Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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Success Then Is Not Success Now with Tarun Agarwal : Howard Speaks Podcast #090

Success Then Is Not Success Now with Tarun Agarwal : Howard Speaks Podcast #090

6/30/2015 12:00:00 AM   |   Comments: 0   |   Views: 797

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AUDIO - Tarun Agarwal - HSP #90

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VIDEO - Tarun Agarwal - HSP #90

Listen to Tarun Agarwal, DDS explain why you need to accept insurance, why you need to answer the phones on the weekends, how to be a more patient-centric praactice, and other things you need to do today to help your practice succeed.


Dr. Tarun Agarwal represents the next generation of leadership for the dental profession. As a respected speaker, author, and opinion leader, he is changing the way general dentists practice. His common sense approach to business, dedication to clinical excellence, integration of technology, and down to earth demeanor has made him a recognized educator.

Howard: It is seriously the hugest honor in the world to be interviewing today T-Bone. You guys know him as Tarun Agarwal. My God, seriously you are my idol, mentor. You are.

Tarun: Come on now, Howard.

Howard: My dad's biggest business mistake that he taught me was having partners, and he just always told me a million times how easier his life would have been without partners and I have always told dentists, "When you get married to a woman and have children and holidays and family, that fills half the time, and you're going to marry a male dentist that you don't have sex with, don't sleep with, don't have children. Are you kidding me? I can give you the names of 100 dentists that said the divorce with their dentist partner was twice as bad as the divorce with their spouse with children. It's crazy. 

You, my man, are the only partner, you and Sameer Puri, were the only partner I ever had in my life and I love you like a brother, a son. Really, the story with T-Bone is I had a full-time practice, I was lecturing, I started this website and magazine, and the townies were saying, "We talk to each other all day on Dentaltown but we want to meet in the flesh, and let's have an annual meeting," and I just thought if I have one more project, I'm just going to fold. You and Sameer, and you had never met each other in the flesh either, had you?

Tarun: No, we hadn't. No.

Howard: You were one each ends of the country. Sameer at the time was in L.A. and you were in Raleigh?

Tarun: North Carolina, yeah.

Howard: Is it Raleigh?

Tarun: Yes.

Howard: We had no contract. We just said, "Okay, let's do it," and we were partners for 10 years and you were the brainchild, you and Sam of the townie meeting, and then after you guys did it for a decade, you decided you didn't want to do it anymore and you gave it back to me. 

Tarun: No, we loved it. It was great. It worked out for everybody, I think, and it really shows the power of the community and these podcasts are just an extension of that at the end of the day, how people are thirsty for knowledge and they just want to get in touch with people and I think ... What we started with Dentaltown and the townie meeting and even these podcasts is people want to hear from everyday people. They want to hear from people that are doing it every day, that are struggling and succeeding, and doing all the different things, and that's what I really enjoy doing is helping people see what's possible in dentistry.

Howard: You know what I love about you? I always said a lot of dentists think that the only money you can make is in like a Ruth's Chris Steak House in Key Biscayne, Florida. It's like, "Dude, I'm pretty sure McDonald's makes 100 times more money than Ruth's Chris." So many of your colleagues all want to be full-mouth reconstruction on movie stars in Beverly Hills and all this, and you're just crushing it. No offense, but Raleigh, North Carolina, that's not exactly Key Biscayne, Florida. That's not Beverly Hills.

Tarun: No, it's not Beverly Hills.

Howard: You are keeping it real and you even say, "Dude, take insurance." I want to open with that. How is a rock-star like you, with a CBCT, surgically placing implants, guided, bone grafting. Your cases look like they flew in some king from another country and paid a gazillion dollars to do this, and you're doing it in Raleigh. Start with is there still money to be made with insurance in the middle-class?

Tarun: I would say that is the easiest place. I didn't say the only place, but the easiest place, and really I think where I always go back to, Howard, and I tell everybody this, is when I started practice, I wanted to be cash-only, and we were cash-only, and I almost went bankrupt. My parents and my wife gave me about a year of saying, "We can try it your way, and then if it works great, if it doesn't work let's change." I remember hearing from you on Dentaltown at lectures that it's okay to take insurance, and everybody else was saying insurance is the devil, insurance is bad.

What I say, 10 years, 12 years later after having started taking insurance is, I couldn't have the cone beam, the CEREC. I couldn't have the luxury of doing the procedures I do if it wasn't for the fact that we take insurance and we have patients, and our bread and butter dentistry pays the practice, pays my bill, pays my lifestyle, pays my ability to take continuing education, pays my ability to be charitable with my work, and it really is about working within your patient base at the end of the day, what your market will bear. Our market bears insurance. 

Howard: There's 9 specialties in the ADA, and everyone wants to talk about the 7 clinical ones, endo, perio, pedo, prosth, but they don't want to talk about the 2 non-clinical ones, and one of those is public health dentistry, and the other one's oral radiology, where you're trying to look at a CBCT, which looks like some telescope looking into deep space and you have no flipping idea what you're looking at. 

But public health, I came from Kansas and I remember going to some of these lectures and they were talking about the A patient, the B patient, the C patient, the D patient. I said, "Well, my entire pedigree is D patients. All my roots in Kansas are what you're describing as D patients and they need dentists, too." I think it's free enterprise's goal is to go in there and make money off slinging what might be considered by others as McDonald's instead of a filet mignon.

Tarun: You know one man's junk is another person's treasure. Absolutely. Yeah.

Howard: The things that I see you posting that are just mind-boggling is you always loved technology. You were one of the first guys on Dentaltown when 99% of the dentists didn't even have an email address. By the way, history folks, we started Dentaltown in '98 and looking back we should have started it in 2002, because all the way through my lectures in 2000, 2001, I'd go into a room, there'd be 300 dentists. "How many people are on the internet?" One hand would go up.

Tarun: Zero. Yeah. Exactly. 

Howard: And he only got it for the kids' homework. The teacher at school said you need to do this so you can go to a jet propulsion laboratory website to do a book report on Mars. It was way, way, way too early, but you dove on that. I think the burning question, the hot spot where I'm glad I got you today is it's changed, implantology.

Tarun: Yes.

Howard: It was a conversion of technologies, because it was the X-ray machine going from 2D to 3D that really was the game changer, so it was really the specialty of oral radiology that changed, that impacted implantology because I got my fellowship in the missions, too, back in the late '80s, early '90s and my Diplomate in International Congress of Oral Implantology. That was crazy because you'd have a 2D pano, you'd think you have an inch of mandible, you'd flap it back, it was paper thin, and you'd have a huge inventory of implants because you never knew what you were going to need until they were flapped open.

Tarun: Yeah, or if you could even do it.

Howard: Tell me this. What year, this is 2015, what year did you get 3D X-ray and how has that been a game changer for you?

Tarun: We bought 3D X-ray in the fall of 2008 in the midsts of the biggest global meltdown that we've seen in our lifetime.

Howard: Lehman's Day. 

Tarun: Yeah, basically.

Howard: Yeah, September, 2008.

Tarun: Yeah, it was September, October, 2008 that we bought our machine, and we have not looked back. I think one of the things I like to really help people understand is I'm not a surgically oriented dentist, or was not a surgically oriented dentist. When I was a freshman at UMKC and I went to watch a tooth being taken out, I was 2nd assistant and I passed out just watching the tooth being taken out, so I have always been against surgery in my practice.

Howard: Did you really faint? Did you faint?

Tarun: Oh, yeah. It took 2 people to pick me up, but that's a different story. I've never been a surgical guy. 

Howard: Looking back, when you started, you didn't even like molar endo.

Tarun: No, I didn't. You're one of the people that forced me to do molar endo. To me, that's the beauty of all of this, Howard, is dentistry, we have the best time in the world, the best time in history to practice dentistry, but too many people are still stuck in what was successful in the '80s and '90s and early 2000s and being a restorative dentist. A general dentist today, most of them cannot survive or thrive just being a restorative dentist. They have got to focus on ancillary services. 

They've got to learn how to take out teeth, they've got to learn how to do socket grafting, they've got to learn how to do endo, they've got to learn how to do implants over time. They've got to learn how to do ortho. They've got to learn how to do so many things, but that's the beauty of our profession is we can do so many things. As technology evolves, as education evolves, as the social community evolves, we can do all of this stuff, and I've been a great example of that, is by engaging with my specialists, going to their offices, watching them, learning from them, pushing myself, saying, "Hey, do you mind if I try this case, and if I screw it up will you bail me out?" That's how I've learned. I haven't learned by being gifted. I've learned by not being afraid. 

Howard: T-Bone, in our profession, let's be honest, when you're talking to lawyers and physicians, and dentists, 80% are book-smart and only about 20% are street-smart, so why is it guys like you and me got so much free CE from all of our specialists in our backyard, and other people will never make a phone call to the periodontist in the same building and then pay $4,000 and fly 5,000 miles to go take a perio course?

Tarun: They're nerds, that's why. They're afraid to have a conversation. They're afraid of somebody saying no or yes, or challenging them, or they're afraid ... To a certain degree, I didn't feel this way in dental school, but how people felt in dental school, that you never ask the orthodontist how to do what they do because that's why that specialty exists, and I never subscribed to that. I always subscribed what's the best interest of my patients? If my patients want me to do it and if I keep saying no over and over again, then I need to learn how to do that or bring somebody else into my practice who could do that. 

Howard: That' the first clue to street-smart. Street-smart, I don't care what business you're in, they always start customer-focused.

Tarun: Yep. You have to, more now than ever. You've got to be customer-focused. 

Howard: Explain to the listeners, because every dentist I talk to thinks they're customer-focused and then I just ask them 10 things, like "What are your hours?" "Monday through Thursday." 

Tarun: Do you work Fridays? Do you answer the phones on the weekends? Do you take insurance? Do you provide payment plans? Do you provide services? Do you go around and ask your patients what they want? Do you ask your patients do they want same-day dentistry? Do you ask your patients do they need evening hours? Do you need early hours? Just simple ... I grew up in a motel. Maybe I was disadvantaged from that, but advantaged from that, because we never stopped working. If somebody came to our motel at 3 a.m. in the morning, we got up, cleaned a room and made it happen. 

Howard: What city was that in?

Tarun: In Rockingham. It's a town of about 5,000 people, about 2 hours from here.

Howard: You grew up in Rockingham?

Tarun: North Carolina.

Howard: North Carolina in a town of 5,000, and you grew up in a hotel?

Tarun: Hotel, please. Motel.

Howard: A motel?

Tarun: A motel, yeah. I lived in room number 40.

Howard: Wow. Now is that where you were born?

Tarun: No, I was born in India and I moved here when I was 2, and then about 2 years after we moved here we bought a motel in North Carolina and we lived in the motel until I was probably 14 years old.

Howard: Yeah, I feel like I grew up in a Sonic Drive-in restaurant. When I woke up my dad was at work and when I went to bed he was still at work.

Tarun: I mean, think about it, when you go to a Chinese restaurant, what do you always see there? The little kid doing their homework at the Chinese restaurant. To me, I eat, live, and breathe my business. Some can call it good or bad, whatever it is. But my business is affording me now all the opportunities that I've ever wanted: to work 3 days a week, to be able to cut down from 9:00 to 3:00 for me to work so I can spend more time with my kids. If I hadn't taken insurance, or if I hadn't expanded my services, I wouldn't have those luxuries and we keep our practice open 5 days, looking to add a 6th day, because that's what our patient base wants.

Howard: Now do you have an associate?

Tarun: We do. 

Howard: Is it a partner or an employee?

Tarun: Right now he's an associate employee.

Howard: Yeah, and are you going to keep it that way forever?

Tarun: No. It's about what he wants. If he finds it to a great place, I'm very open and interested.

Howard: After your only partnership in life, and by the way, I have to tell you of everybody I know, I'm serious, of every dentist I know, my God, the only one that has a perfect wife is your wife, Mona.

Tarun: Mona, that's correct, but we're far from perfect.

Howard: She's a MD psychiatrist, right?

Tarun: She is. Yes.

Howard: My God, I have never met anyone who gives off more karma and she's always smiles, and she always has something profound to say, and that woman loves you more than you'll ever know.

Tarun: I think it's a fake. I think it's all fake.

Howard: Oh my God, she loves you. You can just tell when she looks at you. She just loves you.

Tarun: I've been very fortunate.

Howard: Yeah, you're lucky, and you have 3 kids now?

Tarun: Yes, 9, 7 and 5.

Howard: 9, 7 and 5, so I'm 52, how old are you?

Tarun: I turned 40 this year.

Howard: Okay. You're just about 12 years ... Okay, so are kids are about the same. I want to get focused right there. I want you to address this question first. South Korea has 20,000 dentists and 15,000 of them placed an implant last month. Last month.

Tarun: Last month. Amazing. 

Howard: What's going on in America? We have 150,000 dentists. 

Tarun: If we have 100,000 dentists, we would probably have 15,000 dentists placing an implant last month, if that. If that. 

Howard: Yeah, well the research is showing that, there's a couple of numbers you can look at, but basically 95% of the general dentists in America did not place last year. If they placed implants the same rate as the South Koreans did, our implant industry would grow 700%. T-Bone, I want you to take this away right now. 

There's a woman dentist driving her Honda Accord to work, and she's got a hour commute, and she's never placed an implant and she's sitting there saying, "T-Bone, I don't pull wisdom teeth. I'm not really into blood." Talk to this person. Can they place an ... What would be the baby steps? Let's not just say, "Yeah, we need to go to the 2nd floor." To get to the 2nd floor, there's about 10 steps. What would be step 1 to these 95% of American general dentists who didn't place an implant last year? How could they be more Korean?

Tarun: How can they be more Korean? Well, I think step 1 is understanding that you need to do it, and you have to do it moving forward. To me that's the first step is understanding that, "I can do an MOD, or I can place an implant, and I could do MODs all day long and it's not the production of placing that implant." That's the first step to me. The 2nd step is, and I firmly believe this, I think you've got to engage with your surgical specialist. 

Engage with your oral surgeon and your periodontist and say, "Listen, fact of life, I'm going to learn. I want to support you. I want to continue to diagnose more. Let me come watch." Just go watch what they do, because people think of this as this big voodoo, at least I thought it was a voodoo. Then I went and watched and I'm like, "Well, that didn't look all that hard." Then you watch a few times. Really the way I got started is I got 5 patients and I asked my surgeon, I said, "Listen, I want to ..."

Howard: Surgeon, periodontist or oral?

Tarun: Oral surgeon. I said, "I want to come watch you place implants on my 5 patients. You charge them. No problem. I just want to be able to watch." On my Friday, my day off, I went over there and I watched him place my implants. Then I said, "The next 5, if you don't mind, I'd like to place the implants. You charge the patient, but I want you to be my assistant and just hold my hand and walk me through it." Then it was off to the races from there. 

Howard: Now, was he thinking, "Okay, this is a scam. I know what's going on. I'm going to make money off the first 5, the second 5, and then I'm out." How did you have this challenging conversation with a oral maxillofacial surgeon?

Tarun: Look, I'm a little bit different, Howard, is I just tell them that, to a certain degree, I say, "Listen. This is what's going to happen. You can be my friend and engage with me and you can have all the business I don't want to do," and as I've grown, I've gone from diagnosing the occasional implant to literally diagnosing these kind of cases every day, and I can't do them all. Not because time-wise, but I don't want to do them all, so my surgeon gets all those cases I don't want to do, and all the cases I don't want to do today is more than every case that I had 6, 7 years ago. It's just that what we're diagnosing and what we're understanding is too significantly better. 

Howard: Are you still feeding this oral surgeon anything?

Tarun: Absolutely. Not everything, but anything that I can't do, or I'm not comfortable doing that's not in the best interest of the patient for me to do, goes all to the surgeon.

Howard: Yeah, and I tell the orthodontist, every time I see a kid that needs orthognathic surgery, it was because the general dentist learned zero ortho, didn't see the ortho, couldn't refer the ortho, and there's total ignorance. If the orthodontist were getting all the kids in school to do a couple class 1 molar cases or whatever, they would see ortho and diagnose and refer a ton more ortho.

Tarun: Absolutely. Look at Invisalign. Invisalign at the end of the day brings the conversation up and a lot of our cases need confidence of care, so we'll just send them over to the orthodontist. We're not providing that service in our office at this time, but I refer out to my orthodontist, and we have a great relationship. When I have problems with Invisalign cases, I pick up the phone and call him, and say, "Hey listen, can you look at this clincheck for me? What's going on? What do I need to do?" Sometimes they'll even say, "You know what? Just send them over. We'll take care of the case for you. No charge." Because life is a relationship. It's give and take. You cannot expect somebody to teach you and give you everything, and you not throw them something occasionally. It's a give and take relationship.

Howard: Oh, that's all life is. You try to manage relationships at the family level. The most important relationship you try to manage is the man in the mirror, and then you try to manage your family relationship, and then religion was just a form of managing the people, government's a form of managing the people, business is managing people. All life is is just relationships. There's nothing more to life. Then occasionally you take this relationship pool and you throw in some more technology. That's why the more things change the more they stay the same, because it's still just people trapped on a ball of dirt traveling 60,000 miles an hour around the sun every year.

Tarun: Yeah. Everything's about people: the people in your office, the people that visit your office, the people that you buy from. The other thing I look at is how many dentists are really ... I use the word exploit, but that's not the right word, but exploiting their rep relationship. How many times do you call in your Invisalign rep and say, "Listen, I want to be one of your best customers. What do we have to do? How can you help me help you?" When's the last time you called in your ... 

What is that, the blue stuff that you put in perio gums, Atridox or whatever the other stuff is. How many times have you called him in and said, "Listen, we want to be one of your best customers. Can you work with my hygienist?" How many times have you called your Patterson rep or [Schein 00:19:45] rep, or whoever you're working with, and say, "Listen. I want to be one of your best EagleSoft users. What does it take to get training?" "I want to be one of your best users of your RevenueWell or Smile Reminder, whatever it is. What kind of webinars can you do with my team?" 

Howard: What these people do is the reps come by the office, they stand there, trying to get a minute. They'll wait there for an hour and then sometimes they'll finally leave. I told my staff back in 1987. "These people are our sovereign colleagues. Anybody who works full-time ..." That was a big war we had initially in Dentaltown, remember? A lot of the dentists only wanted dentists, and then these reps would come on ...

Tarun: No, no, as important to our ... Our industry goes nowhere without the manufacturers supporting us, providing technology, and yes, they need to make a profit, but that profit turns into better technology, better techniques, better everything, and we all win. I engage my reps. I tell my reps, "Listen, you come in and you meet me. Let me introduce you to Heidi at my office, or let me introduce you to Melinda. Melinda's our point person. Heidi's our point person. I want us to be the very best. All you need to let me know is if Heidi's not supporting you. Just let me know so we can figure out what we need to do on our end." There's so much free, quality education because everybody complains that their team is not on-board, their team holds them back. To me that's a leadership issue. You don't have to be a great leader. You just need to ask people to help you. That's it.

Howard: Well, the reason you're a great leader is because despite you're all that, you're the most humble guy. You're just a humble guy, and that's what [inaudible 00:21:10] keeps showing, that when you read the letters on the 10-Qs and the 10-K annual reports on publicly traded companies, the top 10% most profitable companies, they're always saying our team and my team and giving credit to other people who had a great idea. Then the bottom performers are always, "I did this and I did this, and I'm going to do this." They said humility ...

Tarun: Listen, all I do is whittle on teeth. Everything else is my team. They do 90% of the work, I do 10% of the work, and honestly, they could replace me with a monkey probably and continue to work. 

Howard: Now, are you that humble because every night when you go to bed you're sleeping with a psychiatrist that programs your brain?

Tarun: Well, you know that ... It was very funny that my wife used to never give me water or make glasses for me or anything like that, but recently for the last few years, she gives me a glass of water every morning, and there's these white specks floating in there. I used to think it was chlorine, but really what she's doing is crushing up medication and putting it into my water for me to drink every day.

Howard: Okay, so I said the steps, you were absolutely right. The first step of AA is to admit that you have a problem. You're saying the first step of placing an implant is admitting that you need to learn how to do this. The second was finding someone in your backyard or in your medical-dental building that can do this.

Tarun: You're going to have failures.

Howard: Yeah, and that also saves you from, for a lot of them, a CBCT. A lot of specialists I know would do anything to have lunch or meet with a dentist or a friend, and there's a ton of periodontists and endodontists and oral surgeons in Phoenix where if you need a CBCT just come on over. They want to see you anyway. [crosstalk 00:22:50]

Tarun: I'm happy to take CBCTs on your patients for you. I won't try to steal the even, for God's sakes. 

Howard: I want you to focus, though, on that 95 out of 100 dentists who never placed a single implant. What would be the lowest hanging fruit, the easiest case that he could cherry-pick off and say, "Okay, I'm going to start with training wheels?" What's learning how to ride a bike with training wheels on placing an implant?

Tarun: First molars and pre-molars.

Howard: Maxillary or mandible?

Tarun: Maxillary's a little bit easier. The bone's softer. Mandible brings the nerve into consideration, but to me they're equally good, great places to start.

Howard: Okay, and the first molar, that's the tooth most likely to be lost.

Tarun: Yeah, of course, absolutely.

Howard: Okay, so I'm going to keep pinning you down, so [what we do 00:23:37] a maxillary first molar. Now, what percent of dentists do you think could pull that maxillary first molar? What percent of dentists do you think would stop you there and say, "T-Bone, I can't even get that tooth out?"

Tarun: I would say 80% are comfortable taking the tooth out. 

Howard: You'd say 4 out of 5 dentists could pull a maxillary first molar?

Tarun: Yeah, or I would say 95% could, but I would say about 80% are, pulling first molars.

Howard: If you were that 20% that didn't really like to or couldn't or whatever, what tools would you recommend them to learn how to pull a molar better? Would it just be again going in and watching your oral surgeon across the street?

Tarun: I keep going back to it. Go learn from somebody who is literally an expert and speed of taking out molars.

Howard: I'll throw a plug. Have you been following the Tommy Murphy thread?

Tarun: Yes, Tommy, his hands-on programs are fantastic. Fantastic.

Howard: In the US or international?

Tarun: I think he's doing them in ... I don't know what country it is.

Howard: Guatemala, Dominican Republic.

Tarun: Yeah. 

Howard: Yeah, and some of those guys go down to Guatemala and everyone wins because they'll pull 3, 400 teeth in a week.

Tarun: Or go to your mom's clinic. In North Carolina we do this Missions of Mercy clinic. If you want to take out teeth, go there. Half of them are easy. They just pop right out, but volunteer to learn.

Howard: You train dentists in your office.

Tarun: We do. We do. We train dentists that are looking to use technology as their jump-start for implants.

Howard: Okay, but do you teach hands-on how to place it?

Tarun: We do live demonstrations. It's harder because of licensing issues to do hands-on.

Howard: You know what the work around on that is?

Tarun: You have to do educational programs. I don't ...

Howard: The work around is that Missions of Mercy, you just go to the state board and say, "Can any licensed dentist in good standing perform surgery in the mission on these people?" We just did that 2 months ago at the homeless shelter for vets in Arizona. I told the director to ask the board and call them. They said sure. I mean, who's going to say no to a licensed in good standing to come do charity dentistry on homeless vets? Who could say no to that? Everybody's ranting and raving about your courses in your office. Talk about that. You built a facility to ... It's going to go through, is it just the CBCT and the surgical guide, what you're teaching?

Tarun: Our focus right now is offices that have CEREC technology and cone beam technology. We'll be expanding to basic implantology courses as well, starting in the fall, but right now our focus is on CEREC and those who have cone beam, and how to make it come together. Because Howard, listen, what I always, it goes back to is again, back to this being consumer friendly, what I call patient-centric is time is money for your patients. 

Right now the average person that comes in and is missing a tooth and needs an implant, it's 5 visits for them to get a tooth there. In our office it's 2 visits. Which is more profitable? Which is better for the patient? To me it's about using that technology that you have to drive down how many visits it takes for the patient, drive up profitability and giving you more flexibility to work with your patients.

Howard: Now in your course in your office, is that CBCT, is that agnostic technology or it more specific to just Galileos and all Sirona package?

Tarun: Right now it's pretty much specific to Sirona technologies.

Howard: Because you just find it easier with the CBCT and the CAD/CAM working together in the same platform?

Tarun: Well, they only work with each other.

Howard: Yeah?

Tarun: So it's kind of limited.

Howard: Okay, so we got a maxillary first molar and if you can't take that out, go to Dominican Republic with Tom Murphy, just go watch your oral surgeon, watch your periodontist, whatever, and so now this person driving to work is saying, "Okay, I got a ..." And always look at your family. The first sinus lift I did was on my mother-in-law.

Tarun: Mother-in-law. Yeah, of course.

Howard: I mean, come on. Look at the family. I got a whole ... My family pedigree has more white trash than a dumpster behind a paper plate factory, so I have all kinds of research animals to do this stuff on. This dentist is driving to work and she's thinking, "My Uncle Eddie. Perfect. Perfect. Perfect." Okay, so what if this molar was ... What if he's got an upper flipper and upper partial, and that molar was pulled 10 years ago? This girl's driving to work, and her cousin Eddie is a 50-year old man. He's got a beer belly and he smokes a pack a day, and he wears an upper flipper and she says, "There's my guinea pig. I'm going to call my Uncle Eddie and get him in here." What's step 2? What's the next stair?

Tarun: Well, you need to evaluate. You can do that with a radiograph. I think it's always better and safer if you're starting to do it with a 3D scan.

Howard: Absolutely.

Tarun: So if you don't have it, call your surgeon, call your neighbor friend. Listen, you know what? I'll make the statement. Call your Patterson or Schein rep. "Hey, listen. I'm interested in your technology and I have a patient. Can you find me a person in our area that's willing to let me scan so I can see what in the world this looks like?"

Howard: If you call the rep who sells the machine ...

Tarun: They better be willing to do that.

Howard: They'll give you 3 names of someone you can take it ...

Tarun: Yeah, just send the patient up there.

Howard: Okay, so now you got a CBCT, so I'm going to stop you first ... Does that legally concern you to have a CBCT? 

Tarun: No.

Howard: A lot of dentists, some people think, "T-Bone, you just took a CBCT and you didn't see they had a cancer in their brain or a clogged artery."

Tarun: You're not going to see those things. CBCT is going to focus on the hard tissue structures. It's going to focus on the mandible, the maxilla, some level of the sinus, and pretty much these are not full volume cone beams. The types of CBCTs that we're looking at for general dentists are essentially limited to the maxilla and the mandible and a little bit of the sinus. It's things that we're seeing on a panorex anyway, that technically was responsible for anyway.

Howard: Are you sending all of these off to a board certified oral and maxillofacial CBCT radiologist?

Tarun: No, we've learned and we've learned how to look at these. We're reviewing every single scan that we take. We review them and if we see something of concern, we will then send it out for a professional reading or we will work with our oral surgeon or periodontist, depending on the type of thing we're seeing, and say, "You know what? I want to refer you over there. He has a copy of your cone beam, and we're going to let them take a look at it." 

Howard: I went in for a professional reading [crosstalk 00:30:16]. I just slapped her across the face and said, "I bet you didn't see that coming, huh? If you could predict the future you would have blocked my hand." No, so I want to ask you, the biggest controversy right now on these is surgical guides. Half the people placing them saying, "Dude, you got 2 teeth. You got one in front, one behind. You need to learn how to be a surgeon. You need to learn how to lay back a full thickness flap, look at that and if you can't parallel the mesial, distal and the buccal lingual, then you're coming in from the side and you should be having that patient in your lap. You can aim the mandible or you could just drop it right down." That a surgical guide would be like training wheels and you're never going to ride your bike without training wheels. Then you have the other group, like our very good friend, Jay Reznick. 

Tarun: Yeah, or me.

Howard: Or you. Well, I didn't want to throw you under a bus. 

Tarun: That's okay. Listen you could throw me under the bus all day long. 

Howard: Well, first of all you wouldn't fit under the bus. We'd have to find another ... I'm just kidding. 

Tarun: We'd have to jack it up a little bit.

Howard: We'd have to jack it up, so we got a friend, Jay Reznick, who's a board certified oral and maxillofacial surgeon, DDS, MD. He's one of the greatest oral surgeons, if not the greatest oral surgeon.

Tarun: [inaudible 00:31:31] by the way.

Howard: He always uses a surgical guide, so my question would be like, can Jay not see ... Why would Jay need a surgical guide? Answer that question. To surgical guide or not to surgical guide?

Tarun: Well, it depends. If you want to be egotistical and thump your chest, don't use a surgical guide. If you want to be smart, fast, efficient, and do the very best for dentistry that you can do for your patient, use a surgical guide. My question back is why not? If the answer's money, that's the worst excuse anybody can give me. If your answer is, "I don't know how to do it," all those things, okay great, we can work with you on that, but if the answer's money, don't.

All that time you spend explaining how they look at things and do things, I could have placed 3 implants in that time period. Why in the world would I not want a crutch? When my kids go bowling, my 5 year old goes bowling with us. He uses that little thing where you put the bowling ball on and you roll it down the thing and it keeps it straight. Why would I make my 5 year old try to throw a bowling ball and not have a good time when I can let him use it?

Howard: I use that thing too after the 3rd beer. 

Tarun: Well, you're a different scenario, Howard.

Howard: The other thing is that when you lay a full thickness flap, that's a lot more swelling and surgical and soreness than ...

Tarun: Yes. Imagine if I ripped the skin off your face. How would your face feel after I put it back together again?

Howard: Yeah, so are you just going through ... If you have enough attached gingiva, are you just punching right through the middle?

Tarun: Yes. My 2 qualifications are enough attached gingiva and I'm not doing any bone grafting. If those 2 things exist, then we're just making a small tissue punch and going right through the tissue and placing the implant. The pain that comes from implant placement, the horror stories, are from the flap. I'm not saying flaps are painful, but a flap is more painful than not a flap.

Howard: Dude, you know what we used to do, and this is embarrassing to tell, but do you know how bad it was in 1990, '91, '95?

Tarun: I can imagine.

Howard: We would take a 15 blade from retromolar pad to retromolar pad and you'd do the buckle and dissect down the middle frame, so you had to find out where those were, and then you'd reflect the lingual and then you'd sew those to each other, and that's what you did before you started.

Tarun: I would be like dead. I would have already passed out. 

Howard: Remember subperiosteals? 

Tarun: Oh my God. 

Howard: The guy across the street from me used to do 5 of those a month, and man have things changed. Okay, so back to focus, so you said 2 different things. Talk about that attached gingiva. Buccal lingual, be specific about that. You're looking at this missing first molar space and the attached ... Explain in detail what's going to happen. What is enough detached gingiva? Do you need a millimeter and a half all the way around the implant?

Tarun: I like to see 2 to 3, ideally 3 millimeters beyond the emergence of where my tooth is going to come out. Not where the implant is, but where my tooth is going to come out, I like to see 3 millimeters of attached tissue there. If I don't have that I'm going to make an incision and push the tissue from the crest out to the buccal.

Howard: Okay, and then bone grafting. Now that's a whole other can of worms. What percent of the cases, implants that you're placing, are you bone grafting?

Tarun: Well, that's a little bit of an unfair question, so let me answer it [crosstalk 00:34:52]

Howard: Well, thank you. I take that as a compliment. 

Tarun: I bet. Let me be a politician here and say in the very beginning, because that's who we're focused on, 100% of my cases did not need bone grafting in the very beginning. Now what I found was is that about half the cases that I thought would need bone grafting by looking at it clinically with my eyes, once I evaluated them in 3D, I found that those cases didn't need bone grafting. Now, as I've expanded my practice and as we've grown our implant practice or the implant cases that we're tackling, I would probably say that about 30%, 33%, 1 out of 3 cases requires some type of bone grafting.

Howard: Okay, so when we're talking about the 1 out of 4 Koreans who don't place implants last year or the 95 out of 100 general dentists, would you obviously recommend picking cases you don't have to bone graft at first?

Tarun: If you're talking about the lady or the guy who has never placed one, is getting started, yes. I would say your best place to start ... I think in that particular situation, the best place to start is the cases you take the tooth out on, do some socket preservation, because you know the bone will be there 6 months later and go back and place that case. 

Howard: Okay, so then get ... Extremely specific name brand detail, how do you socket preservation, but first of all why? Tell them why they need to do that.

Tarun: What happens is typically when you take the tooth out, assuming you don't lay a flap, you're going to get about ... I don't know the exact numbers, let's call it 30 to 40% collapse of the alveolus by not placing anything into that socket. It's erosion at the end of the day. Take a tree out of the ground, there's going to be less dirt there a month later than there was today. What socket preservation is essentially is filling up the socket with a bone material, cadaver or ceramic or cow bone, preferably cadaver bone and allowing that to maintain the space, and the body turns that back into its natural bone.

Howard: Okay, so go through this. Number one, give us some name brands, some websites.

Tarun: You can use Life Sciences. I'm using from the bone bank, I believe it's called Maxxeus is the brand I'm using, and my bone costs 1/2 a cc, I want to say 50 bucks for a cadaveric ... It's a combination of demineralized, mineralized corticocancellous bone. 

Howard: Okay, and it's from Life Sciences?

Tarun: It's from a company called Maxxeus. M-A-X-X-E-U-S.

Howard: M-A-X-X-E-U-S?

Tarun: Now, okay, don't worry about the brands that I use. I'm willing to take the time to find ... These companies come out and seek me. Just call your implant company. In the beginning, don't worry if it costs 5, 10, 15, $20 more, just get started. Don't let people get confused on that. Call your Nobel person, call your Biohorizons person, call your Straumann person, call whoever it is ... Call your Patterson person, they sell bone, or your Schein person. They sell bone. Say, "Listen. I want to start using cadaveric bone. What do you sell?" That's the easiest common denominator.

Howard: My job is to try to estimate what these ... 

Tarun: Let's call it $17.

Howard: My job is to try to estimate and guesstimate what these dentists, all by themselves, are thinking during the podcast and want to ask you a question and can't. The first thing they're thinking now is, "Well, what implants does [inaudible 00:38:09] use?" T-Bone, at the IDS meeting in Cologne, Germany, they were 275 different companies that had a booth.

Tarun: I believe it doesn't matter. Listen, Howard, and I really believe this. I don't think there's much difference in implant to implant. It's titanium, it's medical grade. As long as it's made pretty well, it's going to have a 95% success rate, integration rate. To me it's about the relationship and I always go back to that. I maximize, I exploit my reps. Which rep? I interviewed every rep in my area when I started and in my particular case, I chose the Nobel rep, because he was the most responsive, ready to be there, and he said, "When you're ready to get started, I will come and hold your hand for the first few cases." He helped me introduce myself to my surgeon, said, "I've got a great surgeon in the area who is happy to help you," and to me that's exploiting the rep. Find out who the best rep is.

Howard: So you're still using Nobel?

Tarun: Yes.

Howard: Which is the highest cost implant.

Tarun: Yes, but I [crosstalk 00:39:10].

Howard: I want to explain to the viewers that, since they make profit, they can have reps and do these things. Then the dentist says, "Oh, no, I want to buy this on eBay. I found an implant from Russia for $49," and now they're standing there all alone. 

Tarun: And they work, Howard, they work, but all these things hold people up. They're barriers to entrance. Go the easiest way to get started. We're talking about a very profitable procedure that has a reasonable fee to patients, and who cares if it costs $200 more when you're getting started? Don't let these things be the hold-up. It drives me bonkers when people are so worried about which implant to use, where to buy it from. "I can buy this one for $125 but that one's $300." Who gives a shit? It doesn't matter. If you're that hungry for $125 you've got other problems and we don't ...

Howard: If you're a doctor in America, and anything under $5,000 makes you blink, you've got way, way too many other problems. Yeah. Hey, by the way, on that bone grafting material, what'd you think of that new grinder that [inaudible 00:40:19] just came out, where you take the extracted tooth, you throw it in there and boom, it's shredded with 3 times the volume of the tooth because it's all particlized. 

Tarun: I don't know much about it. I saw that where they're grounding up the dentin and [inaudible 00:40:31] in there. I have to do some more research on that.

Howard: Yeah, I talked to some periodontists and oral surgeons in Manhattan a couple weeks ago and they're just like, "Oh my God, it's so cool. You just take that tooth out, throw it in there." It's their own body.

Tarun: I wonder if you could put a whole kid in there.

Howard: A whole what?

Tarun: One of my kids.

Howard: Well, actually they got the idea from the last scene of Fargo where the guy puts his wife in the ... Was it the wife in the grinder?

Tarun: Yeah.

Howard: Remember a foot was sticking out and he's like pushing down the foot when the lady with the gun shows up. Did you see that movie?

Tarun: No, I did not, but I'm familiar with what you're talking about.

Howard: Oh my God. Fargo's great. Okay, so we're talking about the implant. What I hear you saying is this is a huge, lucrative part of your practice, so maybe you should buy the most reputable implant on the market because you get a full service rep to help hold your hand.

Tarun: Yes. Interview. Interview your reps. Not every rep is the best or the same in every area. Your area, it may be XYZ implant, versus my area I believe the Nobel rep is one of the best. Interview your rep, interview your surgeon, and say, "Listen." If your surgeon says, "Well, I use this implant and so if you place this, I'm not as familiar with it," then place whatever implant that person is placing.

Get support. Listen, people get so worried about, "I don't want to have to buy another kit." Who cares? At some point ... Look, Howard, we do over a half million dollars a year in implant treatment in our office. If I have to spend 5 grand on a new implant kit, I don't give a crap. Who cares? Most of the time, the implant companies are willing to switch it out to make ... It's the razor blade. They will give you the damn handle to sell you the blades for God's sakes.

Howard: Right. 

Tarun: This whole conversation drives me crazy. It just drives me bonkers.

Howard: Awesome. I want to have another podcast with you back where this is all we talk about. I want to just drive you mad during the whole deal.

Tarun: I'd love it. I love getting mad.

Howard: Okay, so, but I'm still focused on the training wheels. These podcasts, we put them up on Dentaltown. We put them up on YouTube, and we put them up on iTunes, and every single day, every podcast I've ever put up still gets more views and clicks. Believe it or not, the biggest is iTunes.

Tarun: Yeah.

Howard: There's someone listening to you from every single country within 24 hours of us putting this up, so talking about how important the local rep is is so meaningful, because it could be totally different in Venezuela versus Tanzania versus North Carolina.

Tarun: Of course.

Howard: But I'm still pinning you down to that first case. Their fear base, they're afraid, they're afraid, they're afraid, and now they're thinking, "Okay, so you say 95% success rate. Okay, I want to avoid that 5% that fail." Is that because he was a smoker or diabetic, or was he too old. [crosstalk 00:43:19] Talk ... Does health history concern you? How much does health history concern you, because they're trying to get the lowest hanging fruit.

Tarun: Yeah, I'm aware of health history. 

Howard: And their cousin Eddie's a beer drinking, cigarette smoking ...

Tarun: Good. Even better. I mean, those things concern me. The biggest things that concern me are diabetics.

Howard: Insulin dependent?

Tarun: Uncontrolled diabetics. Insulin dependent, uncontrolled diabetics concern me and then I worry about my patients on osteoporosis medications, Boniva and those things, I worry. Those cases go to my surgeon. Automatically, surgeon.

Howard: Absolutely.

Tarun: I don't want to deal with it. I pick and choose. See, this is the other thing that drives me crazy. People are thinking, "If I'm going to be an implant dentist, I've got to do every implant that walks in the door." No. Pick and choose. Choose the easy ones. Be just like a molar root canal. Howard, I know you do lots of molar root canals. You look at the X-ray and you say, "This is one in my wheelhouse and I do it, and this is one not in my wheelhouse, I'm going to send you somewhere else." 

Howard: You know what's been the game changer on the CBCT with endo? Because I lot of times you'd think this is low hanging fruit and you're looking at a bicuspid.

Tarun: And it's not.

Howard: Then you see, oh my God, it's one canal for 15 millimeters, breaks into 2, and you see that and you're like, "I don't even want to do it."

Tarun: It's not worth it.

Howard: It's not worth it. 

Tarun: Especially when you're like me. I work with PPOs. I get paid $690 for a molar root canal. I don't have time ... I can't justify dealing with 5, 6 canal endo. It's just not worth it.

Howard: Yeah. Absolutely. Okay, so yeah, definitely. Let's not ... If you haven't placed 100 implants, let's not do an uncontrolled diabetic. Let's not do someone on osteoporosis medication. But the smoking, the smoking. 

Tarun: High blood pressure, cholesterol, smoking, not a big issue for me. I'm not concerned about that. 

Howard: Really? Okay.

Tarun: I keep it in mind. It affects some of my judgment, but generally speaking, I would probably say 80% of our patients smoke.

Howard: Okay, so now would you go into more detail or more specific about how do you make a surgical guide? How does that actually happen?

Tarun: You can make it yourself if you're very technologically savvy.

Howard: But what are you recommending. This is someone who's never placed one. 

Tarun: I recommend ... When you're starting here's what I recommend. I recommend you third-party it to a service. For example, [Armin 00:45:32] has Cadre. That's a great solution to get started. In the long-term ...

Howard: Yeah, but then you have to deal with [Armin 00:45:36] and his British humor is so ... No, I'm just kidding. I love Armin. Yeah. 

Tarun: No, absolutely.

Howard: Can anyone send ... Can Armin make it? I thought Armin has territorial locations.

Tarun: No. I don't believe so. I think he's a full-fledged USA or worldwide service. He can make your surgical guides.

Howard: Do you have a www on that?

Tarun: But you need to learn how to do these things yourself, at least understand them, but at least in the beginning, to get you started ... My goal is just to get people started. If that's what it takes to get you started, do whatever it takes to get started, because then once you get comfortable with it, you'll take off with it. 

Howard: Right.

Tarun: Use a third party service. Let them plan it for you, but don't let them just plan it and you say yes. Be involved in the process. Be on a webinar. Let them show you, "Why did you plan it here? What are we doing here? What do I have to worry about? Let them fabricate your surgical guide. Don't get worried about the few hundred dollars here or there, and let those barriers get in the way. Just say, "You know what? I'm going to turn it over. Let's let you, the expert, do this. Let's figure it out. Show me why we're doing it and then move from there." It's amazing how much you learn by just watching people.

Howard: Okay, if you were a 29 year old dentist in Fargo, and you wanted to make your first surgical guide, where would a dentist in Fargo go?

Tarun: You need one thing. You need a cone beam and then you need an impression. That's all you need. 

Howard: Okay, so you need a cone beam and you need an impression.

Tarun: Yeah, whether it's digital or whether it's analog. That's all you need. To get a surgical guide made you need those 2 things, and then you can work with any number of implant savvy labs. You can use Armin's Cadre, you can use Sequence Dental, you can use ROE Dental, you can use 360 Imaging. There are many different choices available and you just send them the data, and the ones that know what they're doing can take it from there, and they'll include you along the way. 

Howard: Okay, talk about that, the biggest thread on Dentaltown about a surgical guide was the $50 Blue Skyo surgical guide. I think that has 10,000 comments on that post. Have you seen that thread?

Tarun: I am familiar with that process, yes.

Howard: What do you think of the Blue Skyo?

Tarun: The Blue Sky Bio Guide? It's a great option. It is for technical savvy people. 

Howard: Okay, it's for technical savvy. 

Tarun: Yeah. There's a lot of steps involved in that.

Howard: Is this good advice or bad advice? If you're in Fargo, North Dakota, and you're working with a crown and bridges lab up the street ...

Tarun: [inaudible 00:47:55] probably a good idea.

Howard: Couldn't you just call him? Couldn't you just call your lab man and say, "Can you figure out how to make this surgical guide?" 

Tarun: You could. I would highly advise against it. This type of ... Implant labs, implant surgical labs are a different animal, a different involved ... More than likely, your local guy or gal that owns that lab that does your crown and bridge, or your removal, is probably not the lab to do this with. 

Howard: Okay, so that softball question I threw at you, I was kind of beating around the 4,000 pound gorilla. Didn't the largest lab in the world, Glidewell, stop making surgical guides?

Tarun: They did for a time period, but I believe Glidewell will be back in that business.

Howard: Why did they leave it and why do you think they'll get back in it? Was it just ...

Tarun: I don't know exactly what was going on there or what their reasons were. I mean, there must have been good reasons. I know those guys very well. They'll be back in that business.

Howard: They will? Okay. Okay, so baby steps. We're going over the first floor, 95 out of 100 dentists never placed one. Let's decide we're going to do it. Let's meet an oral surgeon, periodontist, does that really matter, the oral surgeon, periodontist? It just depends on the person?

Tarun: No, it's a relationship. Whoever's the nicest and willing to work with you.

Howard: And you have the best chemistry with, and then we're going to a molar. Okay, so back to this molar. If we say mandible, they're afraid of the inferior alveolar nerve.

Tarun: Yeah, but with the cone beam you don't need to be worried about it.

Howard: Explain.

Tarun: With a cone beam and a surgical guide, that guide is going to keep ... Because everything's virtually done. I know where the nerve is, I know that I have XY ... Let's say I have 40 millimeters.

Howard: But the guide's going to do the angle, buccal, lingual, mesial, distal, but ...

Tarun: And depth. 

Howard: Explain to them how it's going to stop the depth, so they don't drill into the inferior alveolar nerve.

Tarun: Sure. Every guide is made with the stop, so it's made to be X millimeters above the implant, and then your drills have a stop on them, and you just place your drill through the guide and it hits a stop and then you can't go any deeper.

Howard: Okay, and then let's flip it around upstairs. I'm afraid I'm going to hit that sinus. 

Tarun: Okay, that's not the end of the world. The nerve is a big problem. The sinus isn't the end of the world. But the same thing with the guide. You can plan your implant short, long, whatever it may be, and you can leave short of the sinus. At the end of the day we can learn how to do sinus lifts and things like that, but that's not our conversation for today. Our person starting doesn't need to be doing sinus lifts on their first case, doesn't need to be doing nerve repositioning on their first case. They need to focus on the slam dunk, no other obstacles in the way.

Howard: Okay, but if they're going to be driving up to their office and finishing up an hour with T-Bone and they're going to have the lookout hunt for a missing first molar, just looking at a 2-dimensional bite wing, how much bone would you like to see before it goes into the sinus?

Tarun: 10 millimeters.

Howard: 10?

Tarun: 10. That's what I'd like to see.

Howard: 10 millimeters? YOu'd like to see 10 millimeters?

Tarun: If you're not planning on doing any lifting or anything, which the people we're talking about aren't, I like to see 10 millimeters.

Howard: Okay, and have implants changed a lot? I mean, length was everything back in the '80s. 

Tarun: Not anymore. It's all about surface area. 

Howard: And so they're getting a lot of that surface area with getting wider, not longer, and lots of grooves.

Tarun: Yes. Right. With the grooves, the surface area, the surface tension, the coating, we're seeing shorter and shorter implants. Bicon was one of the very first to use short implants and make it okay and acceptable to use short implants.

Howard: Okay, I'm just going to keep going. 

Tarun: It's fine. I love this. Keep going.

Howard: I'm going onto questions based on most likely asked on threads on Dentaltown under implantology, so the next biggest one obviously, okay so now we've got this implant placed. Am I going to screw this on or cement it? 

Tarun: I want you to screw the tooth on. I want you to 100% of the time screw the tooth on.

Howard: Why is that?

Tarun: 80% of the time we leave cement behind on implants. Peri-implantitis - cement retention is one of the leading causes of Peri-implantitis, which is one of the leading causes of failure, failing and ailing implants. Do not ... I just do not believe in cementing. I want to screw everything down.

Howard: So it sounds like we could almost call this podcast of why you should always have a surgical guide and screw all your implants on. Is that fair?

Tarun: Yes, absolutely. 

Howard: Is that fair? Did you hear that, John? Did you hear that?

Tarun: He's over there sleeping.

Howard: Yeah, he's over there ... Well, John is amazing. My podcast director is amazing because he's learned how to sleep with his eyes open, so I think he's working all day. 

Tarun: That's called daydreaming. 

Howard: Yeah, okay, so then the next biggest question they're going to ask, T-Bone, is this immediate load, or do I let it heal for 3 months?

Tarun: When you're starting, let it heal. Let it heal.

Howard: So you'd put the tissue over? You'd bury it, sew it up?

Tarun: Bury it, sew it up, and then uncover it. Yeah, absolutely, when you're starting.

Howard: Okay, and explain how long you would bury it, mandible versus maxillary.

Tarun: 3 months.

Howard: 3 months mandible or maxillary?

Tarun: Pretty much 3 months all across the board. 

Howard: Okay, but explain your rationale. Why?

Tarun: Well, osseointegration, depending on the surface coating, typically occurs at the 3-month mark, about the 12-week mark, so we'll wait 12 weeks and then uncover the implant.

Howard: Okay, and now I'm going to ask the improper, rude, crude.

Tarun: That's okay.

Howard: What do you charge for these? 

Tarun: These are great conversations. At our office, and I'm not trying to do fee collusion or anything like that, in our office an implant is $3,500 from start to finish, includes everything.

Howard: And that's so huge. I figured that out with smile makeovers back in the '80s. 

Tarun: Yeah, it's 10 grand, 12 grand, whatever it is, from start to finish.

Howard: For a smile makeover?

Tarun: For a smile makeover, yeah. Whatever the number is. Just make up a number. Who cares?

Howard: Yeah, but I figured out in the smile makeover business is that a dentist would say, "Well, a crown is 1,000, and I'm going to do [inaudible 00:53:35] 10,000." I'm like, "Dude, a face lift and a boob job is under 5 grand. Why would someone pay twice for their teeth than they would their face or their boobs?" It just doesn't make any sense. A lot of these dentists can sell the cases because the patient will ask ... I mean, they taught me in MBA school that 80% of the time the decision's going to come down to price, and they'll say to the dentist, "How much is it going to cost?" The dentist says, "Well, I can't give you an answer because I don't know if we'll have to bone graft or I'm going to have to do this and I'll have to do that."

Tarun: Blah, blah, blah.

Howard: Yeah, and I can't tell you ... I want you to commit to something and neither of us have any idea what this is going to cost you.

Tarun: Yeah. $3,500 start to finish covers everything. Surgical guide, no surgical guide, scan, no scan, custom abutment, no custom abutment, screwed down, cemented, it doesn't matter. What material I used, those are all my problems. My patient just wants to know what the number is and then I commit to it, and that's it.

Howard: Exactly. 

Tarun: That's all that matters. Bone graft, no bone graft, it doesn't matter. It's 3,500 bucks. 

Howard: And do you as a doctor throw that fee out or is that something ...

Tarun: Yes. 

Howard: You'll say it. 

Tarun: All my team members know that fee, too, so if I'm not in the room, my hygienist or assistant can answer the damn question. Listen to this. Howard Farran is in your chair. You're missing tooth number 19 and you ask your hygienist, "Oh, I'm interested in getting something there. How much does something like that cost?" And you're hygienist says, "I don't know." That makes it sound like it's outrageously expensive. I mean, it's stupid that somebody can't answer the basic question. It's $3,500 from start to finish. That may be $4,000, it may be $3,000, whatever the number is for your economics and your market, just make up a number. That's all they want to know.

Howard: Yeah, and you have a beautiful business mind. I love your business mind. The bottom line is until you can throw a number out, they're not listening to anything you're saying.

Tarun: And you've got to have options.

Howard: Furthermore, every financial treatment plan presenter I've ever talked to, no matter what field they're in, ortho, oral surgery, whatever, they always say, "If the doctor threw out the price, before they walked in the room, with confidence, it's a lot easier to sell."

Tarun: Absolutely. 

Howard: If someone says to the oral surgeon, "Well, how much does it cost to pull all 4 of [inaudible 00:55:37], it's $3995 or $3900 and he says it without blinking, they're like, "Okay, well that's probably a fair fee, because he just rolled it off the tongue and said $3900." With smile, that's what I was doing is I was just saying $4950, and I didn't even know if I was going to do 6 or 8 or 10, but I knew the appointment length wouldn't be any difference in time. Who cares if I did 6 or 8 or 10? Who cares if one had to be a crown? What happens if I prep in some twisted laterals and had to do an endo real quick? Who cares?

Tarun: It doesn't matter.

Howard: Yeah.

Tarun: Yeah. It's about being consumer friendly, patient-centric, making it easy for your patients and your team members to really know what's happening. Combine that with some financial options and you have a recipe for patients to say yes. 

Howard: I want to ask you, I only got you for 4 more minutes. I'm going to ask you this. What do you think of the fact that half the dentists in America still don't have digital X-rays? What would you say to that dentist driving who's still using film?

Tarun: Man, do I have to be nice to them? No, I just want to know what in the hell is wrong? Why would you not want to be digital? Who wants ... Look at the environment at the end of the day, and I'm not one of these crazy environmental people, but that stuff's bad. Why? I don't know what to say. I want to say they're stupid, that's why. 

Howard: Well, I want to say that it's back to what you're saying about patient-centric versus dentist-centric. I can read an X-ray film on a view box. Patient can't. But I could blow up a digital X-ray to the size of this paper. 

Tarun: Yep, and you could email it to him and all kinds of things. 

Howard: Yeah.

Tarun: It's crazy. Why would you not be digital? Software, scheduling, treatment planning, case presentation. Why would you not be digital in X-rays and then over time why are we not digital in impressions, at the end of the day?

Howard: T-Bone, would you recommend the full Sirona system right now from the CAD/CAM to the Galileos? Would you recommend the closed system, or would you recommend an open format?

Tarun: Look, it's a tough question, Howard. I'm biased. What I recommend is something that works, that works, that's easy to use, that has a great community and service and support behind it. Sirona is a "closed system," but it works and that's all that matters. I don't care if it costs me 200 grand. As long as it works, it makes sense, but if it costs $150,000 and I got to do all kinds of work to make it work, it's useless. I'm not using it. If a closed system allows me to have something that works seamlessly, allows me to have a rep that will service and support me, allow me to have a community that has training in everything that I need, whether it's webinars, whatever it may be, then I'm all about that. The extra, 10, 15, 20 grand doesn't matter.

Howard: Is this a fair statement for me to make, that the Sirona all-in-one closed system, the CAD/CAM and the Galileos, is they're like Apple. It's really intuitive, easy to figure out. Whereas the open system's more like Microsoft, and when Microsoft rolls out software, there's an entire consulting industry that comes out with it, selling DVDs on how to figure out how to use their Word and PowerPoint, whereas when anybody gets an iPhone, they don't read any directions because it's just all intuitive.

Tarun: No, you just turn it on. It's intuitive. Yeah, it's a fair statement.

Howard: Yeah, I think it is a fair statement. I think when you walk into a lot of these systems, they say, "Oh, its open. It's this and that," and then you just ask the assistant, "Okay, you just took a CBCT. Hand it to me. Burn it out on a flash drive or a [crosstalk 00:58:57]."

Tarun: And they can't.

Howard: And then they can't figure it out.

Tarun: Yeah. They're like, "Which button? Which format?" Look, take it, press a button, call it a day.

Howard: Yeah, okay, so then the last ... I've only got you for 1 minute, so you're basically charging $3,500 for a missing tooth, full implant/crown package?

Tarun: Yep, start to finish.

Howard: Compare that, on overhead, you know, we see the average overhead in the American dentist is 65%, so it's 2/3 overhead. Compare that ... Where would the overhead be on that compared to other common procedures like a root canal, a crown, and an [MOG 00:59:27] composite?

Tarun: My cost of goods sold on that $3,500 implant is right at $900.

Howard: Cost of goods?

Tarun: I'm sorry, about 800. Cost of goods is about $800 using all name brand materials.

Howard: Okay, so now we're looking at $2,700 after.

Tarun: Right. 

Howard: But would you compare the profit margin to endo or fillings?

Tarun: Probably endo and extractions.

Howard: Endo and extractions? 

Tarun: Endo's one of the most profitable things you can do. It's [inaudible 00:59:53] is like $50 in materials.

Howard: Of the 9 specialties, endodontists have the lowest overhead at 35%. Then it's oral surgeons at 40%. That's what you're saying, that root canals and extractions are lowest overhead. 

Tarun: Yeah. Because now we're at a point, Howard, where we've maximized the technology. I've got about a hour and 20 minutes of total chair time from start to finish to do these implants. 

Howard: Wow, an hour and 20. By the way, T-Bone, I'm going to ... I want to make a pilgrimage out there.

Tarun: Oh, any time. Always ready to ... Welcome to come, my guest. Come over, stay with us. Whatever you want to do, no big deal. Stay at our home. You can bother Mona. She can probably help you a little bit. 

Howard: Will I get free psychiatric advice from your wife?

Tarun: Yes. It'll cost me a lot, but yes, you can have free psychiatric advice.

Howard: T-Bone, I just want to tell you, seriously dude, I love you. I love you like a brother.

Tarun: [crosstalk 01:00:44] Good to me, and great for my career. Dentaltown is fantastic. What you're doing now is fantastic. I would love to come back on. I would love for you to irritate me and get me going. It's fun. Listen, I want to help people. That's all. I want everybody to be successful. We have the greatest profession in the greatest time, and too many of our colleagues are unhappy and not living up to what their potential is. 

Howard: Give them a www, website if they want to take your hands-on class.

Tarun:, or you can reach me on Facebook or on Dentaltown or by email, I'm always happy to help. 

Howard: Is it a one course, or is it a 3-part series?

Tarun: Right now we have individual courses. I don't like to stick people into taking multiple weekends. Take what you want, but right now we have 2 courses. Starting in the fall we'll some initial implant training that'll be 3 weekends, with, as you were mentioning, the ability to place a live implant on your own patient. 

Howard: So they can bring a patient to your office?

Tarun: Yes. We're working out the scenario to bring a patient here. If I can create what you're talking about, where I can do work on the charity population, then that way people don't even have to bring their own patient. That would make it even easier for everybody. 

Howard: Yeah.

Tarun: But if people are looking for live training, Dr. Arun Garg has great courses in Dominican, to go down there and do exactly what you're saying. He'll do 10, 20, 30 implants. It's unbelievable what's out there. Just go out there and explore, see what's possible. Spend the money. It's okay. What are you going to do with it anyway?

Howard: That's right, and on that note, love you bro. 

Tarun: Thank you, Howard.

Howard: Thanks for all that you do for dentistry and Dentaltown.

Tarun: Thank you.

Howard: Bye-bye.

Tarun: Bye.

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