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AUDIO - HSP #136 - Don Bell
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VIDEO - HSP #136 - Don Bell
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"Doctors--at some point--will run their office without ever placing a direct restorative material again."
Director of Marketing - Ivoclar Vivadent
www.ivoclarvivadent.us
Howard: It is a huge extreme honor to be interviewing Don Bell today with Ivoclar. We are here live at Buffalo, New York. Actually we're in Amherst, right?
Don: Amherst, New York.
Howard: Amherst, New York, outside of Buffalo. I want to start with the story I want to call the ideal story, the original days of Dentaltown. Because when we started Dentaltown in 1988, [Dennis 00:00:26] actually got mad when anybody from her dental company got on and I called it Dentaltown and they literally thought it should be Dennis out and I'm like, "Why do you say that? They're selling something." I'd say, "What are you doc, are you a volunteer? You did free dentist in the community? Last I heard you are making a couple of 100,000, you earn, driving a nice car." It's just weird how American they're so cynical because if you make a profit they think that you must be bad.
I said, "No." Because if you took away about 500 dental companies in the world, us and dentist would be horrible, we wouldn't have 300 rpm [inaudible 00:01:00] to do endo, we wouldn't have Apex locator, digital x-rays. We wouldn't have anything. What's funny is when go to IDS in the United States, when you go to a dental meeting, the dental manufacturing of this [inaudible 00:01:13] and they're not allowed to sell anything, because it almost hit, it's like biblical, like Jesus and the money changers in the temple or something. Then you go listen to these dentists speak and these dentists they don't know a fraction, like Ivoclar, how many PhD researchers do you have in [inaudible 00:01:32]? What would you guess?
Don: Probably five or seven, somewhere in that range. There's one here in our facility here in Amherst that works with us.
Howard: Yeah. People have a PhD, a doctorate in organic chemistry. They work on these products for years and years and years. No one wants to talk to them, they want to talk to some dentist, and we're talking about in America. Who will be talking about a bonding agent, but if you took him to a white board, you say, "Draw the organic chemistry of the molecule you just said." He won't have a clue.
Don: Sure.
Howard: When you go to Europe, IDS, they don't have dental lectures, they don't have them. It's an honor for the dentist in Europe, they try for like 140,000 dentist and it's an honor for the dentist to go meet the founder of the campaign and to talk to their PhDs and it's just more trusting, open relationship. I just love that. I love the fact that you guys have always render extremely open with me for 25 years. I can't think how many times I flown down here in the last 28 years. You are very involved with Buffalo next door, it's like everybody else.
I want to with, thanks for having me down here and interview me. We're looking at the open house, talk about the open house system that you do.
Don: The open house is a very interesting concept about five to seven years ago. We started bringing doctors back in our facility. It gave them the idea, the idea was simple, come in and see what's behind the curtain, so you can learn about materials, you can ask questions about our PhD. Our people have really have a ton of expertise on bond testing and understand how to use the materials better. What it's evolved into is a program where we talk about answering the why. You as a dentist to understand, if you understand more information about how the product is used and works, you're going to make better decisions when the prep is not perfect, where the clinic communication is challenging, but if you understand the materials better you're going to know how to use that more effectively, instead of making up your own recipe.
The fine story that I always like to tell is when the first doctors that came in here asked us to do all bond testing and he mixed and matched, adhesives and primers and cements. We said, "Why are you doing all these?" He was, "I want to study club in X state." All of our group just mixes and matches whatever want to make our own chemistry set. We show for the first time we actually did this live how when use a full system that was contained, like a full system of an adhesive and a cement from the same manufacture and we started mixing and matching stuff. You would see bond strength drops as high as 50%.
Most clinicians don't know that, they don't understand what's the difference if I mix and match this adhesive with this bonding agent or cement. When you do that you see a drop sometimes, and in various widely on the manufactures, the chemistries. You guys don't know that, you might assume as a clinician, well they should work with this. It was fascinating because that was a very illuminating topic of, "Wow, this is a lot more than we thought." It's evolved into understanding the whys of cementation, of adhesion, ceramics, with everything you can do with the materials to be successful. When the doctors come in, that's what they learn, they walk away learning, hopefully, and knowing more than they knew when they came in.
Howard: I heard from a visitor of you who says I'm going to study the most successful CEOs. The number one adjective that they always find is humility, humble. They find the worst performing CEOs, lacking [inaudible 00:04:57]. If I ask the American people, describe a dentist or a physician or lawyer, humility wouldn't be on the top 100. It would arrogant, know it all, whatever. It's funny because these dentists, when they buy a product and they see instruction of how to do it, they're so arrogant, they're like, "Yeah, yeah."
They're not humble enough to think. There was eight PhDs in organic chemistry that have been working for a company for 10 years, who did all these stuff and they know all these knowledge you don't, and then they'll just say, "Instruction, I'm going to add this. I'm going to add that. I'm going to try this." They're just arrogant. Humility is why people are successful, because they have force you to listen to your staff, listen to your patients, listen to your suppliers.
I hear at labs all the time, lab people say that 80% of the impressions they get are just horrible, but they can't call the dentist because they're afraid the dentist will say, "Screw you all, get another lab." They're not humble enough to open to learning to say, "Yeah, help me be better." I thought that was the most interesting thing for me with CAD/CAM. If I look at all the CAD/CAM attribute, I think the neatest one, as a clinical dentist when I went to 2.5 loupes, I saw a whole new world, then I went numb at 3.8. When I would scan those preps and you would see your prep, 25 to 45 …
Don: Changes perspective.
Howard: You're like, "Am I the worst dentist in the world?" Is there like, "Could Stevie Wonder do this better than me?" It just really change you … but I'm going to ask you a question, Don. You've been in digital dentistry and I've been here for 15 years. This month, last Thursday, 5,000 dentist just graduated from 56 dental school, I want you to walk me back in memory lane. Tell these 5,000 kids what was it like 15 years ago, how is digital dentistry been going and then what's you're prediction, where do you think you'll be 15 years from now.
Don: Okay. Let's go back. Back when I first started here, I came from a non-dental background. I was at a industrial valve company. I had no dental background. I walked in Ivoclar and I got involve without a first block for CAD/CAM. I had the only machine on the market and the restorations weren't great, the scanning was okay, everything was okay but not great.
What you started to see is the evolution of how it evolved to 3D and then it got more precise and more accurate and got faster and the more materials came to market, like Emax, to help utilize the machine better. Now you can do indications like bridges and [inaudible 00:07:40] and it's just evolved very rapidly. Last five years it's grown dramatically from what it was, very high quality three dimensional image to something that's just amazing.
When you scan today, if a dentist were to come out today and get a scanner in their hand, they can take a digital image, design a restoration, probably with very little direction, which is amazing how far its come from 2000. Where it goes forward, to me it's a very similar to a lot of other technology that's on the market. Thinks evolved pretty fast and very rapidly. One of the things that we always want to stress is that things are going to evolve rapidly, you have to be comfortable with change. Software is going to change, we get updates on your iPad, on your app, probably every week.
Software is going to change in the CAD/CAM machines to make it better, faster, smoother. That's going to always be the case. We talk about it in our building the fascinating concept of doctors at some point will run their office without every placing a direct restore of material again. They'll scan, design and either milled or sent to a lab for a final restoration, but what they make will probably be milled or produced in office, resin temporary ceramic restoration that will be finished. The days of temporary our of a cartridge or a direct composite IV, syringe will all eventually, probably just go away, it will be completely customize fabricated restorations done in office.
Whether it's 10 years from now or what, that will probably be the case where doctors will be doing that with the use of technology to get you a better fitting, better anatomy restoration that's monolithic, that's extremely strong and durable anesthetic and custom for the patient.
Howard: I'm going to go down a whole different area. Implants, when I get to school 20 years ago, we call it the golden revolution, the gold [inaudible 00:09:38] of dentistry. It was just good times. Now I think we're calling it [inaudible 00:09:44] because as people live longer, and longer, and longer, their saliva decreases more and more and when grandma gets into a nursing home she has no saliva and the root surface decayed, pretty much wipes out, almost half of her teeth at 18 months. I see dentistry, now we're really double thinking, we're thinking, okay these … if I build a barn in a field out of aluminum, I'm not to worry about termite. If I build it out of wood, I can brush the wall three times a day, but eventually the termites are going to get it.
The aluminum barn implant and your crowns or a big feature, i just wonder, do you think 15 years from now filling will be more bio active? I have people spray on my house every day for termites, do you think someday white fillings will … the bug start eating in or eating around it will die or bioactive or bio [inaudible 00:10:46]. You know what I'm saying?
Don: Yeah. One of the things that we see happening in a the technology is that currently we take a block and it's milled down in a process of basically chipping away the ceramic to either make a crown or making [inaudible 00:10:59], a custom [inaudible 00:11:00] or bridge or whatever they case maybe is. Fast forward a few years, it will be an additive process where restorations are built and will create out layers and finish. With that there could be a bioactive component in that material, which will allow you to reject or push away bacteria and bugs. That's the easiest way to do it, because as you're building the restoration you're going to be building a custom restoration for the patient, but also with an additive material to prevent decay or any other type of secondary cure. I definitely see that happening down the road …
Howard: You definitely say bioactive being … me being 52, graduate in '87, when I got out of school all the filling that they were all silver. To get out of my school, University Missouri, I can say we have to do 75 fillings. We do have to do one two color filling. I don't think I did want two colored filling. I got in '87, all fillings were silver, which was half mercury that have silver, copper and [tung 00:11:57] and now half the dentist in America don't even have silver fillings. When I think of that cosmetic revolution and all honestly, I only associate that with … apparently it only maybe two names, Ivoclar and maybe Bill Dickerson, who ran a Las Vegas and [inaudible 00:12:16] on Vegas, but you guys led that way. Bob Ganley and Ivoclar, they're the ones who are [inaudible 00:12:23], Tetric Ceram.
Do you really feel that Ivoclar led that cosmetic revolution?
Don: Yeah, when I got here in 2000, it was the aesthetic revolution as Bob coin the phrase, it really put us on the map and took dentistry in the directing of … it doesn't have to be metal, it could be tooth colored restoration, it can look great, but it can be better dentistry. It could be a bonded restoration that's very strong, very durable and last. Empress then become Emax, which became a more durable restoration that was …
Howard: Explain that to these kids how Empress became Emax.
Don: If you think about things that you always learn about your own materials, we learn about materials every day, ours and competitors. Empress was a great material. The limitations were in posterior restorations, especially where there's lot more force, it became … there was a need for a stronger, more durable material. If you then get proper reduction and didn't bond it, it might fracture. Many ceramics that fall in that category were good strength but not great. What you started to see was some doctors would say, I'm still placing a PFM in the posterior.
Then Zirconia came on the market because they want to have stronger restoration, the posterior. Emax became an evolution of, we are trying to evolve Empress and it evolved into ultimately what became Emax to make a more durable restoration that could last and hold up and posterior restoration is extremely well.
Howard: What do you call both … We're just having [inaudible 00:13:52] the lithium disilicate.
Don: There are completely different chemistries. Empress has a leucite crystal in it. The idea with Empress as it exist that it was tapped out as far as how strong we could make it. It became an evolution to, "Let's make another material." Lithium disilicate was the chemistry that we chose. That became Emax and then that evolved into a monolithic restoration that had great aesthetics. Which was very unique because for a while a layer PFM looked okay, a layer zirconia looked okay, but nothing had the great aesthetics and strength durability that Emax represented.
This became really a mix of strength, durability, but also it looks like a tooth and it has translucency like a tooth.
Howard: Can you also explain, just for my curiosity.
Don: Sure.
Howard: When we mill this out and we put it in over it goes from purple to white.
Don: The idea behind this, we made the block in a way and that's the difference between the chemistries of the ingot that gets pressed and versus block. In this case, when the blocks were manufactured, we need to make them in way they can got into a mill and be efficiently milled because right now there's burrs that grind down to the ceramic and actually milled into the final crown. If the material was too strong, it would either wear the spindles or chew up the burrs.
This blue stage that we found was really this intermittent stage where it's soft enough to be milled but it's so strong enough to stay intact when you're actually handling it and packaging it and shipping it. This was the step to get it from, I mill it efficiently, get it out of the mill and then you put it into the furnace where it's final crystallization process. The ingots never have to go through that, because they're heat pressed. They never have to, they're already white. The ingot is already white, they go under the press machine and there actually the restorations are pressed, the final tooth color.
This was the step to really allow milling to occur.
Howard: I want to go back to the cosmetic revolution of this kids and I want to point out one thing. When you're 25, you're walking on dental school, I just want to give the historical perspective from my perspective, going back to '87, is that I believe that all people are the same and if they don't feel good about something, they're not into it. What I saw the biggest happening of the cosmetic revolution whether it be two colored materials, bleaching, bonding, veneers, the whole thing is that when people started liking their teeth, they start taking care of them, they started brushing twice a day. I always notice that if you bleach a girl's tooth, she will come get her teeth clean every six month the rest of her life, at the worst case scenario. She might start want to get them cleaned every three months. I have tons of them who come in after three months because they're starting to get stain.
I would say with American ... not Americans, to all people, you either haven't been bowling in 20 years or you own your own ball, there's no in between. You haven't gone skiing for 10 years or you own your own boat. I associate William, Ivoclar, and Bob Ganley more with mental health than oral health. When you made everything, tooth color pretty and jazzy and your Smile to the Max campaign, I think when people get into their teeth then they're in to them. If they're in to them they're going to brush every morning, night, floss when they go to bed, tongue scraper, mouth wash. You know what I mean?
Don: Yeah.
Howard: They're just in to it. If you don't like your teeth and there are ugly fillings, you cover your smile and your mouth, you're likely to want to go brush and floss and get your teeth clean. I associate Ivoclar more with mental health than oral health. Mental health is more important than oral health.
Don: To that point, looking at it from a positive aspect too is when people become aware of things like the condition of their teeth, to your point, they take care of it better, they're more aware of it, they want to look as nice as possible. It's the same with your health, your physical health. If you're not in great shape, you start working out or start taking care of yourself and eating better, you become more aware of it and then you're more, I have to have better habits. It's very similar tie or link between health and awareness. If you go back to 1987 versus now, consumers are much more aware. They're more aware of what's possible.
They're online, they're Googling, they see stars getting their teeth done or whatever the case maybe is and they can see and figure out what's possible with dentistry and what's possible that they can achieve. They go to their dentist to think more of the plan and saying, "I want to look like this." Because I know it's possible, it's not just a guess anymore. They're not just getting a tooth fix that hurts, they may be looking at the bigger picture as I want to look in a certain way or I want my teeth to really pop and really look great. I think there's an awareness element in this day and age of social media and information that allows people to see what's possible and faster than ever before.
It inspires people to want more, instead of just, "My tooth hurts, fix it. I don't care what it looks like." Now it's, "My tooth hurts, I want it fix, but I want it to be white and I want all my teeth to look white."
Howard: I think John F. Kennedy said, a rising tide lifts all the ships. I think so many dentists Nobel Biocare, the implant company that got into … the implant center, what are those called?
Don: I can't remember. Yeah, I remember that.
Howard: There's some implant centers and [0 on 4 00:19:17]. They are doing all this advertising. I thought it was funny because on Dentaltown, everybody, all the dentists were talking about, "Should you do the [0 on 4 00:19:26]? Should you do 5 or blah, blah, blah, blah, blah?" I lived in the whole experiences [inaudible 00:19:32] I'm having patients coming in, in my office, seeing those commercials and they're not going to the Nobel Biocare, they're not going to the [0 on 4 00:19:41] centers. When those companies are marketing, they're raising the tide for everybody, I can't tell you how many questions that generated coming on my office.
I remember one time when I mailed out my first newsletter, I mailed it to every dentist. I mailed to every household in my zip [85044 00:19:59]. This dentist came in the next day and he told my receptionist, "This came to my house. You tell Dr. Farran, I don't ever want to see this in my house again." He drove and he left. I thought, "That's just crazy." Because it was all an issue on a dental sealant. The happier dentists were telling me for the next six month, I had 20 patients bringing in your newsletter on dental sealants and all these moms asking … he said, "I saw more sealants from newsletter." I'm going to ask you about your B2C campaign, Smile to the Max, the website there. What are you trying to do B2C, and what's your goals there?
Don: Ultimately, it's very similar in terms of wanting to make people aware of what's possible. Consumers from a standpoint of, I want to have a white smile. Part of it now is it's not only white, but it also is biocompatible, it's an animal friendly, it can be restored in some cases in a day if it's on a CAD/CAM office. Smile to the Max allows the consumer the consumers to see what real life patients and doctors and laboratories working together, what can be achieved by the patient. They can see real life of what can be done but also what the process is to understand it.
Sometime you see cases where you think and this 24 hour makeover show was a tough show in a lot of cases, because when you watch it, patients would probably they come into your office and say, "I want to do that in 24 hours. I wanted all my redone. I want to look it like star tooth makeover in one day." In some case it's not possible, it might be they might require [Orafil 00:21:39], they might need implants, they might need a bigger treatment plans. Part of Smile to the Max is what's possible but it's also is what to expect from the patient and from your doctor. It's not, my expectation is here but it's going to take me multiple steps to get there, so they can understand a little bit better how to get to that point.
Howard: Yeah. Kudos to Bill Dorfman for probably the most influential on the television, big box. IN Europe, [inaudible 00:22:10] is it Miguel Stanley?
Don: I believe so, yeah.
Howard: Miguel Stanley who ran six seasons in Portugal. Every Portages, dentist I talk to you so that after Miguel Stanley did that series, all of Portugal went from amalgams and missing teeth, they're wanting wired teeth, implants and tummy tucks and breast augmentation, it was just wow. It really has been a huge revolution. Most dentist, you know in Dentaltown we have form, we have one for CAD/CAM, we have one for [inaudible 00:22:47] users and then we have another, which used to be E4D, and now Planmeca, the big company from Helsinki is a partner of that. A dentist only uses one of those. Talk about, what is it like working with two partners. Also, I know I can ask you this question, so I'm going to ask it, because I know it's politically incorrect. When kids come out of dental school and they see two systems, they see Planmeca, they see Sirona.
Does it really matter? Is CAD/CAM, CAD/CAM? Is it Honda, Toyota, Acura? Can you talk any about that would getting yourself in too much hot water?
Don: That's almost impossible. Let's start with …
Howard: I have four kids, I can't tell you which one is my favorite, because then the other three [inaudible 00:23:38].
Don: Partners from our partner perspective we work very closely with Sirona and the CEREC side of the … in their system and with Planmeca now. Planmeca is bought into the E4D company and essentially is working on the design and the design of the production of the … was the E4D system now into the plan scan system. Both partners are very driven to providing a great experience for the dentist and for the end user. It's how do we make it faster, more streamline, easier to scan, make the process more consistent, things like that. They're both been excellent to work with. As far as machines, I sit in between both and it's fascinating because when you talk to owners of both system, they love their machines.
Sometimes it's, I love my rep. I bought the technology because I bought into the rep and the specialist who help me and got me to this point or I love the software interface or I live the community that's been developed on the CEREC side or there are just differences. That's where it's difficult. If you are to compare machines for student, we always encourage people, look at both but you will have decisions that sway you that we don't know about. We don't know about your relationship with the dealer, for instance that I work with Patterson because they are my first dealer that I work without a score or may Shine was.
That's where I started working with from day one or maybe Shine was on campus with me and my universities, that who I know and I know my rep, I love the software interface or I love some aspect of the technology. Both systems allow you to put a block in the mill and design a restoration. How you get there is complete different. Probably the biggest difference right now is that Sirona because they've been out longer, they look at further ahead and some of the technology, advancements since far as indications for use and some of the other things are doing. Both are extremely good. We would encourage for a student, use both, demo both, try both, see what you like and there will be something that jumps out at you about either one that say, "I want to go this direction." Some of those are not hard, it's not just the software, it's not the mill, it's some other relationship issue or support issue or whatever the case maybe is.
You is your dealer is an example.
Howard: My first dealer was in college, that's a whole another … I'm sorry go ahead. Nothing I'm the industry … no, what you said is amazing, because probably one of the largest dental holding companies in the world is Danaher.
Don: Yeah.
Howard: They acquired a low cost implant, Implant Direct. They acquired the highest cost, Nobel Biocare. A lot of people think that's weird. How could you on a high cost, low cost, when they're both touching implants? I look to [inaudible 00:26:24] and it's mine to is that he likes the rep at Nobel Biocare and that's the person available. When I do an implant, my lady is three miles from my office and if I call her, I have a question or whatever I'm missing something, she's right there.
Don: Sure.
Howard: As far as what dealer I use, I just switched dealers, I've been with one for decades and switch another one. Why did switch? Do you know why?
Don: No.
Howard: Because my rep switched.
Don: There you go.
Howard: I don't even care. In fact she started to tell me why she switched. I list to that, I respect, I didn't care. I see my supply deal with this lady and [inaudible 00:27:09] 28 years and we're a team, and we have each other in our iPhones. You're right. My best friend and dentist in my area, [Tom Madern 00:27:22], we went to Creighton together. I have the Sirona CEREC, I had the CEREC 1 and then went CEREC 2 and CEREC 3 and [Tommy 00:27:32] went for the E4D because his rep, that's what his rep told him to get. Yeah, so it's very [inaudible 00:27:37].
Imagine if you're Tiger Woods, it doesn't matter what club you're swinging with, it's [inaudible 00:27:42] and practice. Looking back to these kids on CAD/CAM is that, I don't really care what type if piano you buy, but you're going to have to take piano lessons and it's going to take you a long time to get good at it, you just can't buy an E4D or Sirona and be good at it overnight. If you're a businessman like I am, I do have an MBA, I decided when I got this thing, when I took the Impergum impression to send to the lab, I didn't do any of the lab work. When I bought the CEREC I said, "I'm not doing any of the lab work, I'm not going to buy $150 machine to reduce myself to a lab tech." What I did is I bought a $150 machine and I upgraded my dental assistant to a manufacture.
I created a manufacturing job. That's what I did. If 120 dentists all bought a piece of technology and made their dentals to manufacture, that creates $125,000 manufacturing jobs. I created for [Cristina 00:28:40] and [Jam 00:28:41], and [Yoni 00:28:42], and [Zach 00:28:45], they're now manufacturing people and they did it all. I go in there and I numb and then I prep, and then I go to another room do root canals, whatever. They scan, and they design, and they mill, and they take it from here to here, to here, and they try it on, they adjust it. It was just absolutely perfect, stained, glazed, everything, and I don't care how much time they are because I'm in another room pulling four wisdom teeth or doing a molar root canal or placing an implant. When it's all done, I just come in there and cement. I'm always confused when Dennis always walks up to me and they ask me all these little laboratory deals. When you took an Impergum impression and sent it to the lab, do you know what [inaudible 00:29:28] with? Did you use a mixing bowl?
You didn't do any of those steps. This has slowed down a lot of dentist who aren't thinking about the business side of it. You know what I mean? The business side of it says, your lab man use to do all these work and now you're doing all that work when your assistant is standing right there suctioning. She doesn't want to stand there and suction all her life, she wants to get in the field. She wants to get in there and roll her sleeves up and just do it. What I think is another interesting thing about the [inaudible 00:30:03] is it's made … [Millie 00:30:06] and her self-esteem, her confidence, five years of doing those because I remember she was so proud when the girls … Someone came in and [inaudible 00:30:14] front tooth and the other three assistants are like, "That's tough. I think we should send it to a lab." Millie is like, "No, I'll do it."
It turn into where the whole team is like, "Millie can crash that." I swear, don't worry. Millie's got it. She's telling me the prep design, she's telling me, "Just give me two millimeters." She's looking at it and I'm all humble, I'm like, "Millie, do you like this? This is good." She would just take it away and by time she's cementing that thing, the patient is high fiving her. It's been a fun journey.
Where do you think CAD/CAM was going?
Don: First let me comment on the workflow in your office, because that is probably the ideal scenario that when office first go in the CAD/CAM they struggle with the setup. They implemented a lot of times and say, "I don't want to change what I was doing. They want to fit in in their existing schedule. I want to take the scan, I want to prep and mill and somehow see that it all in this very short window of time, instead of saying, " I'm going to do this, I'm going to turn over to my staff who I've trained now to handle the material, to get it to look like the final restoration and then come back and see that and have already and gone in one appointment." That workflow is probably the biggest paradigm shift that dentist … our challenge with it is when they buy the technology, rethink how you schedule into something like that and rethink your staff on who's doing what.
Once you do that, everything works. Your office sound like it probably work extremely efficiently, because you did that. If you try to do it all yourself, it would probably be a train wreck. That concept of what you implemented is very good. I think it's not a small aspect of why technology will stick ultimately is because it's … I'm expanding rules of other people to help do things in my practice to be very efficient. That's really a big aspect of integration and how machines stick and how they're successful. As far as the future, I mentioned earlier, I think the big rush right now and we see a lot of 3D printing. You see 3D printing everywhere, probably. You can go on a airline flight in a magazine, a thousand dollar printer and print toys, they're also 3D printing.
The thought is it wouldn't be three printing crowns tomorrow. It will probably get to that point, that additive technology, whatever that's called, whether it's 3D printing or some other technology will allow you to build custom crowns which will be custom color. You may not need to stain and glaze.
Howard: Because you couldn't make this had a goal and them mill it back, you waste so much, price is gold. If you did want [inaudible 00:32:49] do you think … What are you calling that?
Don: We call it additive technology. If 3D printing, you basically layer and it forms into that final product, whatever that is, car parts or dresses, or whatever you can, or toys. You can 3D print almost anything. A process would allow you to layer components to be able to make a final restoration. I don't think that's a tomorrow thing, but I think what you get out of that is a custom built crow with color, shade, translucency that's formed in your office, that fits perfectly and drops right out in the prep.
Howard: You think in five years, 10 years?
Don: I think it just depends on what's the job. Right now, what we know is you can 4D layer, resin based materials, when we say resin, like a polymer material. Doing something like ceramic or maybe is more challenging. The question will be, what's the material that best fits that process?
Howard: I'm going to say we have a podcast coming up with the actual, the original inventor of CAD/CAM. Talking to him, when I was in dental school, they had the whole idea if this CAD/CAM. Really what the problem was looking back 20 years, it was the power of the computers, the software.
Don: Yeah, change, exactly.
Howard: This iPhone has more power than the Apollo astronauts that went to the moon. They did not have this much computer. Now that we have much more robust computers, it won't take 25 years to figure out something. They might take that 25 cycle and might get it down to 10 years or …
Don: I use this example a lot with 3D technology and I follow certain technology trends. I've seen fashion shows down with 3D printer dresses, or car parts completely assembled into a car that functionally runs of 3D printed parts. The technology allows you to do a lot of things today that you could have never done 10 years ago, because you can custom made parts in 3D printer and put them together and the materials are durable enough to run.
Howard: I want to say that I'm friends with probably every household consultant that you can think of that's been out there the same length of time. We all have these horror stories of people that in the old world they had [inaudible 00:35:03] of hygiene and they were doing four crowns a day, they may do them 2:00 in the morning, they'd schedule an hour and an hour and a half. They would numb, prep and press for temporary, prep the tooth, take the impression, take the old impression, make a temporary and they'd flip that chair in 90 minutes. They would do four crowns a day for about $1,000 piece. They bought CEREC or CAD/CAM, and now that is a three-hour appointment, she can only do two crowns a day the doctor is in there and she is taking the whole thing through for three hours.
What they don't realize that … the bottom line is doing four crowns a day for 4,000 is always going to be a better decision than do a two crown a day for 2,000. In the 4,000 world, you have a lab bill, you are now paying a lab man 150 units or the 300, 600 bucks for that 4,000 and you got to pay that lab bill, that's going to be the assistant, it's going to be another operatory. I also want to note that so many dentist something that they don't have room for another operatory, in 28 years I've never been able to agree with the dentist, ever, they'll say, "I don't have room for operatory and their private office is big enough for operatory. I'm like, "Why do you need this [inaudible 00:36:15]? Why do you have a bathroom and a shower?" Anyway, long story short, I have never walked into a dental office where some dentist will say, "I would do that, but I don't have [inaudible 00:36:25]."
I can squeeze an extra operatory or two and anything. What's interesting, if you go down to your dealers, Shine or Patterson Benco or whatever and you give them the dimensions of your dental office, here's a great project you should do. If you're dental office is, say is 20 by 20, or say it's 20 feet wide by 60 feet long, whatever the dimensions, go down to Patterson, Shine, Benco, Burkhart and give the exact dimension of your office and say, "Just give me the floor plans of every dental office you've ever made in these dimensions." It's amazingly crazy, like you take a 2,000 square foot office. The very [inaudible 00:37:03] between four and nine operatories. How did two dentists get the exact same dimension and one could fit four ops in there and one fit nine and then you're telling me, because I think the CAD/CAM is very, very neat, but I think it should be an extra room, I think you should be able to stain and glaze it, and I think your assistant should do the whole darn thing.
I think if you just go in there and numb, and talk to the patient, and while the [inaudible 00:37:35] soaking in, bond and all that, then prep, then leave, and then go do all kind of other thing and you come back and it's all done. I think that's critical. I've had you for 38 minutes, I'll only get you for 20 minutes less. What else did you want to talk about?
Don: One of the standpoints from out company as far as what we evolved, material-wise is it's a big aspect of technology and I've seen these a lot in the recent history with development of technology like zirconia and even the CAD/CAM world where materials come out or doctors are placing restorations in the [inaudible 00:38:14] as well, it's good enough, it looks good enough. It looks aesthetic but it looks good enough. Aesthetic is not great. One of the things, I hear a lecture recently where a dental technician talked about technology is not a race toward mediocrity. Just because you can put something in a machine and allow the restoration or send it to a lab and allow zirconia crown. It doesn't mean that restoration has to look good enough.
One of the great things about lab technicians, about what they can do and we have seven or eight on staff here, they can make restorations look just amazing. It's talent, it's skill, there's some artistic ability to it. It could be taught and it could be explained and transition to other people in your staff or to other chair side offices. The goal should be make this restoration that goes in the mouth really nice. The expectation sometimes is that, you talk about the cynical, how cynical we are in the US, in America in general, is that patients come in and maybe they're looking for my tooth hurts, I need to have a crown. That's a body part, you're replacing a body part.
You should put something in, you should want to put something that looks really good and looks nice and natural. Is it not just fill in the hole anymore. Just because you bought a machine or bought technology or you send it to a lab that mills a restoration, it shouldn't just be good enough, it should look really nice, whether it's a first molar or a central. I should look really good. For as a company, the aesthetic revolution was a drive toward that, about making … striving to be more and raising the bar, so to speak, or what you can accomplish. Technology should be a race toward that as well. It's how do you get the efficiency of technology with this high end aesthetics or what you can use to get from a lab in your practice and not settling for less.
Because I hear that a lot, and I think as more people get into technology, I think that's the downside risk of it, it's the race, almost to the bottom of, "Yeah, it looks okay, I got it down fast." As oppose to, "No, I made this look great. I place it and it looks really nice. My patient absolutely loves it and I love it that it went in and it looks like a phenomenal restoration." For us that's a huge aspect of what we do. As we develop materials and shades and translucencies, it's going to be about what you see and what you can do in your practice with interiors or whether the posterior restoration, interior restorations with shades and translucency is that it look amazing that you can do in your office and have great respect or great outcomes for and not settle for, "Yeah, it looks okay."
Howard: I'm sorry asking, my job as a moderator is to try and predict what thousands of dentists are listening individually, now the modern Dentaltown is … With Dentaltown no dentist will ever fly solo again. I always think of the question as what is the most commonly asked on the message board. I know the most commonly asked question that today's listeners or want to ask you right now is, they hear a lot of Emax, they hear a lot of zirconium. They hear zirconium stronger, maybe that Emax is prettier in the front. To the young kids, the one think I never thought I would see, when I get out of school, PFMs were their age.
Don: Sure.
Howard: I never thought I'd see the death of the PFM, it virtually almost died, there's [inaudible 00:41:41], because of zirconium and Emax. Talk about the difference in zirconium and Emax, what clinical indications would you think are when you do? Would you do Emax front and back? Talk about difference between those two
Don: Once of the things that's fascinating too because we see that downward trend of PFMs go even faster, the curve for a while I think was sort of slight and then it became almost like a drop off, where PFMs are really dropping off fast, because clinicians know that you can go to zirconia or lithium disilicate and get a great restoration.
Howard: Are PFMs down half in your life time or more than a half?
Don: The last data that we have looked at and I might be off in here, I want to say from 2005 to now, back in 2005 it was about three quarters of restoration were PFMs.
Howard: 25%?
Don: Now it's almost … the minimal about 25 were all ceramic, it was categorized all ceramic. It's not quite to that extreme opposite but it's very close now. It's almost …
Howard: In 10 years it flipped.
Don: Flipped dramatically. Because of the materials have evolved so much. When you talk about now what's available, I can go with white, a tooth colored restoration that I can get from my lab or I can do chair side and they both look great, or they both can look great. The difference between the materials and what I find fascinating is that Emax is a very unique application because it's got strength and durability. Zirconia, in terms of raw strength is going to be stronger material. One of the interesting aspects that we have learned is a study that our clinical research did while back and that was three years plus really quick, Emax into a bunch of offices and posterior crowns and full contour zirconia, and neither one of them broke in three years.
The point is that you can really do either one in indications and be very clinically successful, you can put Emax in the posterior and be clinically successful for a long period of time. Sometimes in this [inaudible 00:43:42] stronger is always better, I don't know if that's necessarily even needed. If you get a decent prep and you were able to cement or bond an Emax in the posterior, it's going to hold up, probably for decades.
Howard: That's been my pet peeve with dentists. I love dentist, I am a dentist, I'll always be a dentist. The one thing that I always try to tell my sovereign colleagues is that, whenever they talk they always sound like a civil engineers. They always talk about bond strength and wear and this and that. As a 20 year practicing dentist, this barn is going to come down from termites, it's not going to fall down. They always talk about wear rates of [inaudible 00:44:19] molar versus Tetric Ceram and they'll be having all these thoughts of shall I do [inaudible 00:44:23] molar, shall I do Tetric Ceram. We talk about where and all this, it's like … I'm pretty sure after 28 years I've never seen either of those two materials fail because they wore down. Pretty much every single time, it's because they didn't floss their teeth and they got a flossing cavity in between the teeth six and a half years later.
I'm pretty sure that we're not having failures from wear and bond strength. People talking about bond strengths, bonding on [inaudible 00:44:52]. I don't have crowns falling off, I have crowns that in this tooth needed a crown in the first place because you didn't brush and floss and take care of your teeth and they your teeth clean. Just because I fix it all up and put a beautiful crown in there, I didn't change your cousin Eddie, he's still your cousin Eddie. He don't brush, he don't floss, he doesn't use a tongue scraper, he doesn't use Listerine and he smokes a pack a day and he thinks orange juice is called Budweiser. We're not changing their behavior.
Don: That's right.
Howard: Yeah, I think if a tooth colored and a charismatic dental office can motivate you to get into your teeth and you started brushing more and flossing more. That's why when hygienist and dentist talk down to patients or scold them, or makes them feel bad, I got back to my four boys and myself and sworn to me you … the only reason you start with a certain sports is because you fell in love with that coach. Some coaches made you feel bad and run off half the team. Another coaches made you just want to be all that you could be for your coach. You know what I mean?
Don: Yeah.
Howard: If a dental office can have that charisma … and when I walk in office, every consultant agrees with me that when you walk to the office, they either have it or they don't and you can sense it in one second. You just either walk in and the place is just charged and everybody is just into it and come on and everybody is into brushing, everybody wants to do better at oral health. Whether it be tooth color, brushing, flossing, re-care, come on Don, you got to schedule for your next cleaning. It was two years, so come on, let's get you scheduled today, let's get on your iPhone. You either feel that or you don't. I don't get into the civil engineering stuff. You think Emax is strong enough, [Gordon 00:46:43] thinks it's strong enough?
Don: Yeah, it's interesting data. When we saw that most of the premise that they went in to study with is most materials, especially ceramics will fail on that one to three year range. That seems to be the most … the data that they run was very typical that that's when the failures is going to occur. Once you're beyond that point it's going to last as long as any other type of restoration or longer. To get it to that point three years where they were both comparable was [inaudible 00:47:09] was a great indication of saying, "You know what? Yeah, zirconium might be stronger, but it doesn't mean that Emax won't last in the posterior just as long or long, because the physical properties are very good."
Emax offers a very unique blend of balance. One of the things about zirconia that I think is true but also gets back to the clinician of what their … what is their objective or what is their focus as far as the successful restoration and if it's put in a crown and it never breaks, then you would put in zirconia, because the crown will never break. Bottom, because it's probably the strongest material available, or I would put in a gold restoration, gold and something else. You're going to put in something that will never break. Is it over killed? Possibly. Can I do it and use lithium disilicate instead, will it look a little bit nicer? Could I do an interior side machine? Maybe.
It goes back to the clinician placing the restoration a little bit and what if their desire for their patient as well. That's the difference sometime is, and as manufacturer, I will say, we're as guilty as anybody of looking at microns and seconds and how strong and megapascals, because that what we talk about a lot. We don't always talk about the restoration looks good and it look for one, three, five, seven years, regardless of the strength properties or anything else. It was about that it was a good material that will last. We talk about specifics like megapascals …
Howard: Let's switch gears, because I only got you for 10 minutes left. Starbucks was a surprise business [inaudible 00:48:47] because where I grew up in Kansas, coffee was free, any gas station had a pot of coffee in a 10 cents Styrofoam cup. Coffee, I always thought coffee was just free, you can get in any gas station and they serve there, everybody had free coffee. Starbucks said on, "Coffee is free, but I think people will pay 5 bucks for just a super-duper fancy mocha. You do that with denture teeth. Denture teeth were just plain Jane and no one ever thought about a denture teeth other than just a denture teeth. It is about 10 year ago.
Don: Yeah.
Howard: What was it? Blue lane? Now you have [inaudible 00:49:24]. Talk about what make you guys go into a high-end aesthetic denture teeth? Because when … one of the failures of cosmetic dentistry is the message got taken by people who thought cosmetic dentistry was 10 veneers on a hot looking runway model. When I think of the majority of lawmakers, 31 million Americans have no teeth. For every one lady who got veneers who looks rocking high wearing a gunny sack, there were 100 grandmas who got a smile makeover with dentures. I still have people all the time and dentures are still huge because America is a huge immigration country. We had million immigrants here.
I'm down there in Phoenix and dentures are so huge, because you have people moving in, I might just did three on people from Bosnia and Herzegovina. A lot of people, their smile makeover is a denture. Everything was trash and gone. Talk about your high-end denture teeth and then why do you have two of them?
Don: I think the extension, it make sense when you talk about the aesthetic revolution with Bob Ganley's initial premise of where we are as a company, what we're trying to accomplish. The dentures became a natural extension of that. We offer X, which was a good system that had a good fit to it and they look nice and then evolved into one occupation's options to have more aesthetics. Just like you would do if you're going to do a smile makeover. Why should you not have the same options if you're going to go into dentures? It became a tiered process of having more anatomy, better aesthetics, bleach shades, which do offer in our denture teeth as well.
To offer you the benefit of saying, "You know what? Just because you're going to get a denture, it doesn't mean it just has to be one side fir all, it could be a custom fit, beautiful fit, high-end aesthetics, pain tissue, beautiful teeth that look like a natural smile. For us, it was really just an extension of what started on the restorative side from direct composite to ceramics and now it was extended into our denture line. It allows you to give you that of transition to, again, I go back to the settling part, you don't have to settle for, "It's a good enough denture." It can be a great looking highly aesthetic denture and have a great fit and high-end aesthetics to go with it.
Howard: The people crashing dentures, they are the first ones to say, we have a $500 unit and we have 750 unit and we have $1000 unit. What would you call your lower cost or lower-end and higher-end?
Don: Yeah, we tier a lot of it based on the basic parameters of your tooth options, your shades, as well as your contouring effects of the teeth. You get different molds …
Howard: What would be the low, medium, high-end, the brand name?
Don: I would say blue line …
Howard: Would be a high-end.
Don: Would be our low line and then [inaudible 00:52:21] would our line limit.
Howard: All right, line limit. I also want to tell you that the hugest return on investment that I've been seeing is dentist will go get implant training and then they'll go down in the poor part of town and go buy the denture world where for 30 years some old man was in there doing dentures for … they had the 300 units, 600 units, 1000 units. They were doing about a half million to a million a year, but they learned how to place implants. They would bought this thing for $0.5 million. Then offered two implants with locators or four implants with a bar and Hader. There was offices went from doing a half million a year to three million a year. They bought $0.5 million business, but since they could upsell they had implant training and they walked in there with a 3D X-ray machine and making surgical guides, which almost gets you to where Stevie Wonder could place an implant.
If you got a surgical guide …
Don: It's predictable. It's consistent and it's predictable. That's the goal. I've talked to doctors that still do surgery unguided. Now the more that they learn and watch the process realize, "Yeah, I can do it. I'm probably okay. I can see everything, I can see on [inaudible 00:53:48] where everything should be, where I place the implant and it's consistently predictable all the time and I have less risk associated with it." To back to that point, that's where the technology becomes a huge advantage, because a bigger case like that where you're placing implants now becomes … it's predictable.
I know where I put it, it's going to stick and it's going to last with a high degree of how predictability and the patient is going to have a great result. That's how the technology has really evolved in all these areas where you can do all these types of restorative cases with whether it's restored materials over dentures to service the patient and give them options to look as good as they possibly can at any step into the process. That's what's really cool about it, because we've done cases in our campaign showing patients, older patients have their dentures done. I've seen cases shut and [inaudible 00:54:34] where you will get it fast. You would have not known if that was a denture ad or an Emax add, because the teeth looked that good.
That's where I think it becomes dramatic, because again, you're not settling for a generic denture getting really good and it can look really good, and it should look really good.
Howard: It's funny how times change. I'm only going to say this because two of my two of my three uncles have passed on and the other one, I'm pretty sure doesn't every listen to my podcast. [Inaudible 00:55:03] you realize that all three of my uncles in Parsons, Kansas, all were in the full dentures before they got through high school. Have times change or what?
Don: Yeah.
Howard: On World War II, the number one reason to reject a soldier for infantry to World War II was they didn't have seven teeth. You had to have seven teeth to go into the army, navy, or the air force, or the marines. That was the number [inaudible 00:55:30]. A lot of people talk about flat foot. Flat foot was high on the list, but number one was teeth. I didn't have a single uncle that got out of high school with a tooth on this head.
Back in this since I only got you for four minutes, but I'm talking about, if you can get a CBCT and you can learn implantology, it's more important than root canals because when you do a root canal in your cousin Eddie, you're not going to change his behavior, he's still got a Mountain Dew in his hand and that root canal you did is going be mush in seven years, because he's never going to learn how to brush or floss. The same thing, did you see that, let's on bypasses on identical twins? They found 40 sets of identical twins where the one guy was lucky because he had insurance, so would got the $100,000 coronary artery bypass graft, CBG, where they take the graft out of your … coronary artery bypass graft out of your leg vein and put it in your heart. The other twin didn't have the insurance but decided to quit smoking, lose weight, started exercising, taking care of himself. The identical twin who did not get the surgery lived three years and seven months longer. Just because you did a bypass, [inaudible 00:56:40].
Don: Yeah.
Howard: You see him in the hospital, they go out there and right out the front door and they're smoking, right, by the ashtray. We saw this was gum disease forever. You would do four quadrants [inaudible 00:56:52] curettage, you do four quadrants of surgery and then they go home and never change their behavior. About three years later, back to square one. I'm going to end, I only got you for three more minute. What does Ivoclar do with implants, the titanium implant revolution?
Don: Right now, I'll say right now because I think it could change in where we're going to be. Right now we're restoring implants. We work with our partners, implants are placed, we work in the case with Sirona and their system or restorative system in the chair side application with [inaudible 00:57:28] base that we put a custom of [inaudible 00:57:29] on and cement it and then restore that with a crown. Right now it's the top half from the implant up. We see the same thing, implants are becoming more the norm, they're extremely predictable now, more so than ever before.
They offer great solutions, do a less and bases in a bridge, in a lot of cases because you're not grinding down other teeth. It give you a great solution. Right now we are from, I'll say from the tissue level is what we're really focused on and we're focused on technology like this where you actually are able to take the block and mill your own custom of [inaudible 00:58:00], attach it to a Sirona titanium-based that will fit in virtually, any implant that's on the market today. You can do that in your office, you can do that, the implant placed and then do the restoring part in your office. It give you the ability to finish the implant and then drop the final crown on and get a beautiful looking restoration.
Howard: Some people are taking this white stuff and making white porcelain implants. You are the leader in white stuff porcelain, all that stuff. Do you think Ivoclar will ever make an Emax implant?
Don: I think we've looked at it, I know we've looked at it to some extent. One of the challenges that we all have realize is that the one down side about implant going to into the bone right now and that's why titanium is so good, is that when you start placing ceramic it's great until it breaks. When something goes awry and it splinters or comes apart, zirconia is really bad for that, anything glass, then you're trying to retrieve glass out of bone, which was never an ideal situation. Right now that gets perfected, or smoothed out, or improved in some way. The risk of that failure occurring, and it could be because of an accident. The patient gets hit, shears off the implant but not it's seared, you've got glass.
Howard: What you're saying is the ideal of it going to in, that's easy nice?
Don: It looks nice, you're right. It will look nice.
Howard: It had broke, the …
Don: That will happen. Unfortunately it could be a variety of things, it could be patient not taking care of the bone, bone gets weak and then for whatever reason there's some force …
Howard: I'll tell you what, the one thing that … I'll just close on this because we just hit our hour. I'm in 85044 and there's a dozen nursing homes. My patients have been with me forever, they call me up and they need me to come by the nursing home or whatever. When you go into those nursing homes, the implant crowns you did, they're perfect. Their grandma is sitting out there in the room eating whatever she wants to eat, but those bridges you did, those are mush in 18 month, because they don't have dexterity, they have rheumatism, they got Alzheimer's, they got dementia, you have one little $11 an hour certified nurse, assistant taking care of 15 people on a [wing 01:00:14], and they got to brush their teeth and bathe them, and feed them. The oral health care is going to be like [inaudible 01:00:20].
The luckiest patients I had were the ones I did implants and crowns, not bridges.
Don: Yeah. That's a great point, because I think that's most predictable restoration as you go forward, that would be most predictive solution and the longest term, lasting restoration. Because I think to you point, you're not going to have to deal with all the other stuff. The stuff you can't control won't matter, because as long as the bone stays intact and the implant stay, everything else is going to be in really good …
Howard: I'll end to that. You've done this 15 years but your boss Bob just celebrate, what? 35?
Don: Yeah.
Howard: You think you're going to do it 20 more years or you think you're going to go back to gaskets?
Don: I don't think I'm going to back to gaskets. That was a tough market. B to B, it was very tough competitive market. This is but not to the same extent. That was a Penny's business. Penny has made a difference between one valve purchase and another, this is not quite that. Not yet, anyway.
Howard: Thank you for an hour of your time.
Don: Thank you.
Howard: Thank you for inviting me down to Ivoclar. Last but not the least, if the dentist comes out here with his staff they can …
Don: They can visit open house and I would say contact your local rep and talk to him about how you can access to one of our open house programs.
Howard: Yeah, you got to do it and you're right into the street from Niagara Falls and then when you see Niagara Falls, you can go check into a room with a bed that's the shape of a heart and put a quarter in and it will start vibrating. If you happen to slept in a vibrating heart bed while you see Niagara Fall. Thanks again for your time. You guys just come down and check it out. Thank you very much.
Don: Thank you.