Howard: It is just a huge honor for me today to be podcast interviewing Parag Kachalia all the way from San Ramon, California. It’s about thirty minutes East of San Jose. And he says he does know the way to San Jose, by Dionne Warwick.
He’s a tenured associate professor and former vice chair of Simulation, Technology and Research at the University of the Pacific. He’s a fellow of the International American College of Dentists, as well as the American Dental Association’s Leadership Institute. He’s also a member of the Omicron Kappa Upsilon honor society, which obviously I must not be. In addition he is a researcher, as well we a published author in the areas of dental technology, digital diagnostics, contemporary fixed prosthodontics, and financial management.
He was selected as one of the top ten young educators in dentistry in the United States. He’s lectured internationally in the areas of adhesive dentistry, cosmetic dentistry, photography, CAD/CAM technology, fixed prosthodontics, treatment planning, erosion, and digital diagnostics. He acts as a consultant for many dental materials, dental technology companies, and helps guide product development.
He’s a member of the Seattle Study Club and the Catapult Speakers Bureau. He’s also a member of the Selerant Best of Class Selection Committee. As a forward thinker he is frequently interviewed regarding his vision of dentistry’s future. Throughout his time in academia, he has maintained a private practice geared toward restorative dentistry with his wife, and fellow Pacific Alum Doctor Charity Duncan.
He believes his continued involvement in providing patient care, as well as a role in academia, has given him a unique balance that allows him to blend the best of both worlds. In his spare time he enjoys travelling with his wife and his nine year old son. As a family they make it a point to travel to at least one country outside of North America every year. So that they can experience different cultures and truly understand the world. In addition to travelling he enjoys golfing and photography.
I want you to know that I’ve lectured in fifty countries, and I always take one, two, three or four of my boys. And it is… now that my boys are twenty-two, twenty-four, twenty-six and twenty-eight. Some of their most profound memories were all in foreign countries.
And I think it’s so funny when Americans will bad mouth another country, like ‘socialized medicine, well that’s socialized medicine’. Dude, you’re not smart enough to ever have gone to Scandinavia. You’ve never been to Australia, Denmark, Norway, Sweden, Switzerland. And if you have, you’d want to live in that country, not Oklahoma City. You know what I mean? So…
Howard: When you’re born in a country, and all you do is drink their kool aid and believe all their thoughts. You’re not edumacated. And I think I… if I had to… if I had to pick between sending my son to four years of college, or sending him four years out of the country. I’d pick sending him out of the country. So, kudo’s to you. Your boy will be so smart because of that. So I called you. It’s an honor that you came on the show. What are you passionate about today?
Parag: So I’m… I think it’s great that we’re here talking about… I think my passion really lies in letting our patients know about what we can do. Dentistry’s hit this point where we’ve almost becoming commoditized. Everyone believes they can just walk into any new dentist's office that’s opened up on the street, and they get the exact same level of care.
So what can we do today to change that? And a lot of what I think about is technology’s influences. Right. I grew up in Silicon Valley. I remember when Apple was one company… was one building, and Intel was one building and they really weren’t that big of a deal. And little by little, by little all these companies kind of grew up and developed.
But the thing they always hit on was that connection. Right. There was a connection with, in their case, the consumer. In our case, the patient. And how they built that connection, and in their case it was technology. Right. I think we can leverage technology today to let patients know what’s happening in their mouth, what’s happening with oral healthcare. And show them that dentistry is much more than fixing teeth. It’s a whole different place for us than pulling a filling and a tooth. There’s so much more we can do.
Howard: Well it was the… when I got out of school in ‘87, it was right in the boom of the dental materials technological revolution.
Howard: And that was the foundings of cosmetic dentistry, adhesive dentistry, bleach and bonding veneers. And then, probably about 1995, all these companies you just mentioned started the technological revolution. Which has led to digital xrays, computers, CBCT’s, and all kinds of things. So we’re really in the middle of a technological explosion.
Parag: Absolutely. And patients have so much access to information today. Right. They can Google everything. It’s become the world of doctor Google. It’s not even Doctor Oz anymore, it’s Doctor Google.
Parag: Go there first. Right. So… but the problem is doctor Google has a lot of really good answers, but there’s a lot of garbage on there as well. So how do we get our patients to understand what’s good information versus what’s inaccurate information? And it’s our job to do that.
Howard: Well my most passionate thing. I started in ‘87 and I was drilling, filling and billing. And the Pulpotomies were off the charts.
Howard: So I closed down every Friday, for a year, and got from Phoenix to fluoridate the water.
Howard: And so that was in ‘89. And the Arizona State Dental Association gave me the Arizona Award for flouridating Phoenix. And then… they put a timeline on it to expire in twenty years. So we just had to do it again. And if you Google water fluoridation, ninety-nine percent of the sites are fake news, it’s a communist plot…
Howard: It’s a toxic deal. So when you… so that’s the only thing I’m really an expert on. I mean I’ve read every PubMed article ever published on water fluoridation.
Howard: And the internet is taking you back to the Flintstones on that subject. And that’s the only one I really, really, really know. And you can’t find any quality information on the internet about water Fluoridation.
Parag: Absolutely not. And so the tough part the patient faces today is, as academics and healthcare providers we talk about evidence based dentistry. Right. Well what’s evidence based dentistry on the internet? It’s… well what do I rank on page number one of Google? And that’s what is evidence based for the patient. Right. They don’t get to page number two hundred where we might actually have true evidence.
So we can’t expect patients to be able to filter that information. Right. That’s our responsibility. And to do it in a way that’s appropriate. It’s not beating them over the head saying, ‘you must read this journal’. It’s just talking about the right things. But to do that we have to educate ourselves first. Starts with us that’s number one.
Howard: And the scary thing is when you point them out and you say, ‘this is what The Centers for Disease Control…’.
Howard: One fourth of everyone in Phoenix, when you say The Centers for Disease Control, they think anti-government, they’re shillings for the pharmaceutical industry, it’s all corruption. And it’s like… so what I am most alarmed by is that the biggest institutions in the world, whether it be the Supreme Court, the Centers for Disease Control.
A quarter of the public thinks those should all be closed down and they’re corrupt, and they’re the bad guy. And it’s like, wow, we live in a society where one fourth of Americans think that fifteen thousand people that work for the CDC are paid shills for the fertiliser industry.
Howard: It’s like these guys are dedicating their entire life to fight disease, and one fourth of Americans think they’re corrupt people taking money from fertiliser companies.
Parag: Right. It’s sad isn’t it. It’s just the way...
Howard: Oh my God. It makes you lose faith in democracy.
Howard: Because every one of those idiots has the right to vote. Then you go to Singapore and China, where they don’t have the right to vote. And those are the fastest growing economies in the world. And it just… And to me it just looks like law and order, and everything’s organized, like Singapore. Who could go to Singapore and come back with a list of complaints?
Parag: Oh, absolutely. It’s unbelievable. I had an opportunity to go to Singapore last year. And just the level of organisation and commitment to like moving the country forward is unbelievable. Right?
Howard: Yeah. So we live in chaos so that every four years we have a right to vote between two sociopaths. You’re either a donkey or a republican, and they’re both sociopaths taking bribes.
Howard: And… yeah. I mean it’s crazy. But when you talk about technology, I’m going to be dead honest with you.
Parag: Please. Yeah.
Howard: These come out of school and they say… they say, ‘Parag, I’ve got three hundred and fifty thousand dollars in student loans. And if I buy a CAD/CAM, there’s a buck fifty. If I buy a CBC, there’s another hundred. And if I buy a biolaser, there’s another hundred. I could double my student loan debt with three purchases. So what is the return on investment? What do I have to buy to be a high quality dentist, where you’d want me to treat your nine year old son? And what is not necessary to be a high quality dentist?’
Parag: Absolutely. And in stage number one I would say is, I completely agree with you. Our students are strapped with this half a million dollar loan package. Right. They’ve all sorts of issues occurring in terms of pay back. Do you go and buy all these hundred thousand dollars pieces of equipment? I would say absolutely not. When we talk about technology today, it doesn’t have to be a Columbian CT, it doesn’t have to be a CAD/CAM unit. He can browse the purchases… be a camera. Be a simple digital camera you can take some photo’s with, and shoot that over to your iPad or iPhone.
And start to talk to patients about the basics of what’s going on. And as time goes on, sure you can built on to these other more extravagant technologies. But stage number one is have a camera, for God sakes. Start there so patients sort of visualise what they see. In two thirds of all learning we know it occurs with visualisation. Not through auditory communication. There’s not just talking, it’s seeing each other.
And let’s think about what we’re doing right now. We get to communicate with one another over Skype. We weren’t able to do that twenty-five years ago. We can have a conversation, and actually see each other, and that communication piece that we get is very different.
Howard: Yeah. But…
Howard: Microsoft bought Skype. So it will probably go to hell in a handbasket. It’ll probably… within a year or two it’ll just freeze up and we’ll forget the word even exists.
Parag: Well, I don’t know. They’ve got a new CEO now. Right. Steve Ballmer’s climbed out, he’s got a basketball team to worry about. He’s not there anymore. We’ve got a new CEO up in Seattle.
Howard: And you know what that basketball team… What’s the name of that basketball team?
Parag: It’s the Cleverest.
Howard: No, the Seattle’s… the Seattle basketball team.
Parag: Oh. So the Seattle team is now the Oklahoma City Thunder.
Howard: But it was the Seattle Supersonics.
Parag: Supersonics. Correct.
Howard: And you know what that was named after? That was for… Boeing was and that was when… after they were starting a Supersonic Transport deal. It ended up going to France and England, and being the Concorde.
Howard: Boeing was most excited, when they started that team, about the future of Supersonic Transport.
Parag: I had no idea. That’s great. See? I got to learn something today. Great.
Howard: I even edumacated you.
Parag: That’s right.
Howard: Imagine that.
Howard: So I agree with the digital camera. I think it’s the highest return on investment, because you started off with talking about Google. And when you go to a website, and all you see is a mugshot of some dentist who looks like he’s being arrested for a DUI. And then you say you’re a cosmetic dentist, and there’s no photographs saying, ‘this is Doctor Parag’s actual work’.
Howard: And you say you’re an implantologist. There should be three or four before and after pictures. And I’ve always thought that a digital camera is the highest return on investment, because you’ve got to build up your website with your own work. And these companies that build websites they always say, ‘well doctor send me all the photo’s of the work you’ve done’. And ninety-five percent say, ‘I don’t have a single photo’.
Parag: Exactly. Isn’t it amazing how many websites we go to, we see the same three amalgams being replaced by a thousand practices out there.
Howard: Yeah. Yeah, exactly.
Parag: But our patients got around. So I think yeah… my whole thing is let’s visualise things. So camera, number one. Right. When the time is right consider digital impressioning, but not necessarily to replace impression material.
Howard: But wait, go back to the digital camera.
Parag: Yeah. Of course.
Howard: My homies, they always want names. Do you have a… make the decisions easier for them. There’s probably one thousand digital cameras on Amazon. Do you have any… any shortlist?
Parag: Oh, I think on my shortlist, the companies that do a really nice job imaging are going to be kind of Air Tech, Acteon, and probably Carestream and the Cable camera. Those four do a nice job for traditional every day cameras that (inaudible 11:49).
Howard: Okay. Air Techniques. Carestream
Parag: Air Techniques.
Howard: What was the…
Parag: Right. And then Dexis has a new camera, a new high definition camera, as well.
Howard: Okay. So Air Techniques, Acteon, Carestream, and Dexis. Carestream used to be Kodak. Right. Then they split off.
Parag: Carestream used to be Kodak. That’s right.
Parag: That’s right. Now, quite frankly…
Howard: They also own Softdent.
Parag: That’s correct. That’s right.
Howard: Yeah. Okay. So digital camera was your number one. And… when you… so when you said digital camera, you meant intraoral camera.
Parag: Well no, actually both. I would say intraorals are a nice place to be. Okay. But if you’re kind of a student on a budget, these cameras might be three to six thousand dollars. Somewhere around there. Right. They got out of school. Stage number one, I would say some kind of… even an external camera is to look at a DSLR type camera if it’s a Canon, Nikon, or whatever it is. Get a ring flash and a macro lense. And that camera is going to be with you ten plus years. Those things are work horses, they’re there a long time.
Howard: With a ring flash, as opposed to a point flash.
Parag: Correct. So there’s ring flash or two point flashes. If you want to get into kind of higher level aesthetics, and really show teeth and shadows. Or you can do two point flashes. But if you want a nice get started every day camera. You get a ring flash.
Interesting enough Smile Line USA, this year, released a flash that’s been called a Smile Lite MDP. Or a Smile Lite Mobile Dental Photography, comes from Italy and a group called Styleitaliano. And that’s pretty ingenious. What they did was they took, for all intents and purposes, a lighting system and attached it to a smartphone. So every time your smartphone improves. Every time your Google pixel, or android device, or iPhone improves you get new hardware. And It’s essentially a flash system for about five hundred dollars that goes onto your phone, you can get started really well with it.
Howard: Okay. I’m going to try to find that… what’s the name of that company? www what is it?
Parag: Smile Line USA.
Howard: Smile Line USA. And it says, ‘Superb Swiss quality dental lab’.
Parag: So they sell… they sell dental lab equipment. But there’s also a product called the Smile Lite MDP. Or Smile Lite Mobile Dental Photography.
Howard: Do you think that’s the best camera they should get?
Parag: I think that’s a nice place to get started. You can take some intraoral photos with it, with a mirror you can get some nice extra oral photos. Easily have it go onto your smart device to show patients.
Howard: Okay. So they have a camera. And what do you think of that cost.
Parag: So it’s about four hundred and fifty to five hundred dollars.
Parag: For a… yeah. To get a flash put onto your smartphone and it’ll take beautiful photos. I mean that’s a great starting point.
Howard: So you take a photo and it goes right to your iPhone?
Parag: Goes right to your iPhone.
Howard: That is really cool.
Howard: Man, I wish… I mean that’s good enough for an article. I wish you’d just write an article on that for Dentaltown, because these websites… I mean everybody is searching their dentists out on their websites. They’re all typing in… the number one search word for a dentist is ‘near me’. So they type in ‘dentist near me’...
Howard: Their iPhone, smartphone, GPS knows where they’re at.
Howard: And then they look at two or three websites. And three out of three of those websites were about five to ten years ago. There’s nothing there. There’s no video. Like when I see you, I already like you. I can tell you’re a good guy. They don’t even have a Youtube video showing the human side of them, or talking…
Howard: They don’t have any dental work. They should get an extraoral camera and get some work done and build up their website. And put a damn Youtube video on there so they know they’re a human, because it’s basically just trust and comfort. I don’t know who you are. And who is Doctor Farran? I mean who is that?
Howard: They want to see Doctor Farran. And then they want to see that I’ve actually done some work. I mean we’re surgeons. Where’s the before and after pictures?
Parag: That’s right.
Howard: So that’s… so your first was a digital intraoral camera.
Howard: Your second was an extraoral camera. Then what’s your third?
Parag: Yes. And when we start to look… I would say the next thing I would look at is intra oral impressioning. Let’s look at a digital scanner.
Parag: But I use it… I use digital scanners for much more than impression material replacement. So it’s not about replacing the impression material.
Howard: Well, talk about that. What did you mean when you said that?
Parag: So I’ve been using a couple… I have a university lab and a private practice lab. At the university I’ve pretty much had a chance to play with every scanner that’s out there. In my private… so true definition is what we use quite a bit from 3M. And then 3Shape Trios system is what I use quite a bit in practice.
So what I’ve done now is I take those… as I’m scanning the patient, and once it’s on the screen, I actually have my assistant or a staff member kind of hold up an iPad and record the conversation I’m having with the patient as I discuss their case. So as I point this out on the digital scan saying, ‘your bites really deep here and you’ve worn these teeth down, et cetera’. And I’m pointing things out on the digital scanner. My assistant can stand back and actually record the conversation I have with the patient.
So what that allows us to do I can now send a video file to that patient. Where I can record these things, have a little video file on my tablet computer. And send that over to the patient so they have their new patient experience in our office. So we’re much more into scanning, I wouldn’t say all of our new patients, but a number of our new patients today. As we scan them from day one to create a digital record and a communication piece.
Howard: What… so you like the Trios made from… whose company makes Trios?
Parag: So 3Shape makes Trios.
Howard: 3Shape. 3Shape out of Copenhagen, Denmark. Right.
Parag: That’s correct. Correct.
Howard: And you like the Trios. And how much is the Trios?
Parag: The Trios runs between thirty-five and forty-five thousand dollars. Somewhere around there.
Howard: And you… and you… you thinks that’s a buy?
Parag: I’d like the price to come down. Absolutely. But for what we have today, for the bells and whistles that it has. I think it’s… that’s the price for it unfortunately.
Now the other side of the spectrum. What’s interesting is historically in dentistry we’ve got the things like…
Howard: I’m trying… I’m trying to retweet your Twitter so my homies can find you. You’re @Tech DDS? Oh no that’s…
Parag: That’s my…
Parag: Instagram. Instagram. I’m not really on Twitter, unfortunately, Howard. I have a… I have a URL there but I don’t do much work there.
Howard: Well that’s what everybody thought. But after you found out, after the last election, that if you have five million Twitter followers you’re going to become the President. I actually am falling in love the most with Twitter. You know why? Because you build up a Facebook following.
Howard: And then when you make a post Facebook won’t… like I have three hundred thousand Facebook followers.
Howard: If I make a post and don’t give them any money, only a hundred people will see it.
Howard: If I give them a hundred dollars. Only one out of three will see it.
Howard: I have to give them three hundred bucks to boost my post, for them to push it out to the three hundred thousand people who like my page. So I’ve never given Twitter a dollar. But Facebook and Instagram, the more you use them the more money you have to give them. But Twitter. I mean… I mean Trump called it right. Twitter.
Howard: You’ve got twenty thousand followers. You send a tweet. Boom. They all get it instantly.
Parag: It makes sense.
Howard: So I’m a Twitter convert now. Do you know what I like the most about digital scanners?
Parag: What’s that?
Howard: Is the fact that I think the number one link for quality in the dental office, is get everybody who’s putting their hands in a mouth to wear loupes. Dentists will complain their hygienist didn’t get the tartar off, but she’s forty-five years old and not wearing loupes. And he has them on.
Howard: And he complains the dental assistant didn’t clean the cement off the implant case, and all this stuff. And she didn’t have loupes on. Everybody working on a patient needs magnification. And the first time I did digital scanning was with my… I looked at my prep on a screen forty times larger, and I thought a blind chimpanzee had cut the prep.
Howard: And I don’t think I’ve ever scanned a tooth and not been humbled instantly, and gone back three or four times. And I saw… I think… the endodontist.
Howard: The greatest endodontists I know say before they operate they pull just a microscope, just eight or twelve, and they look down there and they might find a missing canal. They might say, ‘oh my God, that one canal still has crap in it’. Magnification… when you work with your hands magnification is pretty intense.
Parag: Absolutely. It goes back to the adage, we can only treat what we can see. Right.
Parag: And how do we… how can we see something with our naked eyes at all times? And (inaudible 20:29) a ten or a fifteen, the only people that find those caries are my hygienist. Right. So when she finds it back there then I’ve got to treat it. So I’ve got to make sure I’m wearing good magnification, and scanning takes that to the eighth degree. We’re all looking at preps at two, three, four times. It’s fifty to a hundred times, if not more, on the screen. And the more precise we can get the better off we are. The beauty is…
Howard: So you work… so you work with the 3M company at the university. And you work with the Copenhagen 3Shape Trios in private practice. I hear that’s what’s best about 3M’s true definition is that it’s the smallest intraoral camera.
Howard: But the negative is that… that you have to use powder.
Howard: And then the Trios is all that and a bag of chips, but does it… sometimes it frustrates me when dentists say, ‘well I don’t want to use powder’. Well you should be saying, ‘I want to use powder if that is a better scan’
Howard: Like with bonding agents.
Parag: Right. Right. Right.
Howard: I still think the best bonding agents we ever had were Acid Etch, Primer, Adhesive. But the dentists like, ‘I want it in one step, I want Prompt-O-Pop, I just want to scrub it…’ It’s like, dude.
Howard: You’re a doc… I don’t want to get a bypass.
Howard: By some surgeon that thinks like that. I’d rather go to a cardiovascular surgeon that says, ‘this is going to take me twice as long, but it’ll be three times better’. That’s the guy I want. But dentists seem to be like… now… now the problem with posterior composites is they shrink. So what’s the dentist… what’s the dentist's response? ‘I want to go on Bulk Fill. Hell yeah. Just plug it in there, smash it with my thumb, and hit it with the light’.
Parag: That’s right.
Howard: ‘Because I can’t do this layered increment bull shit’.
Howard: I mean it’s like… So I don’t care if you have to put some powder on if that means your gosh darn scans going to be a lot better. But what do you think about true definition’s smaller but you have to have powder. Trio seems like they’re just exploding. If one of my homies are listening to you right now saying, ‘come on I don’t got all day which one shall I buy?’ What would you tell them?
Parag: Well honestly what I tell people in my lectures is those two are probably the two most accurate scanners today. The low end of the price curb, and the most expensive in the price curb. From an accuracy standpoint, they’re almost identical. That’s what’s amazing. Right. And that’s all from a third party data standpoint. Not what the company tells us today. But you’ve got a general pros, last couple of years. Those two scanners come out top notch.
Powder. Ten years ago I was concerned about powder. I had to put a lot of powder on to get a scan. We had to put thirty-five microns of powder or something. The true definition scanner. You’re dusting it. You can barely see the powder. So I’m not concerned at all about powder today. And I think it’s a great place to enter the digital spectrum. If you can get in for sixteen, seventeen thousand dollars, somewhere around there. And you get a very highly accurate scanner. If I had a crown done on my mouth today, I’d use either one of them. No question.
Howard: But it seems like they’re actually cheaper. Because every… every lab owner that I talk to. I mean a lab owner…
Howard: … not an MDA.
Howard: But the guy that actually works at the bench.
Howard: They all say the same thing. They’re running at about six percent remakes with polyvinyl.
Parag: Right. Right.
Howard: And they’re running one percent with their scans.
Parag: Right. Right.
Howard: And then a lot of the labs actually charge you less money if you send in a scan.
Parag: That’s right.
Howard: Because they don’t need a monkey to pour up the impression with stone, trim the dye.
Howard: So since they’re skipping steps… so if you looked at the chair time cost…
Howard: … of five out of a hundred crowns where the patient comes in. It’s a deadhead appointment, meaning like if a semi goes from Phoenix to San Jose and drops off a load of tomatoes. It’s not going to make a penny unless it picks something up at San Jose and brings it back.
Parag: And brings it back. Right.
Howard: That’s why the individual truck driver is out of business. Because you can’t deadhead. So if a patient comes in for a crown seat.
Howard: And you scheduled a half an hour and the only thing that came out of that, five out of a hundred times, is to re-impress. Oh my God that’s a...
Parag: Kills you.
Howard: That’s a fortune. That kills you.
Parag: Absolutely. Kills you.
Howard: So if you could go from six percent to one percent remakes, you would have to… have you seen the labs charging you less if you send a scan?
Parag: Absolutely. Because the vast majority of our single unit posterior crowns, we have no models. None at all. So they… we get the crowns back faster. So we’re getting them back in roughly seven days or so, versus two weeks. So patients are happier with shorter temporary times. At the same time I’m not getting any models back so there’s a… because I… if they make me a model, that model’s never touched until it comes into my office. And I do this and say, ‘great here’s twenty dollars for it’. Right. Because the model’s simply for us to feel good. The lab doesn’t use it, it’s a variable. There’s no reason for it. Now if you get it… if you’re doing six, eight, ten units. Different story. But for a single unit posterior no reason for the model.
Howard: Oh. Okay. But finish that thought.
Howard: That just flew over her head. She’s twenty-five years old. Why… why does that work for a single unit? But why does a prosthodontist not do it for a full arch?
Parag: So now at some point will it work for a full arch? Potentially. The one thing we can do is… for a single unit crown the reason it works so well, is we have the adjacent teeth as landmarks, we have the opposing as landmarks. So we can build a crown now to a proper occlusion, contour, function with no issues, for a single unit. When we get to multiple units, start thinking about guidance and kind of waxing the full arch, et cetera. Then there could be some potential little issues on the occlusion standpoint. But even that’s getting a lot better.
Like I did three inner bridges today with no issues. I delivered three crowns yesterday in a quadrant, we had no issues at all modeless. So I’m becoming more and more comfortable. But people would say today if we’re going to do more than three or four units, consider getting… it’s going… but you’ll find they’ll get a model.
Howard: But you said something earlier for a crown. You said on a single you got a tooth in front and a tooth behind.
Parag: Yeah. Yeah.
Howard: Talk to any lab man. What’s the biggest problem to... the last one, the second molar, there’s nothing behind it.
Parag: That’s true. That’s true.
Howard: And they’re going to call up and say… why do you think, the second molar, the fact that there is no tooth behind it. Why do you think that is such a nightmare, and do you think it almost rules out a triple tray and go to a full arch tray just so that you get some other tripod contact? Or why do you think the second molar is always off the most in occlusion?
Parag: Yeah. The second molar. There’s so many variables back there. Right. And from the standpoint of where’s this patient closing tooth in the second molar standpoint. First point of contact. We start negating those factors. They start pulling them out. So triple trays, I was never a big fan of them on second molars. But digital scanning, I’m okay with that. I’m perfectly fine scanning a quadrant from a digital standpoint. Because my bite registration is still true. It’s not collapsing the tray. It’s based on what the patient’s dentition goes to.
Howard: So… so the 3M’s true definition is seventeen thousand. Is that right?
Parag: That’s correct. That’s right.
Howard: And what is the Trios 3Shape?
Parag: Between thirty-five and forty-five thousand.
Howard: Thirty-five to… what just depending on what? Bells and whistles?
Parag: Exactly. Because they have a card standpoint, a laptop standpoint, black and white versus colour. They kind of operate off a tester model, where you get all the bells and whistles to start off. But they turn off the features until you pay the extra if you want them. So you can start with a black and white scanner today. Or a monochrome scanner for about thirty-five. And if you decide you want to go to colour later on, you call your distributor and say, ‘hey I want colour, here’s a check for seven or ten thousand turn it on for me’.
Howard: Yeah. And when you go… I should not say this on the air, but since I’m completely insane and I don’t have the little birdie telling me what not to say. Every time I’ve ever gone to some of those foreign countries, you see Americans down there buying stuff. Because they say, ‘well if I fly to Germany, I can get the CAD/CAM forty thousand less. Because I don’t have to give Patterson it’s cut’.
Howard: So they literally go down there. Go buy the damn Serac machine, and fly it home.
Howard: And it’s the same with the… when I was in Copenhagen. There were dentists that said… it’s actually cheaper to go to Copenhagen, Denmark and have a vacation with my family, and buy it there and bring home my deal. And the biggest savings is every time I’ve ever been to Hong Kong, New Delhi, or Brazil. They’ll sell that five hundred dollar a bonding agent for Clear Fill SE.
Howard: Five hundred dollars a bottle. And they’ll sell it in Brazil for fifty. So they’ll go down there and buy a year’s supply of their composites and bonding agents. And won’t even take up one suitcase, ‘they say, yeah, my wife and I just spent a week in Rio and it was free because we bought our bonding…
Parag: Sounds nice.
Howard: Oil is a hundred dollars a barrel.
Howard: Bonding agents are between one point two million to one point five million dollars a barrel. I think every drug dealer, instead of risking going to jail, they should just start making illegal bonding agent.
Parag: Bonding agent. Right.
Howard: Because that stuff is… I mean when you… a bottle of bonding agent costs more than the equal weight of heroin or cocaine. What’s wrong with that picture? Why does heroin and cocaine cost less than Clear Fill SE per gram?
Parag: Well, look at the packaging. Isn’t it amazing packaging?
Howard: Oh my God. Crazy, hey. So you mentioned labs. So which labs are you using and they give you a discount to send in a scan versus an impression?
Parag: Right. So we’re primarily four cases a day. We use a lab called Techsource. So Techsource is out of Texas.
Howard: Techsource out of Texas.
Parag: Techsource. Yes. I mean it’s just outside of Dallas.
Howard: So how did you, in San Jose, end up finding a lab clear in Dallas?
Parag: Well isn’t that the beauty of digitalism? My digital impression can go anywhere in the world at the same time.
Howard: So if the techs… like T-E-C-H, or techs as in T-E-X?
Parag: T-E-C-H. So T-E-C-H source. Techsource.
Howard: See I would never ever use Techsource Dental because they’re outside of Dallas, and they’re probably those obnoxious Dallas Cowboy fans. And being an Arizona Cardinal purist I could never use anything within a hundred miles of Dallas.
Parag: I love the Cowboys. So…
Howard: And what would Techsource… The number one crown is a first molar.
Howard: What would they charge me if I sent them a Impregum, and what would they charge me if I sent them a scan?
Parag: You’ve got a twenty dollar difference between the two. It’s like at least one nineteen or so versus ninety-nine.
Howard: Okay. And one nineteen versus ninety-nine.
Howard: And then on these scanners. Do these companies charge you per scan? Once you buy the scanner can you send unlimited scans, or do you have to pay every time you use it?
Parag: Yeah. So for the most part the whole click fee world has gone. You no longer pay per scan. We’ve moved past that. But you do pay a monthly fee, or a monthly or yearly fee for the scanners.
Howard: And what is the monthly…
Howard: What is the monthly, yearly fee for True Def or 3Shape?
Parag: For a True Def it’s about two hundred dollars a month. And then 3Shape does theirs a little bit differently, depends on your distributor. So let’s… the ballpark is about two thousand dollars a year. So one eighty-ish a month, one sixty a month.
Howard: Two thousand a year versus twelve… so twelve hundred a year for True Def, and two thousand a year for 3Shape. Now does that… is that bundle like warranty, updates, all that? Or is that… or not?
Parag: Let’s go over what I said. True Def is about two hundred per month, so about twenty-four hundred a year.
Howard: Oh twenty-four in a month.
Parag: Twenty-four. And then 3Shape’s like to the (inaudible 31:52). They each have slight differences. So I think in True Definition’s case, the first year the warranty is included. And the second year the might be a slight additional fee. And I believe the same thing’s true with 3Shape. But it all depends on how much you pay in the front end with 3Shape. They modify your monthly based on what you pay on the front end.
Howard: So that… that’s… so… so when you buy a 3Shape True Definition scanner, you’re going to be paying two hundred dollars a month twenty-four hundred dollars a year.
Parag: Right. Right
Howard: In perpetuity.
Parag: That’s right.
Howard: And with 3Shape you’re going to be paying a hundred and sixty-six a month.
Howard : In perpetuity.
Parag: So while on those in the monthly fees. When I first saw those, honestly I was irritated, I said, ‘man, I’m already paying x thousands of dollars for a scanner. And now I’ve got to pay this monthly fee’. So while it’s frustrating and no one likes to pay a monthly fee. I’ve got to say the software improvements over time with both companies, have been pretty spectacular. So my 3Shape scanner today, I bought it three years ago, is very different today than it was three years ago because of software upgrades. And without doing any hardware upgrades. So the money we pay monthly is almost an incentive for innovation, for the company to be pushing forward versus just selling you something and not getting any updates. So I don’t like to pay it but at least I’m getting something out of it.
Howard: Well it’s a feast or famine… you can’t run… it was actually one of the first… the first billionaire that ever… So yeah, here it is. So your dental lab Techsource Dental is @TS_Dental.
Howard: And I will… and their pin tweet is actually an iTero scanner, ‘check out the many iTero elements scanner. Marketing resource now available for download’. And then the second one is, ‘love seeing this in my mill. The new 3M Lava Esthetic Fluorescent FC Zr #gamechanger’. What is that?
Parag: That’s some beautiful material.
Howard: What… what?
Parag: Yeah. It’s a new… it’s a new kind of anterior zirconium, and a translucent zirconium. It’s absolutely beautiful. It’s very nice.
Howard: So then 3M Lava Esthetic Fluorescent. What’s FC Zirconia? Zr is Zirconia. What’s FC?
Parag: Yeah. It’s a… usually it’s Full Contour. FC is Full Contour
Howard: Okay. So 3M Lava Esthetic Fluorescent Full Contour Zirconium gamechanger @3MOralCare. Interesting.
Parag: Yeah. Right.
Howard: So you like that? You like that better than Ivoclar
Parag: In E-Max or…
Howard: Well do they… do they… they still do empress on the anterior?
Parag: They do. They… yeah. I saw that… I saw… I would say it’s not quite a empress or an E-Max. But it’s getting closer to the E-Max, well that’s how it looks. But it gives you an ability if you need to kind of conventionally cement something, maybe a (inaudible 34:34) margin, concern about moisture etcetera. Needed something stronger in a bicuspid region for a patient. Does a nice job.
Howard: And what I draw the line is just male.
Howard: I mean men don’t show their… I do the aesthetic health compromised stuff on women with high smiling. Because they…
Howard: They care so much. But when grandpa’s in there with a liver spot on his head.
Parag: That’s right
Howard: He want’s it to last the longest. He really would… whether having an amalgam…
Howard: On a class five…
Howard: That go to the grave than you’re AACD, inner plastic…
Parag: That’s right.
Parag: Sixteen layer composite.
Howard: Let me just talk about that. There’s so much disturbing information on amalgam. Like the insurance companies say the amalgams are lasting thirty-eight years.
Howard: And the posterior composites lasting six and a half. You see these dentists they go get their fellowship, and their AACD. And in comes alzheimer’s mother, who can’t recognise her daughter. And when you put those root surface cavities with inert plastic composite they’re lasting six months.
Howard: And we use amalgam, they’re lasting five years. Now who in their right state of mind would use… and then when you… and then when you… and then the doc says, ‘I don’t even have amalgam in my office’.
Howard: Okay. You’re an extremist. You’ve already past thinking. Well can you use a glass ionomer? ‘Well that’s only used in Japan, Australia, New Zealand. Them are socialist countries. I’m from Texas dammit. I don’t use that Japanese glass ionomer. And I’m a fellow of the AACD’. No dude, you’re an idiot is what you are. I mean why would you put composite in a alzheimer’s patient who doesn’t know her children’s name? That’s my question to you.
Parag: Right. Right.Yeah, I think you kind of a nail on the head for a standpoint. If we happen to pick the right restorative material for the patient that’s in our chair. That’s not a blanket category across the board.
Howard: It is a blanket category for all women. If a woman will say… I’ll say, ‘would your filling tooth coloured or do you want silver or gold?’ ‘no, I want what’s natural’.
Howard: And I’ll say actually the amalgam’s natural because it starts off as a Hydrogen’s sun, and the gravity compresses two into Helium. And then the whole thing turns into Helium. The gravity’s so intense it explodes, a supernova. And there’s your silver, mercury, zinc, tin, copper, all natural.
Howard: The composite stuff of 3M is made by men in lab coats pouring chemicals in a beaker. And they like, ‘yeah, that’s what I want’. Okay, then why did you ask for what’s natural?
Parag: Natural. Right.
Howard: Natural like what? Hepatitis C. Natural like a tornado. So I… if a woman says, ‘well what do you think of the tooth colour?’ And you say, ‘well it’ll be a hundred and five percent chance it’ll cause thyroid cancer’. They say, ‘okay, I’ll do it… I’ll do it’ So I just put, after thirty years of this shit, I’m not going to introduce anything. Women want the aesthetic (inaudible 37:33). They’ll do anything to look good. I remember I was five years old. I was watching my overweight grandma, Mary, and pull herself into a girdle and she looked like she was going to kill herself. And I said… I said, ‘grandma why do you put that on?’ And she snapped at me, ‘because I’d rather look good than feel good’ And she’s cranking this two hundred pounds into a barbie doll girdle. So women it’s just a blanket category, it’s tooth coloured. But gosh darn it when I say to their little boy, ‘hey, you’re six years old if I put in silver I’m the only one who will see it, but it’ll last until you’re my age. But if I put it in tooth coloured, like your mama's asking me I’m going to have to give you this here shot every six years. What do you want?’ ‘I don’t want a shot every six years, I want the silver one’. Grandpa, same thing, he’s got a liver spot. He says, ‘I want whatever lasts the longest for the cheapest’.
Howard: Okay. Let’s go amalgam, and let’s go… and if you want the best crown, I still think it’s a gold crown… every one of my fillings is gold.
Parag: Oh there’s no question. We still can’t say we have something better than gold. Right. There’s no question gold’s still the best. It just becomes a point of, let’s educate the patients, let them know it’s available. And leave the choice in their hands. And so I practice about fifteen minutes East of Berkeley, California.
My patients, they’re not accepting any kind of metal today. Right.
Parag: They barely accept… they barely accept drinking water. That’s a debate in itself. Right. So we’ve got to fight those ballots. Now with that being said we’ve got to be really good at how we place our restorations. Right. You can’t… we know we can’t throw a resin in, you do it’s going to fail. We’ve got to make sure it’s technique sensitive. Do the right things. Don’t take the shortcuts with it and we’ll get longevity. But are those longevities that of amalgam? Maybe, maybe not. As long as you take the time to put it in proper. If you just throw it in there, it’s going to fail. And it’s going to make…
Howard: Well. Everybody says that their… they do it better.
Howard: But when you… when you see a hundred million claims processed.
Parag: Yeah. Right. Right.
Howard: So everyone must suck. Because they’re only lasting six months. It’s kind of like Endo.
Howard: Ask a general dentist, ‘what percent of your root canals fail doc? You’ve been doing root canals for thirty years’. ‘Well, knock on wood. Knock on wood. I’ve never had one’. I say, ‘okay, dude, well there’s four thousand endodontists who work forty hours a week.
Howard: And three out of every root canals are retreat. That’s a shit load of immigration. Because none of the dentists here have ever had a root canal fail. But when you look at insurance claims, it wakes you up.
Howard: When a general dentist does a molar.
Howard: In five years ten percent have been extracted. When an endodontist does a molar, in five years five percent have been extracted.
Howard: Well I’m debating whether it’s working, failed…
Parag: Right. Right.
Howard: We’re just talking extracted.
Howard: So ten percent of molars fail.
Howard: By general dentists. Five percent of molars fail by endodontists.
Howard: And your damn posterior white fillings last six and a half years. And what’s the dentist’s answer? Bulk fill. So my question is what do you think of Bulk fill? I mean they’re only lasting six and a half years. Why don’t we get that down to five?
Parag: Yeah. So I have to be candid here. So I did the clinical studies for SonicFill, so they should understand that. The audience should understand that. So the clinical studies portion were run out at University of the Pacific. We ran it about five, six years ago now. And going forward my first Bulk fills were placed right around five or six years ago.
With that material and others like it. We’re not seeing any difference between Bulk fill and traditional resin composite. As long as you make sure you’re using a Bulk fill material with a proper curing light. Right. So if you don’t… the curing is important. And we can’t take a product that is not developed for Bulk fill and put it in Bulk. And unfortunately that’s a lot of what’s occurring. That people take the Filtek Supreme, it’s a great material, and they put it into five millimetres and try to cure it. Don’t do that. It’s not going to work.
Now if you take SonicFill, Filtek, Bulk one, Dentsply’s product SDR Flow, they work pretty darn well.
Howard: Dentsply’s product is what?
Parag: Dentsply has an SDR flow that a Bulk fill flowable material.
Howard: S-T-R flow.
Parag: S-D like D, like dog. S-D-R flow
Howard: SDR flow is there in Bulk fill.
Howard: And you said Sonicfill. Who makes Sonicfill?
Parag: Sonicfill’s made by Kerr.
Howard: So Kerr makes Sonicfill. Dentsply makes SDR.
Howard: I think they should’ve named it STD flow.
Parag: That should be a big seller, right. Big seller.
Howard: No one. No one would forget the name. No one would forget. And then… and then who… and then 3M makes the Filtek Supreme. But what’s 3M’s bulk flow?
Parag: They have a new one called Filtek Bulk One.
Howard: Filtek Bulk One.
Howard: And you think… you think these are equivalent to the layered composites they replaced.
Parag: We are…
Howard: The incremental composites they replaced.
Parag: I do. So when we look at the third party data coming out today. There’s no difference. So a variety of research show there’s no difference in kind of… marginally…
Howard: You know what? You could be the most valuable researcher in the world.
Parag: What says that?
Howard: Well. No. I’m not kidding. Because you are a part-time faculty at UOP right?
Howard: And that is the greatest Dean that ever lived in a dental school.
Parag: Right. Art Dugoni.
Howard: Art Dugoni. And the… when I was in school thirty years ago. The dental school model was the marine mentality, boot camp, treat you like you’re dirt, treat you like an asshole. And Art was the first one who said, ‘no, these are our customers and I want these alumni to donate money to the university for the rest of their life’. And then the dental school out here was started by Jack Dillenberg.
Howard: Who idolised Art Dugoni. And I’m so sorry that Art’s wife passed away, that’s just got to be tough. But Delta Dental has about nineteen different Delta’s. And Delta California is the biggest.
Howard: And the CDA, whether it be in Anaheim or San Fran, has never once had the CEO of Delta ever lecture. Ever. I mean it’s basically like communism versus capitalism. They… These… Delta will give some bastard dentist in San Fran a hundred thousand dollars a year for ten years. And he only hears from them once a year, and it’s some letter that he didn’t cover something. And they used profanity.
Howard: And Delta… and CDA would have Dickerson come in and give lectures called ‘Delta or the Devil’.
Howard: It’s like are you shitting me these days. Do you know what it’s like for Delta to go to a California company, and get these employers to subsidise their employees dental insurance in this competitive economy. That we’re between international competition, and artificial intelligence. And I mean there’s no margins left, and those boys out there in Delta sell a billion dollars worth of dental insurance.
And CDA is too arrogant, and assholiness to ever have that guy come in there and tell them, ‘there’s something…’ because if you could get Art Dugoni to bring together Delta and UP, or the CDA and start sharing their data. Because you guys will do studies of like a hundred fillings, they have hundreds of millions of fillings every year, just in California, going back to the fifties.
And once you started data mining it, and then you could go to Google and write an algorithm. And then you could sit back and say, ‘in the state of California’, because I know that Californian’s all think the people that do all the shitty posterior composites live in Arkansas, or Mississippi, or Kentucky. And say, ‘just among California dentists’ or you can just shrink it to the ones who think they’re all that in Beverley Hills, and San Jose.
Howard: And say, ‘look at these. Look at all these elite dentists. Here’s the math on what they do’
Howard: And I think that trying to figure out if Russia tainted our elections. I don’t give a shit. I want Delta and the ADA to start talking. And when I talk to the Chief Economist of the American Dental Association, he can’t even get in Delta. And they’re right there in Chicago.
They don’t share because of the abusive behaviour that the ungrateful bastard dentists have shared toward their value chain. And you ask a dentist… if there was no checks and balance right now. A crown would cost four million dollars, and Delta would pay a hundred percent. That’s the bubble that dentists live in.
No one’s going around selling companies to subsidise their employer's cell phones.
Howard: This iPhone cost me eight hundred bucks. Obama didn’t pay for it. Trump didn’t pay for it. I bought my house, my car, my iPhone. These dentists should be grateful that there’s companies… like Delta sold… last year the dental industry in the United States was a hundred and three billion dollars. And Delta was almost twenty percent of it. Did they get a thank you letter. Oh hell no. They don’t even get invited to the CDA. That’s my rant.
So are right there. You should go to Art Dugoni’s house. You should go to the dean of UOP. And you should drag both of those guys into the headquarter of Delta and say, ‘look, we do research’. Damn it would be nice to see your data. Your claims data. And if you had that data, you’d be the most cited dentist on earth. Because you’d have the most data points on everything.
Parag: I could.
Howard: What percent… what percent of the patients who got four quadrupling (inaudible 46:38) wore a denture five years later. I want to know that. Delta knows. They just won’t let me know.
Howard: I mean there’s… I’ve got a million questions I want to ask that data.
Parag: Yeah, there’s… I think you’re absolutely right. There’s a power of big… kind of big data. And can we get it to happen in dentistry. Right. Because all we know is what happens in our individual offices today. There’s no aggregation of all this data that’s out there. Other than the insurance companies who have it. Right. But if we can actually tie that back to kind of patient demographics, how things are placed all these things. Dentistry will move forward. We can actually move oral healthcare forward. Right. It’s not about that filling.
And I think that’s where digital spectrum is going to help us. Is all these scanning companies that are out there, at the end of the day they’re collecting lots of data. Let’s not kid ourselves about it. So every time we take a scan that’s there, that scan is residing somewhere.
And ultimately they will know that patient was scanned on x day for a crown on tooth number three. And year after year, after year they start to bring all this data together. It’s your 3Shapes, your 3M’s, your Allianz. They will know exactly how long that crown is there until the next time it’s scanned again for something else. So they’re collecting all this stuff.
Howard: You know what’s even…
Parag: Who… who takes this data and does something useful with it. Is going to (inaudible 47:46).
Howard: And do you know what’s even scarier?
Howard: I had to do jury duty.
Howard: And they called me in on a trial and it was three weeks.
Howard: And you just said that you didn’t know this guy, and then they pull out a recording of every phone conversation you had with that guy six years ago.
Howard: Every text message. Every… really you don’t know him?
Howard: Well, isn’t this your voice? Here’s you talking to him six years ago. And I mean I’m like, ‘oh my God’.
Howard: Because every face time, every phone call, every email and text is somewhere.
Parag: That’s right.
Parag: That’s right. That’s how it is.
Howard: So when I talk to reps they tell me that if they ever take in the device to check the dentists curing light. Ninety percent of them, parts of it are burned out, it’s not curing. So when you said posterior composites. The number one cause of failure rate is probably, you don’t even have a strong enough light. Your lights not working, your lights old. What should they think about with their light when they’re doing composites?
Parag: Yeah. I honestly cover a base of things. Number one is to set a regimen in your office to check your lights. Right. A radiometer is a start, it’s not an absolute, but get even simpler than that.
Take a ball of composite, roll it in your hands, get it about two or three millimeters thick. And hit it with the light, and see if it actually cures. Are you actually hardening that ball of resin? So I do a really simple…
I believe in a kind of simple research. Those little instrument rings that are colour coded so we identify our hydrogen instruments versus our operative instruments. They measure about two and a half to three millimeters thick. Somewhere around there. It would be key for anyone to make it up to four millimeters. Somewhere there.
So they take those, and they block their side, they squirt some composite in there, and they cure it from the top. And they squish out all the stuff that’s uncured below. And if it’s not curing. Your restorations in the mouth are not curing. Is we don’t need a big research project, we need a twenty-five cent instrument ring. To figure out if our light’s producing the energy it should. But let’s make sure there’s not composite caked on the end of it, the optics aren’t broken. Work out the basics.
I’m all for saving money. eBay’s not the place to get curing lights. But I’m not… I saw an ad not too long ago, is you can buy five curing lights for a hundred dollars. Now how is that curing light any different than a blue bulb stuck in a flashlight at Home Depot? I don’t know.
Howard: Now is there any curing light that lasts longer or is easier to check, or… if someone twenty-five years old started a De Novo dental practice said, ‘what curing light would you buy?’ What would you buy and why?
Parag: Yes. I think there’s three curing lights I’d look at. I’d look at the Ultradents VALO light, that thing’s a beast. It’s indestructible, does an excellent job. Kerr’s Demi Ultra light, and 3M’s Elipar S10.
Howard: Okay. Ultradents HALO, 3M…
Parag: VALO. VALO.
Parag: VALO with a V. Yeah.
Howard: And what was the second one?
Parag: A Kerr Demi Ultra.
Howard: Kerr Demi Moore.
Parag: Demi… that’s the… that’s the extended version. You have to pay extra for that one. So…
Howard: She’s missing her front two teeth. Did you see that?
Parag: I know. I did see that.
Howard: She was on Jimmy Fallon missing two front teeth.
Howard: So Ultradent VALO, Kerr Demi Ultra.
Parag: And 3M’s Elipar light.
Parag: Elipar. E-L-I-P-A-R.
Howard: Those are weird names. VALO, Demi Ultra, and Elipar. I think the marketing department is not working as hard as they could be. And why do you like those three?
Parag: So those three lights. I’m a big… I like to look at the data and see what the data’s showing us today. And those three lights, on the last ADA study, actually out performed the gold standard halogen. The halogen curing lights have been our gold standard, and those three out performed it.
I get concerned when I hear curing lights can cure in one second. ‘Here’s a curing light, it can cure in one second and save fifteen seconds a patient’. It’s like well at the end of the day what do you have? Forty-five seconds. What are you going to do with that? Or sixty seconds. It’s like no, let’s cure the right way the first time.
Howard: I know.
Howard: But the human wants to believe. They saw with what they want to believe.
Parag: Right. Right.
Howard: And what’s the most frightening thing is what dentists are sharing on Facebook. And they’ll have some crazy story, and it’ll be from like international world news. Dude, I’m sure… I’m pretty sure that’s just a server in somebody’s garage.
Howard: Why are you sharing a story from… and then you ask that dentist why would you be sharing that shit? ‘Well, CNN and Fox News it’s all a conspiracy. They’re all bought and… it’s just… the human mind is very bizarre.
So you talk about building patient relationships through trust. That is the… that is the number one element in dentistry. I mean if… back to the insurance data.
Parag: Right. Right.
Howard: When you diagnose one hundred cavities, the country only drills, fills, and builds thirty-eight percent.
Howard: You say, ‘well it’s because they don’t have money’. Well it’s true, one out of three don’t buy ever.
Howard: But you take two dentists, the data’s there always.
Howard: The dentists doing seven fifty a year are filling, and drilling, and filling thirty-eight percent of their diagnosed decay. And the dentist doing a million to a million three, they’re doing two out of their three diagnosed.
Howard: We’re just talking cavities.
Howard: We’re not talking about veneers.
Howard: And implants.
Howard: And all that stuff.
Howard: So the difference between you come into my office and I tell you, you need four cavities. And you look at me like, ‘I don’t know if I really do’. And then you leave.
Parag: Right. Right.
Howard: That’s the little guy.
Howard: One doesn’t because you’re the doctor. One’ll never do it because you’re probably paid for by the Pharmaceutical industry.
Howard: But that one in the middle. I tell the dentist the most important thing you have to have, is a chairside manner that makes people feel at ease, and they trust you. What do you… what are your thoughts… how would you help dentists build trusting relationships with their patients?
Parag: Yes. I think… let me go back a little bit on my time. I’ve been practicing about sixteen years now. My wife and I bought a practice about fourteen years ago. Right. And when we bought it we were the young kids out of school, we thought we knew everything. We sat down and honestly we probably treatment planned correctly, but didn’t build a trusting relationship first. Right. So it’s all like, ‘here’s what you can do. Here’s all the issues we see in your mouth’. And they had a lot of kind of supervised neglect. But they loved their prior dentist. He made them feel good every single time. Right. All these things kind of went on, and we came and treatment planned all the different issues that were there. The trust piece is missing.
Hindsight’s twenty, twenty. Now going back in time saying, ‘well what could I have done differently?’ You could still educate the patient. But it’s about understanding them, and building a connection with them first. Right. See what the value in the patient is first. God sakes ask them their name. What’s going on with their child? What’s important in their life? What’s happening? And then bring it back to dentistry.
But the goal is (inaudible 54:44) more health. Great. ‘Here’s the issues I see in your oral health. Here’s what I have to take care of. Maybe we can’t do that all today, but over the next x number of years let’s try to treat that and get you to where you want to be. And then show them. Bring the cameras and etcetera. But I never put a patient ultimatum unless I’m truly scared about their health. I never say, ‘you must do this’. Right. It’s about, ‘here’s what I see, here’s what you should let us do, and here’s how we can fix it if what’s important to you is establishing your health’. But if you can’t do it today, or there’s financial limitations. Give them alternatives. All of the alternatives are there. And don’t just watch things.
I get irritated today when I place in dentistry out here when they say, ‘we’re going to watch all these things’. What are we going to watch it do? Watch it get worse? Instead let’s manage it. And sometimes that management is not drilling and filling. That management is helping them get a toothbrush in their mouth. Helping them get the fluoride through the water, the regimens that are there. Help protect them, and when the time is right they’ll do their surgical therapy or restorative dentistry with me.
This unfortunately we had to learn during the economic downturn. If I look back at the ‘08, ‘09 timeframe, how all my Silicon Valley patients. Yeah. They may be making over a hundred thousand dollars a year. But they’re still tight, their fifteen hundred dollars in benefits. Right. And they will come in and say, ‘doc, I’m afraid I’m going to lose my job. I can’t afford to do that crown’. So we had to make a decision. Do we just turn him away and say you can’t do anything? Or do we manage them? Do we say, ‘fine we’re going to put a large filling in. It’s going to buy you some time’. Yes, it may breat. But it bought you time.
Those patients eight, nine, ten years later are very happy with how we treated them. And now we’re converting that direct care into indirect care. Right. And to indirect frustrations. But they believed in us because we didn’t shove something down their throats. So I think if making patients take ownership in their health, but you’ve got to be a partner their health. You have to be a partner in what’s there and show them why you need to do what you need to do.
Howard: And I think the number one way to build trust when they’re doing their Google searches. You’ve got to have a Youtube video showing your smiling face and talking.
Howard: And then have your wife next to you as a dentist, and your kid, and your cat, and your dog, and bring your goldfish with you. Show them that you’re a human to build that trust. Do you think any technologies build trust? Because you started the show talking about first thing you’d get is an intraoral camera. I mean seeing is believing. It’s one thing for me to just have a poker face and say, ‘Parag, you’ve got four cavities’.
Howard: It’s a whole other thing to actually show him four black dots on your tooth coloured tusk.
Parag: Sure. The sell a couple of things today. One is Dexis CariVu, has helped us a great deal in showing patients kind of cavities and cracks on their teeth. And then the second has been the caries detection standpoint with things like the new products by Air Techniques they called Spectra. So a Spectra system that will actually colourise the decay or caries. It will actually show a colourised image that patient can resonate with. So those things get patients to go beyond stick men.
Howard: That’s Air Techniques. What’s it called?
Parag: It’s Air Techniques and it has a product called the CamX…
Howard: K-M-X P-A-M
Parag: Cam. Camera. CamX.
Parag: And then X. CamX Spectra.
Howard: Got it. Good old Google.
Parag: And then Dexis CariVu.
Howard: Wow. So that is a neat deal. I’ve heard of Dexis CariVu.
Howard: Cari… C-A-R-I-V-U?
Howard: But Air Techniques shines a new light on CamX Spectra, and introduces CamX Elara. Interesting. So you like that? And you like that because you think it explains to the… shows the patient more so they actually see a cavity, than you just saying, ‘you have a cavity’?
Parag: Exactly. So I always tell people that these devices don’t replace our brains. But they help connect with the patients brain. But it’s not replacing our… but to help connect with the patient. So what these will do, it will help you kind of find things, track them, and then make a decision ultimately. The patients will resonate with colour imaging.
It’s funny. Most dentists today are still poking teeth. We’re still poking teeth to see if there’s a cavity. And yes, did that work? We missed a lot of the… we missed a lot of the unknowns. We find the obvious but we missed the things that aren’t as obvious.
Howard: So trust. Intraoral camera. Caries detection technology like Dexis CariVu or Air Techniques. Any other technologies that you think build trust,or to help us sell the invisible? Because that’s what it comes down to. We’re selling the invisible.
Parag: Right. Well I think we talked about scanners. So scanners are the intraoral scanners are the thing I would put in there.
Howard: But how’s the intraoral scanner build trust with the patient?
Parag: So let’s take an example today. Our patients who come in there, they’re thinking about maybe having orthodontics, invisalign type treatment done. Something like that. Right. And we’re starting to talk to them about how… and there are hygiene visits, their teeth are overlapped and we can’t get them clean. Well today I can scan that patient’s arch form, put it on the machine and show them. Looking at that intraoral camera but making it three dimensional. So I can rotate things all the way around.
Tell you a good… an example of the very first try doing this. I had a patient walk into my office and they said, ‘hey doc, I know I have a cavity in my mouth. I’m not chewing as well as I once did’ I’m like, ‘okay, well that’s interesting. Let’s take a look in the mouth’. Patient opens up and have massive amounts of erosion, not a speck of decay. There’s not a single cavity anywhere. They’ve lost fifty percent of posterior tooth structure all based off erosion. Significant amounts of reflux are occurring and actually some alcoholism in conjunction as well. I scan their mouth. Scan upper arch, lower arch, (inaudible 60:29). I put it on my scanner. I explain to them I go, ‘look you’ve never had a cavity in your mouth, but the reason you’re not chewing as well as you once did’. And I can rotate that arch for him, ‘pretend you’re sitting on the uvula of the tongue. And you can see the teeth don’t contact’.
They’re able to see for the first time why they’re not chewing. They have no lingual cusp left. It’s all… they’re all gone. There’s nothing that’s left there. So now you tell this patient who’s never spent really a dime on restorative dentistry, that I need to restore your entire maxilla to get you back to where you were. And it’s going to cost x thousands of dollars.
That couldn’t have happened in the traditional world of x-rays and even a couple of single intraoral camera views. Right. Digital scanning allowed a case like that to resonate with the patient what’s going on. Before it would’ve been resin impressions, study models, put on an articulator. And I say, ‘hey, look at all this dentistry in my hand’. Patients don’t resonate with that. They see a colour image on a screen. They get it. They get it.
Howard: Was that alcoholic patient… was he Irish or Russian?
Parag: He was actually neither.
Parag: Neither. Yeah.
Howard: Who’s trying to pretend they’re Irish or Russian?
Parag: That’s right.
Howard: My God if you ever lecture at Russia, Poland, Ukraine. They have pitchers of vodka at room temperature. And they pour them… those orange juice glasses they have at the CDA.
Howard: Those dentists there in the morning they’re drinking orange juice or tomato juice and then filling it fifty percent with vodka. They don’t kid around with their vodka.
Sorry I can’t believe… I’ve loved talking to you so much we went over the hour.
Parag: No problem.
Howard: Can I still have a couple of overtime questions?
Parag: Sure. Please.
Howard: In my three decades out. It seems like the number one variable that predicted success. Success being I love dentistry, I’m not burned out. I’m making money. I’m happy. I’m smiling. I’m having fun. Was directly correlated to the hours of continued education. The docs that took a hundred hours or plus more. They always crush it. The ones who got their FAGD, their MAG. It’s not the FAGD and the MAG, it was the fact that they were taking a hundred hours a year and they were… you’re a summary of your five closest people. When you join the AGD, your buddies, your homies were going for it.
Howard: When you hang out with a guy just because he’s across the street from you. He may hate dentistry more than anything, but you just like watching football with him because he’s so damn hilarious. Because he’s just always whining, and moaning, and bitching about dentistry. So that’s why I do this show, because they’re commuting to work and they’ve just got to listen to you speak for an hour. What do you think about these kids coming out of school? What would you tell them, who now say,’ well I finished all my requirements, and I graduated on top of my class I’m done with that’. What would you them about continued education?
Parag: Yes. I would say dental school has simply made you a safe beginner. Right. And we have to continue keep learning if we really want to deliver good care for our patients. If you’re lucky in dental school you may have done twenty crowns. Well fantastic. That could be a really busy month for you at some point. You may do that in a month of what you did in your entire dental school education.
So I think surround yourself with people that are going to help you push the envelope. But ethically. Right. It’s the goal of things standpoint say, ‘they are going to improve my dental skills’. I think things like Facebook, and Twitter, and podcasts are a fantastic place to start. Get your appetite whet by what’s out there in dentistry. But take live courses. Take hands on courses. Keep pushing yourself and then take photography of your cases so you know where you screwed up.
I learned the most from looking back at my old cases, because I photographed and know I could do better. I messed up here. And I show my mistakes when I lecture, and say, ‘look here are all the mistakes I made’. And we learn from it and we go on. Never stop learning. You’ll get bored with dentistry if you stop learning. At that point you’re a mechanic, you’re not a healthcare practitioner.
Howard: And my last question since I went eight minutes over with you. Seriously I could listen to you all day. We just had six thousand kids graduate last week.
Howard: If you had to give them the three minute commencement, see that’s my final question. What would your message be to the graduation class of 2017 who graduated last week?
Parag: I would tell dentists to… you work in a phenomenal profession as long as we take care of it. Right. So it’s our job to be kind of be stewards to our profession and take care and understand that what we have responsibility to our patients and their care.
Now with that comes continue to learn, doing the right thing. But always being cognisant of your success. You worked really hard. Come out there and celebrate your success, and celebrate things along the way. So take time out for your family. Take time out for yourself. Don’t get so caught into your own office, your own little world that you don’t explore the world.
So kind of take home message would be dentistry offers us tremendous opportunity and responsibility. We have to be able to do both those things together. Right. When we take the responsibility, take the opportunity. Enjoy it. Enjoy it and go out. And don’t feel like you’re stuck behind the eight ball at all times. Don’t compromise your ethics. Stick with pure ethics, that’s all we have at the end of the day.
Howard: So I’m going to ask this question last. So if it’s offensive or you don’t like it I can just delete it.
Howard: But can I ask you one personal question?
Parag: Of course.
Howard: Your wife is a dentist. Did you meet her in dental school? Did you marry her in dental school?
Parag: We did. We met at a Halloween party.
Howard: At a Halloween…
Howard: But what… so there’s a lot of husband and wives commuting to work right now, and you’ve been working with your wife. So you work in the same office with your wife for fourteen years. Right.
Parag: We do.
Howard: And you have a kid together. And you live together.
Howard: So are you in heaven or hell? Right now. Where… where… and to all the couples commuting to work right now in their thirties. And they’re husband and wife. And they’re thinking about this and they’re thinking, ‘I don’t want to ruin the marriage. And I don’t want this nine year old to be…’. What advice would you give everybody dating in dental school right now? Because twenty percent of these podcasts are with dental students, and the other eighty percent are probably all under thirty. What’s the marriage advice?
Parag: So for us it’s been absolute heaven. From the standpoint that we both come from families that work together. But even if it wasn’t for that. My wife has made our marriage very successful in a sense that when she leaves the office, the office could be burning down it doesn’t matter. Dentistry’s done. Right.
And we have our rule that says… she has a rule that says no more than one hour of dentistry at home. And that’s it. And then we turn it off. And we move on with life. And maybe set those parameters and set kind of responsibilities and things for each one. And don’t get in each other’s way. You’re going to be just fine. So when we’re in the office together the staff knows that we’re equal bosses. There’s no question. That’s there.
There’s not looking at her when she’s looking at me. We each respect one another. We each get out of each other's way at the same time. There’s certain things that I should absolutely not be involved with, whether it’s the practice life, the home life and vice versa. And we stay out of each other’s way. We trust one another to get things done.
Howard: Well when I talk to staff, you say it’s heaven, the staff say that when the husband and wife own the offices. It’s heaven or hell depending on if they have a org chart.
Howard: Because if I go to Doctor Parag and he says no. So then I run over to his wife, Doctor Duncan and she says yes. The staff’s always… they’re always… whenever like every… there’s a general, there’s a major, there’s a (inaudible 68:01), there’s the Pope, there’s a Bishop, there’s a Priest. Whenever there’s a org chart the staff is good.
Howard: But whenever you have two Gods, one’s Lightning, one’s Thunder. And all hell breaks loose. So how do you do the org chart at work?
Parag: So our org chart is… so my wife and I are equals at work but we separate our responsibilities. So there’s certain things that only go to her, and I know not to answer those questions and defer to her. And vice versa. And certain things only come to me. If the staff ask further questions she’ll say, ‘let’s ask Doctor K’. Let’s go to defer to him. We’ll get a answer from him. And we separate. We don’t cross those lines. So you’re right, if those lines are crossed then we get…
Howard: So they call you Doctor K?
Parag: They call me Doctor K. Yeah.
Howard: And what do they call her? Doctor D?
Parag: Doctor D. Yeah.
Howard: Do they?
Parag: They do.
Howard: That’s amazing.
Parag: Yeah. Yeah.
Howard: So when your son doesn’t become a dentist. Is he going to be disappointing his mom or his dad? Or does he have to be a dentist?
Parag: He actually hasn’t… He does not have to be a dentist. He doesn’t want to be. He actually has another… he wants to be, at this point, a paediatric neurosurgeon. That’s what he’s decided he wants to do. We’ll see how it pans out.
Howard: Holy Moly. I didn’t even…
Howard: I can’t believe a nine year old even knows what a paediatric neurosurgeon is.
Parag: Yeah. We’re blessed. We have a smart kid and he’s a bundle of joy.
Howard: Well that’s actually… you want him to be unedumacated so you don’t have to face college.
Parag: That’s right.
Howard: If he wants to be a paediatric neurosurgeon you’re going to be paying at least ten years of college.
Parag: That’s right. We’ll be working a long time.
Howard: It’s funny. When you look at dental school indebtedness, the seventeen percent that have no student loans. They all have one thing in common. Mom or dad’s a dentist.
Parag: That’s right. Exactly. That’s right.
Howard: Well, hey, thanks for the… any marriage advice to these couples? I mean the most important you’re ever going to do is have the institution of marriage, kids, family. You guys were in school. You’re happily married sixteen years. There’s a ton of couples right now driving to work listening to you. Any last take away marriage advice to… ?
Parag: Yeah. My marriage advice would be stay out of each other’s way. Trust one another. Have responsibilities for each other. And stay out of each other’s way. And be able to believe in one another. I could not want to do what I do if it wasn’t for the support of my wife. And I one hundred percent know that. My dad told me he could do nothing right in life. Very smart. I think I was fortunate enough to do that. Because it’s going to cost you a lot if you don’t.
Howard: Yeah. But marry smart.
Parag: Very smart. Very smart.
Howard: I mean you married a doctor of dental surgery. And have you seen divorce data? If you both have a post graduate degree, a master's or doctorate in the same field. You only have a ten percent divorce rate.
Parag: Is that…
Howard: It’s the lowest divorce rate in the free love marriage. When you go to like India, an arranged marriage, the whole country only averages ten percent. Because your mom and dad can pick your spouse better than a kid in heat.
If you both have a post graduate degree in the same thing, you have the lowest divorce rate. So you couples listening right now, if you’re husband and wife dentists. You’ve got a ninety percent chance you’re going to make it. So just don’t screw up the other ten percent.
Parag: That’s right.
Howard: Hey, dude, I could listen to you the whole day long. Thank you so much today for coming on the show and talking to my homies. I know they thoroughly enjoyed you.
Parag: Thanks Howard. Have a great one.
Howard: Alright, you too buddy.