of the time first three months yeah.

Howard: but when you count you're ninety seven percent success rate are you counting including the failures not first three months or do you mean after that first three months?

Sean: Even the first three months.

Howard: because that's one of the confusing things about life expectancy of humans it was always the the child the infant mortality rate and a lot of people believe that you know 10,000 15,000 years ago people didn't live very long because they were taken about a median age with that infant mortality but when you cleaned out the infant mortality actually lived a very long time but you're saying you have a 97 percent success rate including the high initial that the failures are in the first three months.

Sean: Correct

Howard: and the other thing is who is that failure in the first three months because they come out of dental school and they're told well a good candidate wouldn't you know smoke drink cuss or be Irish and then and then they open up their practice and those are the people that need it also again who do what do you think sums up that that three percent failure rate out of the gate?

Sean: So those three percent including the ones that actually don't follow instructions and they go home and do everything that you told them not to do but they still do it mostly are autoimmune deficiency patients could be diabetic patients type 1 or type 2 smokers are definitely in that category I can go to the two most important failure factor is smoking and diabetic.

Howard: Yeah I know I'm Carl Micsh when he was on the program and he said he'd you know he did smokers I know that was one of the more controversial things he said the other controversy there was a well there's a lot of implant all just to just say I will not do this on a smoker end of story there's other people that say you know everybody needs a chance. How do you draw the line between being a tough guy and saying no I won't do it if you smoke versus I know you're human, humans are complicated as long as you're aware that you know so so how do you balance crazy people versus high-tech medicine?

Sean: I think I agree with the earlier everybody deserves a chance and I've learned that if I explain to my patient in advance what their risks are for them if they're smoking and if they agree to go ahead and move forward with the procedure who am I to not do it for them because not every implant that not every patient that smokes is going to have an implant fail yes there will be some but not every single one of them so as long as the patient is informed and that's what we do as soon as I find out someone is a smoker I would recommend for them to stop smoking if they want the implants to last a lifetime and if they say I will not stop smoking then my next question is would you still want to proceed knowing that there is a chance that your implants will fail and it's 100% percent of patients decision to move forward or not it will not be my decision at that point.

Howard: What if they just switch from marble to Marlboro light bud light Bud Light.

Sean: It might help.

Howard: So is there other people that are afraid to scale I'm on dentaltown and these there's a big long thread about all on four what do you do what one guy would antenna says well I'm afraid to remove it because I'm afraid if I remove and don't get it back on I now own it the other person says I do not scale the implant because that's bad do you do you think for a while there are a lot of people were making cleaning instruments that were plastic so it wouldn't scratch an implant is that is that something you think about or not really?

Sean: Yeah I mean our hygienists use plastic instruments and we also have ultrasonics that are specifically made for implants for implant cleaning.

Howard: and then another guy asked on under implants he says Medicare and all one four can any as anyone ever successfully been paid by Medicare for any part or all of the all on four procedure?

Sean: I wouldn't know because I don't work with Medicare so I honestly could not answer that. I know that they would pay for the extractions and maybe for the denture part but definitely not for implants but I've never tried it.

Howard: So have you ever tried medical billing for not Medicare but just Medicare medical billing?

Sean: We've done some medical billing but that's through normal insurance is not Medicaid.

Howard: Yeah have you been successful with that or not really?

Sean: We've only done occasional cases where we actually knew that we had a pre-authorization so we don't just you know patients don't just walk in here and say oh I have a medical insurance can you just bill my insurance and then we do the procedure and billed insurance we don't can't do it that way but there's been a few cases where patient came to us and specifically let us know that their insurance will cover and we send them pre authorization we got the pre-authorization then the procedure.

Howard: Another question I'm somebody posted an article on one for treatment concept a systematic review by Sebastian but basically the question is the patients always gonna ask how long will this last, how do you set expectations for a complicated human I mean if you buy a car a refrigerator the consumers got to have some framework in their mind about what would be expected or not expected how long do you think how do you guide they say satisfaction equals perception - what - expectations how do you form expectations of longevity with this procedure?

Sean: You know I tell my patients that nothing in life ever lasts I mean even God gave you teeth that don't last you forever right so I'm not better than God I'm not gonna promise you teeth are going to last you a lifetime but what I will promise you is I will place implants that are successful 100% percent successful and if you maintain and coming to our office for your normal regular hygiene I will guarantee those implants meaning that if seven years down the line if one of them fails and you've been coming in for your yearly or six-month checkup then I will replace that for you at no charge that's the way I do it but I do not guarantee the prosthesis because I don't know what they're gonna do. You know I tell them that the prosthesis or the cheek that you were over those implants are kind of like the tires on your car you know depends on how you drive them depends on how many miles you put on it they could last you a couple years if it lasted six months or ten years I really don't know but that's how we go about doing it and patients are very susceptible to that they understand.

Howard: and what what kind of labs I mean Glidewell does labs now for all on four there's a guy posting a picture today of a of a prosthetic that he got back from Glidewell Labs did you know Glidwell was doing these procedures?

Sean: I'm not sure if they do the actual surgical part of it but I know they do restore them yes I know...

Howard: Yeah the lab for the restorations

Sean: Yeah

Howard: So do you have your own lab or do you use Glidwell or who?

Sean: We have our own laboratory in the 4M dental implant center in Long Beach so our all of our cases comes here to Long Beach in-house lab yes so we don't use any outside labs and that's where I was telling you about the advantages that we have over clear choice is in the prosthesis in the teeth that we actually create the zirpeek that I told you earlier.

Howard: Wow so you know that's you know a lot of people say that was Aspen as they were the most successful DSO is instead of doing mergers and acquisitions and buying other people they had their own model and that model was included a lab and they they you know and I see that business model I mean when I grew up my next-door neighbor Kenny Anderson it's a dentist that's why I'm a dentist I want to be him when I grew up and he had his own crown and bridge lab and it seemed like it was really common back then I mean on the set on the west side of Wichita almost it seemed like every third or four dentists had their own crown and bridge man of course it was simple one-man operation a pfm or gold crown do you think putting a lab back in the dental office like Aspen is doing now is something that we're gonna see more of is it a big strategic advantage do patients like it do you think that's a big part of your mojo and success?

Sean: Definitely I mean especially if you're doing all on four cases and that's where your practice is headed you definitely need to have your whole lot and you know it's very critical to be able to duplicate things in a timely manner or provide patients with services that are required you know all on four practice and you cannot do that if you have an outside lab. You know for example if Glidewell every time you send something it takes two to three weeks or whatever the procedure is or to return back to you I mean you can't really sustain unless you're doing one two three cases a month maybe but if you're doing that on a daily basis you definitely need to have an in house lab at some point.

Howard: and Lyla asked on the all on four, how do you close up the all on four screw access holes from what I've learned teflon tape to fill the holes and a couple of millimeters a composite without any adhesive is that how you do it?

Sean: Yeah very simple exactly what you said sometimes we if we know that the patient is coming back in six months we put the Teflon and we fill up we backfill it with some Lightbody impression material so that way when the patient comes back the doctor doesn't need to go back in there and drill it out because what composite now you need a doctor to go in there and drill that composite out a few packs fill it with light body impression material you put an explorer in though you pull it out the whole thing comes right out.

Howard: and I know I can't believe we already hit an hour but who are these people getting it all on for I imagine a lot of people it's real easy to say well Sean's out there in LA and he's getting a bunch of movie star millionaires and I'm in Parsons Kansas and we don't have all the movie stars and millionaires or is it mostly rich people millionaires of movie stars or they Walmart people?

Sean: They're Walmart people are most of our patients are blue-collar patients these are patients that haven't had the proper whether it was finances or time or whatever it was they didn't have the proper dental care and now they're at a point where their life has hit it in a place where they just can't go further whether it's in their love life withers in their occupation or whatever it is they've kind of hit a spot where they just need something new they need help a lot of our patients get help from family you know mom and dad or cousins come together they cosign for them we really rarely work on millionaires and we maybe wants the blue moon we get someone that walks in here and writes a check for us but most of our patients I would say 90% of our patients are done by financing and these people are not rich.

Howard: 90 percent?

Sean: Yeah

Howard: and who's the financing is it Care Credit, is it?

Sean: Different parties we do Care Credit one of the big ones we use is Green Sky definitely want to look into that because Green Sky is probably the only finance company that does $50,000 40,000 some big numbers I think all the other had a cap of 20 or 25 so for these big procedures where you're doing a full mouth you need any Green Sky there's a Spring Stone yeah there's West Fargo is quite a few of them.

Howard: What is your fee on average for something like this?

Sean: We charge around $25,000 for arch.

Howard: 25,000 per arch

Sean: Per arch yeah

Howard: and what are the and what's clear choice charging for that?

Sean: About the same I know sometimes in the beginning of the month they go up to 28,000 and then towards the end of the month they come down to 20 to 23 depending on you know how this but they might get but we're also flexible we're really here to help patients so if some patients financing comes to a certain point where they need a few thousand dollars of help we help them we really do we're here but we're here to change patients lives and we don't let a few thousand dollars get in the way so that's what we like to charge about twenty five thousand for arch sometimes if we're doing a full mouth we may be a little more flexible as well upper lower but I want to add back to where you said some of you doctors say well I don't you know live in Beverly Hills and I don't have these patients millionaire patients, there's a huge market out there and these people are the blue-collar market that's really really needs this procedure when I'm gonna give you an example, we have a little bit time don't we?

Howard: Yeah I'll go all day.

Sean: If you look at Southwest Airline and find out how Southwest became Southwest it wasn't because they came into the market to compete with Delta or American Airline or all those other good airlines that are out there we came up to the market because they knew there a lot of people that hate to fly they'd rather drive to Las Vegas for many reasons number one is too complicated to buy a ticket yeah I call you know in case you don't want to fly your money's never returned to you you lose your ticket it takes too long to go through the airport so there's all these complications that make people not want to fly so Southwest idea was what should we do to grab those people that don't want to fly and bring them into the market of flying and that's how they basically created the philosophy of you know when you call the first ring somebody answers your money is always there if you don't fly you can reuse it towards other flights you know simple get in get out there's just so many things they create it so now take that into the dental wall there's so many patients out there that don't go to the dentist because they don't want hundred appointments they don't want a root canal every tooth they don't want to go in for 20 cleaning appointments and then have to do it every month and they don't want to spend seventy thousand dollars they cannot afford it there's just so many or they're scared of going to the dentist. When you put all this together this all on four fits into a huge market that's just sitting out there that nobody's tapped into. So if your dentist that feels like there's too much competition in the dental world there's absolutely zero competition in the all-on-four world out there there's just so many patients just waited to be treated.

Howard: Well I'm always I'm always beating them up telling them over and over and over that the average American buys thirteen new cars in their lifetime before the age of 76 that's a verified obvious number my gosh it's from the average new price the average new car price in America is thirty three thousand five hundred and sixty source Kelley Blue Book and today on average Americans buy 13 new cars buy age 76 source Anthony Pratt pole character of forecasting so you're selling a dental cripple a dental solution for 50,000 to an American who will buy 13 new cars in their lifetime and 95% of dentists will never sell one case their whole life were thirty three thousand five hundred and sixty so what separates the big boys like you with wearing big-boy pants versus 95% of Americans you say well my patients don't have any money even though they're driving a fifty thousand dollar Ford 150 pickup truck which tonight is Monday it's my favorite night of the week because it's Monday Night Football and it'll just be all commercials for Ford 150 pickup trucks and if you're poor you'll get two f-150 for 50 grand if you want hotter women you'll get the f250 for 75 grand and if you want the hottest girl on the block you'll get the f-350 for a hundred grand so why what are dentists just thinking when they watch Monday Night Football and see all these car commercials I mean do they think just people in Beverly Hills drive trucks?

Sean: I think one of the problems with dentists is they think for their patients they choose for their patients how many times as a patient walked in and a dentist decided oh this guy can't afford whatever it is, so I'm gonna give him a lower option without really knowing if this patient can or cannot afford it that's the biggest problem that I see, I stopped doing that a long time ago I do not choose for my patients I will tell them their choices and I will allow them to choose.

Howard: and you you said that these were blue collar workers twice and I have to tell you about blue collar the word blue collar comes from because they would wear blue denim and in the 32 years that I've had my dental office I've had a couple of people who retired here and they always come in and plaid pants or the striped pants they they kind of look like goofy from the late nineteen fifty and I you went you get to know them over the years and they're so proud that they've never worn blue jeans ever because if you grew up if you grew up during the Depression it is really you really made it if you never had to wear blue jeans again but some of the point I'm trying to make is some of these corny old goofy looking men wearing these plaid pants that they don't even sell anymore you know JC Penney's would even carry these things and you look at I mean you think this guy's a homeless guy he didn't have a dime but he's got 50,000 he buys an f-150 pickup truck he paid here writes a check for 50 grand so everybody needs a dentist and they don't need your judgment they don't need your you know if they want to be judged they'll go to church if they have a finance problem they need to go to a bank or Green Sky not you you're the dentist you're supposed to tell them these are your options not what it should a cutter you're bad cuz you smoke and you shouldn't have been born Irish in the first place you drink in full you know you should be a yoga instructor or not a welder I mean this is nothing to do they're here at your door they then and they have the money and I just my gosh it's a I Drive around these streets of Phoenix and it's amazing how a city of poor people with no money they sure have a lot of nice cars on the freeway don't they but I can't believe how long we went you're being so nice you let me go well over an hour but is there is there any question that I should have asked that I didn't ask?

Sean: You know if I have to make any suggestions to the dentist my colleagues out there is number one don't judge the patients and number two go get trained in being able to do these because it starts with your confidence if you're confident that you can provide this service to your patients it will come across and people will buy it and number three is to get your team members trained and on board if you're only the person that knows how to do a procedure and your front staff don't know how to talk about it your your marketing doesn't apply to that then you're going to get disappointed because those kind of patients don't come through just out of nowhere, so train yourself and your staff and team and start marketing out there you'll see how just start flowing in.

Howard: and when are they ready to visit the you you're not the place to go to place the first implant?

Sean: Well we do have a couple of those courses coming up in 2020 so if you want to just learn how to do single implants yes you can come to our courses in 2020 go to 4MInstitute.com but if you already placing some implants even if you place twenty to thirty implants you should be able to now get into the all on for come and learn how to do this procedure I mean I have oral surgeons periodontist prosthodontist who will never place the implants or do the surgical part they still come and learn every time they walk out of here saying that this was an eye-opening for them.

Howard: and what percent of the patients when they get it all on four are put to sleep and you teach that or do you use an anesthesiologist and that separate training?

Sean: Both me and Dr. Javid are licensed for IV sedation so most of our patients are IV sedated by us if a patient is medically compromised and we bring in we have two or three days out of the month where we do just anesthesiologist cases those are compromised cases for doctors out there I don't teach the IV sedation here but there are a lot of good courses you could take you know that doesn't have to be the fact or that doesn't have to be the determining factor whether you do these cases or not when I first started it I would do oral sedation for patients just start with one arch they're not that complicated obviously if you do a lot of them a lot easier and you save a lot of time if you could either have anesthesiologist or do the IV by yourself.

Howard: Well you're out there in southern California I assume that Michael Jackson you have to use propofol?

Sean: I don't use propofol but I'm sure the anesthesiologist do.

Howard: My anesthesiologist he so upset that Michael Jackson used that one because he said it really hurt the brand he gets a lot of about 10 percent pushback on that my gosh, great marketing for your course we put up 401 hour courses on dentaltown and they've been viewed almost a million times well it should be an honor to get you to do online CE course on all on four so they can get to know the concept they get to know you and maybe they're ready for you now or maybe they're still in dental kindergarten school and it'll give them something to look forward to someday when they grow up but if you're a virgin that'd be an honor to have you do an online CE course on dentaltown.

Sean: For sure for sure we'll do that.

Howard: Alright well thank you so much for staying in our after a long day of work to talk to my homies it was just an honor to podcast you today.

Sean: My pleasure, it was very nice talking to you.