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Office Visit: Dr. David Boschken by Kyle Patton, associate editor

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Office Visit: Dr. David Boschken 

This Townie believes in the power of purchasing—and Phase I treatment

by Kyle Patton, associate editor
photography by Lori Eanes

Orthodontists spend most of their working hours inside their own practices, so they usually don’t get many opportunities to see what it’s like inside another doctor’s office. Orthotown’s recurring Office Visit profile offers a chance for Townies to meet their peers, hear their stories and get a sense of how they practice.
Dr. David R. Boschken doesn’t like braces. It’s a strange notion, especially when one remembers he’s an orthodontist. Eight years ago, though, braces—specifically all those broken brackets and the pesky parents of patients preternaturally good at breaking those brackets—had Boschken eyeing the exit. Overrun and overworked, he flipped the practice on its head and stopped offering traditional ortho; from then on out, he decided, it was aligners all the way.

And he made it work! Today, Boschken’s office is almost 100% clear aligner patients. Along with saying goodbye to busted brackets, he has ditched all things analog, purchased a second practice and turned himself into an investor in the profession he almost left … all while seeing half the number of patients he used to. For the past two decades, he has also worked as a mentor, lecturer and advocate, which includes traversing the country to speak, educate and pass along the knowledge he’s accumulated over the course of a remarkable career.

In our exclusive Q&A, we got Boschken to sit still long enough to tell us about his impressive practice transition, what to look for when buying property, how future ortho offices will look, aligner tips and more.
OFFICE HIGHLIGHTS
Name:
Dr. David R. Boschken

Graduated from:
University of Pennsylvania School of Dental Medicine (both dental school and orthodontic residency)

Practice name:
Boschken Orthodontics,
San Jose and Los Altos, California  

Practice sizes:
San Jose: 2,200 square feet, 6 chairs
Los Altos: 3,300 square feet, 10 chairs

Team size:
10
How’d you get into the profession?
My path to becoming an orthodontist might be considered straightforward. I majored in biochemistry during college, which opened my options for a graduate degree in life science. During my senior year of college, I was exploring medical school as the primary next step. However, at the time, I was dating a girl whose dad sent me an article about dentistry. The article explored the explosive need for dental care in the U.S. and the advantages of owning and running a small business.

I also was heavily influenced by my childhood pediatric dentist, who had mastered the art of customer service. His office was a playground for fun with a full arcade, fish tanks, trains mounted to the ceiling that ran the perimeter of the office and music blasting all the current hits. The culture he created would later become an inspiration for my own offices.

Fast-forward to dental school: I was fortunate to work in the orthodontic department on a research paper with an orthodontic resident exploring the transverse dimension using periapical films. This would later become the foundation of my thesis topic. The chairman at the time—Dr. Robert Vanarsdall, aka “Slick”—was perhaps my biggest influence on becoming an orthodontist. His passion for our profession and open-minded approach to embracing all techniques and clinical approaches would lay the foundation for my future orthodontic training.


You’ve been involved with clear align therapy since the beginning. Tell us about the early days.
In 1999, I was certified with Invisalign while still in my residency. As one of the first residents/orthodontists to get trained with the product, I instantly saw the future would likely include aligner therapy.

After graduation, I purchased my first office in San Jose, California, from an orthodontist who was also certified and had started about 20 patients.

Inheriting those patients instantly required a skill set I did not possess. Those were the early years of product inconsistencies because of PVS impressions, unknown force mechanics, poorly trimmed aligners and no clear best practices. I had to effectively learn on the job with each patient.

Signing waivers required from Invisalign was not uncommon. The waiver effectively read, “We do not think this is an Invisalign case and as a result, you will assume all liability.” Not exactly a confidence booster.

A few months later I was asked by the co-founders of Invisalign, Kelsey Wirth and Zia Chishti, to start training orthodontists on the Invisalign system. Align Technology spent $30 million in a direct-to-consumer advertising campaign in 2000 that lifted the awareness of the product and brand, but had very few doctors properly trained.

This is where a few of us were brought in to quickly fill the onboarding process. Those early years from 2000 to 2005 required me to travel and give 30 lectures a year to orthodontists and general dentists, all while I was practicing full time. Crazy to think about all those cities, flight miles and doctors that I was fortunate to meet!

Then in 2010, I purchased my second office in Los Altos, California. For nearly 15 years I was tracking around 40% Invisalign share of chair. This seemed to work well for a while but over time, seeing 100 patients a day and trying to make an analog and digital office work seamlessly proved too much.


There was a time you almost walked away. What brought you to that moment?
I hit a hard wall in 2015 that brought me to a serious consideration of selling the offices.

It was a Friday in late February that I still remember to this day. We had our typical trouble calls of broken brackets and poking wires that normally would not affect me. But that day, we had five broken brackets and a few moms who were angry with the continual breakage of brackets. While I would have loved to say, “It’s your kid’s fault,” I just tried to hear their frustrations and explain this is part of the process. After patients left that evening, I found myself drowning in anxiety and burnout.

I consulted with my business partner, Nicole Pruitt, and asked what could we do to reduce the number of trouble calls a day. She immediately suggested we switch to more clear aligners, which would reduce the number of office visits, slim down the trouble calls and allow for more consultations.

The next Monday, we stopped offering braces in our office. We knew getting to 100% would take time. It took 18 months to get to 87% and another six months to reach 98%.

Our daily number of patients went from 100 a day to 45 a day, and our number of consults increased from four a day to eight a day. We were able to push patients out from the typical eight-week intervals to an interval of 12–16 weeks.

The first six months, we had parents who decided to go with another orthodontist because of our heavy push with Invisalign. We quickly learned to offer a choice of braces or clear aligners, but with a subtle encouragement of the latter.

We developed a talk track quickly that allowed parents to feel comfortable with their 8- to 10-year-old patients using a removable product. We continue to offer a guarantee on Phase I clear aligners that includes, for any reason after six months, if movements are not achieved, we will switch to braces at no charge. Rarely, if ever, do we have to switch.
 


 What benefits did you get from ditching analog systems?
Seven years ago, we had 15 team members at 40% Invisalign share of chair. Now we have a streamlined team of 10.

The daily grind of seeing 100 patients a day, broken brackets, limited column space for consultations, wear and tear on our team, and the constant hustle to scale up operations while strapped by an analog model are now just a distant memory.

Of course, I would be remiss if I didn’t mention our main tool that enabled this narrative to happen was the iTero scanner. We have leveraged iTero scanners since the acquisition of Cadent by Align Technology in 2011.

While the scanning hardware has drastically improved over the years— HDU required a forklift to move to the latest 5D with near-infrared imaging—it’s the software that has pushed our customer experience and office systems to the next level.


You turn more than 95% of your consults and second opinions into accepted treatments. What tips do you have for other doctors who want to increase their acceptance rates?
When new consumers come into our office, they have no idea how amazing their smile will be once they finish treatment. They have no reference point for our experience or skill sets. What they experience immediately during a consultation is how we make them feel. We believe this is the key to case acceptance.

We routinely get second and third opinions that often aren’t even related to the treatment plans. People are looking for an office that is warm, fun and empathetic. Be those things.

Of course, at times they are looking for flexibility in a treatment plan that fits their lifestyle. We lean into the idea that we customize each consumer’s experience to fit their needs. I think what sets us apart is our ability to customize each patient’s experience to what works for them. Working this kind of flexibility into your office isn’t hard to do.


Why would we say, “You are not a candidate for Invisalign” if that’s the sole reason a patient is in the office for a consultation?
Many of these second and third opinions have been turned down and told Invisalign is not the right choice and that brackets and wires would be a better solution.

This constantly confuses the consumer, who believes if one doctor says they are not a candidate, then it must be that Invisalign as a product is not possible.


What are some other clear aligner tips you wish you had known or done sooner?
If I had to do it over again, I would have embraced Phase I earlier.

I had dabbled in Phase I Invisalign using the former Invisalign Teen product for about 15 years with success, but never had that “aha!” moment. Deciding to switch my practice to all digital would require a new way of thinking, including designing a new talk track for parents and retraining our team to work with these young, growing smiles.

All of this would require a new mindset, which is exactly what we did. I can emphatically say that treating Phase I patients with Invisalign First has been one of the most rewarding and clinically sound decisions I have made in my 23-year career. These young kids are phenomenal at wearing their aligners, which helps us remove the traditional wire-and-bracket issues of breakage, white spot lesions, dietary restrictions, root shortening and endless appointments.

Sixty percent of our Invisalign First patients start with an upper RPE and 20 lower aligners. We are able to align the lower arch (expand, align all teeth and create leeway space around C’s) while the upper expander is executed.

The ClinCheck treatment plan gives us a transverse analysis of how much expansion will be needed for the 6s and primary teeth. This is a detailed quantitative table every doctor has access to, to achieve precise expansion. Once the upper RPE is completed, a new scan of the arches is done to create new upper/lower aligners for the finish and detailed stage of Phase I.

Our Phase I cases are treated comprehensively with all three plans of space (transverse, sagittal and vertical) addressed. Midlines, overbite, overjet, Class I occlusion and smile arc are all completed to ideal standards. This makes Phase II Invisalign down the road more straightforward.


What types of cases excite you the most?
Probably the most exciting clinical cases I’ve been working on for the past three years are my segmental virtual Class II and virtual Class III cases.

This technique sets up the “sagittalfirst” concept of moving the posterior teeth into a Class I occlusion by segmenting the aligners and using heavy (8-ounce) elastics.

[Editor’s note: Dr. Boschken’s presentation of one such virtual Class III case was published in the July/August 2022 issue of Orthotown here.]

This technique has revolutionized my practice by finishing complex Class II and III skeletal/dental cases in half the customary time (often in less than 10 months of treatment).

Patients who have heard that surgery and/or extraction are the only viable options can be effectively treated using this technique. Of course, a detailed cephalometric, airway and smile analysis is critical to exploring all clinical options.
TOP PRODUCTS
Invisalign and Invisalign First clear aligners. My office has been 98% share of chair Invisalign for the past five years. Invisalign First is for Phase I patients, 60% of which get upper rapid palatal expansion and 20 lower aligners at the same time. Once RPE is complete, upper aligners are created for a comprehensive Phase I all within the same system.

Align Technology’s doctor subscription program. Great Invisalign retainer and touch-up model service. We purchase 400 aligners a month, which includes all retainers and touch-up cases.

LightForce treatment planning software. Only 2% of our cases in the office are traditional braces, but we leverage 100% of them through LightForce’s digital workflow, which includes indirect bonding braces. The LightPlan setup pairs nicely with our scanners.

iTero intraoral scanners. We have seven scanners between two offices. We use them for initial exams (outcome simulation with iOS Pro) and appliance fabrication (Invisalign, RPE, sleep apnea, mandibular anterior repositioning devices, Herbst, LightForce, Vivera retainers and more).



Give us a rundown of your typical day in practice.
I typically get into the office 30 minutes before patients arrive. I like to help open the office, which allows me to ease into the morning. I review pending treatment plans submitted the day before.

We see about 45 patients a day on average, which includes five to eight scheduled consultations. Most consultations are in-office, but we still run a virtual consult when requested, leveraging SmileSnap and, more recently, Align’s Connect feature, which enables prospective patients to send in photos.

My time is generally not in the clinic, because my assistants are delivering aligners, reviewing, checking virtual care utilization (remote monitoring), adding attachments, and, when braces are required, placing LightForce Orthodontics 3D brackets with indirect bonding (IDB) jigs.

Our model requires our assistants to have a comprehensive understanding of Invisalign and LightForce techniques to ensure our customer experience and clinical outcomes are executed to plan.


Let’s talk team building. What qualities make a great team? How do you manage yours?
While I would love to claim our culture is the result of something I have said or implemented, I have to give Nicole the lead on this.

Before coming on board with me 12 years ago, Nicole was the regional manager at ADP, a payroll company, for 15 years. Her corporate training in marketing and sales and her innate understanding of how people want to be treated have been the backbone of our office culture. She has created an environment that expects accountability from all team members— including me—and pushed a “the customer is always right” mindset. Nicole also created our digital ecosystem, which includes onboarding of technology, training protocols and an open-door policy of giving real-time feedback on our systems and processes.

Not one thing we do in the office stays static. Our team is instrumental in helping us evolve quickly as patient feedback and new technology emerge. Because Nicole does all the hiring, I have seen a consistent pattern over the years of finding that a unique individual who understands working in our office is a privilege.

She looks for that spark in their eyes, that desire to help people realize their full potential, the willingness to work in a growth mindset culture and an understanding that we are a cohesive team.


Some would say the “customer experience” in ortho is more important now than ever. What goes on in your office from the patient’s perspective?
From the first phone call through the new patient exam, we are fully aware that customer experience is the key ingredient. We have built two beautiful offices but that alone does not ensure acceptance.

From the time patients enter the office, we want them to feel at home. These new consumers today are discriminating—they are not only looking at the office (modern office, colors, lighting, scents, team uniform, etc.) but also watching how the doctor interacts with the team and how the team interacts with each other. This experience is also true in the consultation when presenting the diagnosis and treatment plan. After verbalizing the findings to my treatment coordinator, I will confirm the need for treatment and offer patients a choice of braces or clear aligners.

At that moment, I will offer my strong recommendation that clear aligners are my choice of tool, which will be discussed further by my treatment coordinator. The consumer hears my recommendation and, most importantly, I have transferred my confidence. Ninety percent of the time, I do not come back into the consultation.

From my experience visiting offices all over the country, doctors do not routinely transfer that confidence and conviction that clear aligners are a superior choice for the patient’s care. This is a key reason why millennial and Gen Z patients will seek multiple consultations. They’re looking for a doctor who will confidently give them what they want: a beautiful and lasting smile using clear aligners.


What do you predict the profession will look like in 10 years?
Predicting the future of orthodontics can be a little like predicting the stock market. I do know that having an adaptable team and a growth mindset to change is important. My perspective on what the future of orthodontics will look like is rooted in experience. I’m sure I’m not the only one out there with a story like this. My prediction is centered around physical office space.

Around the time Nicole and I decided to switch from analog to digital, we also lost our lease for our Los Altos location. I tried to buy that space, but the owners were not interested and the lease terms that were presented to me did not work for a long-term solution. The new terms offered the 1,100-square-foot space a new 10-year triple-net lease that resulted in my rate going from about $3,200 a month to $8,500 a month.

Given the number of years left to practice, I believed there must be another solution. I was able to find a new building that had received construction permitting in downtown Los Altos that was about 5 miles from my old location. The new space I purchased was 3,300 square feet—a space that is, frankly, too big for a modern digital office. I believe our offices will look much different in 10 years: Ideal office space will average around 900–1,200 square feet, with remote financial coordinators or third-party payment support, one private consultation room and two or three clinical chairs.

The new consumer is not looking to spend a lot of time in the office. They value their time, which highlights the need for seeing patients every three to four months (or longer and remotely monitoring progress weekly).


Imagine you’re in a room full of docs who prefer to rent. Why buy?
When I purchased my building, I was looking for security and wealth generation. Losing my Los Altos location lease and having few options to relocate was a stressful time in my life.

However, I also evaluated what I’d been paying for my San Jose location over the past 23 years—an average of $5,000/month, which comes to about $1.4 million in rent paid. Zero equity to show other than what my practice is worth. Before the DSO/OSO movement, there was little chance of creating generational wealth from selling practices. Even today, the value of practices is often calculated around 80%–100% of gross receipts averaged over five years.

As a frame of reference with wealth generation, I purchased my 3,300-square-foot space for $900 a square foot six years ago. As part of my SBA loan requirements of getting a reappraisal every few years, I recently had my building value increase to $1,840 a square foot. I have effectively doubled my equity in this purchase.

My point in sharing these numbers is to offer another option to renting. I didn’t enter into this purchase because I expected or thought my value would double in six years; I bought because I was over having someone dictate my lease terms and the real possibility of losing my lease in the future. There’s also the added benefit that when building out the tenant improvements, a return on a higher level of finish will help when appraised.

Purchasing office space is a personal choice and not always possible. Restrictions in every town on medical/ dental zoning can limit availability. There is also the cost factor! Many young orthodontists are strapped with student loans that prevent this as a practical option.


What are some tax benefits you’ve found that might interest other potential buyers?
I purchased three of the five commercial spaces available in my building. My accountant has set up a monthly rent of $21,000 the corporation gets to write off each month. While I am not an accountant, it’s been explained to me that the IRS allows me to depreciate my rental property each year.

For commercial properties, I get to divide the purchase price of the building by 39, which allows me to write off every year against my income as a way of compensating for the building getting older.

There are other tax benefits, such as property taxes, operating expenses and, of course, mortgage interest. Because I own the building, I can set up “reasonable” lease terms that favor my tax base. (Please consult your accountant for more details.)


What are a few things docs should look for in a potentially shady lease?
Read your lease! My San Jose office building was recently sold to a large commercial private equity firm for $13 million. Unknown to any of the tenants, there was a clause in the lease that had been never been realized that allowed the owners to charge for common-area maintenance.

Because the previous LLP owners had never acted on this clause in the lease, the property purchase price was justified through this line item in the lease. The day the escrow closed, all the tenants received a change-in-ownership letter stating the new owners would be adding $610 a month for this maintenance. You can imagine how this went down. Threats and mistrust are not good ways to start a relationship.

I would also make sure to have at least 10 years left in a signed lease with the option for one or two more renewals. If you are considering selling your office to a single doctor or a large group like DSO/OSO, having an extended lease makes your practice more desirable. (With all this said, ownership takes many of these rental pain points away.)


You’ve navigated SBA loans. What should docs know?
I’m not sure I’m a loan expert, but I do have some thoughts. First, have a trusted person in your office or an accountant who can help with all the paperwork and correspondence. Nicole was that person for me: She researched private banks that would quarterback the negotiations and lengthy paperwork. We ended up switching our banking to City National Bank, which took over the SBA loan process.

For those who are not familiar with SBA loans, it’s a government-backed long-term loan program that is designed for small businesses like orthodontic offices. The key benefits are funding up to $5 million, terms up to 25 years, and fully amortized (no balloon payments). This program was designed to allow for owner-user commercial real estate purchases and for-profit businesses.


You’re big into investing now. What are you involved in and where do you see it going? How can other docs enter this world?
Practicing and living in the center of Silicon Valley, I routinely have patients and friends who are part of the startup world. A wide variety of technology is constantly created and funded every day in this area.

As a result, I have educated myself over the years to review investor decks, understand term sheets, key performance indicators (KPIs) and profit-and-loss balance sheets (P&Ls) and forecast growth potential.

Having some of my investments exit has increased my desire to learn more. About two years ago, I was approached by Dr. Jeremy Krell, co-founder of the Revere Partners oral health care venture capital fund, to join as an equity partner and investor.

To date, we are invested in 30 oral health care startups, with another 600 in the pipeline for diligence. We usually fund three to five companies per quarter, with an average check of $1 million. Our fund value at end of 2022 was $60 million, with a projection of $100 million by end of Q1 2023.

We have about 12 limited partners and another 200 advisers/investors. What Krell and his team have created is a solid platform for oral health care start-ups to receive funding and advice.

While there is always risk with any investment, I believe the dental space is a wealth of opportunity for growth and acquisition.

As Warren Buffett always says, “Invest in what you know.” (If you would like to learn more about Revere Partners, feel free to email me at drboschken@gmail.com.)


Give us a snapshot of your life outside of practice/work.
I live in Los Altos Hills with my wife, Amanda, and four kids (three girls and a boy). One is a freshman in college; the other three are a senior, a junior and a freshman in high school. We’re clearly busy with the teen years … but when free, we are often up in Tahoe at our house skiing, hiking and relaxing. My kids are active in tennis, water polo and swimming, which finds me at games or meets most weekends.

I’m also an avid runner and into everything Peloton, and I work out every morning at 6 a.m. without missing a day.
Orthotown Magazine
March 2023
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