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VIDEO - DUwHF #712 - Frank Milnar
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AUDIO - DUwHF #712 - Frank Milnar
Frank J. Milnar DDS, AAACD is a graduate from the University of Minnesota, School of Dentistry. He is an Accredited member of the American Academy of Cosmetic Dentistry and a Board Examiner for Accreditation. Dr. Milnar maintains a full-time practice in St. Paul, Minnesota emphasizing appearance related dentistry. He has published numerous articles about the direct placement of composites, shade selection and minimally invasive dentistry and is on editorial review boards for numerous dental journals. Dr. Milnar is co-founder of the Minnesota Academy of Cosmetic Dentistry and has lectured extensively within the U.S. Armed Forces as well as internationally on the subject of direct composite restorations, shade selection and minimally invasive dentistry. He has been voted “Top Dentist” and voted into the “Top Dentist Hall of Fame” for the last six years by his peers in the Minneapolis/St. Paul Magazine. He has been voted by Dentistry Today as one of the top 100 dentists contributing to dental education. Most recently, Dr. Milnar was nominated to the University of Minnesota School of Dentistry Continuing Education Advisory Board.
Howard: It is just a huge honor for me today to bring back a friend of mine for probably three decades Frank Milnar, DDS, AACD, all the way from St. Paul, Minnesota. Frank is a graduate from the University of Minnesota School of Dentistry. He is an accredited member of the American Academy of Cosmetic Dentistry and a board examiner for accreditation. Dr. Milnar maintains a full time practice in St. Paul, Minnesota, emphasizing appearance related dentistry. He has published numerous articles about the drug placement composites, shade selection, and minimally invasive dentistry, and is on editorial review boards for numerous dental journals. Dr. Milnar is co-founder of the Minnesota Academy of Cosmetic Dentistry and has lectured extensively within the U.S. Armed Forces as well as internationally on the subject of direct composite restorations, shade selection, and minimally invasive dentistry. He's been voted top dentist and voted into the Top Dentist Hall of Fame for the last six years by his peers in Minneapolis/St. Paul, Minnesota. He has been voted by Dentistry Today as one of the top 100 dentists, contributing to dental education. Most recently Dr. Milnar was nominated to the University of Minnesota School of Dentistry Continuing Education advisory board. Frank, it is just an honor to have you on the show today. How are you doing, buddy?
Frank: Howard, I'm doing very well and I'm quite humbled by that introduction. You know, I've only been a dentist for 41 years, coming up on 42. And I would have achieved all those things that you said sooner if it wasn't for one thing and that was lack of talent.
Howard: I would say, guys like you ... My read on guys like you is just a natural curiosity, humbled to learn new things. You listen to other people. If you're naturally curious, and you're humble and you hustle you can really learn a lot and dentistry can make a great profession for you, wouldn't you say?
Frank: Well, it comes back to the title of this podcast, Howard, I'll let you troll on me. It's called The Path Less Traveled and I'll tell you where this curiosity and creativity came from. And I'll tell you where it didn't appear and that was through dental school. Because in dental school no where was there any mention of creativity and artistry. It was all science, left brain stuff, but I'll let you start it out, Howard, and we'll look back into this and this is really kind of a cool story.
Howard: Well, tell the story.
Frank: Okay. So, just for your viewers out there, for disclosure, I'm not the smartest guy in the room. Okay? I'm creative. I find ways to get around the smart guys. I came from the back of the room. I did not sit in the front row because I didn't want to be identified, embarrassed, by who I was. However, I studied the guys in the front and I saw what they did and how they learned and I wanted to work my way from the back of the room to the front of the room. Okay? I was the guy who always made the last cut. I was the guy that just barely made it into the B's. I was the guy that just sneaked into an A, once in a while. But very seldom could people outwork me because I have a very strong work ethic accompanied by creativity and of different ways to achieve what the smart guys do. Now, you tell me, Howard, in undergraduate school 1967 through 1971 as a science major like all of you took the biology, the chemistry, the physics, the calculus, the philosophy. How many people do you know, Howard, had a minor in english and art history?
Howard: I would say none. You're the first one.
Frank: I was the first one. I was the only guy in that whole science building that would hang out with the art students. I'd be the only guy writing english papers and I hadn't a clue, but it just felt like a natural fit. Okay? So be it. On to graduation 1971, on to the University of Minnesota. 1972, welcome to the world of science. Okay? Now, I bought into it. I had to to get a degree. Get my diploma and get going. I started out ... I did a GPR residency at the VA hospital in Minneapolis. Oral surgery and prosth were my two components, he two foundations that ruled dentistry back in the 70's back then.
It was like totally overwhelmed prosthodontics and my head of the VA out there, Dr. Dave Tuomey was the king of removal prosths at the University of Minnesota and I wanted to study under the master. Well, I hung out with a prosthodontist. Then I became a clinical instructor in removable prosths right of the get go after the GPR. And then I bought into dentistry quadrant amalgams like you did, Howard. I mean, it was rock and roll in tooth destruction, quadrant amalgams, gold crowns, you name it we did it, anterior composites just on the scene, phosphoric acid. We didn't know what mega pascals were. We didn't know anything about how many dentin tubes we were opening up.
But the big thing I always remember about the practice management people that arrived in the 70's is ... was all about production. We were successful dentists, if we could produce. How crowns could you prep? What was your daily production? What was your daily production goal? How could you share that with the staff? How could you give them bonuses for your production? How could you make more money by destroying tooth structure? That was the bottom line and I bought into it, Howard. I was really good because I'm really competitive. And I destroyed a lot of teeth and I made a hell of a lot of money.
Now, here's the part. In 1993, I hit the wall. I went emotionless in the dentistry. I looked in the mirror and said, like Carly Simon, "Is that all there is?" I hadn't a clue what had just happened to me. I had no passion. I couldn't look at myself in the mirror and say, "Who am I? What am I gonna do? Where am I gonna go?"
And some ... one of my good friends who is a ... Chuck Maragos from Valley Dental Arts in Stillwater said, "Frank, you oughta come to the AACD." And I said, "What's that?" "Well, it's the American Academy of Cosmetic Dentistry." And I said, "What's that?" He said, "It's a [inaudible 00:07:06] all the leaders, the Ron Jacksons, the Larry Rosenthals, people like that. They teach you. He says, "You gotta try it on for size." I went down there in 1993, Howard, looking for something. A new message. A new vision. That was in Miami. As soon as I walked into the door, I saw people having fun. I saw people going into class. I saw people socializing. And I saw people like Ron Jackson. I saw people like Larry Rosenthal. I saw them teaching and socializing with the people in the classes and I said, "That's it. I'm in. That's all it took.
Now, I had a problem. I didn't know enough. So what I did is I reinvented myself in 1993. Everything I knew got destroyed. Everything I was in that office that I practiced dentistry, I told the staff, "We're gonna go on an amazing journey. I'm not sure how long it'll take, but you're gonna see something different. The next version of me." Immediately I went back and I called the professors at my undergraduate school in St. Paul, Minnesota. And I called them in art history department and I said, "Hey, guess what. I'm coming back. I'm gonna be a student in art history. I want to go through the renaissance again." I wanted to attack every single cause of ignorance that I could perceive that I had and I wanted to seal the breach.
So I went through a year of art history in undergrad school. I learned all about pointillism, cubism, Monet, all these artists that had a major influence in color theories, color blending, the color wheels and then I went into the dental laboratories at Valley Dental Arts. And I said, "Here I am. I want to start at the bottom. I want to work in your model department, pouring up models. I want to die trim. I wanna work form the ground up in the dental laboratories and learn what you do that I take for granted." I did that one day a week for three years. I evolved, Howard. I evolved from ... I wasn't Dr. Milnar there. I was Frank. "Frank, could you pour up that model? Frank, could you do this? Can you get the call on some guy who said you die trimmed his model wrong?" Well, it was a bogus impression. I just tried to make up margins like they did for me. He didn't know I was a dentist. I was just Frank. It was interesting, Howard. I gained a lot of empathy for the dental technicians that got blamed for poor content. They had to do that.
Now, this is getting interesting. So, I became accredited in three years. From a guy from the back of the room to accreditation in the AACD in three years. That was the biggest mountain I climbed. I had no idea how I did it. Nor did my family cause I was totally consumed by this. But I was reinventing myself as I went along. I was a piece of clay. That's all I was, trying to shape myself figuring out how to do this the right way. I picked on some world class mentors, to be nameless. I said, "Help. I just became accredited. I want to learn how to teach."
Because I saw these people with microphones, laser pointers, slide carousels, no less. Some with three. I said, "This is it. They have recognition. They have respect. They are learned people. They are willing to share." I said, "That's what I want to do." They said, "Listen, Frank. Do you have any idea what you're gonna need to do to do this?" I said, "Well, I dunno. Let's go. What are we gonna do?" They said, "First, you have to be a better clinician. Sure, you're accredited. That's just the start. That's number one. Number two, you have to be an educator. You have to be about ... Learn who you are before you learn who your audience is. You just can't talk to slides and have speaker notes from the manufacturers. That's bogus. That's unethical. But it happens. Number three, you have to be a publisher of your works." I said, "How high is this mountain?" They said, "Higher than you'll ever ... can imagine."
I started that, Howard, that climb about 1997. 1999, I was asked by Larry Adelson from San Diego, head of AACD examiners to be a board examiner 1999, after three years of being an accredited member, I have no reason ... I don't know any good reason why they picked me to be a board examiner. They saw something.
Something was growing, Howard and at that point I was learning who I was and what I was meant to be and what ... How could I overcome the difficulties in the kind of the sense of the past in the 70's and 80's. And teach people don't do this. It's not worth it. You're gonna wind up like me. Your staff knows it. Your patients know it. And I said, "I'm gonna ... This is gonna be my message. Going forward, sure I can sell product. I can show you artwork on the slides. I can show you complex bonding, smile design. I can show you a lot of really good artwork slides. But before we talk about that let's talk about who you are. I'm gonna tell you who I am. Who are you? What are you gonna offer this profession that's ..."
You know this, Howard. It's been the best to us. It's been very good. Better than anything I know. If you get your head screwed on straight and you get this figured out what this is all about. And some day you're not gonna be here. I'm not gonna be here. And we're gonna pass this on to the next generation unless we get to these kids that are coming on here online and get them connected with mature mentors.
I am a little bit worried the future of dentistry and how corporate dentists are gonna come in and have a major influence on the quality of dental care. Now, that's started to evolve. Once I became authentic with integrity, once I became unique as an individual and we'll talk about that. How did my personality develop, it came from a certain place before I went to dental school is ... Where are we gonna go? What are we gonna do about this? And this is where you and I are in the legacy stage of our career, trying to make sense of this before our time is up.
That's kinda the story, Howard. But it all started once I could look in the mirror and find out where I was going, doors started opening up for me. I know this wasn't by chance. That this had to get out. That there was toxicity in our profession. We can be seduced by pay, by production. We can be seduced by lack of leadership. We can be seduced in so many ways of dentistry. But there's only one way to do it and that's the right way. And that's what dentistry's all about is doing it the right way for our patients, for the teeth. The dentists come third, Howard.
Howard: That's a beautiful story. And it shows ... You know, you practice for ... You graduated in '75 and you said you hit a wall in '93. It sounds like in '93, you were just starting to be dead inside about the profession.
Howard: And then you found the AACD and others might've found the AGD or Spear or Kois or Pankey or Dawson. But that's where these high dollar institutes really give you a return on investment is when they ... Not teaching a clinical skill, but getting your head back into the game. And it sounds like the AACD was that and a bag of chips for you. It really inspired you. And that's the same thought I have about ... A lot of people think I'm against CAD/CAMs and lasers all that stuff. They're not listening to me. If that's what makes you run 20 red lights on the way to work, God dang, you gotta get it. As opposed to what? A burnout, you get tired, hate your job. But if you're broke with $350,000 in student loans and you think you have to buy a CAD/CAM to be a great dentist, well that I disagree with. Do you agree with what I just said on CAD/CAM and laser? Do you think you can be a high quality dentist in St. Paul, Minnesota without a CAD/CAM or laser?
Frank: You sure can. What's most important when these dentists say, "Frank, what product do you use? What was that instrument that you touched that with? What was that finisher and polisher I just saw on slide 50 in the handout or in the workshop?" And I said, "Do you understand something? It's not those products. It's not that instrument. It's not that laser. It's your patients. You get to know them. You get to earn their trust and respect. And then you can get the lasers and you can get the all the other stuff to go with it, but unless you understand the trust and confidence and why they look at you as their dentist, the rest it doesn't make any difference." Howard, it just doesn't.
Howard: You know, one of the greatest things I learned at a AACD course, I was actually lecturing at it in Jamaica, like a zillion years ago, is we were talking about an instrument, I asked. I said, "What instrument was that?" He goes, "Dude, I dunno. I buy all my direct composite stuff from Hobby Lobby. They have ... Arts and crafts stores." I came home and I went to Hobby Lobby and got all these spatulas and [inaudible 00:17:55] When I'm doing direct, you know, for all the interior teeth on pretty girls. Have you ever bought any instruments in the mouth that you didn't buy from a dental company and it was intended for arts and crafts?
Frank: No. I did ... Oh. Well. Well, yeah. I did. My sculpting brushes. Yeah, I bought them from [inaudible 00:18:16] You know, they had some kind of neat angle things. I did that. And I can say for the most part, I'm more artisan, which we'll get to. But yeah, I can take things offshore and, you know, incorporate them for the most part. But usually as a consultant for a lot of manufacturers I'm kind of foundational in their instrumentation and coming up with new designs that fit the need for what we're doing, the paradigm that we're restoring.
Howard: Well, to this day, if I had to do an interior class four or a direct anterior composite, there's one instrument, Frank, that I can only buy at Hobby Lobby.
So you just two weeks ago you gave what? Three lectures at the AACD meeting in Las Vegas. And by the way congratulations. I mean that's like the Rock and Roll Hall of Fame. I mean, you can't play at the Rock and Roll Hall of Fame. You can't lecture at the AACD meeting unless you're all that and a bag of chips. What were you lecturing on?
Frank: Well, it's interesting, Howard. This is my passion. This and the workshops because this is where we get a real affect on a one to one relationship with the attendees. And one of the cases you have to submit to become accredited is six composite veneers and you have to show the step by step to the examiners. We grade your work and it's usually the final hurdle. Everybody passes the other case types and then they stumble on case type five because, as you know, six composite veneers. That can be the Bataan Death March. There's so many different trip wires in there. So about seven years ago, I stumbled when I became accredited. I just, my God, probably seventy-five hours into a case and I was still not there. So I said, "Listen. I'm gonna do this. I'm gonna develop a case type five protocol with slides [inaudible 00:20:27]" And then my laboratory accredited technician Jenny Walberg from Valley Dental in Stillwater. I said, "Jenny, we're gonna teach this. Okay?" So Jenny and I were the first ones to teach the case type five in the AACD. However, Howard, this gets better.
As a board examiner at the AACD, I got to know who is who and sitting in these board rooms. But then you got to meet them personally, and I sought out Brian Lesage from Beverly Hills. And we had some small talk and I said, "Hey, Brian. Let's teach case type five together with a lab tech, accredited lab tech Jenny Walberg. Let's be the first one." So we were the first ones to arrive at case type five in the AACD three instructors, one lab tech and two accredited members. Well, as the story goes, that went on for two or three years. Now, Brian and I have been teaching probably for five years together and our course is probably sold out in five minutes on an annual basis. Because of the content, Howard and how we teach the course. So that's one. I always look forward to that. 50 people in a classroom, two guys were gasping at the end of the day. It's grueling.
The other one that I've introduced that I have a lot of passion in. I was curious like you said. I was real curious in the 90's about pink composites. Not much there. How do you use it? There are no instructions. But I was used to this from the 70's, Howard. Heck, we just picked up stuff and figured out how to use it. Well, I picked up some pink composites from Voco and GC America, everything. And I kinda just looked at them and said, "Wait a minute here. This is anything goes." They just sell you a box and you're supposed to create these things, roots and things like that. I said, "This doesn't make any sense.
So three years ago, I consulted with Shofu, one of my sponsors as with ... Many sponsors and they became very interested in developing a pink composite in which they had the full array of finishers, polishers, burs. So all I did was sequence the darn thing, package it with burs in a step by step video illustration in how to use pink composites. It's called the Trilogy of Pink. [00:23:06] In fact, I just gave an all day pink composite workshop up here in Minnesota for the Minnesota Academy of Cosmetic Dentistry. The first part of the Trilogy of Pink is gingival recession because if your patients don't want grafting procedures and they're scared. They don't like these exposed roots. What does the clinician do today, Howard? They put in VITA composites. A2. A3. And what do you get? You get a big long white tooth. Doesn't look good. So, the first part is how do you restore gingival recessions.
Now, this is the artist in me and in the, as you say, the curious part. I also did the trilogy of this. I did one on a typodont with no sulcus. I did the second tooth with a different color and a sulcus and no micro-texture. The third one, which is the artistic design, is a different color with a how to create sulcus and how to create micro-texture to mimic the pink prosthetic area that you're restoring. That was the first part of the Trilogy of Pink.
The second part of the Trilogy of Pink is closing dark triangles. And if you know Dave Clark up in Tacoma, Washington with Bioclear. This is the guy that's really revved me up. I've taken his courses. I'll be teaching Bioclear with David, for David. And the bioengineering way to do things that makes sense and how to close dark triangles. Our profession does not know how to close dark triangles. With flat mylar? Give me a break. You can't do it. You're gonna get purple inflammatory tissue versus pink healthy tissue. That's number two.
Third part of the Trilogy of Pink is after you have dark triangle closure with white heated composite, injection over molding, is that you do a cut back where the pink prothetic area is. And then you apply the lessons learned in component one in how to overlay the gingival portion of the dark triangle closure where there was gingival tissue. I mean, that ... I just gave you a mouthful, Howard. That's a lot of stuff.
Howard: Who is that guy you were talking about?
Frank: Dave Clark. Bioclear. He's the guy you want to talk to.
Howard: Bioclear. Where is he at?
Frank: Tacoma, Washington.
And I'll tell you why. Should I digress now, Howard?
Howard: Well, first of all, I would never podcast a Seahawks fan. I mean, there's just no way. There's just certain things I will not stoop to.
Frank: Well, okay.
Howard: But I want you to digress. This is Dentistry Uncensored.
Frank: Okay. This where it really gets cool, for me, because it's who I am. I worked undergrad school and dental school in heavy construction, okay? I wasn't afraid of a shovel. I wasn't afraid of any of this hard work. Going up 15 floors with no safety rails. I could look over the edge. I could do this kind of stuff.
I didn't know, Howard, if I was getting into dental school in 1972. Why? My grades weren't there. Okay? I wasn't the first one to get accepted. And time was marching by. It was right after school in May, no acceptance letter in dental school. So I'm thinking this, "What happens if I don't get the acceptance letter in dental school? What am I gonna do?" I walked this one back a year before. I got my 49ers license. I was a tower crane operator. Okay? I was up in a tower crane.
Howard: Wasn't that the Vietnam War too?
Frank: That was ... Yeah, the Vietnam War was there at that time too. As you know, that was not a good time in this country.
Howard: But were you worried about getting drafted?
Frank: No, my draft number was high so I missed that one.
Howard: What was your draft number?
Frank: Oh, I forgot what it was. Was it a 200 number or something.
Frank: It was high.
Howard: Okay. So you became a tower crane operator.
Frank: So anyways. Tower crane operator. So I saw construction from straight on as a laborer. And then I was a concrete tester. I was around pile drivers. I was around steel workers. I was around carpenters, electricians, plumbers. I saw the whole thing. I saw the guys brooming slabs. I saw flying slabs, pumping concrete. And then from an aerial view, I saw it from a different dimension, but I got the artisan part real good. I saw framing. I saw finishing, polishing. I saw how to finish things and cinch them and seam them. I knew what grade level was. Okay? I knew what blueprints were. Okay? I could see the blueprints. Everybody had blueprints.
So when I got accepted, probably one of the last ones to get in, I climbed out of the tower crane for the last time and I started my career as a dental student. Again, no artistry, no creativity, but a hell of a lot artisan principles and construction. And I had to put that in the back of my mind cause it didn't exist in dental school. When this thing came full ... When this came out, Howard, and this art history thing, the construction principles came out with is. So today, when people take my courses, we're talking about construction. We're talking about common principles of architecture, of building, of installing, uninstalling. All these things are true, not to dentistry, but to the artisan skills that would have been through ... with, for mankind long before dentistry arrived. So you're gonna get a unique perspective of a common sense guy, hard working, artistic, creative, with a construction background.
Howard: I want to go back to something though. I asked you what you were lecturing on at the AACD a couple weeks ago in Las Vegas, the annual meeting. You said case type five, six direct composite veneers. You've been in dentistry 41 years. I graduated from dental school 30 years ago, yesterday on May 11, '87.
Tell these kids cause a lot of people don't like to tell the truth, but tell these kids if you took a 21 year old and you filed down those six anterior teeth just a millimeter or so and did six indirect porcelain veneers and cemented them versus doing six direct composite veneers on a 21 year old girl. Let's say she's 20. What would happen to those teeth if you did an indirect porcelain veneer? You prepped the teeth. What would those six teeth look like from 20 to 30 or 40 or 50? Now she's 60. How many ... At 60 years old, how many of those would have had to been redone? How many of them would turn to endo? How many of them would have turned to a full coverage crown? How many of them might have even the endo failed and been an implant and a crown?
Frank: Lots. More casualties of war than we care to admit, Howard. We went through the AACD seduced by porcelain laminates, [inaudible 00:30:51] All of them. Leading the pack, [inaudible 00:30:57] Dorfman, you name it. They were all there. We all wanted these beautiful website photos of all the indirect veneers. Now I'm gonna tell you this. I'm gonna answer your question straight on, Howard, is that in the AACD now if you ... If we smell dentin on a direct veneer, you fail. It's responsible aesthetics. [00:31:25]
I don't think ...
Howard: Nice. Responsible aesthetics. I have not heard that term.
Howard: I always considered it the aesthetic, health compromise.
Frank: No, no. No. If you and I start out our own dental school right now, I would not let them one porcelain laminate on an anterior tooth until they learn how to do reversible, repairable bonding, which is the ethical standard of our time. You cannot take an indirect procedure on a juvenile in 20, 21 years unless they sign the contract that you disclose you're gonna lose some of these teeth. They will be lost. Every time you have irreversibility with these porcelain surfaces, albeit more stain resistant. I don't know. But those things are gonna be taken off and when you take them off, you're drilling deeper into these teeth. Pretty soon, you lose your foundation of your dentin support. The stress distribution mechanism of that whole tooth, the shock absorber that nature gave it in the first place, is screwed. It's done. It's cooked. You have no out, except drastic dentistry, which is what they should major in if they're gonna do that, cause you're gonna see train wrecks.
Howard: But, you know, you and I saw the hypocrisy cause I think we talked about this over more than a drink or two decades ago. A lot of the guys don't always force veneers when his 18 year old daughter had crooked teeth and wanted veneers, he said, "No way. You're doing ortho and bleaching and bonding." So did you smell that 10, 20 years ago where they kinda ... They knew in their gut this wasn't good, because they had a different behavior for their wife and children than they did on their patients.
Frank: Well, how true, Howard. We were practicing anecdotal dentistry. We were being pulled along by corporate America saying, "This is great. This targets [inaudible 00:33:21] This everything. It's so cool. It's gonna work." But we didn't know about the problems. We gave them the data about the failures that we had. Ergo we get the new and improved this. And the new and improved based on what? Based on our failures. Okay? We didn't know anything about that. Now, today as you know, everything is evidence based. You cannot do anecdotal dentistry without clinical references. And I may say too, in front of a patient, you have to disclose your competency about what you know about this. What are the risks? Going forward, when you touch tooth structure, what are the risks? Doing nothing sometimes, Howard, is your best option for the patient.
Howard: I'll never forget when I met thee oldest dentist ever. His name was George Ruey, Sr. And his son George Ruey, the second was a dentist. And his son George Ruey, the third was my roommate all through dental school. And I asked the 92 year old George, I'll never forget, I said, "Which tooth lasts the longest?" And he said, "The one you never touch."
Frank: Uh huh.
Howard: Treatment condemns it to re-treatment. Fillings turn to crowns. Crowns turn to root canals. Root canals turn to tractions.
Frank: We saw it all, Howard. In our time, we saw it all. With these amalgams that we put in. And we saw what happened when we messed up the stress distribution and these cusps started snapping off. And then we started entombing these amalgams underneath and then the teeth died and then you put reamers in the teeth and you open up the big access openings in these teeth and they broke off at the gum. Then you put a screw post in or a gold post and then you screwed up the radicular support of the tooth and then there she goes. Then we grab the forceps and out it came, partial dentures. And you knew how that worked, you put a clasp on a tooth and that just headlocked it into submission. And then you kept on adding on and on until you got a full denture.
Howard: Frank, I want to ask you a real ... I'm gonna hold your feet to fire in this. I'm gonna bring you down to real world reality. You got lots of kids driving to work right now and they're out in the middle of just, you know ... We were born and raised in the the flyover states and they're driving to work in Shawnee, Missouri, you know, Edmonton, Oklahoma, Parsons, Kansas and a cusp breaks off and a lot of the AACD guys say, "You know what. I just replace what's ... You know, I take out the old filling. What's broken? Maybe I'll bevel a cusp. And I just take an impression and do an inlay or an onlay or whatever. I just replace the missing tooth." But the reality, the cold, brutal, ugly truth, if she just takes out everything, [inaudible 00:36:11] a functional cusp if it's in jeopardy and submits an impression and does an onlay, insurance says no dice. But she gets out her diamond and files that tooth down for a full coverage crown, they pay 50 per cent. That's a brutal reality for at least 80 per cent of American dentists. What would you say to that young girl? She's 30 years old listening to you on the way to work. What would you say to her? [00:36:37]
Frank: First of all, you have to pay your debt, Howard. I know this. I know that these young graduates are deep in debt. I feel bad for them. That's a tough one to get out of. I can tell you where your future is right now. Whether you work in a corporate setting. Whether you're just starting out in a small, rural environment. Whether you're in a thriving practice. Things have turned. Before you amputate that tooth structure into 360 degrees of tape or adhesion that you can adhere the zirconia crown or whatever it is, you can scan it. You can do anything you want. Just remember this, the new emerging frontier in dentistry is bio-activity and therapeutic materials, glass ionomers, pulp dentin.
Before you crown that darn tooth, you gotta ask yourself the question, "What is the survival rate?" In this, 15 percent of all crowned teeth need root canals, Howard. So how can you get around that one? What if you snap that tooth deep around the pulpal tissue or deep into the dentin or sub-gingival? Why not put a therapeutic build up that is a dentin substitution such as glass ionomer. Why not put a therapeutic material like Pulpdent activa in there and let the tooth heal. First to determine the survival rate and then come back later and harvest it in the future. All you're building is integrity with the patient. Don't go to that crown right away. Don't do it. You're gonna see it come back at you and the patients are gonna wonder why you put a big hole, man hole cover in that brand new crown that you just put in a year ago. They get suspicious. You cannot lose, Howard, by doing something else as a option to the patient. You can't lose.
Howard: Yeah, I want to ask you another hard pounding question. A guy with 41 years can brutally tell the truth. She wants to be a good dentist. Does she need to buy a $150,000 CAD/CAM to be a good dentist? She's got $350,000 of student loans and she's in Parsons, Kansas.
What you need to be is a good communicator. What you have to do is learn where the risks are. And here's another opening. What I do now, Howard, versus pick up the hand piece and look at the x-rays and hell, 40 years ago, I'd say, "You need a crown, Howard. You need quadrant amalgams. You need this. You need that, based on ... to fit my treatment plan, to fit my equipment, my production." Today, I look at risk assessment on all patients. How many restorations do they have in their mouth? How old are you? How old were you when you got your first cavity? I check oral environment first with litmus paper to find out the pH of their saliva, to find out if they're moderately acidic or highly acidic environment. I do not touch these people with anything but glass ionomer if they are in risk categories because your work is gonna be doomed.
And if you walk into a hostile, non-friendly ecosystem in the mouth and you think you're gonna do fun dentistry and crowns, they're going down. They're gonna go down in five years, Howard. And you're gonna have to tell the patients whose fault it was. It was you. You never established the risk. So today, I'm telling all this graduates understand the environment that you work in is full of bio-film. Three per cent are the bad guys and if you let these guys loose with moderately acidic or acidic saliva, they're gonna take down 97 per cent of the good community. The work's gonna fail. I think that should be a good starting place because a builder of the mouth before you get in there and take that hand piece and start removing tooth structure.
Howard: Frank, I want to ask you another international question. Why do you think the Americans ... Well, I mean, the bottom line, seriously ... You say you started off as a tower crane operator?
Howard: When you go to dental seminars, I mean, when they're talking about composites like the morning half they're talking about all the wear rates of these composites. And the afternoon's about all the bonding strengths and mega pascals, the bond strength. They're talking like mechanical engineers. But when that darn filling fails, nine times out of 10 it's not gonna be because it wore all the way down and fell out. It's cause bugs from the bio-film came and ate the whole thing out. And when you go to the AACD meeting, like I've gone several times and you talk to dentists from Japan, Australia, New Zealand, they're into glass ionomers. They want a filling that combats bugs. And when you go to America, it's like a mechanical engineer and a tower crane operator and wear rates and bonding strengths. And we finally got one company, Pulpdent, that's trying to change the course and ...
Dude, you always talk about building a barn. And you always talk about your wooden barn. It's the patient's responsibility to brush and clean it. But at the end of the day, it's always eaten by termites. So we kinda ... Do dentists need to kinda go from being more mechanical engineers to more the Terminix man who comes by my house every month and sprays down an active ingredient so that less ants and cockroaches ... And by the way, Ryan, did you see the scorpion I killed yesterday? My God, we're in Arizona. I killed a scorpion two feet ... I didn't even have to get on my chair to stop it. I mean, but anyway. Do you get what I'm saying?
Frank: Yeah, I do.
Howard: The bio-film is the issue. Not wear.
Frank: I do. Is he ... The dentists that are ... They really are entranced by these restorations. And the final restoration. I'm a perfectionist. I said, "But, excuse me. Wait a minute here. Whoa. What's the environment you're working in there? Are you controlling the pathogens that cause this disease? Are you bonding in bio-film central?" They look at me like I'm from Mars. I said, "Let's have a conversation. Let's go outside. You better understand bio-film like Larry Clark and Pulpdent. And you better understand injection over molding like Dave Clark and Bioclear. And understand how to restore teeth the modern way versus doing tension joints. And these are slot preps that we've been doing for decades and get into compression joints, that surround the teeth with hydroxy appetite to protect the teeth so they don't break down. But first you control the bio-film and then you blast, get the bio-film off the teeth. You blast it off and then you can actually get into some really good sub-straits like hydroxy appetite." Things like that. So to answer your question, absolutely. Materials are probably the last thing for me. It's the environment that you work in is probably more important than the materials that you're using.
Howard: So tell ... So rant some more about that litmus paper. Where are you buying this litmus paper? Is this at a dental supply house? Is this from a chemistry shop?
Frank: Walmart online. It's cheap.
Howard: Love it.
Frank: Okay. All right. Let's get some corporate love here, Howard. GC America is the first one that came up with that.
Howard: Hang on one second. The Walton family is calling me on line three to thank me for increasing their sales of Walmart online litmus paper. Tell them I'll call them back, Ryan. So Walmart online, you buy litmus paper.
Frank: Yeah, but here's where it came from, Howard. You gotta know the history on this. This came from GC America and minimally invasive dentistry came from Graeme Milicich, Tim Rainey, things like this. Now, it's echoed by Brian Novy across our country. He's the bug man, okay? So ...
Howard: Brian Novy?
Frank: N-O-V-Y. He is the man.
Howard: N-O-V-Y? Brian Novy?
Howard: Is he a dentist?
He knows more about bio-film than anybody else around this ... in this country.
Howard: Is he your buddy?
Frank: He's my buddy.
Howard: Tell him ... This is the question I want you to ask him. Email him. Tell him to come to the show. I got the best question in the world ever asked of me by a hygienist. You know what it was?
Howard: They taught me for four years of school, I'm supposed to scrape all the tartar away. She goes, "But in all my patients. Where do they have the most tartar?" Lingual anteriors.
Howard: Where do they the least amount of gum disease? Lingual anteriors. She says, "It doesn't even make sense. I'm supposed to be going crazy at every spicule of tartar off, but we're ... They have the little spicules. They have the gum disease. And where they have the big build up, they have no gum disease." That's a great question. How would you answer that?
Frank: Well, that's because they're buffering, Howard. When you have your submandibular glands gone, their sublingual glands, and you have high calc producers, they're buffering. Their saliva pH is probably very alkaline. Okay? That's the deal is that GC America sells a saliva check. They do the whole saliva thing. You can go have a lunch and learn. You can go online. You can do the pdf. You can read it. But after you get up and running, then you can buy your own litmus paper and just check them in the mouth. Hell, it costs you about five cents. And takes you five seconds to determine risk.
Howard: And what pH are you looking for? What are you finding? What's good? What bad on that?
Frank: You and I as humans, our neutral pH, we're seven point zero to seven point two. Your resting saliva is seven point zero to seven point two. Ergo, you get into high calc producers, you're gonna be buffering. There's a lot of calcium flying around and depositing on teeth. These are alkaline people. These can be high on the alkaline scale. But if you get into people with interproximal decay, especially lower mandibulars, Howard, these are acidic ecosystems. Their acidity, heck, they can go down into the fives, anything like this. And then they're feeding themselves sport drinks which is highly acidic. Bottled water could be almost acidic. You're actually creating the perfect storm and you have to re-educate these people and re-mineralize them with ionic exchange, these calcium pastes and things like this. [00:47:43]
Howard: So Kim Kutsch talks about that too.
Frank: Yeah. Yeah, he was there. Absolutely.
Howard: Interesting. So I definitely think dentistry needs to move. I think we were great mechanical engineers in the past, but we need to become biologists.
Frank: Yes, sir. We do. Howard, that is brilliant, because they have to be able to communicate this with their patients. I get so much respect, so many referrals based on my ability to diagnose before I prep.
Howard: So then, 41 years ... I want to tell you this. Where do you think this professions going? Because remember, we got out of school. We saw the Orthodontic Centers of America on the New York Stock Exchange and on NASDAQ, they all imploded. They went away ten years ... Now they're all back. They're about 12 per cent of the dentistry's done by chains that have more than 50 locations. But humans are linear thinkers. They think, "Well, if I bought a house for 100,000 and it doubled to 200,000, it's gonna double to 400,000. So buy now." Then they experience their first real estate bubble crash. Do you think ... Where do you think dentistry will be in 20 years? Do you think corporate will take over? Do you think it'll plateau? Do think it'll contract? Will we all be working at McDentals in ... If some girl that just walked out of dental school today and she said to you, this is the question, "Frank, in 41 years will I be working at McDentals?"
Frank: I think the trendline is unquestioned at this point. You have a political, economic situation, Howard. You have the dental schools who are taking money from corporates to come in there and get them into corporate structures. Okay? These young graduates don't know any better. They want money. They want cash flow to service the debt. They don't know what we know in private practice. I'm not knocking it. I understand why it's there and what they do, but the politicians as you've seen with the Affordable Healthcare Act and we saw with Hillary Clinton in the 90's. They're drooling to get dentistry on board and get this into the same container as medicine. And if you get that kind of behavior, quality care is out the door.
So I'd say be wary. Keep your antennas up. Stay alert. Don't surrender your sword to politicians. Don't surrender your swords to corporates. Keep private practice alive. And the gap is widening now between corporates and private practice. It's getting hard to sell these practices, Howard. You know this. These young kids, they have no equity. They can't buy these expensive boutique practices. They're going some place where it's simple and they can make some money. So there will always be a need for the practices that offer solutions, bio-film, smart materials, therapeutic materials, scanners, all the things to fix things and prevent things. There's always gonna be a market for those individuals that want to thrive there. But I think that number is gonna decrease in the future.
Howard: I want to ask you another politically incorrect macro-economic question. Some of these kids are wondering, "Maybe I'll go into the Air Force to help pay off some of these student loans." What's dentistry like in the Air Force, the Army, the Navy, and of course, the Navy dentists are the ones the who do the Marines, but you're familiar. You've actually taught Air Force. What is dentistry like in the armed forces? Because I believe, to this day, the largest employer of dentists in the entire world is the Chinese military, the second is the India ... Indian ... India's military, and third is the United States Pentagon. So the largest employers of dentistry to this day is actually not corporate. It's the military. What's dentistry like in the military today?
Frank: Okay, great question, Howard. And if we wrap up this discussion ...
Howard: No, I'll go 40 days and 40 nights with you. You're not gonna get out of here on a timer.
Howard: You're gonna have to-
Frank: Remember those doors that opened up for me?
Frank: Well, military opened for me. I'm gonna thank Dan Fisher from Ultradent back in the 90's. I had heard that they do military seminars. I'm a very patriotic guy. And I saw my buddies going to Vietnam. I saw them come back. I saw some of them that didn't come back. I saw some of them that came back messed up. And I saw what our country ... How they didn't acknowledge these people in a positive way when they came back. It was disgraceful. And I just said, "I have to do something." I was curious about the military. Kinda physical guy myself.
And I sought out Dan Fisher and I said, "Okay, if you get an opening, I want to go." And he introduced me to Pete Lund who did all the military seminars. I said, "Hey, I'm your guy if you need somebody. Let's go. Let's do this thing." So we started doing the military seminars, Howard. Either you're a AGD resident, can go into the armed forces, Uncle Sam's gonna pay for your dental tuition. You know, how much is that, Howard? That's like major money and in turn you give Uncle Sam, you put on a uniform and you give Uncle Sam three to four years. Okay? Army, Navy, Air Force, Coast Guard, public health.
Now, my experience in the military is extraordinary. It opened up so many doors for me, Howard. First of all, I got to see the commanding officers that sacrificed 20 plus years, taking their families around the world. Moving them around to schools, housing, they didn't live lavishly. They sacrificed. I got to meet those men. And I got to meet the new graduates, the AGD graduates, the residents. And people on their journey and what they got was competency. They got oversight. You cannot evolve as a military dentist, unless you are competent because they can't take men and women off the front line in any of these places because a filling falls out. Especially the Air Force.
So I've been to most bases around the country, teaching. I've been fortunate teach over Tokyo for the tri-service elite. These are the best men and women in all three branches of the military, including the Japanese. Okay? I've done seminars on aircraft carriers. I've been where the Marines are. I've been to Okinawa. I've been to Pendleton. I've been to Lejeune. I've been to Fort Bragg. I see the men who serve and then I see the dental personnel as well.
So when you go into the military, first of all you have to have a direct style of talking, like you and me. No candy coating. They want the direct thing. They want it now. When you are done, if they like you, they give you a coin like this one. I've got a whole stack of these, Howard, from all branches. That's a sign of respect. You know what that's worth?
Frank: That's worth ... That's priceless. When you go into Pendleton, you get a Navy SEAL hat. What's that worth?
Frank: It's priceless. When you go into Fort Jackson and the commanding officer gives you a black colonel's beret, because they liked you, what's that worth, Howard?
Frank: Priceless. Answer your question, you put on a ... If you ever so desire to put on a uniform, go do it. It's the best thing you can do. When you come out of that military, Air Force, Navy, Army, you go on the short stack of the applications when docs are looking for an associate or a partner. That anybody with a military background is in that short stack because I know who these people are. They're disciplined. They know how to take orders. They are qualified people, Howard. They're mature. They see a different view of the world. And I may say is that I'll be 68 years old this year, twice I've been called out on military bases in pushup contests to go against 27 year old lieutenants. I go toe to toe. I've done this twice. I've been set up and they bring in their hot shots. We go toe to toe for one minute with a stopwatch. I'm two and oh.
Howard: Ni- How many can you do in a minute?
Frank: Back then I was doing probably 75.
Howard: Damn. I don't even know if I could eat 75 french fries in a minute.
Frank: But anyways, I salute the military. I think it's a no brainer. Same with public health.
Howard: I want to ask you another tough question. You know, I call Dentistry Uncensored, it's politically incorrect because like I say, my homies just want to hear the God honest truth from a guy that has the balls to say it. Again, she wants to be a good dentist. And you're living up there in St. Paul, Minnesota. 3M's in Minneapolis, but right now she's just takes a $17 impregum impression made by 3M. And she sends it to a lab and a lot of people are telling her she needs to buy ... She needs to upgrade from a $17 impregum impression to a $17,000 true depth scanner. That if she really wants to be a good dentist, she gotta be a good scanner. And they keep saying things, "Well, you know, when you send an impregum impression to the lab, or polyvinyl slot. Saying there's about a five or six per cent remake. But when we get these oral scans, we only have a one per cent remake." And she's like, "God, that's a lot money." What would you tell her? Is it worth 17 grand to go from a $17 3M impregum to a $17,000 true depth scanner?
Frank: I wouldn't start your journey there, Howard because I'm old school. I think you have to do it manually. You have to do a good job manually, know all the pitfalls, control all the parameters that build a successful impression. You have to know the tray selection. You have to know adhesion. You have to know what generation graft [inaudible 00:59:08]. What are you using on this? Cause you and I came from rubber base. You and I came from hydrocolloid.
Frank: Okay? We're talking a long time ago. I tell them today, straight up, I'd say, "I want to see your impressions first and see what kind of quality you're feeding into the laboratory, putting your signature on a lab form, putting it in a box, and letting somebody pour it up like I did in the dental laboratories." And only if you can qualify or somebody's vetting you to get into scanning, then I would say, just because you got a scanner, Howard, doesn't mean you're gonna get the detail you want if you're not giving the scanner good information. It's the same thing as a polyvinyl. What the heck? You gotta know what to look for first. Technology's not gonna overrule quality. It can't.
Howard: And that's the difference between dentistry and physicians. When five dentists are sitting at lunch, they're all bragging about their high tech toys, you never hear physicians, you never hear dermatologists and family physicians talking about all this high end equipment. I mean, you just don't. It's almost like a lot of this stuff in dentistry, almost, you know ... I want to ask you one question. We went over. We're in a minute over time. Can I keep you for an overtime question?
Howard: Why do you think corporate medicine is so different from corporate dentistry? You're up there in Minneapolis/St. Paul. You're right an hour away from Rochester where, I mean, in medicine when these guys want to get big, they're doing like Mayo Clinic, quality quality quality, or Cleveland Clinic or Sloan Kettering or Scripps in San Diego. It seems like when a dentist ... When the physicians want to open up a big clinic, they just go for Mercedes-Benz and people ... How far away do people fly from to go to Mayo Clinic up the street from you in Rochester because they just know that if they go there, it's gonna be someone like Frank Milnar who's just gonna do it the best possible way, not what the insurance company, Medicaid, Medicare place. But when you look at the 50 ... the 35 corporate chains in that have 50 or more locations, it's always something faster easier cheaper. No one's gone after ... No corporate dental chain's going out there to be like, "We just want to be the best. We want to create a dental office where our grandchildren and great-grandchildren would go after we were dead." Why do you see the difference there?
Frank: Okay, there's a huge difference. My father was a physician. And that's why I'm a dentist, cause he was never home. But he was the old guard. He ruled the golden age of medicine by making house calls. He did all ... He had to go work grueling days and then do admin, discharges, things like this. He says, "Don't do this." He said, "I ..." He was the old fashioned guy that paid attention to all the details and they had no personal life. Now, you can see in medicine, we got good docs that are owned by the insurance companies. In Minnesota, no different than a lot of places. They're all owned by big conglomerate insurance companies. There's still good docs, Howard, but what's on that keyboard? What's in that software that tells them what you can have and what you can't have? What is available and what is not available?
Now, you can't diagnose anymore. You're not the true physician that you were educated in medical school. Now bring up the Mayo Clinic down there, they're salaried. They're not on production. They're on outcomes. And they're one phone away from just picking up the phone, calling Howard, talking to Frank about diabetes, about neuropathy, about cancer. They find solutions down there and they have departments that talk about your case, Howard if you have a complicated, rare case. They talk about it and find the best doctor for you, to meet your need, to get the best possible solution.
My fear is when you go look at the medical doctors that are keyboarding or they have a scribe, a physician's assistant doing [inaudible 01:03:28] is that they have so much time because they are booked so much differently than at the Mayo Clinic. I don't know if that answered your question.
Howard: It did. But it's kinda sad because once all the physicians are employees of the insurance companies, where do the patients go when they need a doctor?
Frank: Don't know, Howard. You gotta ask yourself the question, as you know, you saw the medical students when we were dental students. And the old rub was if you weren't smart enough to get into medical school, you became a dentist. Well, that one kinda hurt. I took that personally. Well, it was actually true. But I took it personal. Now, why are there more applications for dental school than there are medical school today?
Howard: Because once you get in bed with anybody, you're gonna get screwed.
Frank: You're gonna get screwed.
Howard: And in 1962, when the physicians got in bed with government for John F. Kennedy and Lyndon Johnson's Medicaid and Medicare, once they got in bed. It sounded like a hot date and a one night stand, but once they got in bed together, you know, it's gonna be different.
Frank: So you and I, as we wrap up our lively discussion, no holds barred. Bare knuckles, okay? That's what you and I are. We're the last guard here, coming through a different era of dentistry where we stood up straight to our bench instructor. They could ruin us and they could do anything they wanted to us. And we took it. But we're in the world's best profession right now. And I don't want anybody to give it away. We've invested too much time. We've had too much of our own investment, from the past, from [inaudible 01:05:24] so on and so forth, all our bench instructors, all our clinical educators, all the publishers, all the people who stand in front of you and we can't give it away because we'll bastardize dentistry. And then what's left will only be fading memories in the history books about what you and I used to do.
Howard: Well, we will not let that happen. And one of the ways we will not let that happen is because I'm able to get amazing dentists like you to come on the show and talk to these young kids on their smartphone while they're commuting. You know, they have an hour commuting to work. Frank, seriously, thank you so much for spending an hour of your life with me today talking to my homies.
Frank: Well, Howard, I won the lottery and it took me a while to figure out what this thing was all about, but I got it. And now when I'm coming down, coming into the back nine of the golf course, I don't see the club house yet, but I want to give away as much as I can to anybody who will listen and teach it in an ethical, practical manner.
Howard: Give some of that away on Dentaltown magazine. It's amazing. It goes to 125,000 general dentists, but it's sent digitally in email to dentists all over the world so maybe someday you'll grace us with an article on Dentaltown magazine which is really digital, really. It's print and digital. Or even better, an online CE course, that would epic to have one from the man.
Frank: Howard, let's do a pink composite online course.
Howard: Ah man, you do that, it'll be my birthday every day.
Frank: All right.
Howard: All right. Again, thanks so much for coming on the show and tell your lovely, adorable wife I said, "Hello."
Frank: God bless, Howard.
Howard: All right. Same to you, buddy.