Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
How to perform dentistry faster, easier, higher in quality and lower in cost.
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706 The Past, Present, and Future of Digital Radiography : Dentistry Uncensored with Howard Farran

706 The Past, Present, and Future of Digital Radiography : Dentistry Uncensored with Howard Farran

5/12/2017 9:08:42 AM   |   Comments: 2   |   Views: 259

706 The Past, Present, and Future of Digital Radiography : Dentistry Uncensored with Howard Farran

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706 The Past, Present, and Future of Digital Radiography : Dentistry Uncensored with Howard Farran

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VIDEO - DUwHF #706 - Joel Karafin

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AUDIO - DUwHF #706 - Joel Karafin

Joel Karafin is Chief Operating Officer of XDR Radiology. After earning degrees in Mathematics and Semantics from California State University, he joined Logicon RDA, a defense industry think tank, where he worked with Douglas Yoon, DDS, developer of the Logicon Caries Detector. After leading the technology divisions at small businesses in a variety of industries, he joined Dr. Yoon at XDR. There, he has helped hundreds of dentists decide and design their imaging solutions and led the installation of XDR at over 3000 practices. With 40 years of computer science experience, he has coordinated with dozens of dental companies in developing integrated solutions. He resides in Los Angeles with his wife Erika, and is insufferably proud of their children Xander, 13 and Sophie, five. 

Howard Farran: It is just a huge honor for me today to be podcast interviewing Joel Karafin all the way from Los Angeles, California. Joel is Chief Operating Officer at XDR Radiology. After earning degrees in mathematics and semantics from California State University, he joined Logicon RDA, a defense industry think tank where he worked with Douglas Yoon, developer of the Logicon Caries Detector. After the leading the technology divisions at small businesses in a variety of industries, he joined Dr. Yoon at XDR. There he has helped hundreds of dentists design their imaging solutions and led the installation of XDR at over 3000 practices. With 40 years of computer science experience, he has coordinated with dozens of dental companies in developing integrated solutions.

He resides in Los Angeles with his wife Erika and is insufferably proud of their children, Xander and Sophie. Xander is 13 and Sophie is 6. I love that, "insufferably." You're just conceitedly proud of your children, right? Aw, that is so nice. Now, do they get along being a boy and a girl?

Joel Karafin: A boy and a girl. Their ages are sufficiently separated so that there is not too much conflict, and so it's working out great.

Howard Farran: Well, I was raised with five sisters so I played Barbie dolls until I was 12. I had my own Barbie house, the Barbie car. I never changed my oil. I never did anything manly my entire childhood.

Basically, I wanted to get you on the show. I wanted to start off with, what percent of general dentistry do you think are still using film versus digital?

Joel Karafin: We think it's somewhere between 20 and 30% still. 

Howard Farran: Twenty to 30% are using film. I wanted to get you on because you know so much. What would you say to a dentist, and by the way, this is not a commercial, you didn't pay to come on the show. I actually sought you, you did not seek me. There is no money in this thing. I just love information. What do you think a young dentist, and she's working right now, she's commuting to work right now, she has an hour commute. She's working her ass in Harlan or whatever. She's thinking about opening up her own place next year. How should she wrap her mind around all these big high-tech equipment purchase decisions?

Joel Karafin: She shouldn't have to worry about the fact that they're high tech. High-tech delivered properly means that she doesn't have to think about it. She gets to think about the functionality of it, that it's simply working. If it's more complicated than that then the delivery is wrong. As simple as that. When you buy a high-tech car, are you supposed to know, you don't even have to know how to change the oil, right? Someone can do that for you. If you want to do it yourself, great, but you shouldn't have to be able to do that. I'd say the same thing is true here.

Howard Farran: Now talk about your journey. How did you end up in dentistry? What have you learned along the way?

Joel Karafin: Wow. That's my good friend Doug Yoon. Doug started writing code in year 1999 because companies that are now our competitors paid him for advice, but wouldn't take it. He's more of a scientist than a businessman so he cared more about the technology than about the money. That's how XDR was founded.

He brought in one of his two partners. That's Dr. Chen, who was a practicing dentist for decades at that time, retired just last year, to bring clinical aspect to what's going on. Then once he realized he had a business on his hand, something Doug would never want to deal with, he brought in his best friend. That turns out to be me. I've run the company since.

Howard Farran: I want a big shout out to Doug. He won UCLA School of Dentistry, he got the 2014 alumni, an honorary alumni of the Year. That's pretty outstanding.

Joel Karafin: He and Dr. Chen as a pair, that's right. 

Howard Farran: Yeah. It's almost Star Wars. I got out of dental school 30 years ago this week, May 11. I graduated in '87. We thought we were so lucky. We were laughing because as we were leaving they were installing computers for the next class. We thought, we got out just in time. We'll never have to deal with these stupid computers. Now you guys actually have computers diagnosing x-rays. 

Joel Karafin: Oh, I'm sorry I beg to differ. There isn't a product on the market in dentistry that's diagnosing those radiographs. The Logicon Caries Detector will make a guess and will suggest something to you, but even it doesn't claim to actually tell you you should definitely drill. That Logicon Caries Detector was programmed by Dr. Yoon, by Doug. He knows exactly what's in the innards there and it would not be appropriate to tell the doctor to drill just based on that. It always requires multiple modalities. Every doctor knows that.

The radiography is important, a piece of radiographic software and hardware can give you an excellent look, maybe better than the average bare look at what's going on radiographically or photographically, but no way it's going to actually diagnose. You haven't done any tests. Is there is softness in the tissue? There's lots of things to be looking at.

Howard Farran: Your lawyers have coached you well. Give them my kudos.

Joel Karafin: No. That's not my lawyer, that's my partner. That's Doug saying, "Don't you dare."

Howard Farran: But it shows ... I mean, 30 years ago it wasn't even concept. The point was 30 years ago, it wasn't even a thought or a concept. Imagine what would it look like 30 years from now.

Joel Karafin: That's cool. What's it going to look like 30 years from now? No one's ever asked me that question. The computers will disappear. They're going to be embedded in everything. You won't actually see them, which will be a great boon to dentist. Because right now room in the ambulatory is a significant issue that we have to deal with in terms of installations and so on.

What else will be true? I predict that the sensors will be soft that the technology will have arisen to create electronics on soft and pliable materials. That will be a huge boon to the patients with sensors in their mouth as well as to the assistants that will have to place them.

Howard Farran: Right. You hea0r things ...

Joel Karafin: One more thing.

Howard Farran: Yeah, please.

Joel Karafin: Your computer display will be your wall. There will be no difference. Your entire wall, the whole thing. You'll be able to control it without a mouse.

Howard Farran: I just want to know, when can I replace my assistant Jen after 30 years for the droid named C-3PO or R2-D2. How much longer till I don't have to deal with staff issues and I can just hire droids?

Joel Karafin: I don't know if your patients will like that.

Howard Farran: That's a great point. That is a very great point.

Joel Karafin: No. They say that health care is probably the last bastion of human being, a great place to be if you want to avoid being replaced by a robot.

Howard Farran: Well, I think it's funny how all these government talking about the high cost of health care and it doesn't make any sense to me. Because they never talk about the high cost of cars and housing, and iPhones, and all that stuff; they always complain about health care.

If I go up to any American and I say, "Here's your choice. Xander or Sophie has a disease and is going to die. There's only one person that has the pill and they're clear over in Copenhagen. The only way you can get that pill is to sell your house, your car, your phone, everything you've got to go buy that pill. Would you do it?"

Joel Karafin: Yeah, of course.

Howard Farran: Everybody. In fact, in dentistry, if I walk up to any woman and I say, "How much money do I have to give you to pull your very front tooth and never replace it?" They always say, "I wouldn't do it for $1 million."

I predict that when you have everything, when everything lasts forever, it's all solar, it's all perfect, and you inherited everything from your great-grandmother, you never have to work or do anything [inaudible 00:08:04] Then you go to the kitchen and you open the refrigerator, your eyeball falls out. What would that kid do? He'd sell everything to put his eyeball back, or to get his hearing back, or his front tooth back.

I actually think health care was 0% in 1900. It was 14% by the year 2000. It's now 17%. I mean, 100 years from now, it's probably going to be 1/3 because when everything is faster, easier, cheaper, miniature, lasts forever, the only true wealth there is his health.

Joel Karafin: That's great. I liked that. Just from a mathematician's point of view, the fact that the percentage is going up isn't necessarily bad. If it means everything else is getting cheaper, then of course, the percentage goes up. I think it was a great point.

Howard Farran: Yeah. I have read that no matter what type of VCR you buy that the planet is down to one VCR factory in Japan, and no matter what brand you buy they just take different labels. There's only one original equipment manufacturer. I've also heard the same with dental sensors I have heard that when you go to these big dental conventions and you see all these big booths at Cologne that there's very few original equipment dental sensor manufacturers. A lot of them are just putting many different brand names on their sensor. Is that true or false?

Joel Karafin: Believe me there's more than one manufacturer of dental sensors.

Howard Farran: How many do you think there are?

Joel Karafin: There's probably actually 20 in the world. Here in the American market, you're probably seeing about a dozen.

Howard Farran: Because that's a huge investment, to build a factory that can make a digital x-ray sensor.

Joel Karafin: Well, they're always done in factories that are doing other things as well, doing other kinds of electronics as well. Nevertheless, it is a big investment to design a new sensor. We've been part of that here at XDR. One way to see that they're not all the same sensor is to follow the patents. When a company has a patent on a design for their sensor it's obviously a unique sensor of one sort or another.

For instance, there is one other sensor that's manufactured in the same factory that we use, but it's a different sensor. You can tell that because we have a patent on our sensor. It looks different, its shape different, radiographic coverage is different. Of course, you can go to two other competitors of ours, from Dentrix to Carestream to Schick. These are all manufactured in completely different factories.

Howard Farran: Again, she's driving to work right now, she's 25 years old, how should she gather information about all these, you said there's 20 dental manufacturers that make digital sensors around the world in America, we're probably dealing with 12. You're talking to dentistry around the world, you're talking to them in Cambodia, in Kathmandu. How should they make an analytical decision of all these 20 dental sensors, what should they be getting their head around?

Joel Karafin: The first thing is image quality. If we're not taking good images, what's the point? She should be looking for what makes a good image. She should understand the difference between spatial resolution and contrast resolution. I can explain that if you want.

Howard Farran: Yeah, please.

Joel Karafin: I'll do? Okay. Well, spatial resolution is the one most people are used to. It's the resolution you hear about on a TV set. It's the ability to see something that's small or very thin. Can you see the football on your monitor? Your big wall covering TV, can you see that tiny football? That's spatial resolution. It's important for a dentists in seeing the fine detail of trabeculation on narrow PDL space, and of course, the tip of the file if you're doing an endo. 

That's spatial resolution. It's good. It's important. But frankly, at least as important is the other one, contrast resolution. What you're doing here is determining the ability to resolve subtle differences in density. How do you see that incipient lesion? You've got to be able to see where that demineralization has occurred, even slightly if you're going to catch that lesion early. That has nothing to do with size, even incipient lesion is huge compared to the tip of the number six file.

You should be looking for tests to test for that. There's new tests coming out, there was a peer-reviewed articles in 2013 in quado where a new phantom came into being and, yes, it's patented, you could get your hands on one of those and it has beautiful tests for not only spacial but contrast resolution as well.

I know what she could do, when she's sampling these different systems, she could pull a penny, a Lincoln penny, out of her purse, out of her pocket and take a radiograph of the penny. If she can't see details of Lincoln's face, then she's not getting the contrast resolution. She should be able to see that. If she can't, she should ask why not and make that representative show.

Howard Farran: That is interesting. I've never even thought of taking an x-ray of a penny.

Joel Karafin: I'd love to say that it is a very expensive radiographic fiduciary. It costs a penny. But it's a consistent shape and size. It's got varying depth, varying thickness and so it's perfect for trying to see those fine detail. The earlobe is about 4% mass difference from the surrounding area, so if she can see that. That's pretty good. It's pretty darn good.

If she can see the lips, that's even more challenging because radiographically the column from the monument overlays those lips and creates an only 2% density difference between those lips and the surrounding area. If she can see that she's got a very good image with high contrast resolution. That's image quality. There's more to a sensor than that, but it's got to start with it.

Howard Farran: Dentists are the ones that actually invented copper wire when two of them were fighting over a penny. This penny who were supposed to take an x-ray of ...

Joel Karafin: It's extruded, I think.

Howard Farran: Yeah. They're fighting. A lot of people say, "Well, they're cheap bastards." I think it's intelligence. I mean, I've had the town meeting every year in Vegas for 15 years. I have to tell you that when you're dealing with casinos and you tell them you're bringing a dentist, they don't want to see him. I mean, what's in catering you have to fight to get you in, assuming [inaudible 00:14:44]. Dentists are too smart to go throw thousands of dollars to win. They want bowlers, rodeo riders, they bring in concerts that have the craziest people.

Being smart, you said, there's 20 companies, should price play into a big factor of this? I mean, are they ... It's one of those things you get what you pay for. What's the variance of price with all these digital radiographies?

Joel Karafin: Great variance of price. You can pay $12,000 for a sensor or you can pay, I don't know, maybe 3,900 bucks for a sensor. There's a great varying price. I mean, the price is that different? Yeah. I think that's obviously important. If the price is only, say, 20% different, then frankly, I don't think it's that terribly big a deal. Because the life of the sensor should be long, you should think in terms of five years, something like that, maybe longer. We certainly have sensors on the market that we shipped in 2005. Certainly, the ones we shipped in 2009 are doing quite well. Long life, it is something to expect.

In that context, you amortize the cost of the sensor over a long period of time and things like ergonomics become more important. If it's taking your staff even an extra two minutes to clean that sensor between every patient, can you imagine how much money you're going to spend over the life of the sensor just on greater cleaning costs? It's absurd. If the sensor is uncomfortable enough and you have to do a bunch of retakes to get the images, how much money you're going to be spending on that over the lifetime of the sensor?

Of course, the ease of the software. If the software isn't dead brain easy to use, that's an issue in terms of cost, not just convenience over the life of the system.

Howard Farran: How much is your sensor on that spread between 3,900 and 12 grand?

Joel Karafin: Right in the middle. Actually, closer to lower range. Our typical package has a size 2 and a size 1. Because that's what you learn in dental school, you need that size 1 for interior PAs and certainly for small mouths and those kinds of trouble opening, torn eye, things like that. It's size 1 and size 2. That's two sensors with our system, runs between $11,000 and $12,000. That's the typical package.

Howard Farran: Size 1, interior small teeth, perio, children. Size 2, more bitewings.

Joel Karafin: Bitewings, posterior PAs. I'll say the word "occlusal shot," but I'll shudder as I say it.

Howard Farran: Yeah. When do you think CBCTs will be doing your bitewings?

Joel Karafin: I hope never. I think it's a terrible mistake. CBCTs are generating a lot more radiation for patient. It's just a lot more. It's not a little more. It's not like taking a pan. Even when it's cone beam, even when it's directed in that fashion, it's still a lot more radiation than you need to get an appropriate shot. It's a mistake.

If the voxel sizes are getting smaller and smaller, that's good, but you'll find that there's a correlation between the smallness of the voxel size and the amount of radiation applied. It's just got to be. To get a smaller voxel you need more and more sizes. The math won't yield. It won't yield.

Howard Farran: Explain what voxel is.

Joel Karafin: I'm so sorry. A pixel you're used to, the pixels on your TV or little two-dimensional things, little squares, or little dots that paint a picture for you by filling in a different shade of gray or a different color on each dot, that's a pixel.

A voxel, it's just a free dimensional version of that. It's a little cube, if you will, of intensity, a shade of gray. When you're small enough and you have enough of them now you have a three dimensional image.

Howard Farran: You're absolutely right about user that the software is going to be user-friendly. I mean, I cannot tell you, I mean, I'm in so many dental offices and I mean you ask someone up on the front computer, well, run me an edging report, and they're like looking at deer in the headlights. I've seen several dental offices where someone says, "Well, can I get a copy of my x-rays?", and two assistants, hygienists and a dentist are staring at this computer having no idea how to download it underwater.

Joel Karafin: The job of the software provider is to deliver functionality with ease and in context so that the person doesn't have to look for or click five times to get to it. It should be obvious in context if you're looking at a series of radiographs. One of the things that's obvious you might want to do is to communicate them. When you choose to bring up some sort of email portion of the software, it should easily be brought up, it should easily fold in images of interest, it should easily get it sent out to a series of correspondents.

Here's the real task of a software provider, as technology changes and as the rules change in our society, the software keep up to date. For instance, as far as I know we are the only software on the market that can send an email that's encrypted, that can send secure email over the wires so that you're not violating HIPAA but when you email a radiograph.

Why aren't other software producers doing that? Because the customers aren't demanding it, because no one's forcing them to do it, and they're not interested in spending development dollars. Unless there's an absolute demand regulatory-wise or their customers of course with their dollar signs, we take a different path, we were founded by dentists and mathematicians. Instead of paying an army of salesmen to go across the country, and that's what we do with our money, no, we take that money and we attend ADEA meetings, we attend standards committee meetings, we care about HIPAA, we presented the at the ADEA show annually, and we're doing research on how to improve our software not just clinically but in terms of keeping up to date with technology tomorrow.

Howard Farran: Your different customers, who has different issues with digital radiography, like endodontists looking for files, periodontists looking for cavities, oral surgeons taking implant. What are the different issues of specialists have or looking for?

Joel Karafin: I think the one that stands out the most, if I have to pick one, would be sharpening. Most dentists are at some level of sharpening when they're looking at the radiographs, but boy, do they vary. When you look at a radiologist, no they don't want any sharpening at all, the number zero. Zero, they want a raw radiograph. Others think that looks fuzzy. Personally, the radiologists have a lot of credibility in my mind, but the general dentist wants what he wants and so some level of sharpening should be applied.

Then there's other kinds of users who like a stronger level of sharpening, but no one compares to endodontists. We've been in university after university and it is so consistent that the radiologist wants none, the other dentists at university want a moderate amount of sharpening, and then go to endo. We need to be able to provide these different levels of sharpening to different customer sets.

That's what we did. We just released a piece of software, a version of our software, where the dentist can configure three different styles of sharpening in a variety of parameters and then call upon them when he or she wants them. That's what our newest customers can do and any old customer that's upgrading can suit the sharpening algorithms to their taste. That's how we take care of them.

Howard Farran: Okay. Go back and explain sharpening though. What do you what do you mean by that?

Joel Karafin: God, I can't tell you how much I appreciate that question, because sharpening is misunderstood. Sharpening is really edge detection. The idea that you've got a series of pixels over here that they're generally white or lighter gray, you've got a series of pixels over here that are dark, that are black or darker gray. The software's job is to find where those areas start to meet each other and to highlight those areas, make them more evident for the human eye.

The way it does that is to make the light lighter and the dark darker. It actually alters the data, changing the data in the radiograph. That should not be forgotten. There is always artifact whenever you sharpen. It must be done very carefully and as subtly as possible so that you don't introduce too much artifact. A classic problem with over sharpening is artifact under a restoration where it looks like recurrent decay, there's a dark line under that restoration. That's not good. We want to avoid that kind of thing.

Sharpening is edge detection. That's all it is. It will not show you a restoration as a ... I'm sorry. It will not show you an incipient lesion that's darker than otherwise. It can't do that. All it will do is create an apparent border around it to show you supposedly its extent. None of that is clinically demonstrated. None of that has been validated. Nowhere has sharpening been shown to do anything to improve diagnosis.

It can improve communication with a patient, co-diagnosis with a patient, co-treatment planning, that makes sense. But in terms of actual diagnosis, no. In fact, when you look at an actual resolution grading, this is what you use to measure the spatial resolution of an image. Use a resolution grading and see how well you can see very fine lines. When someone sharpens the image the ability to resolve those fine lines actually goes down. Not up, but down. Sharpening is not improving your resolution. In terms of spatial resolution, it's actually harming it.

Our algorithms, Doug is constantly working on those algorithms with our other mathematicians. We're working hard on decreasing the artifact, decreasing the problems with sharpening so the doctors can see the images in the style they like and still have the maximum amount of data.

Howard Farran: You said something, I asked you, I said, because a lot of people are asking, when can I just take a CBCT and it will carve out the bitewings and all that stuff. You said it's a lot of radiation. Did you see the article recently in the New York Times? "The Rising Incidence of Thyroid Cancer. It's easy to crunch the numbers on thyroid cancer and assume it is a disease fast on the rise. Incidence has more than doubled since the early '70s, and for women. It is the cancer with the fastest-growing number of new cases."

When I saw this the first thing I thought is it seems like the thyroid collar is hardly used in most dental offices and the CBCTs are putting out a lot more than the old phantom. Do you think there could be any correlation between the rise of CBCTs? Do you think there could be a dentistry component to this?

Joel Karafin: I always want to be incredibly humble to the data. I don't have the data, so I'm going to say I don't know. Let me see what I do know. Digital radiographs are less than half the radiation of their film counterparts for D speed film. That's good. Things are getting better in terms of dental exposures. That's one.

Two, as far as I know, there has never been one documented case, not one in all the history of dentistry, where someone got a disease because of dental x-rays. Three, data that I've seen suggests that it's still a case that 99% of exposures are intraoral radiographs, not CBCTs. We may be seeing them more and more, but I don't think ... I haven't seen certainly any evidence that they're actually causing cancers.

Please, there are so many reasons thyroid cancer could exist. There's chemical, there's genetic, there is radiation. There's radiation source as well beyond dentistry going on so I wouldn't jump to conclusions. In fact, let me say that I'm concerned about people jumping to conclusions. The number one cause of poor image quality, I believe and certainly everyone I meet at standards committee meetings agrees, the number one cause of poor image quality is under exposure.

How many caries are not getting diagnosed because of under exposure? I bet that's a much more serious threat. In fact, we have one state of the union who has actually made it a law that the exposure can't be above a certain amount, regardless of the patient, regardless of the position in the mouth. This is absurd. It's not paying attention to the science at all.

Now what we need is the right exposure, which will still be less, no more than half as much as D speed film, but will be the right amount of exposure to do what the radiography is supposed to do and that's to get a good image to diagnose real problems that are in existing right now. That's why we have exposure meter in our softwares.

Yes, it sometimes finds over exposures, but the vast majority of the time we're communicating to assistants that they're under exposing the image, cheating the dentist and ultimately the patient out of a proper diagnosis.

Howard Farran: That was very interesting. There's probably a lot of variables to this rise in thyroid. I find the most interesting research about the thyroid is how there seems to be this autoimmune cluster disease that are all related, diabetes, thyroid, celiac sprue, MS. Those clusters kind of run in family. Obviously, there's some autoimmune deal going after your pancreas or diabetes, thyroid going after your thyroid, celiac sprue going after your colon, MS. Probably a lot of variables in that sauce.

Joel Karafin: A lot of variables.

Howard Farran: In fact, they say that if you have a big huge extended family and someone is insulin-dependent diabetic, if someone has three of those, the fourth will pop up. If you have a big family, someone's insulin-dependent diabetes, on thyroid medication and celiac sprue, one of those kids probably going to grow up with MS. I mean, it's going to show up, the clusters kind of run in family. In my family, it's amazing how many of the men are short, fat, bald and stupid.

Joel Karafin: Not all of them. At least not the stupid part.

Howard Farran: Yeah. It's very, very common in my family to be short, fat, bald and stupid. It's a cluster. 

What else do you think? We have a lot of kids attention right now. Our podcasters tend to be millennials. You're talking to a lot of dentists probably under 30 to dental school. What else could you take this opportunity to educate them on digital?

Joel Karafin: How about coverage of the sensor? There's basically three sizes of sensors out of the market. There's size 2, there's size 1, and there's what some people call a size 1 1/2 you'd know think Dexis. They think that, given those sizes, they are also same, but it ain't the case. When you look at a Carestream size 1, that thing's wide. That thing's almost as wide as their size 2. There's only a millimeter or two difference. That's crazy. Everyone else is size. It's far closer to actual size 1 film packet such as ours. That's really quite different and it explains why Carestream likes to sell a size 0, I think.

Then there's the Dexis sensor. It's size 1 1/2. The question is: does it cover everything you need to cover? There's lots of controversy about that. There's issues of the radiographic field within the sensor, and this is what we have our patent on. In our size 2 sensor, we looked at the mesial dead space. What does that mean? When the doctor is taking that premolar bitewing, or the assistant rather is taking the premolar bitewing, we all know that it can be challenging to get the distal of the canine into the shot. Right?

The question is: what might be preventing that from happening? One of them is simply rounded corners. If the corners are slightly rounded with just 1 or 1 1/2 millimeter radius curvature at that corner, like the Schick 33, then it's reasonably pointy. When you are pointing an interior mesial, you are trying to get that premolar bitewing, it's going to impinge on soft tissues and the patient will stop you.

If the corner is much more rounded, and you've got to give Dexis credit here, it's very round, and ours is the second most roundest. Ours has a 6 millimeter radius curvature there. Six instead of 1 1/2 gives you much more rounding, you're going to be able to pull that sensor much more mesial, much more interior and you're going to more likely get the contact broken.

But there's more. Because if you look at, say, the Carestream sensor you've got dead space along that edge in the sensor where the core comes out. You've got 5 millimeters of dead space almost in that Carestream sensors mesial edge. The Schick 33 has 4 millimeters, roughly, dead space there. We have a patent on having it only at 2 millimeters of dead space. Now that's 2 to 3 millimeters of imaging area that's different.

You're a doctor, you're a dentist, you know what that means in that radiograph. You're going to more often get those contacts, the distal, the canine, you have eight contacts in your bitewing. It's what you want. It's what your patient's deserve. There's differences that are subtle like that.

What else is there? I mentioned the ease of cleaning before. That should be considered. Durability, of course. You want the darn things to last. Look at the warranty that's being offered. Really look at it. Is it a one-year warranty or is it a two-year warranty? One of my competitors talks about a three-year warranty, but when you read it you see that only in the first year do you get a free replacement. That's not good.

That leads me into the ... The first advice I would give to this young doctor: be careful what you believe. Really ask questions. I find it that more questions the doctor asks before they buy the happier customer I have in the long run, and that's what I want. Ask lots of questions and make them prove what they say. Make them prove what they say. 

It is a challenge for me and my representatives when they get on the phone, when they start making claims about their product and service because we are not believed. Doctors have been lied to so much that they no longer believe anything. That's difficult for my representatives, but totally acceptable because I simply instruct them don't ever claim anything you can't prove. That's what every doctor should demand.

Howard Farran: That's why Dental Town is a huge hit because-

Joel Karafin: Absolutely.

Howard Farran: -it's a place where dentists go and talks amongst themselves and all the research we see is that a dentist would rather ask a dentist peer 91% of time where only 9% would say I'll just ask the manufacturer. I mean, they are jaded at the turn a 91%.

I want to go back to these. When you're in emergency room and you go in there, and I have four boys so I went to the emergency room they knew us all by name, and someone falls down. The emergency room guy always wants to know what did you fall on. I mean, it's so different to fall on tile versus cement, versus the backyard.

When a sensor doesn't last 10 years, is it dropping ...? Tell me the top three things of why a sensor stops working. If dropping is number one, which I know I'm just thinking of this, would it be a bigger disaster to drop your sensor if you had a tile floor versus maybe linoleum, something softer, a softer service. Why are these sensors, how long is the longest sensor do you think you had last? What do you think that mean, the mew, the mode is. What do you think are the variables happening so that this expensive sensor is no longer working?

Joel Karafin: It is a big standard deviation. The curve, the bell curve is very wide. The mean, I would say is probably about five years. The mode is about three and a half years, four years something like that. Those were my mathy answers. More interesting perhaps is how they failed. That's a really good question. My total here is not wanting to make claims about other people's sensors when I don't really have the data on that. All I have is evidence I've heard, not really evidence, stories I've heard from users who are coming to us. It's not terribly good information.

Let me talk about my own. Our sensors, once upon a time-

Howard Farran: Say the name of it. I haven't realized that. What's the name of your sensor?

Joel Karafin: XDR. The XDR atomic sensor.

Howard Farran: The XDR, at

Joel Karafin: Yes. That's right.

Howard Farran: Okay. What is the X, D, and the R stand for?

Joel Karafin: Absolutely nothing.

Howard Farran: How about P90X?

Joel Karafin: Exactly.

Howard Farran: You can't find any personal trainer who'll tell you what P90X stands for.

Joel Karafin: X-ray doctor. How's that? Does that work for you?

Howard Farran: All right. So it doesn't mean anything? Okay. Why do these sensors, why do some last in a year and some last five to 10 years?

Joel Karafin: Once upon a time dropping our sensor was a problem. Once upon a time, God, back in 2008 and 2007, yanking on the corner was a problem. Those problems don't exists with our sensor anymore. I won't claim that you can grab our sensor and whop it against the table many times and it won't cause a problem. Casual dropping here and there onto a table surface is not going to damage our sensor. That's warranty.

By far the most common cause of a sensor failing is biting. The issue is that you've got some pretty sensitive electronics in there and the shells are not rigid. It was determined a long time ago that when you have a rigid outer shell, not only is it less comfortable for the patient as they close, but when but it's actually not as strong as if you make it somewhat pliable.

As the closing occurs you can deform the outer shell. If it deforms too much then you're starting pinging on the electronics inside and you will damage that sensor. So it's biting.

I'm not a dentist, you are, you understand the human bite force better than I do. It's strong. That's how they fail. It's as simple as that. We talk about patient management. We talk about using holders. We talk about how you speak to the patient. Don't tell them to bite down. No. Tell them to gently close. Those are the things that preserve the life of the sensor.

Howard Farran: Man, that was worth the whole value of this entire podcast. I'd never heard this in my entire life. I've never heard any of this.

Joel Karafin: That is amazing.

Howard Farran: You're saying there used to be a brittle, more hard sensor?

Joel Karafin: Yeah.

Howard Farran: Then they made them more soft?

Joel Karafin: Yeah.

Howard Farran: If it was brittle they can bite on it harder?

Joel Karafin: Well, what happens when something's brittle it cracks.

Howard Farran: If you drop a porcelain, it shatters.

Joel Karafin: It shatters. Imagine you're doing the risk analysis for the Food and Drug Administration that's going to come inspect you. Right? You need to show them your risk analysis and you have a brittle sensor and you're concerned that it may, as you put it, shatter. Suddenly you've got pieces in the patient's mouth. That is not good day. Then they want you to remediate that in some fashion. They expect it and this is a good way.

Howard Farran: The sensors are built better for dropping.

Joel Karafin: Ours are. Again, I can't claim for others, We've got special in here that's gone in over the past years.

Howard Farran: You're right. The young kids also don't realize that, like when you're doing a crown on the second molar and you take an impression. When you say bite down firm, they over close on the second molar. The lab man, he's like, how come we didn't reduce the second molar? That's because the joint overclosed. It's really patient management of trying to get this 200 pound sapien not to bite down on the sensor.

Joel Karafin: It really is.

Howard Farran: Wow. That's amazing.

Joel Karafin: I can tell you this. We have pediatric practice, but I'm not sure we have very many up them because off times I'll send them away. I'm not kidding. If I get a call from the pediatric practice, "Oh, let's use your software and sensors?" I say, "Gee, what are your patients like?" Do you have them sedated? Fine. Very few do though, of course, properly. How crazy are they, how good are your assistant with patient management? Are you going to take a lot of occlusal shots? Because if you're going to take occlusal shots on four-year-olds and three-year-olds, I'm afraid. I'm afraid that a month from now or a year from now or three years from now you're going to call me up and say, "Your sensor didn't last." I'm going to look at it and now I'm going to see massive bite marks on that thing and I have an unhappy customer. That's not good.

Look, I don't have an army salespeople. Most of my business comes in from referral. Not kidding. More than 60% comes in from people who have spoken with someone that has used our product. That's how they come to us. What's my best marketing? Happy customers. A pediatric practice may not be a good candidate for that.

Howard Farran: Yeah.

Joel Karafin: I actually sometimes send them away and say, "Look, go use a foster storage place system. Use my software, it's wonderful. You're going to love it, but I'm not sure about the sensors.

Howard Farran: Actually, if I was you and they called you up from a pediatric dental though, I'd say, "The x-ray is the least of your problems. Why the hell did you become a pediatric dentist?" What went wrong in your childhood where you chose Deb. That's my favorite specialist because without Deb I don't know what I'd do. Gosh.

Joel Karafin: I think let me tell a little story about Xander. His pediatric dentist found an incipient lesion, this is just when I was starting at this company. Actually, no, it was after I started with the company. I had gotten some education from my two partners about dentistry. I saw the incipient lesion and I said, "He's flossing. He is going to floss every single day." To this day he still flosses every single day. The beauty of it is the incipient lesion went away. It healed itself. I know it was a deciduous tooth, not terribly important, but I thought that was cool. It actually worked. That was dentistry hit my own.

Howard Farran: Are you selling these direct from XDR Radiology or do you sell through distributors like Patterson, Schein, Benco, Burkhart?

Joel Karafin: None of those distributors. We will not do that. It's not what we want to do. It doesn't fit with us. Look, we want to be a top-tier technology at a mid-tier price. We cannot do that and go through the big distributors. There's too many marketers and salesmen and huge trade [inaudible 00:42:21] to pay for. It just doesn't work for what we want to do.

When it goes through distributors you cannot control the quality of the fulfillment, the quality of the delivery. We have clinicians in our support team, they're all RDAs and RDHs. Every single one of them. We have people on the tech support, they're all IT specialists. I will look at the resume, unless it's in their background. We can control that kind of thing and we care about that.

We can decrease the price instead of paying for the salespeople. We don't have shareholders that we have to talk to every three months. We own the company, Doug, Adam and I, and so we can take a lot of that earnings and we plow it back into research and actually advance the field, like the patents we have both in our hardware and software.

This is what we want to do and we can't do that if we're going through the distributors. We go to universities, we can show them a kind of clinical seriousness sending a doctor to meet with them, working with their staff to teach the teacher, being part of AOMR, being on standards committees. We can do all these things because we're not beholden to a large distributor.

Howard Farran: What I love about Dental Town is I can go into Dental Town and on that app that little search bar, just put in XDR radiology and you have a lot of raving fans on Dental Town. I think that's really neat.

What did you think seeing about distributors, what did you think ... and in fact in the Greater New York meeting ... Were you in Greater New York last year?

Joel Karafin: I was not.

Howard Farran: Amazon was there. They've had a significant presence. Now they've been at the Dental Trade Manufacturers Associations meeting throughout three or four years, there's some Benco Dental guys, some Amazon there, but now Amazon has it both. Do you think that's going to be a game changer? You decided to sell direct as opposed to distributors, do you think Amazon will be a game changer in dentistry?

Joel Karafin: I don't know I can tell you that it presents an interesting challenge. It's good for us, of course, because you it's a price leveler. Doctors can see what the competing prices are. On the other hand, companies can hide details in the fine print that some doctors might not read. That claim of a three-year warranty, which is really only a one-year warranty. Doctors may not realize that, on basic comparison things. Will doctors ever hear about, in the imaging area, the size 2 sensor where aware that mesial edge is? They may not hear about that. It's a real challenge.

The idea of vending a sensor. Look, there are places you could call right now and they always give you the cheapest price on a sensor. You will have a digital sensor in your hand, but what are the features of that sensor? Is it going to help you diagnose? How long is it going to last? How easy is the software to use and install and maintain by your IT personnel? How much money are you going to spend on your IT person getting everything to work? How's that going to work out for you? I don't know if Amazon handles all that well. I don't know.

Howard Farran: That's why I was always mad at Microsoft all the time. They would rush out their software-

Joel Karafin: No. We're all beta testers of Microsoft.

Howard Farran: Yeah. You might have paid $300 for that. But then you might have had an IT guy in there working on bugs all the time. You're like, God, Bill Gates, the total cost of your software for me was five grand. Why couldn't you have just hung on to it for another 90 days and saved me $5,000 by working all those bugs out of it.

Joel Karafin: You're going to get me worked up here. I've been a computer programmer for over 40 years. Right? When I look at the stuff that Microsoft puts out it drives me bananas. They have ... I don't know what it is now. Is it $8 billion of cash in the bank? Are you telling me they can't create a whole division just to test their bloody software? Why do we need virus protection against an operating system? Why isn't it built-in? Why don't they have a program? They've got billions of dollars of cash in a virtual monopoly. Oh, please. As a programmer, I get pissed off.

Howard Farran: You talked about that warranty contract. I think the internet has really changed everybody because you go to any website it says accept the terms. I look on Dental Town. To become a member on Dental Town, you have to accept the terms. What percent of people do you think actually read the terms when they go to a website that says "accept here"?

Joel Karafin: Rounded to the nearest percent? Zero.

Howard Farran: Yeah. I mean, even when you're in the airport, to get the wifi, you have to accept these terms. Well, I don't have my whole layover to read this contract. Dentistry, it's really sad because these insurance companies will send them in a PPO provider contract and now it turns out that none of these guys even read it so now all of a sudden the company starts signing up for Medicaid and all these other deals. What's going on? It's like, "Dude, you signed that." I mean, it's crazy, but the way business is you have to read the fine print.

Joel Karafin: Absolutely, you need to read the fine print. I'll tell you what could help, and unfortunately XDR can't do it because if XDR did it, it would look biased. This could be the ADEA, this could be the AOMR, and you know what, it could be Dental Town. We need a decision chart. We need a list of features whether it's clinical or technical or durability or ease of use on the software with number of clicks to do a certain operation, or its price, how long the company has been in business without being sold to somebody.

All kinds of things are decision points and layout ... Have a real study done on all these different things and lay it out for people. I think that would be a game changer for the entire community and would be the real answer to that young dentist you were asking about.

Let's have functional charts and see who does what. Not just claims by the manufacturers, like you see in certain dental magazines where it's just the manufacturer saying, "I have this many installations. I can do this." No, no. Have it reviewed. Have an independent group of people, have the radiologists look at the image quality, have CPAs look at the durability statistics or the warranty or the warranty terms. How real people look at real things really lay it out. That's not something XDR can pay for because it will be seen as biased. Someone independent got to do that.

Howard Farran: She might be working as an associate at office and maybe they have a Henry Schein's Dentrix, or Patterson's Eaglesoft, or Carestream's open dental. But they've only been on that system and I was wondering your software, does it integrate? She's got to be the practice manager software system. Are there practice manager software systems that are easier to integrate with and work with than others from your point of view?

Joel Karafin: Somewhat easier, but I don't think that should drive her decision. That's my problem, not hers. She should get the practice management system she wants, that she likes. Look, there are practice management systems that are really extensive and complicated like a Dentrix. There are practice management systems that are very straightforward, get you right to the point, like an open dental. May not do everything, may not make your coffee for you, but boy, it sure gets the job done and they are very inexpensive.

You have others like that are sort of more than practice management systems they're almost services or communities like in XL Dent or something like that where you've got some real help, you've sort of got a partner, you can call them up, you can ask your peers for advice and help and contact the different vendors. There's a whole spectrum, and I should be up to the dentist, the imaging software should not drive that.

Howard Farran: You said that was the XL Dent?

Joel Karafin: Yeah. X-L D-E-N-T. It's just one thing, but there's so many of them out there.

Howard Farran: XL Dent dental software. Is that the name brand, XL Dent?

Joel Karafin: Yes. I believe it is.

Howard Farran: I know you don't want to say it, but just say it anyway. I mean, if you had to pick a dental practice management software.

Joel Karafin: Okay. Open dental was founded by a doctor Dr. Jordin Sparks. His brother is now running the company. We have a great relationship with them. Yeah.

Howard Farran: It really is nice.

Joel Karafin: I'm changing to that software as we speak. The staffs is doing the training now because it seems like, again, back to Dental Town, you do a search for all these other software companies and all the threads are just bitching, moaning, complaining and then the open dental people have just raving fans and it's cheaper. It's more open. It's more simple.

Can I be real here? If you search hard enough, you will find something on Dental Town that is complaining about XDR. You can't find it. what I think you're going to find right next to it is a response from XDR. For me that's a one ... We've talked about value of Dental Town. This is another value of Dental Town is it into the last gasp. We do our best to serve our customers, our practices, every way we can. But we're not perfect. Something will slip through occasionally and sometimes it shows up on Dental Town. Boy, are we watching for that? We know how important Dental Town is to us and we will respond.

I think you can look and see that we do respond on Dental Town.

Howard Farran: Yeah. I think that's amazing. I will appreciate that.

Joel Karafin: Okay. I appreciate it. No one's perfect. You're amazing. That's [inaudible 00:52:25] why I called you.

Howard Farran: Okay. I will appreciate that.

Joel Karafin: I think you're amazing. In fact, Dental Town now has a quarter million in debt. Right now we have one dentis who doesn't even think I'm perfect. Can you imagine that? It's so funny. There's a bunch of people wanting me to take down my last column, suck it up buttercup. It's all ended on us, the dentists are all mad at me and it's like, I tell them when I lecture or I tell them when they email me I said don't call me don't tell me, go to my column and share your thoughts there.

Why are you all saying all that on the phone or an email or text? I just replied back to an email and said, "I'll reply to you on Dental Town. Here's the article. Here's a link." Dentists, we should be able to scientifically debate in a cordial manner all of these complex thoughts. But they're always they always seem or I get emails every day of all these rants that people want me to post. It's like, well, why am I posting your rant? [inaudible 00:53:27]

Howard Farran: Do you know what's the hardest thing for XDR in Dental Town is not posting. Because we see stuff fly by. We see stuff fly by, a dentists talking to each other making claims or saying maybe negative things about our competition or something. We can't post. We should not pause. We see people being salesmen companies participating in some of these threads, they are just being salesmen. Boy, is it tempting to come on and say, "Oh, really? You know you say you're cheaper, you're not. You say your plan is great, it's not. But we can do, we do not do that we I try and take the high road.

Joel Karafin: There is something you could do. We made that report abuse button.

Howard Farran: Yes, sir.

Joel Karafin: We have a bunch of volunteers and when somebody thinks that somebody is spamming they hit that report abuse. That post goes to a bunch of different people instantly. What we do is we play baseball, three strikes you're out. If they're saleable we'll say you're supposed to be there to help not sell. There's a line there, so you put your signature, your name, your phone number, your avatar, you know who you are. if people like the way you help and share they'll probably contact you but that report of visa. We ban people all the time and we give them one morning and then we give them two mornings and third time they're done.

When they get a second warning anyway. They have to send us an email that explains what they did wrong. It's amazing how many doctors cannot see what they did wrong. So there's a bunch of threads on Facebook about you know how Dental Town is shrinking and falling apart when it's absolutely still growing at 1,000 new doctors per month. It's huge but they don't realize that you can't call people names, you can't use profanity. You can't be races I mean. There's a lot of well there's not a lot I would say out of a quarter-million dentists in 19 years we may be banned thirty-

Howard Farran: That's tiny. That's tiny yeah so.

Joel Karafin: For me, it's not cussing or something like that, it's being salesy in a forum where dentists are supposed to be able to be not have to look at all that chunk. Right?

Howard Farran: Yeah. You hit a report abuse and any of those moderators agree with you that post is deleted and then they kind of send a message saying.

What we try to do is simply ... When we do post, on the rare occasions when we do post, I try to just post the clinical detail. Here's a real image, here's what you're looking at it, here's the radiation, here's the thing. Whatever the issue is I try to just leave it to the clinical and go from there. That's the toughest part though. 

When I started Dental Town all these dentists got mad that there were people from dental manufacturers on there. They said, "Well, they're on board, they're trying to sell stuff." I'm like, "What are you? Are you a volunteer? What do you work in public health? I'm pretty sure you're selling crowns and bridges and root canals and all that." Americans always think they're the greatest and everything. I really like the European, that the IDF meeting better every other year in Cologne because they're big ADEA meeting, which is like 120,000 people. That's like twice big as yearly ADEA meeting. They don't have lectures. So the dentist in Cologne, if I have a question about your sensor, I want to talk to you.

In America, these dentists who sell ortho and invisalign and veneers and bleaching and bonding and their sales went all day long, they say, "Well, I don't trust you because you're selling. I want to go to a lecture and have some dentist." There's all these dental x-ray out there that pretend they're experts in every bonding age and every x-ray deal and all stuff. The Europeans think, "Well, who would know your product better than anyone? It'd be the person who made it in program and they want to go talk to you. I really think the European dental societies are so much more functional.

Then you come to America, then how many trade restrictions do they have at these meetings on booths where you can't sell or you can't take orders you can't make change. I mean, it's like having visions of like Jesus in the temple kicking over the money changers. Oh, my God, this is crazy. The CDA ... and then you go to Cologne and half of those booths have beer and wine and the CEO is there and they're taking debit cards. A lot of these dentists say, "Well, I'm picking between these three systems and I want to go talk to the owner of these three systems. Two of them, the owner is not there, it just sells people. I actually bought this because the owner was there and actually told me everything and that's why I love it and why I called you when you post [inaudible 00:58:32]

I mean, that's a question or a complaint or whatever. You're right there. You're transparent, you're available and that's the European model. I think it's a better model. I like that, especially the beer part.

Joel Karafin: That's an interesting education because I don't have a lot of experience over there from my point of view on the corner bookshop model. I don't want to be the big chain bookstore. I want to be the corner store where when you walk in there they may not actually know your name but they know you and they know you were looking at the travel books last week. They might recognize, "Oh, I have a new book that you might want to see." So there's something personal. There's something real and they love their work, they love what they do.

XDR small, we do one thing. We do, well, two things: 2d imaging and radiography. That's what we do. We focus on that. We tend to our meeting. We think we're the best in the breed and we think there's others that are best in the breed, and we think that matters. We think that the prices can be lower when you don't have a corporate nest to go through. We think that the quality can be higher as these small companies care about being the best. We think these small companies tend to be more open. We interface with every practice management system that we've ever come across.

We're happy to work with any of them in terms of exchanging images with them, in terms of creating bridges, two-way bridges, and embedding. We're happy to do any of that. This is vital as we go to universities because they care about that kind of thing. We think that there's a reason that these small companies still exist even with all these corporate buyouts going on because there really is a better product and we're just nicer to deal with. That's just XDR. There's a whole series of this out there in various areas.

Howard Farran: Well, I like you. I love your helping on the message boards. I learned a lot from this program. I could have sworn dropping it was the worse. It's so sad because sometimes I generally get so mad because I actually triple the cordial. I almost fall down herself. Usually when the sensor hits the floor so that Jan hits it too.

I just want to tell you thanks for hosting on Dental Town. Thanks for coming on my homies and giving them an hour commute to work, educating them more on digital radiography than they ever do before. You're amazing. Thanks so much for coming on the show.

Joel Karafin: Hey, thanks for having me.

Howard Farran: All right, buddy. Have a rockin' hot day. By the way, your other partner-in-rime Dr. Yoon, Dr. Doug Yoon, tell him that he's got an outstanding invitation or, in your words, an "insufferably proud invitation." Tell him you I don't care if it's a year from now or whatever, but if you ever want to come on the show it'd be honored to have him on the show.

Joel Karafin: Fantastic. We'll make it happen.

Howard Farran: All right. Have a rocking hot day.

Joel Karafin: You, too. Thanks a lot.

Category: dental, Podcast
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