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AUDIO - HSP #156 - James Hastings
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VIDEO - HSP #156 - James Hastings
James H. Hastings, DDS shares specifics about how to continue improving your skills after dental school.
James H. Hastings:
Born and grew up in Denver
Military experience: U.S. Army, Field Artillery officer
Graduate of Indiana University School of Dentistry "A long time ago, before masks and gloves."
Immediate Past President of the American Academy of Cosmetic Dentistry 2014-15
In full-time private practice in Placerville, California and still having fun.
Cell: (530) 363-4840
Howard: It is a huge honor today to be lecturing to a man I have known and admired for literally 25 years. I met you, clear back, was it the LVI days, I think I might have met you in ...
James: Before then.
Howard: Yeah, yeah, how long? We've known each other forever. You were on cutting edge. You jumped out and saw cosmetic dentistry as a specialization, a niche area, that consumers wanted, and you were on that. When I think of the cosmetic revolution, I really give a lot of credit to [inaudible 00:00:45]. Bob Ganley saw it with Empress and tooth color, and then guys like you were jumping in on it, and congratulations, dude. You made it to the President of the American Academy of Cosmetic Dentistry, how cool is that?
James: Well, now I'm the past president, so it feels pretty good.
Howard: So, my first question to you is, who is more fun to look at, the past president, you, or the current president, Joyce Bassett?
James: Well, that depends on your point of view.
Howard: She actually lives down the street from me. It was funny, I was climbing Camelback Mountain on Christmas morning, they always have a Santa Claus up there. So, we all got up at five o'clock and drove down there, and who did I see at the top of Camelback Mountain on Christmas morning, with Santa Claus, Joyce Basett.
James: Joyce is out there about every day climbing Camelback.
Howard: Is she ... well, that's the ultimate Stairmaster, because I notice when ... I work out every morning from five to seven, and when I'm on a Stairmaster, it takes so much discipline to not get off.
Howard: But, when you go climb a mountain, your mind relaxes, because you know you're going to go to the top, so you think about other stuff. Then, as soon as you get to the top, you turn around, and you think, oh great, now it's downhill, and then I'm done. I've got a mountain across the street from me, [inaudible 00:01:59] Mountain, and I just can't do stationaries. I can't do stationary bikes or Stairmaster. I've got to do something where my mind is not looking at the clock for an hour, you know what I mean. So, what did you learn as ... in your journey, well, first of all, as past president, why should ... this is probably going to be about ... I think the last episode, I had seven thousand dentists looking at this. What would you tell of those seven thousand dentists, why should somebody join the American Academy of Cosmetic Dentistry?
James: That's a great question. I was fortunate, I think, just going back historically, 1994, I joined the AACD, because Bill Dickerson said, "You should join the AACD." And, Bill was, he was, you know how he is. He's pretty forceful and direct, and he was right, and it was a great organization. Then, he said you have to go for accreditation. I said, "oh, what's that, well, OK," so I signed up for that. And, I got in with a cadre, I might say, of contemporaries, all of whom became accredited and many, many of them are still luminaries in their profession today. The camaraderie has just been wonderful, the learning experience has been wonderful.
So, having said that, we know in AACD, we don't own cosmetic dentistry, but we try to be the best at disseminating information. Now, in the 20 years since I joined, it's changed significantly. As you know, it's got significant market penetration. Anybody can hang out a shingle and say they're a cosmetic dentist, but I happen to feel that the people who are in the AACD have a different mindset. Most of them [inaudible 00:03:34] mindset towards trying to do the very best they can for their patients, and learning how to do it their very best way. Cosmetic dentistry, by definition, in my view is just simply good, solid, restorative dentistry. But, it is a [inaudible 00:03:47] discipline. They have to learn and study. Did I answer that question okay for you?
Howard: You actually nailed it, for me, personally. Because, when I look back at getting my fellowship in the Mission [inaudible 00:04:00], I don't think of the accreditation, or the fellowship, or my diplomat in implants, or anything, I think of my friends that I met there that have now been my friends through this whole journey. The first guy I sat down next at the Misch class was Steven Rasner. How cool was that. So, yeah, I think that when you join a society, you're a social animal, and the biggest, funnest thing about any of those organizations is you go there and you meet somebody of like mindedness, and now you've got a buddy who can talk this with you for the rest of your life, and it's just cool. So, be specific, though. How much does it cost to join the AACD, and how do I become accred ... I see accreditation, and is accreditation, is that when you see a dentist's name, like yours, with after DDS, it has FAACD? Or, is that the fellowship?
James: That's the fellowship, right.
Howard: So, how much does it cost to join, and what's the difference between accreditation and fellowship, and what, exactly, do I got to do to get both of those?
James: Well, accreditation is a matter of documenting five specific case types, photography, photographically, and also doing a case report, a write-up, and submitting in digital format, specific photographs for each case type. There's five case types, shall I name them for you?
James: The first, the flagship case type, the one I call the flagship is porcelain veneers. It used to be called six or more porcelain veneers, now we call it six or more indirect restoration. Because, the dividing line between veneer and a crown might be different, in any case. You know how it is. You might have a crown on number eight, you might have something that has more margins than the state of Florida on nine, and might call it a veneer, might call it [inaudible 00:05:49], whatever. So, it's called six or more indirect restorations. It's all on upper-anterior teeth, all the restorations are on upper-anterior teeth. Case type two is tooth replacement case. You're testing my memory here, I should know this stuff by heart, but I think I do.
Case type two is tooth replacement case. I'm sorry, that's number three. Case type two is one or more indirect restorations. This tests, each case type tests a different skill set. So, for instance, with case type one, we have six or more indirect restorations. You're testing your ability to prepare, your ability to diagnose, your ability to treat, but you're also testing your ability to communicate with a laboratory technician to get what you want. Because, what the patients see is his work or her work, not yours. What lies beneath the surface is what you did. So, case type one is six or more. Case type two is one or two. So, that tests the ability to match shade, possibly to match composite to porcelain, possibly to match porcelain to natural tooth structure. So, those are different skill sets.
The symmetry is important in case type one. Smile design comes more into play in case type one. Case type two, where it's one or two indirect, it's typically a central incisor. It can be two lateral incisors, it can be two central incisors. So, that's pretty much how that goes.
Case type three is tooth replacement case. When I went through the accreditation in 1996, seven, eight, most people were doing fixed bridges to fix a tooth. Now, most people are doing dental implants, and the results are phenomenal. As an examiner since 1999, I've seen lots and lots of cases, and I really can stand behind it and say I'm really proud of the cases that we see come through, and what the quality of dentistry we're seeing. It's amazing, it blows you away.
Case type four is typically done with composite resin. It's either a diastema closure or a class IV [inaudible 00:07:41] replacement. That is the most commonly passed case. I'm going to say, not the easiest, but that's the most straightforward case to do. It does test your ability to handle resin, it tests your ability to match resin to tooth structure. Smile design typically doesn't come into that so much.
The last case would be the direct bonding case. We call that six or more direct restorations, all on anterior teeth, so it's going to be canine to canine, and you, as a dentist, know very well that if you just do the six teeth, you're typically missing something out, you oftentimes have to go back one first pre-molar, second pre-molar, to make this smile come out right.
So, the case type one is six or more indirect. Case type two is one or two. Case type three is tooth replacement. Case type four is, let's just call it diastema closure. Case type five, the flagship case is six or more direct restorations. That's the one that's toughest for most people, it's toughest for me.
Howard: What would you have to do to be a fellow, to get the FA ... Well, first of all, if you get accredited, is there anything after your name?
Howard: What's after your name on an accredited?
James: I typically don't use it because it's a whole string of letters, and it doesn't mean a lot to a lot of people, but you can put AAACD, so you're accredited by the American Academy of Cosmetic Dentistry.
Howard: So, the AACD with an extra A.
Howard: An A, then the AACD.
James: And, the ones that you've seen FAACD, which, I think are only about 50 fellows now, Joyce happens to be one, is the next level of accreditation. Now, the difference between the two is that you document five cases with accreditation, but with fellowship, you document 50 cases.
Howard: Holy moley.
James: Right, but the documentation for the five cases is very much in-depth. You have to have twelve before photos and twelve after photos that are specific to cosmetic dentistry. They're all the same views, the same magnification, and so forth. So, twelve and twelve. For the fellowship case, you only have to have before and after two cases, a smile case and then a retracted case, what we call a one-to-two view.
Howard: My favorite mantra is, we're social animals, we're programmed, we've all got to get along, we've all got to follow the 400-pound gorilla, because we're only going to survive if we all work together. So, it's against our nature to ask an ugly question. I call it the four thousand pound gorilla question. When I'm hanging out with five dentists at a bar, and we're watching an NFL football game, whenever veneers come up, you always hear people grumbling, saying, "yeah, but if it was their own daughter, would they have filed off all the enamel on the front six teeth and done veneers, or would they have done direct composite, or maybe six-month braces powerproxed with Rick DePaul, or bleaching." My crazy question to you is do you think if some 21-year old ... if your 21-year old daughter came in, and her teeth weren't movie star, would you remove the enamel on her front, upper ten teeth, and do indirect veneers, or would you do ortho, bleaching, direct composite? Do you understand what I'm asking?
James: Of course I do. But, there are a lot of ways to answer that question. First of all, as a dentist, you have to do diagnosis, and you have to understand what intra-disciplinary features are available to you.
Let's go back about 25, 30 years, back to 1985 when Robert Gibson brought, excuse me, [inaudible 00:11:26] veneers into the marketplace. I first saw him in 1985 lecturing on porcelain veneers, and it was a phenomenon. Yet, I looked at all of his work, and I thought, those things all look bulky and over-contoured, except for one case, where he had just done a single tooth. I asked him after the lecture, did you not have to prep that, and he said, yeah, I had to prep it. So, I figured, hmm, you've got to prep it. So, going forward in time, when Empress came into the marketplace, it allowed a lab technician, who has a hometown lab to get world class quality because the [inaudible 00:11:54] became easier to do. The drawback to that was we had to prep the teeth a lot. We've gone from Bob Gibson's no prep, no shots, no drilling, to to prepping the teeth, and asking the laboratory technician to get very involved int he case, to do a whole lot more smile design with it, and now it's come full-circle the other way, with dentists, I think, can be congratulated for bringing back the no-prep or minimal prep situations.
I'm going to answer your question, but you've got to let me finish it. I remember when I saw you lecture the first time. You were on your very first cross-country tour, I think you were 27-years old, you, Howard Farran, do you remember that?
Howard: I do.
James: You came to Sacramento, you were hilarious. We were so happy to have a fresh face say the real things about dentistry. You remember what you said, I'm not going to go into it. But, back to your question, I've had a lot of respect for you since then. I've seen you do amazing things since your first cross-country tour when you were having to load up the bus with your stuff by yourself. I know how it was. I've talked to Craig [inaudible 00:13:06] was the one that told me about that.
Howard: That's right.
James: You went to school with him. Anyway, back to your question. It's an unfair question, in some ways, because I can't say with a blanket statement what I would do, but typically, the thinking today, is to be as conservative to tooth structure as you possibly can. Given the fact that the patient is going to own those teeth the rest of his or her life, we may not interact with them for more than a couple hours or a week or so. You've got to make sure that what you do goes in there, in some predictability of longevity with it. Porcelain veneers, sure, but you're asking for trouble if you just go in there and wholesale, lay a whole bunch of enamel, and pop on porcelain veneers. You'll get a good result to start with, but is that the best result. So, individual variation.
Howard: So, I want to ask you another question, which is a play on what Carl Misch told me back in '87. I said to him, "how did you get so good at implants." He said, "You know, Howard, it was cross-training. I started off in removable, and I was watching these people having these implants snap at the gum-line, and they were all blaming it on a weak implant. I was looking at their dentures, saying, 'Dude, you missed the bite, you have to get the forces and the mechanics, and you've got to know how to build a correct denture before you can learn how to make a denture over implants.'"
And, so my question to you is don't you kind of think that's true with cosmetic dentistry? If you're a dentist, and your only tool is an indirect veneer, and you can't do Powerprox, six-month braces, or six-month smiles ... if you don't have any type of unraveling orthodontic short-term ortho skills, can you really be a cosmetic dentist, if you can't sometimes unravel the case. Some of the cases I see, I tell them, if you just let me unravel this for four months, four months, six months, this is going to be such a better case. So, do you need to be cross-trained, at least, in short-term ortho, to be a really rocking, hot ...
James: Well, let me go back ... we're starting to fade out here, having a bit of a lag, but I'll answer your question. The answer is definitive and, yes, you should have a significant knowledge in every discipline. Dan Mayeda, who is a past president of the AACD, a very competent dentist, who practiced in Hawaii, wrote one time, "Cosmetic dentistry is a specific prostodontic discipline that requires significant study and care." So, it's a separate discipline that requires study and care. If Powerprox comes into it, great, orthodontics certainly should be considered, it certainly should be, and the patient has to be, of course, made aware of all the options that are available. Just like John [inaudible 00:16:01] said one time years ago, "If it makes a difference for the rest of your life, can you do it for six months." So, that's the answer to the question. You want to be as conservative as possible, conservative with tooth structure, if it has to do with orthodontics, absolutely. I sent an adult patient to the orthodontist just yesterday.
Howard: The one thing I've always wondered about the orthodontist is the same thing I wonder about the oral surgeons. It seemed like, when I got out of school, 28 years ago, when someone needed an implant, when someone's denture didn't fit, the only option an orthodontist had was, pretty much, a fifty thousand dollar [inaudible 00:16:37] implant. Six implants, all the other stuff, and now, you're starting to see the smart ones say, "well, we have a Cadillac for fifty thousand, and we have a Chevy for five thousand, with mini-implants." You're starting to see some of the leading oral surgeons, in Germany, placing as many minis as they do full [inaudible 00:16:56] form.
I've always wondered, how come the orthodontist, same thing, you go in there with crowded teeth, they only have one treatment plan, a two-year, seven thousand dollar case. And, they don't ever really offer, "here's the other alternative, for half the price, short-term ortho for six months." I've always wondered why they don't see market segmentation, because it's not only in price, but time. One is six thousand and two years, why don't they offer a three thousand and six months. Why do you think that is, there's ten thousand of them out there, and I don't see any of them marketing that.
James: I would guess that the reason is because it has to do with your patient population, and there's a referral base. If your referral source is not knowledgeable, then you're not going to offer the patient something that may be best for the patient, or may be an option for the patient. You know, a six-month period, or a one-year period for three thousand dollars may not get you the optimum results that the orthodontics are trained to look for and trained to like. But, if they're willing to accept certain limitations, I think it's fine to do. My local orthodontist uses [inaudible 00:18:03] anchor devices, all the time, and that's the mini-implant approach, right.
Howard: Right. I want you to answer this uncomfortable question. A lot of dentists don't want to get into cosmetics, because they have this nightmare of some woman coming in with three pages of notes about her teeth, and pictures of how she looked on prom night in high school. They don't want to deal with a crazy lady with all of these high expectations, and be married ... how does a guy like you, who has done a gazillion of these cases, how do you weed out the crazy people with unexpectations, who think they're going to get veneers and look 20 years younger, versus someone who is a moderate, who will say, "Wow, that was a really nice improvement"?
James: That all goes back to inform before you perform. You're always going to have somebody come in who has stories about six or seven different dentists that she's been to, that's a big red flag, you know that.
Howard: Well talk to these younger kids, because we're older. Talk to these kids that just got out of school, inform before you perform.
James: The buy word is don't be too eager, make sure you know what you're doing before you get into it. Make sure the patient gets into the chair, and you get into trouble, and you have to call your lab technician, and you're in a push, or call your mentor, and say, "what do I do now." Make sure you have your guns loaded before you go in there. As far as the patient goes, they're going to want to know, well, let's put it this way, most patients don't know what they don't know. But, they know what they've seen on television.
Some patients are very astute, and they look very, very deeply into things, and they know a whole lot more about porcelain veneers than you'd expect them to know. But, when they say, "I think I need veneers," what they're really saying, you have to get deeper than that, and say, "What's the question at heart," you know, in boot camp, they used to say, what's your dominant [inaudible 00:19:57] motive. What do you really want. If a patient comes in and they're pointing to one tooth, I always stop them and say "back off here, let's talk about the big picture. I see that one tooth might be a bothersome to you, but what, in the larger sense, what do you really want?"
So, talking to these younger dentists that are just recently out of school, or haven't been practicing for a decade or so, it's the psychological game that we play all the time. The people who win at the game are the ones [inaudible 00:20:24] who are astute at understanding even technology, and knowing how to get the right answers back from the patients. Ask the right questions, get the proper answers back. You can tell where you need to go with the [inaudible 00:20:35]. Does that make sense to you?
Howard: Yeah, and that makes sense no matter what business you're in. Because, what you just said, the most important skill, in your entire life is psychology of your fellow man. Everything is just about how do you get along and understand the other seven billion people you're sharing this dirt rock with that's flying around the sun once a year. It's just everything, trying to know ... and, whenever you try to educate a dentist like that, he's like, "I don't want to know all of that liberal soft stuff, crazy stuff, I want to know how to bone graft." It's like, OK. But, it is the most important, understanding of people. The dentists who have the best natural ability at communicating, they always go the farthest.
So, this crazy lady comes in, and I don't mean that in a sexist way, but the one we all fear, the one that's going to have unrational [inaudible 00:21:26]. What I also see is I see two different markets of cosmetic dentistry. Like, if I saw you come in or someone like an intelligent, female lawyer, she would want totally natural teeth, and she would say, if you've got to reduce teeth to make it less-bulky, I want elegant movie star teeth. A lot of the veneer cases, they already come in and they've got huge breast augmentation, they've got dark red lipstick, they've got fake eyelashes on, a lot of them wear a wig. A lot of cultures in Arizona, there are some cultural groups that nine out of ten women are wearing a wig, I kid you not. So, on that case, would it be fine to just sit there and say, "I'm a dentist, and I really don't want to file down your teeth, and you already look as fake as a clown, what's wrong with lumineers, or what's wrong with no-prep veneers, when everything on you looks like a fake balloon," why would you reduce teeth in that case? Did that come through? Did you get that?
James: Not all of that. I think you're kind of skirting around that whole central issue when you say "when a crazy person comes in." Sometimes you can spot them right off the bat, and sometimes it takes a little bit more than that. Oftentimes, your front desk is the one that warns you. The question is about filing down teeth or creating ... you have to go with what your core belief system is and what your philosophy is. If you feel like you can do it, you can correctly execute a case to your satisfaction and to the patient's satisfaction in the minimal amount possible, the most conservative way, that's the way you should go, to follow your heart, don't follow your bank account. Don't do it just because it's going to create a ten thousand dollar bump in your accounts receivable for this month, because you're going to get bit in the behind, every time you think that way, speaking from experience.
Howard: OK, you're talking about seven thousand dentists trying to work, and I bet you half of them, because of age, maybe they just got out of school. I don't know how many people did veneers in dental school. Dental schools have enough on their plate to take a kid from scratch, to turning them loose on society in four years. Whenever I hear dentists complaining about what they don't teach kids in dental school, I'm like, "Dude, go lecture, I'm in there every year." They start with babies, and they've only got four years to turn them loose with a license. They're not going to cover ... and, the dentist that's always whining has always got 30 years experience, and they're fellowship, and they're AGD, and they just lose lapse of time of where they were when they got out of school.
So, this kid just got out of school in the last five years, and he's listening to this, and she's listening, and saying, "James, I want to be like you some day. I doubt I'll make it to the president of the AACD, but I want to be a good cosmetic dentist." Where would you specifically send this kid for training, because there's lots of institutes out there, LVI is out there, [inaudible 00:24:27] all these things, give me names, be specific. I know it's politically incorrect, because you're a past president of the AACD, and you can't do that. But, what would you tell that guy, for specific resources to go and learn how to do this stuff?
James: From the starting point?
Howard: From the starting point.
James: Starting point, where do you go for training. That is a very fluid environment. It used to be that Hornbrook had a thing, Dickerson had a thing, Ross Nash had a thing, you could go to his institute, Frank Spear has a special dedication to cosmetic dentistry, John [inaudible 00:25:05] significantly, he knows everything about everything. He adds a lot of great standards to our mentors from him. I wouldn't have any objection to going to any one of those places. Pankey Institute has a wonderful program. So, it's the foundational knowledge that you need in order to provide the service. Gary Alex once said "I spent my first ten years doing veneers learning how to make them, the second ten years learning how to keep them so they don't break." These are a skill set that you have to learn. There's a lot of different ways to learn. But, I will say this, the most learning advantage I ever had and have had was in doing veneers on a patient under the guidance of an instructor. In other words, a hands on course. [inaudible 00:25:48]
Howard: Who was that instructor?
James: It started with Bill Dickerson and Bob Nixon at Baylor in 1994. Then, [inaudible 00:25:57]
Howard: Did Bob Nixon pass away?
James: He did.
Howard: He had a neat journey. He started out as an endodontist and ended up in cosmetic dentistry, what a journey he had, that guy was amazing. Then, Dickerson, Dickerson is still at it. I still see LVI pop up. Would you recommend LVI?
James: I can't recommend nor can I disavow. I would say that any place you go that you're going to get hands on training is going to be beneficial to you. Just make sure that you're drinking a lot of people's Kool-Aid, because if you just drink one flavor of Kool-Aid, you're going to go that direction all the rest of your life. Does that make sense?
Howard: Yeah, and like, in dentistry, there's a [inaudible 00:26:38] everything. Like, one of the greatest implantologist cases I've ever seen is Bill Schaffer in London, and he just does these short 8mm fat implants, and he's done like 30 thousand of them, and they work. Then, in the United States, you've got all these dentists saying that they would never work. And, Bill just smiles, like, how do you do like 30 thousand of them that work, and then listen to people saying they won't work. Another one in your field is occlusion. You have the neuromuscular people and the conventional Dawson-Pankey occlusion. What do they call that? What would you call Pankey-Dawson occlusion?
James: CR versus CO, I guess you might say.
Howard: What would you say to that young kid who's looking at a camp, and one camp is going to have a neuromuscular occlusion, and one is going to have the old-school Pankey-Dawson CR occlusion. Do you have any opinion on the occlusion camps?
James: Of course. I don't think there was a controversy until Bill invented it. But, having said all that, I think there is a place for neuromuscular, but it's not as, how do I put this. This is my personal opinion by the way. There's a place for neuromuscular dentistry, and there's a place for centric-relationship dentistry, and the two, you have to know something about both of them. But, you have to follow your heart in terms of what works best in your hands doctor.
Howard: I'm trying to defend this kid who just walked out of school with $250 thousand in student loans, and he's only got the budget for one camp, and he's just got this little budget and a pregnant wife at home. Should he start with a neuromuscular camp, or a Pankey-Dawson camp?
James: If I tell you one or the other, I'm going to get into trouble.
Howard: I know, that's why I called. [crosstalk 00:28:28]
James: You want to get me into trouble, that's fine. You can shoot all the arrows at me that you want, it's not going to hurt. I will tell you this, I went to see Dr. Michael Schuster in Scottsdale, years ago, at the Business School for Dentists. He was a real disciple of Pankey [inaudible 00:28:45]. Dawson has been to our academy and lectured there several times. Bill Dickerson has lectured there. We've had Frank Spear, we've had John [inaudible 00:28:57] numerous times. I've been to the Hoist Center, I've been to the Spear Center, I've been to LVI. I have been to Dawson, but not as a student, just as an observer at one time.
I would say any one of those is going to give you some sort of foundation. Where to go, you've got to pick your dollar. I understand that you have to be sensitive to your bank account, and I would say, make sure that any course you go to, you're going to get the fundamentals for sure, because some of these places may want to just churn you. And, once you've spent four thousand, or five thousand, and now, it's up to ten thousand dollars per course, and you've graduated from that course, then you've got to take the next one, you're obligated to. I would say take a course, get the information, settle down with that information, and use it, then take the next course. Don't jump on the bandwagon and figure you have to finish the whole curriculum in a year or two years. That doesn't make sense to me.
Howard: I've gone to every one of those courses you listed, and I've never have ever walked out of any of those institutes, and not learned a hell of a lot of dentistry, and met a hell of a lot of friends. And, the other thing is something about those courses that there's something about leaving your home away from your everything, you break your routine, and now you're in a camp for a long time. Like, Misch was seven three day weekends in Pittsburgh. So, it's like seven times, you're going to Mecca, and all of your routines are busted, and you're hanging out. There was about a dozen of us who would sit in the hotel lobby bar after class every night until midnight. I don't know how you could go to any of those institutes and not love it. [inaudible 00:30:33] And, I also want to tell you the trick on John [inaudible 00:30:36], why his veneers look better than anyone else's is because he's 100% Greek, and he sprays Windex on them and polishes them off with Windex, because he's Greek. You'd have to see the movie My Big Fat Greek Wedding, to get that joke. Did you see that movie?
James: Yeah, but I don't recall that scene.
Howard: Oh, really, the man, every time he had something, an arm or anything, he's spray Windex on it. I mean, his go-to, like duct tape, you know how duct tape and WD-40 is the two American things, and My Big Fat Greek Wedding, the old man, the grandpa was always spraying everything with Windex.
James: OK, well, Windex is good for a lot of things. We kill ants with it here.
Howard: I want to ask you another bizarre question, and that is, it seems like men are more competitive and when they're lecturing, they're trying to blend these restorations with all of these stain, anatomy and grooves. But, when I personally have done this over the last 20 years, and the woman has fake eyelashes, and she's got breast augmentation, and she's bleached her hair blonde, she wants Clorox white. Sometimes, I put stain in there, and she's looking in the mirror and she goes, "Why is it dark," and I'm like I took a number ten endofile and I put in stain, and I totally camouflaged it in your mouth. She's looking like me, like "I don't want any of that."
So, what do you think about stain and all of that stuff? I want to give you another nightmare scenario that I did. This lady came in and she owned one of the biggest spas in Phoenix. And, who was that really expensive lab tech in like, Idaho, was it Matt,[crosstalk 00:32:21], and my God, I sent this case to Matt, and when I got them back, they were the most gorgeous veneers, they had mammalian grooves that started off translucent but got darker towards ... I put those on, and this was like in, I don't know, 1987, 88, 90, something like that. It was the best case I had ever done, and the lady saw it, and freaked, and cried, and wanted it all cut off. Then, I sent them to Glidewell, and made ten white porcelain Chiclets, and she literally cried again, for different reasons, and kissed me and hugged me, and thought they were beautiful, and to this day, every time I see those ten Chiclets, I just think, "I hope to hell she doesn't tell anybody I did them." How do you avoid that scenario?
James: Exactly the same way. What you just said. You just pointed to something that's really interesting. If you have to cut off, just like Frank Spear says, "If you don't get it right the first time, when do you have time to do it over," right, and how much does it cost you. Because, you lose all of your profit when you have to do a case over. David Hornbrook taught me one time, I've never cut off a case that was too white, but I've had to cut a few cases off that the patient thought was too dark. So, it goes back to psychology, give the patient what they want. I don't mind having them sign a disclaimer saying, "Hey, please don't tell anybody I did this," do you know what I'm saying.
James: But yeah, you just have to give them what they want, and people are what they are. We know what the artistic portion of this is, we know what real teeth are supposed to look like, we know Matt Roberts can make them look real, and we love them. But, the patient has to love them, too, because they're the ones paying our salary.
Howard: I'm going to give your international viewers today a big boom, and that is I've lectured in 50 countries. I cut my teeth in this country, and I always saw a big disconnect between what male dentists thought and believed, versus what female customers wanted to get. When I go to countries like England and Finland, and Norway, and Estonia, and Australia, I have so many male dentists come up to me, and they say things like, "What is it with American teeth, they're just so white and Hollywood. People like that don't like them here. They don't want that American crazy look." But, every dentist I know in those countries, especially like London, and Stockholm, and these cities sit there and say, "you know what, I'm going to start doing that American look with these big, white, beautiful, gorgeous movie star teeth," and, dud, they are crushing it.
So, remember, the number one business mistake you're going to make is projecting yourself onto seven billion people. I don't want fake eyelashes. I don't want a boob job, I don't want to wear a wig. Just because you don't want these veneers, start looking around, I think Europe is going to look a lot more Hollywood 20 years from now than they do today. Do you agree or disagree with that?
James: I think you're probably right. However, I've traveled in Europe, myself, and I don't see a lot of, well, I have a sister who lives in France and has for 40 years. I've been there several times. I don't see a lot of emphasis on cosmetic dentistry in France, at all. There might be a few dentists in Paris, and there's one guy down [inaudible 00:35:36] who is a member of the academy that practices cosmetic dentistry. But, I don't think it's got much market penetration there. Now, in England, I know that we had a few courses that have gone over there and have been teaching hands on courses, and then they send their lab work back here to do the lab work, and I'm sure they come out bright white, I'm sure they do. [crosstalk 00:35:56]
Howard: You really get an emphasis on how cosmetics is so regional and cultural. I remember so many times. This happened to me, the most shocking was in England, where this beautiful woman dentist came up, and she was asking me a question at the break. She was just stunningly drop dead gorgeous, and she reached back and scratched her head, and literally had a mop of hair under her arm. You go to a lot of these countries, and they don't even shave their legs. So, shaving legs, when I think of a woman shaving her legs and armpits, I think of an American and a Canadian. I mean, there's so many countries you don't see that. But, I think the cutest one is in China. In Asia, if ... everyone in Asia thinks the Koreans are the hottest, sexiest, best music, best dressed or whatever. So, whenever you're in China, if someone walks into the room, and they're looking all snazzy, the other Chinese say, "Oh, you're looking Korean." So, I imagine this cosmetic dentistry will explode first in Seoul for all of Asia. But, I'm seeing it. I know dentists who are doing this ...
James: As an aside with that, we do have a Korean affiliate of the AACD, and they're very active and very vocal, and they love us. They have a different deal with dental insurance there, some in Japan, as well. Some is paid for by the state, some is not. It's mostly elective, for the most part, as it is here. I agree with you. I spent a year in Korea, as well, some time ago, and it was a third-world country, all the way, then. It's a first world country today, South Korea.
Howard: Now, I want to ask you, probably, the most important question. When I got my MBA, the one thing the economists always beat in your head is that what monkeys say can only be measured with what they spend their money on, and they're never related. Like, if you go up to a consumer, and say, "Hey, would you spend more money on a product if it was made from all natural ingredients, and recycled, and was made in your own town, as opposed to imported from a communist country of China, and made by polluting materials," and they say, "oh, absolutely." Then, when they get their dollar out, they go into Walmart and buy the stuff from China.
So, they stopped doing focus groups, for the most part. I mean, the focus groups was the rage in the 80s and these CEOs were looking at the data and saying, "You know, we don't see any correlation between what the focus group said, and what sales happened ten years later." So, it's kind of died off. And, so, price is the most important thing. Most economists think that 80% of the time, the decisions come down to price.
So, I want you to specifically, I'm going to hold your feet to the fire on this for a long time. I've only got you ... we're two-thirds done, we're at 40 minutes, I've only got you 20 more. Technology, it's expensive. I've got $250 thousand in student loans, I just bought a practice for $400 thousand, my wife just bought a house for $300 thousand, and she's got two kids and one on the way, unless she's Mormon, and then there could be eight of them. What do I have to buy? Do I need a $150 thousand CAD cam, do I need an $85 thousand laser, do I need a $300 thousand CBCT? If I want to be a cosmetic dentist like you, I want to be Jim Hastings when I grow up, what expensive technology am I going to have to bite the bullet and get?
James: That's a great question. I don't think there is anything you have to have. I refer out all of my CBCT stuff, for my implants, to my local periodontist, he has the machine. He charges $245, which I think is dirt cheap. As far as a laser goes, I think it's nice to have. If you're uncovering implants, it's somewhat convenient for tissue modification. I personally use an electro-surgery device, it's much more precise. I have no problem with lasers. If you want to spend the money on it, great, in fact, it's on my wish list to have one of those $2,500 Picasso lasers. But, I just don't have one. I have had in the past. I have electric hand pieces in my practice, I love them, but they're not for everybody. Yeah, that was an investment, but it wasn't a huge investment.
I'd say, if you just keep the patient comfortable, they're going to like it. They don't care about ... technology does not make you a better dentist. Technology may get people to come in the door, but I don't think it makes you a better dentist. To be quite candid with you, I'd love to have something that allows you to scan ... [inaudible 00:40:23] is a great machine, the [inaudible 00:40:26] is a great scanner. There is one, the 3M, I forget, the True Definition, I think is the name of it, it's a great scanner, it's affordable. But, every one has its drawbacks. And, you have to know how to work it, because, if you cannot introduce it into your routine and use it on a daily basis, and have it make money for you, you shouldn't own it.
Howard: CAD cam?
James: CAD cam has gotten significant market penetration recently. I have yet to see out of 100 CEREC restorations, 99 of them don't look good, they don't look like real teeth. Now, does the patient care, I don't know. I'd also say that most of them fit pretty well, because they've got their software to the point where they can really give you a significantly better margin. Is it better than what a laboratory technician would do? Not necessarily. Is it less expensive? There's a huge learning curve with CAD cam, a huge learning curve. If you don't get it down, if you don't have your glazing and staining oven in the office, if you don't have an auxiliary person to run that whole program for you, then you're going to be spinning your wheels.
Howard: Warren Buffet says that 95% of American CEOs spend 95% of their time trying to figure out how to raise their overhead.
James: I agree, yeah.
Howard: So, what you just said, I mean, you and I can name, personally, 100 dentists that have some of the most successful practices in the world that don't have any of these. They don't have the CAD cam, they don't have the CBCT, and they don't have the laser, and they don't have any of these bells and whistles. And yet, the hype of the dental marketing media world makes you believe that if you don't have those three things, you're a loser, and a bad dentist, and your patients should go somewhere else. Do you believe ...
James: Our industry has been manufacturer driven ever since the mid-90s. Honestly, I've tested out, unwittingly, a whole lot of materials that have failed, because they put it in your hands and say, "Try this out, and by the way, you can buy it from us." So, you buy it, and you use it, and then it fails, [inaudible 00:42:25] and I can name a couple of [inaudible 00:42:28] products. It's no secret.
Howard: Targis vectris..
James: That's one of them.
Howard: What's the other one?
James: Let's see, we had Empress II, after Empress. Empress was a great product, but it has its limitations. Empress II. [crosstalk 00:42:42]
Howard: So, when you stopped using targis vectris, did you switch to art glass?
James: I did, but, you know what, I hated that just as much.
Howard: So, you younger kids that don't remember the story ... basically, it was two different materials, targis to vectris and they kind of came apart, and then [inaudible 00:43:00] did the art glass, and they came apart. So, not every company hits a home run with every product.
James: We understand that.
Howard: I want to also say that I turn 53 on Saturday, and I want to tell you younger dentists, that if I had to do it all over again, if you said, "What would you have done differently," it seems like when you come out of the starting gates, you're very susceptible to bleeding edge technology. When I got out of school, do you want to hear my first cosmetic dentistry belief system, that I was formally trained. Here I am, paying student loan money to pay this at UMKC, if a really hot woman comes in, and you want to just do beautiful dentistry, you'll do a dyke work crown, and cement it with duralon. I got out of school, and I had about 500 in the mouth before the first one fractured. Guess how many of those 500 fractured I had to replace for free of charge?
James: Most of them.
Howard: Every single one of them. I don't know of anybody that's [inaudible 00:44:03]. So, if I had to look back, in fact, do you have any bleeding edge stories that you can tell these young guys? Now that I'm 53 on Friday, I'll give you an example, Megagen has this new bone grafting thing, when you extract a tooth, you throw it in this device, and it instantly pulverizes it. And, [inaudible 00:44:26] when you said it has more surface area than Florida has coastline. You know what, I mean, who knows what pulverized enamel and dentin cementum is going to do. I think it's the greatest idea. But, since I'm going to be 53 on Friday, I'm going to let all of the young twerps try it, and let them tell me about it in five years. Because, I'm not going to be the guy, because I did this with implants, originally. When I got into implants, guess what my state of the art was? HA-coated, yeah, and we had problems with that. Now, what percent of the implants are we placing are HA-coated?
James: Probably zero.
Howard: Yeah, zero. So, I got burned on Dicor and Durelon, big time, I got burned on HA-coated implants. I had my diplomat in implants 20 years ago. So now, when I see that really super cool Megagen, yeah, if I was 24, I'd jump on that like a fly on a cheeseburger, at a park. But now, I'm just, I'm not doing it. So how would you help this kid determine bleeding edge, leading edge, so they don't go through a targis vectris, an art glass, a Dicor or Durelon?
James: That's a tough question. Let me back up a little bit and say, as far as knowing the Megagen is one thing. I have a periodontal specialist that I have a significant respect for, and a lot of admiration for, and he knows a lot about a lot of things, and he's not willing to jump into things. But, he does use a laser in his office. He uses it for the [inaudible 00:45:59] procedure, and I saw him rescue an implant that I was dead sure had failed, and the patient was dead sure it had failed. That's what I call leading edge technology, when the periodontist understands it.
Now, going forward, how do you pick and choose on what to use, well, even though the dental journals that we get are, and I've probably got one laying around here, they're mostly not peer reviewed, or well peer reviewed, and they're full of advertisements, you've got to watch what you're reading. Make sure that you read your literature, and, look at it with a little bit of a [inaudible 00:46:33] don't take it for gospel when you see something written down, just because one guy does it. In fact, I have gone so far as to call the author of an article, when I thought I needed to know more about it, and get it directly from the horse's mouth. So, do your own research.
Howard: That's the hottest tip of the day. Another thing is, the one thing the Internet has allowed is community. So, when you're reading a paper from a journal, and you're not sure, go to Dental Town and post it, and say, "Hey, I just read this article all by myself, alone," one way, like a radio, TV, billboard, or the newspaper man just drives by and just throws the paper in your driveway, post it on a community and say, "I just read this, I'm thinking that this is good, do you guys all agree," and see what the community says, because some smart guy like you might get on there and say, "hey, that was sponsored by this company, and I talked to the author," or maybe the author will get on. Don't practice alone.
That's the one thing I don't like about podcasts, is I always fear, dentists tend to be introverts, engineers, scientists, mathematician, and a lot of them are loners. I want them to be more social. That's what you said about the best thing for you to join the AACD was all the colleagues you met, all the people you met, all the friendships you met. So, be more community, be more interactive, and when you read these things, there's no reason you need to be out there alone, there's other sharp minds that can interact with you, with your questions.
James: Yeah, your forum has been really remarkable for a lot of people. When it first came into being, I was a little bit reluctant to jump in there, because everybody has an opinion. Of course, my opinion is right, right? You know, I come to find it, you start reading some of these threads, and there are some pretty bright people that are contributing. That's a great forum, a great forum, I really have to congratulate you on that.
Howard: We just passed 202,000 members, and passed four million posts. So, 202,000 members have posted four million times. Will we ever get a [inaudible 00:48:49] course out of you? Because, the reason I would love to have a [inaudible 00:48:52] course out of you is not only, you're so ... I mean, you've been doing this for ... how many years have you been a dentist?
James: A lot of years.
Howard: I'm at 28 years, and you're past president of the AACD. I wish you'd give, build us an online CE course, and call it "Down to Earth, Real World Cosmetic Dentistry."
James: Actually, our academy does have an online CE that's really getting some market penetration. It's getting some notice. I'll look into that. I promise to do that. I know you talked to me about this years ago.
Howard: So, talk about that. So, if you go to, what is it, AACD.org?
James: No, it's dot com.
Howard: So, tell my viewers, what kind of CE do you have on there?
James: It's a brand new platform, and to be candid with you, I was so busy last year, just doing the presidential stuff, when this thing was introduced, I can't tell you with any degree of veracity, exactly what's there.
Howard: Well, you know what you should seriously think about, marketing 101, a lot of other companies do this, we put up, I think it's 327 courses and they've been viewed 550,000 times. So, three hundred courses got a half million views. What some people are doing is if they got like a six segment CE course, they'll put the first one on Dental Town for free. They'll give up the first one, and then say, "if you want to watch two through six, go to this different website." So, if you've already got the content on the AACD, and you want to do ... you've already got your cost, if you want free marketing, put the first deal on Dental Town, and then send them to your website for two through six or whatever.
James: I'm going to write that down.
Howard: Or, they can just do it the old fashioned way, and make money, and put it on Dental Town for sale. What our business model is on the online CE, you put it on there, and I've got 50 employees, so we'll collect ... you set the price, we'll collect the money, and split it with you 50/50. It's a very simple business model.
So, if you guys have already got all of those courses and just want revenue, you can put every single one of those courses on Dental Town, set your own price, we'll collect the money, and split it with you 50/50. But, my whole ... I just want these guys to learn. My whole mission is to try to get dentists to learn faster, easier, higher quality, lower in cost, and my real passion is not the 20 richest countries in the world, even though I live in the richest country in the world. My truest passion is to get smart guys like you to put all of your information on the website, and then give it for free to Africa, Asia, and Central and South America. When I go into some of those dental schools, those deans literally break down and cry, because Dental Town is basically the entire curriculum of their dental school.
James: I have heard that in some countries of the world, that's their entire curriculum, is online stuff, Internet stuff. [crosstalk 00:51:54]
Howard: I walked into a dental school one time, and I didn't think that dean was going to let go of me. I mean, she just cried for like five minutes. She said, "before Dental Town," she goes, "All we had was Mandarin-Chinese books, and French books that were 20 years old, and no one in our school speaks Mandarin-Chines or French. Then, we found Dental Town, and you made it for free, for our country, all that online CE," and, she goes, "that's all we do, that's all we do, all day, we just sit around one computer monitor, and read threads, and online CE courses, and it's..."
That's why, my other biggest mission on the online CE is, we have so many courses on computer generated implants, Star Wars driven, you know, Obe Wan Kanobe dentistry, but there's seven billion people. That only applies to one billion patients. Three billion people live off three dollars a day, and nobody in the AACD is going to build me a course on how to make a cosmetic flipper. There's more girls that would have their life changed from a cosmetic flipper than pretend veneers. So, when I look at cosmetic dentistry for the planet, a flipper, a removeable, a denture. I love the fact that Iva Clare is taking dentures serious, and they've got their Bluetooth line. Because, when we were little, denture teeth, you could spot them a mile away, and now, with some of these high end denture teeth, they look au-natural.
So, I've only got you for five minutes.
James: I've got a patient, actually. I just got notification, I've got to get to business. I want to say one thing about cosmetic dentistry being a specific process or discipline ... I think a lot of people shy away from our academy, because the accreditation, a part of it has to do with direct bonding. I just saw a direct bonding case I did ten years ago. Does it look great? No, it needs a touch-up, and the patient understands it. She went in and out of braces with it, and now she wants it touched back up. No problem, I can do that. So, direct bonding, flippers, whatever you want. It allows us to have a much, much larger palate with which to spread our paintbrush on. Does that make sense to you?
Howard: Absolutely. Go ahead.
James: One way to get good at it is to do a lot of it.
Howard: I thin, for me, when a patient needs veneers, I always tell them, if it was me, personally, I would do direct composite. We can always go do veneers, but I love direct composite veneers. I absolutely love it. But, hey, you've got a patient in the chair. I just want to tell you congratulations on your career, man, that's amazing. Did you ever thing, when you came out of dental school, you'd be the President of the American Academy of Cosmetic Dentistry?
James: I didn't think of it until just a few years before it happened, actually, no, no, no. It was all political, I didn't want to do it. I love the examination portion of it, I love the camaraderie, I loved being an examiner, I loved learning more about it. But, when it got into the political side of it, it became something that had to be done.
Howard: That's probably why you became the president. Because, I've been in the room with you with so many big egos in the room, and I always thought you were the most down to earth, humble, real-world guy. It didn't matter who you were in the room with, I just think you're just a great person, a great guy. [crosstalk 00:55:12] Thank you for all ... what's that? No, I'm serious man, you and I have been in some meetings before where we're rolling our eyes at some of these guys out there, that literally are Napoleonic characters. Dentistry has their 1% of big egos, and you were always the most ... you had the same amount or more talent, just a down home country boy. I grew up in Kansas, and you remind me of someone who grew up in Kansas, just a down home country boy. So, thank you for all that you've done for dentistry, go treat your patient. Now, my goal is to get my neighbor, Joyce Bassett to do one to follow-up yours. I'm going to launch yours, and then follow-up with Joyce.
James: Thank you, Howard, for what you've done for the profession. You've got my respect.
Howard: All right, buddy, we're even on there. Thanks for a great hour.
James: Thank you.