The Rise of Dentaltown®: An Interview with Dr. Howard Farran
Dr. Michael DiTolla: Welcome, Howard. I’ve known you a while and I have to say, of all your accomplishments, I think the most impressive one I’ve seen is your vision for what has become Dentaltown®. I really think that for somebody who hated computers — I mean, I used to laugh at you for your inability to use computers, and for somebody who fancied himself as being very low tech, you really hit the nail on the head with dentaltown.com.
Back in the day, you talked about how great it would be for a dentist in Topeka, Kansas, to be able to ask a question about how to treat a case and have somebody in New York answer his or her question. It sounded like a flight of fancy, but you turned out to be absolutely correct. Dentaltown is probably the best way in dentistry for dentists to exchange information and to learn new tips and techniques. Give me an update on what’s going on with Dentaltown these days.
Dr. Howard Farran: Dentaltown just continues to grow and grow and grow. The total number of registered users on the site now is 114,699. There are 192 countries in the world, and we have dentists registered from 172 countries. As I lecture around the world, it’s just amazing to see dentists in Australia, New Zealand, Hong Kong, Singapore, Ireland and the United Kingdom get excited about Dentaltown. They’re having a blast being able to talk to colleagues around the world.
In 1994 when Netscape went public, I couldn’t understand what all the hype was about. I kept looking at this stock that blew up 30,000% and checked out the internet, but at the time I thought it was pretty useless. One day I realized that I could use the internet to connect all the dentists on one website. I wanted it to be like an AA meeting, where anybody could go and say, “Hey, I’m Dr. Farran and I have a problem: I’m getting sensitivity under my fillings.” And then some other dentist, for free, who’s been there and done that, can sit there and offer solutions and product names to help fix my problem. I thought by now we’d probably have 1,000 registered dentists, when in reality we will surpass 115,000 registered dentists next month. It’s growing by about 1,000 dentists per month, with 20% of that being international. Dentaltown has become a household name because when a dentist has a problem, he or she can’t really ask the hygienist or assistant or receptionist or spouse; and they view the dentist across the street as a competitor. So instead they can go online. And you know, our motto at dentaltown.com is, “No dentist ever has to practice solo again.”
MD: Yeah, because even if a dentist did pick up the phone to call a friend, and we’ll use your example of sensitivity on direct composites, the friend may not be doing them or may not really have a good answer because they don’t use the same products or the friend doesn’t do many of them. The beauty of Dentaltown is you put something out there and not only do you get one piece of advice, but you’re going to get 20 responses from 20 parts of the country from 20 dentists who went to 20 different dental schools and have seen 20 different lectures and tried 20 different composites. That is really powerful.
HF: Yes, absolutely. And then to have a fun and friendly debate over which product is the best. I mean, there are 100 ways to cook a hamburger, and there are 100 different ways to do a filling. A lot of major companies have a large number of products, and it’s fun to watch dentists debating over which one is the best.
That brings us to the Townie Choice Awards®. We spoke previously about product evaluation and how the world used to be according to one person or another, and people would hang on every limb they said. And some of those speakers might only do esthetic dentistry or root canals or the like. We set up the Townie Choice Awards so that dentists can vote on the best products every year. The several thousand dentists that vote are the ones who are buying these products and lab services with their own money. They’re practicing in the trenches of real-world, wet-glove dentistry and they’re just voicing what’s worked for them and what hasn’t. And I want to congratulate you, Mike, because last I heard Glidewell Laboratories has won 18 Townie Choice Awards.
MD: Yes, thank you. In fact, we just ran an advertisement that shows Jim Glidewell holding all 18 Townie Choice Awards. We do take this honor seriously because the Townie Choice Awards represent the voice of dentists nationwide – these dentists are not paid to make a statement about our products. To us, it is validation that we are doing something right.
HF: Yes. It’s a great thing. And back to your question about what’s new at Dentaltown: We started doing free online Continuing Education (CE). That’s been a major hit. We’ve had 260,000 course views in the first year, all for either AGD credit or ADA credit. A lot of the State Boards of Dental Examiners are allowing online CE credits as opposed to sitting in a lecture. Why the shift? For starters, lectures are expensive. They’ll say it’s $195 for the doctor, but what they don’t tell you is you have to shut down your office for a day. That could be several thousand dollars. And then you have to drive someplace or stay in a hotel.
At Dentaltown, we break down our courses into really nice one- to two-hour courses. You can sit there at the end of the day, after dinner, after the kids go to bed, make yourself a bowl of microwave popcorn and sit in front of your computer and learn. You don’t have to take notes because you can always just go back to that class; you could take it a hundred times if you wanted to. The courses we have are on everything from dentistry to fillings to root canals to implants. It’s amazing how successful that’s been.
MD: You mentioned earlier the international aspect of Dentaltown, and I can tell you we absolutely see that with our educational programs as well. We send every one of our clinical and educational DVDs to U.S. dentists, but we stream them online as well. When you look at views per country, it’s pretty amazing to see what the internet has done for the international dental community. For example, just yesterday I got an email from a dentist in Moldova who has watched all of our videos and loves them.
Shifting gears, I was around when you had your first dental practice and you had a concept for morphing your dental practice into what is now Today’s Dental, one of the most consumer-friendly practices that had ever been put together. It’s been a while, probably eight or nine years, since I’ve had the chance to see your practice. But since nearly everybody reading this interview has a general dental practice, tell us a little bit about Today’s Dental. How has it changed over the years?
HF: Well, Today’s Dental has changed tremendously over the years. I think the biggest change has been technology. Remember hand-dipping X-rays back in 1987, and then finally coming up with a developer like the AT-3000?
MD: I think it was the AT-2000, unless you had one that was a thousand better.
HF: And now we’re completely digital. I think digital X-rays are even more consumer friendly than the intraoral camera picture. You can sit there and take a bitewing and blow it up to an 8×10 piece of paper, and then put it up on a clip board and get a red pen and circle right where the cavity is at the contact of the adjacent tooth.
MD: You know what’s funny? I just read something that said considering all the great things about digital X-rays (and it’s hard to find anything negative about them), that it’s only been adopted by 37% of dentists.
HF: Yeah, and that’s just crazy because when you take bitewing X-rays and try to put that on a viewbox and educate the patient, it’s just a lose-lose situation. You’ve got this viewbox with light constricting your retina while your pupils are supposed to be dilating to see these little cavities; and the patient doesn’t own it — they don’t have mastery over their own X-ray. At Today’s Dental we print the X-rays out and give a copy to the patient every single time. And like I said, we can put that X-ray on a clipboard and show them that there are two types of cavities. There’s a flossing cavity right in between the teeth and then you can circle an existing flossing cavity, and you can trace out the nerve and show them that this cavity only needs to go another millimeter or two before it turns into a root canal. And when you talk about flossing cavities instead of a MO or a DO, something the patient doesn’t understand, well, they understand a “flossing” cavity because the patient knows more than anyone that they’re not flossing. And then you can circle the pit and fissure fillings on the teeth and get out your laser DIAGNOdent® (KaVo Dental; Charlotte, N.C.) and have them hold it for educational purposes, and go around the pits and fissures and write down the numbers over 30 on another 8×10 sheet of paper so now they’ve got their digital X-rays. They can see, “Wow, I have 10 existing fillings, and it sounds like with this laser I’ve got two more.” And then we’ll go around the mouth and show them that they have nine fillings that are in between the teeth where the floss goes. And not only do they have two new flossing cavities, one of them is under an existing flossing filling. So, you can just tell this person, “Look, you’re not flossing at all and you haven’t been for the last 10 years.” That really, really sells dentistry because they can master — anybody can master — and see the black dot that’s printed out on the 8×10 piece of paper. It makes treatment plan acceptance go through the roof. I also still use intraoral cameras to take pictures of broken down teeth to show patients there’s not enough tooth structure to hold a filling and a crown or when an onlay is needed.
The other notable change is going completely paperless. In the past, if a patient were to call the office and say, “I’ve still got pain from that wisdom tooth extraction, can I have more pain pills?” or something like that, the receptionist would never have the time to get up out of the chair and make notes in the chart. When they came in later for a suture removal, I wasn’t aware that this person was in pain for six or seven days. Now that we’re paperless, every conversation is entered at the computer. All the receptionist has to do is just type in the patient’s name and put in the clinical notes. It’s amazing how many times patients call the office with questions about this or that, or maybe they call up and say: “I don’t want a deep cleaning, I just want a regular cleaning. Why do I have to have a deep cleaning?” And then the hygienist sees in the notes that the patient is coming in for their first quadrant or two of root planing. Then she goes over it again, and she can get out a mirror or go back to the intraoral camera or go back to the digital X-ray and show them bone loss. So, I think technology has been the single biggest thing that has affected dentistry. And I think it’s quite frightening that two-thirds of dentists don’t utilize digital X-rays.
MD: Do you think it’s mainly just the cost of getting into the system?
MD: And do you think that’s a valid point for a dentist to say, “Look, I just don’t want to spend the money”? Do you think they’re overpriced?
HF: No, I don’t think they’re overpriced because I think they make you go so much faster. You’re doing a root canal and you’ve got apex locator technology. You can snap a real quick digital X-ray and have it on-screen instantly. Do you remember going back and putting in 12 X-rays for an FMX and having them come out and figuring out which one goes where? That was a 15-minute ordeal, and bitewings were a 10-minute ordeal. Now, instead of spending 10 minutes in the dark room, a hygienist has 10 more minutes in the operatory for education. You know, “doctor” is a Latin word, coming from “docere,” meaning “to teach.” Now the hygienist can be a doctor and spend more time teaching with an intraoral camera, having the patient hold a mirror and he or she shows them the bleeding gums. I think this technology pays for itself just in speed. That’s why I always get upset with dentists when they’re strictly fee-for-service; meanwhile, a third of their patients want them to take a PPO. These fee-for-service dentists don’t accept PPO because they can get $1,100 for a crown and PPO only pays $700. To this I say, change your technique and get more efficient! Instead of spending 90 minutes doing a crown, try doing it in 45 minutes. Try getting the technology. Try Septocaine® (Septodont; New Castle, Del.) instead of lidocaine to numb them up faster. Pack your cord before you prep the tooth so you don’t nick the gums. Push the gums down and outward, and if you don’t nick the gums you won’t have to spend 10 minutes dealing with bleeding or hemorrhage or sulcular fluid. And so you know, Septocaine over lidocaine, packing cord first and taking your preliminary impression using impression materials that set up faster. A dentist who can do a $700 crown in 45 minutes is doing $1,500 in 90 minutes, as opposed to the other dentist who’s losing patients because he’s charging too much. During a time of recession, people are shopping around and they’re calling to find out how much your crowns are.
MD: And that’s how I got into single-tooth anesthesia, for example. I use PFG gel (Steven’s Pharmacy; Costa Mesa, Calif.) and the Milestone STA™ System (Milestone Scientific; Livingston, N.J.), and I don’t give that many blocks unless I’m working on an entire quadrant. I mean, 90 seconds after I start this injection, I’ve got profound anesthesia and I’m ready to prep the tooth. That shaves off waiting eight to 10 minutes for a lower block, maybe missing it, having to give it again. It’s such a great feeling to set down the anesthetic syringe and pick up the handpiece and get to work. And part of it is quality, too: The efficiency allows you to do better work. You have a little extra time to clean up the prep at the end if you need to. Or like you were talking about with digital X-rays — one of my favorite things with digital X-rays that I would never do before is take a picture to check the interproximal margins of a crown before cementing it. In the old days, it was so inefficient to shoot a bitewing and wait for it to develop prior to cementation. I would rather just cement it on and then cut it off six months later if there was an open margin. But today, the ability to have my assistant try a crown in, check contacts and occlusion, take a digital X-ray and have the image up there three seconds later to verify the interproximal fit is a huge deal to me. It not only increases efficiency because I’m not going to have to redo a crown later that’s got an open margin, but the quality goes up as well. Efficiency can really lead to better quality.
HF: Absolutely. Efficiency does lead to quality — there’s been a lot of research on it. Like, for instance, an endodontist will do a root canal in an hour. Compare the quality of that to someone who takes three one-hour appointments. A dentist who requires three one-hour appointments to do molar root canals doesn’t know what he or she is doing, is not focused, doesn’t have the equipment needed, doesn’t have engine driven nickel titanium files, isn’t using a Root ZX® (J. Morita; Irvine, Calif.), isn’t using technology.
I think it’s a fact in dentistry that the faster you are, the better you are. I mean look at the oral surgeon, who will take out all four wisdom teeth in seven to 10 minutes after they’re numb or the patient is put to sleep. And then you have a general dentist who will spend an hour trying to get out one wisdom tooth. And the oral surgeon has got all kinds of toys and technology and handpieces that make his or her job so much easier, and the general dentists doesn’t invest the time or the money to get the technology needed to be that efficient.
MD: Speaking of technology, do you ever see the chairside CAD/CAM milling units being a challenge to the dental laboratory industry and replacing the dental laboratory in the eyes of American dentists?
HF: I don’t, because I think a lot of dentists are using CAD/CAM mills more to replace large fillings with inlays and onlays. I think badly broken down teeth are still by and large being replaced by crowns and bridges and putting things on implants. So no, I don’t see it as being a threat to the dental laboratory business. The other thing is the dental industry in ’08 did $98 billion during this horrible recession; it was scheduled to do about $101 billion, so that’s only about 3% down. Dentistry just continues to grow, at about twice the rate of the GDP of America. That’s why health care went from 1% of GDP in 1900 to 14.7% in the year 2000. Here we are in 2009, and this year it’s expected to be 17.5% of the GDP. Same thing with removables. People were saying that this was the end of dentures and removables, and it’s a lost art and no one is getting them anymore. But don’t forget there are 30 million illegal immigrants in the U.S., and they are the ones who will keep removables going strong. You’ve got people coming into this country who have never seen a dentist in their life and can’t afford to have full-mouth reconstruction with root canals and crowns and bridges going for removable. So, I think dentistry is extremely diverse. There’s room for everyone, there’s room for all the specialties. There’s pretty much room for growth in all sectors.
MD: Let me ask you about something that came up last year. There was a news report on crowns made in China that were found to have high levels of lead in them. It was kind of funny in the sense that there is really no porcelain glaze available on the market today that doesn’t contain at least a microscopic amount of lead. So it’s really not a China thing, and it was hard to tell whether this issue was just xenophobia or what. But Walmart has certainly proved to become a successful company selling predominantly, if not exclusively, items imported from China. Why is it, do you think, that the American public had such a knee-jerk reaction to crowns being made in China?
HF: Well, I think it’s funny. You know, many dentists drive cars made in Germany or Japan, whether it be a Lexus or an Infiniti or a Mercedes-Benz or a Porsche or a Jaguar — and that’s not a problem because it’s Japan and Germany and we won that World War. Japan’s the second-biggest economy in the world. In 1998, the entire world’s economy was $50 trillion, and America’s economy was $14 trillion of that, Japan was $5 trillion of that, Germany was $3 trillion, China was only $2.6 trillion and the United Kingdom was $2.4 trillion.
When it comes to imports, China is a communist country, and that just stirs great emotion. No one complains that they’re using materials that are made in Germany, whether it be Sirona or Ivoclar or whoever. No one cares about importing stuff from the United Kingdom. It was an extremely emotional response. However, I want to point out that America doesn’t make a single television, ever. If I asked a group of dentists, “What make is your TV?” they’ll say “Sony” or “Hitachi.” Well, why is having a Sony television and a BMW and shopping at Walmart not bad? America doesn’t have any textiles mills either. So you’re either running around naked, or you’re importing clothes from India or China. Name a textile company in America. That was Warren Buffett’s great insight. He bought the 10 textiles called Berkshire Hathaway, and they were draining so much money trying to improve their textile mills that he just took all that money and returned it to the shareholders. And with all that profit, he just started buying other companies. And he said America’s too high-cost to make textiles; we’re not a country where everyone is going to be sitting on a sewing machine making shirts and pants. So, I think the response to the crowns with lead made in China was extremely emotional.
MD: For the average dentist, it really does come down to value. I believe that if you can give the average dentist, for a fair price, a crown that drops into place, contacts are good, occlusion is good, esthetics are acceptable — I don’t think they care if it’s made in California, China or Sri Lanka by a team of 12 monkeys. I think it’s all about the final result. And I agree with you that it’s emotional.
So, are you saying that if you could get a crown from China for the same price, or maybe a little cheaper than one you got in the U.S., you would not have a problem doing that?
HF: I would not have a problem doing that. Another thing I’d like to point out is this: American labs have issued price increases for a long time. However, the insurance companies don’t give us dentists a price increase. I think Jim Glidewell is the Herb Kelleher of dentistry. For those unfamiliar with Herb Kelleher, he is founder of Southwest Airlines. And he once said, “Everyone calls up to check what the price is to fly from L.A. to Las Vegas, but no one ever calls up and asks what meals we’re going to serve.” So Herb just stripped out all the cost he could, limited it to one type of airplane, a Boeing 737, so he could limit his parts and overhead, and got rid of the meals and doesn’t do layovers, just flights point to point. And what Herb has done is given people the freedom to fly. So when Grandma wants to go visit her granddaughter for her First Communion, she, with Southwest Airlines, can actually afford to fly to see her granddaughter’s First Communion. And that’s what Glidewell Laboratories has done. By keeping an eye on costs, you’re giving the middle-income and lower-middle-income people the freedom to save their teeth.
MD: And you know what our newest project is? Yesterday I cemented our first model-less PFM crown. We did not make a stone model for this crown. I took a digital impression in the mouth, I sent the information to the laboratory, and they made a model-less PFM crown for me. You can do this with all-ceramics — obviously CEREC® (Sirona Dental Systems, Inc.; Charlotte, N.C.) has been doing this for decades — but a lot of dentists are skeptical of all-ceramic crowns because they break or they’d rather cement them into place because of post-operative sensitivity concerns. So we made the first model-less PFM. It’d be like if your CEREC machine was able to spit out a PFM crown at the end of milling. And we’re realizing that by not making the model, not having to produce it all here, not having to have the dentist ship us the case via FedEx because it’s going to be digitally transmitted, that by being able to send out a tiny little envelope with a crown in it instead of a big box with a heavy model in it, we’re going to be able to save $20–25 per crown. We then pass that savings along to the dentist, so the crown will be $20–25 cheaper if you’re OK without a model. To me, that’s a great example of what you just explained — stripping away the unnecessary to make it more affordable for the dentist who hopefully can make more dentistry available to more patients.
HF: That is fantastic because we’re in a recession, and people are keeping an eye on their overhead and where they’re spending their money. In fact, we’ve had to adjust Today’s Dental for a recession.
MD: In what ways?
HF: Well, I think there are four basic things that have to be done during a recession. Number one is to cut costs, whether that be cheaper crowns or supplies or reduced labor costs. For example, if you’re having a central sterilization person stand around all day and there are open holes in your schedule, you’ve got to lay people off. The second thing is you’ve got to double or triple your marketing budget. It’s just amazing to me how people will not be coming into the dental office and the dentist is not aggressively trying to replace those people. Advertising is so lucrative. You’ve got two big facts staring you in the eye: One is that 50% of the population didn’t go to the dentist last year, so that’s fertile territory to market to. And then number two: it’s a fact that 8% of Americans moved. So you might say, well, my neighborhood is mature and there’s not a lot of new growth, but you still have turnover in houses and you still have people not going. And some of these marketing things are no-brainers, like 1-800-DENTIST. They charge $1,500 a month and guarantee you 15 new patients, and a new patient, if you take an FMX on them, that is $100. If I were to walk a dentist into a stadium and say, “You can have any patient in this stadium for your practice if you give them a free FMX, how many patients do you want?” the dentist would say, “I’ll take them all.” Then join 1-800-DENTIST. There’s other great marketing places: There’s newpatientsinc.com with Howie Horrocks. There’s dentalpostcards.com, where all you have to do is call them up, give them your ZIP code and a credit card number, and they’ll drop the direct mail piece the next day.
MD: And how much more willing would that dentist be to do those free FMXs just to get those new patients if he had digital radiography?
HF: Exactly. And then the third thing I’d say is you’ve got to add new products and services. “You know, you used to refer out all your endo — maybe it’s time you started learning some endo.”
MD: You know what I just did for the first time two months ago?
HF: What’s that?
MD: A crown that matched! (laughs) No, I surgically placed my first implant for a missing lower molar, and I did it with the Inclusive® Digital Implant Treatment Planning Services we have here at the laboratory. They made a surgical guide for me. It’s like a bite splint, it snaps onto the teeth. There’s also a hole in it — about 5 mm long so that the drill can’t go in at the wrong angle or can’t go in too deep. Howard, it was the easiest $1,200 procedure I’ve ever done. And that’s probably at the low end for Newport Beach. And it’s easier than prepping a crown. You look at prepping a crown and you start with this whole tooth, and you need to three-dimensionally be able to imagine what it’s going to look like 2 mm shrunk down and not have any undercuts. All I did here, and I didn’t even lay a flap, I used a tissue punch through the surgical guide and then used each drill down to the depth and then placed the implant right through it. It was the most fun I’ve had and it was certainly the easiest high-dollar production procedure I’ve done in the last 10 years.
Why do half the general dentists in Europe place implants and in the United States it’s 5%? Your European brothers can do this in England and Germany and France. Why can’t you do this in the United States?
HF: Right. And you know, there’s an interesting thing about that. I mean, why do half the general dentists in Europe place implants and in the United States it’s 5%? Your European brothers can do this in England and Germany and France. Why can’t you do this in the United States? Or take orthodontics. You’re telling me you can’t even do Invisalign® (Align Technology; Santa Clara, Calif.)? I mean, Invisalign, they do all the work for you. You can’t do minor tooth movement? Another one is a crown lengthening procedure. I mean, how many impressions do you get at Glidewell Laboratories where you’re looking at the impression thinking, man, that patient should’ve had crown lengthening. So they’re sitting there pumping epinephrine in with the ligamajet trying to stop the bleeding and they’re jamming cords down into the attachment for this subgingival margin. Like you were talking about digital impressions. You can’t take a digital impression if there’s blood or fluid.
Insurance companies pay about 80% of crown lengthening, which is about $750 a quadrant. All you need is a scalpel and some sutures and a bur. It’s just amazing how, with crown lengthening, not only do most dentists not do it, they won’t even refer it out!
MD: No way. Especially not if it’s 3 mm subgingival like we see in some cases. And even if it does turn out perfect, the margin is a millimeter away from the bone, and now it’s a periodontal nightmare, not a periodontal and restorative nightmare.
HF: And insurance companies pay about 80% of crown lengthening, which is about $750 a quadrant. All you need is a scalpel and some sutures and a bur. It’s just amazing how, with crown lengthening, not only do most dentists not do it, they won’t even refer it out!
MD: And why don’t they refer it? I think they don’t want to lose the production of doing the crown that day. That’s how shortsighted it is.
HF: Yes, I absolutely agree with that.
MD: And they don’t want the periodontist using up the patient’s insurance benefits for that year instead of the crown.
MD: Which is not a decision made in the patient’s best interest, and it’s very short-term planning. You put a crown on a patient today that has a 3 mm subgingival margin and you got the money, but you’re going to have to redo it and your hygienist is going to say: “Wow, everything on this patient looks good here on recall except for the margin on this crown on tooth #30. It’s purple and it won’t stop bleeding.” Or, worst-case scenario, the patient moves to another city and the dentist looks at it and says, “The tissue around this crown looks horrible, who did this?”
HF: Right. And that would be 8% of your patients. So 8% of your crowns in any given year move to another house somewhere in another city.
MD: Yeah, and now you’re not just having to fool your hygienist, you’re having to fool a dentist in another city, right? And then a peer review board. I saw President Obama on television the other day talking about national health care, and there’s some question about whether or not dentistry would be covered in this health care plan. I’m interested to hear what your take would be on the government getting into dental care?
HF: Well, the government is broke. They’re $14 trillion in debt. Their projected revenues versus costs over the next 20 years is negative $50 trillion. The bottom line is, Obama would like to do everything. I’m sure he’d like to buy everybody a new car if he had the money. He has a big heart, but he’s not going to have the money. And when we look around the world of the 40 richest countries in the world, based on GDP per person, we’re the only one that doesn’t have universal health care. But a lot of these countries that cover dentistry are getting out of it as fast as they can because they have to cut costs. They’ve already got 60% taxes and they still are broke. So I don’t think that America can afford to get involved in dentistry. And if they do, it would only be for disadvantaged, poor children under the age of 18.
MD: Yeah, that’s what I saw. It would be for patients under 21, basically in high-needs categories. I’m interested to know if you or any of the dentists at Today’s Dental still routinely place amalgams? You and I got out of dental school and started in this profession when the word on the street was that amalgams were evil and soon to be banned, but amalgams make up a big part of bread-and-butter dentistry. That was 15 years ago. Where are you today in regards to amalgams?
HF: Well, Today’s Dental, I think we did our last one in 1990. So it’s been 20 years. The reason I got out of them had nothing to do with mercury, because I’ve read a lot of mercury research, and mercury in a silver filling is ionically bound to silver and copper and nickel and tin. And it’s an insoluble salt. And when you swallow an old amalgam, the next day, your body just disposes of it. It doesn’t get absorbed. But when you start finding mercury in brain tissue or things like that, it’s ethyl mercury or methyl mercury, which is basically coming out of seafood because of burning coal. In 1950, the oceans were 1 part per million mercury, and after a half-century burning coal, now it’s 4 parts per million of mercury in the ocean. So I don’t like mercury in coal, but in the mouth I find it fine. The only reason I don’t do it is because if I asked 100 blind patients, “Would you rather have a black filling or a white filling?” they’re always going to take the white filling. And we did it back in 1990, that was a real economic boom, because all the other dentists were doing silver fillings, and they didn’t like them and they didn’t like them in their kids’ teeth. They’d come in and say, “Look what this dentist did!” And the kid would smile and there would be a metal crown that still said “B4” on the side of it and a couple black fillings here and there, and that just kills self-esteem. We did it for business reasons, not health care reasons. But I think an amalgam lasts longer than a composite. I mean, the research is extremely clear on that. How could a heavy metal not last longer than a piece of plastic?
MD: Yeah, and plastic versus porcelain, even. You look at the difference with composite inlays versus porcelain. You’ve got a pool, you look at the ceramic tile, it does pretty good. But anything that’s plastic around the pool, you can see it just gets beat up in the presence of constant moisture. I don’t think there’s any doubt that plastic doesn’t do as well as metal or glass when it comes to being submerged 24/7. So, if a dentist in Kansas emails you and asks if he or she should stop doing amalgams, is there an easy “yes or no” answer? Or do you need to know more about his or her practice before giving advice?
HF: Why not have a two-chair level? Why not have an MOD amalgam for $150 and an MOD composite for $200? Let’s call it market segmentation. That’s why GM has Chevy and Pontiac and Oldsmobile and Buick and Cadillac. How much do you want to spend? Want a basic car? We’ll sell you a Chevy. Want all the bells and whistles? We’ll sell you a Cadillac. But when they ask me which one lasts longer, I always tell them the Chevy.
MD: Right. You know back in the day, too, we heard a lot about concepts like dropping insurance. And I’m sure you remember we were being told by some of our clinical gurus that it was time to drop insurance — become free and independent of the insurance companies. Tell me how Today’s Dental views the dental insurance industry.
HF: Well, first of all, the majority of all those speakers didn’t even have practices. Secondly, I think the only people that can get away with no insurance are running monopolies in small towns with 3,000 people and they’re the only dentist. But when you get into a competitive market, a metropolitan area, if you don’t take insurance, you’re insane. And that’s another thing we did to cut costs with digital X-rays and being paperless. We can shoot out the insurance claim right when we check out the patient. Remember back in the old days when you had paper charts and on Fridays you would do insurance billing? That’s all gone. And what we do with every single person that comes in, we have a person — our insurance coordinator — who physically calls the insurance company and has a sheet that they fill out. That sheet basically covers all the technical questions of insurance coverage so that when we do the financial arrangement, we can say with extremely great confidence exactly what that insurance person is going to pay. I mean, Mom loves her benefits. I’ve heard: “Yeah, my husband works in construction, and he used to be in this small company and they didn’t have dental benefits. I’ve been egging him to get on to this bigger company because they have benefits. I’ve been waiting three years for this.” And they bring their insurance coverage in and they’re all proud and they want to use it. I mean, why not have someone else pay for half of your crown?
MD: That seems to me the more rational thing to do. It always scared me when I heard people recommending to dentists that they get rid of insurance: “We know it’s going to be really difficult, but do it and it’ll be the best decision you ever made.”
HF: I think it’s anti-consumer. You know, Mike, deep down inside we all have to be a public dentist, too. We all have to do charity cases in our office for free when, you know, some girl has been beaten up by her husband, she’s living in a shelter and she can’t get a job because she’s missing tooth #8. I can’t tell you how many of those I’ve done. Sure, we have upper-class people who can pay cash for all of their dentistry. But we also have middle-class people barely making ends meet, especially in this economy today where we have 10% unemployment. But what about the lower class, whether it’s good times or bad? I think cutting costs and offering, when you treatment plan, cost alternatives. You can do a low-cost partial or you can do a high-cost bridge, implant and a crown. I think by treatment planning market segmentation so these people can have choices and then having financing available like CareCredit®, is being extremely public health dentist oriented. That’s why they fluoridated the City of Phoenix water. I got here and I thought it was just an atrocity that there were 2,000 dentists doing dentistry in Phoenix and the water wasn’t even fluoridated. So, I spent every Friday for two years trying to get the water fluoridated and finally got the City Council to pass it 8–1, and I got the Public Health Dentist of the Year Award (’95). And I’ll tell you what, that’s a greater achievement than anything else I’ve ever done.
MD: Yeah, that is pretty important because of who you’re helping there. When you get right down to it, I don’t know many middle-class families who drink tap water. I think the middle class believes tap water is evil. Meanwhile, in a city like Phoenix, if you assume the inner-city kids are drinking tap water, the people who have the least amount of access to dentistry now have the most amount of access to the free fluoride. And they’re the ones who can’t afford dentistry and need the stronger teeth, versus the middle-class kids drinking essentially distilled water and ending up with interproximal decay.
HF: Yeah, and that’s why I participate in PPOs. I’m not a fee-for-service dentist; I’m a production-per-hour dentist. I can go in there and do $1,000 an hour; I don’t care if you give me $700 for a crown on a PPO or $700 cash. And I might do that PPO crown and in that same appointment do another two fillings. Two things on that: A lot of dentists don’t want to numb up the other side of the mouth and they’ll make two appointments out of it, and then right next door to them in a dental building is an oromaxillofacial surgeon who spends his entire life numbing up all four quadrants of the mouth. When you sit there and slash your prices by joining a PPO, which is the fourth thing dentists need to do in a recession, it is that you just need to work harder. You can’t numb up with lidocaine and then go in your break room and get a cup of coffee, and then go in your private office and sit there and start playing around on Dentaltown. You need to stay in there and work.
MD: Are you saying Dentaltown is bad for your practice?
HF: Well, you know, when you’re in your practice, the private office has never made you a dime.
MD: You did make the point that if you’re taking Dentaltown CE, it should be at home in your underwear with some microwave popcorn, not at the office.
HF: I want to say something else about PPO, another public health dentist thing. Most of the people with PPO can’t afford to get their teeth fixed any other way. And if you, once again, concentrate on production-per-hour and quit concentrating on fee-for-service and get faster and more efficient and do better dentistry, you can make a fortune on PPOs, especially since you know half of your competitors across the street don’t touch them.
Also, I want to say one more thing about marketing. Let’s say that you’re a slow dentist, and you’re just never going to get faster. You know, a PPO might discount your fee 20%, but why not spend 3% on marketing? It’s always amazing to me that a dentist will sign a PPO and give up 20% to 30% of their fee but won’t spend 3% on marketing to retain new patients, half of which have no insurance at all.
MD: So how have you guys done through this recession?
HF: We grew 8% this year.
MD: Well, there you go.
HF: Just doing what I’m talking about. And the best example, Mike, of this — how to handle a recession — is to go back to March of 2000 when the NASDAQ was at 5,045 and then the whole bubble popped and the stocks came crashing down — the internet stocks. Remember all those internet stocks that went from $50 per share to pennies per share? Look at Michael Dell. He’s only 45 years old and he’s a multibillionaire. And when that recession hit, what did he do? He did all four things that we’re talking about. He cut costs; he tripled his marketing budget. Remember the Dell Dude on every television channel: “Hey, dude, you need a Dell.” Full-page ads in every magazine. And then, number three, he added new products and services, he started selling servers and other different devices. And he grew his earnings every quarter all the way through that recession by just cutting costs, tripling his marketing budget, adding new products and services and slashing his prices. I mean, who would’ve guessed in the year 2009 that today you could buy a Dell laptop with everything needed for $750? In the year 2000, that laptop was almost $5,000.
We joined a couple PPOs and we started advertising our daylights out and just really bumped up our new patient flow to replace all the people who didn’t have the money to come in or were moving away.
At Today’s Dental, we joined a couple PPOs and we started advertising our daylights out and just really bumped up our new patient flow to replace all the people who didn’t have the money to come in or were moving away. We got a slew of new patients and did a lot of hard work on them and did a lot of dentistry and added new products and services like Invisalign. I got my Diplomat in International Congress for Implantology; I got my Fellowship in the Misch International Implant Institute; I’ve been really trying to build an implant practice within my practice.
MD: How’s that going?
HF: Great, great. I mean it’s kind of funny, but upper-middle-class people do not like to have two teeth filed down for a bridge.
MD: Is it just the upper-middle class? I’m not sure anybody likes the idea of having two teeth ground down to a nub, as they so often put it.
HF: Yeah, I like it when you prep lower anteriors for a crown. What do you have left, a rice kernel?
MD: Yeah. It’s a good thing the impression takes four minutes to set because that gives you time to start praying that the preps won’t be in the impression, as you stare down at the pulp chambers. Can you see where a service like Inclusive Digital Implant Treatment Planning with the surgical guide for implants would be helpful, or do you think it’s overkill to have every patient go out for a scan?
HF: No! You cannot overkill on the diagnostics and placement of implants. I mean, you’ve got nerves, you’ve got sinuses, and you’ve got the mental foramen. I think you have to overkill on diagnosing and treatment planning and, once again, need to be fast and efficient. You were talking about your implant and how fast it went, and it’s because you were using technology. For implants you need high technology.
MD: That’s how I felt. It was fast because basically there had been so many safety precautions built into it that I could go fast. It was fun, it was fast and the feeling of not grinding those two adjacent teeth down was so nice. What a great feeling. Have you ever done a case where you remove a 3-unit bridge and instead of placing a new one, you place an implant and two single crowns there?
MD: And that’s a great feeling, too, isn’t it? Just knowing the patient can floss in between there and you’ve created a healthy periodontal situation?
HF: Right. And as I look back at some of my slides from like 1990, Mike, I remember some of these horseshoe bridges I was so proud of, like 14-unit roundhouse bridges, where someone was missing five or six teeth in the arch. But then you watch that over the next 10 or 20 years, and one tooth looks bad, and what happens? You lose the whole case. I think that times have really changed and implants are a big part of that. Once again, why are half of the dentists in Europe placing implants and only 5% in the U.S.? Because they are scared by the oral surgeon and periodontist, who both claim you have to be an oral surgeon or a periodontist to surgically place an implant. The fact is periodontists had zero implant training in their periodontal program because they graduated 10 or 20 years ago.
MD: Well, Howard, is there anything else you can think of that we didn’t bring up or that you’d like to talk about?
HF: Yes. I’d like to say this: In 1941, when Pearl Harbor was bombed, 99.9% of Americans had never heard of Gen. Patton or Gen. MacArthur. And then the United States rounded up 6 million boys and told Patton to go get Nazi Germany and MacArthur to go get Japan. And those two men, because of the gravity of the situation, they rose to the occasion and they achieved their destiny. If there wouldn’t have been a World War, they could have never achieved their destiny. When times are tough, like they are now during this “Great Recession,” and things aren’t going to be easy for another year, year and a half, maybe even two to three years, now is your time to rise to the occasion — to be Gen. Patton, to be Gen. MacArthur. Don’t sit back in your private office and be a wimp and whine about the economy and cry to your spouse at night. Stand up and lead. Stand up and start marketing. Stand up and start taking CE — take it for free on Dentaltown, go to some courses, learn how to place implants, start doing Invisalign, join a PPO where you have to work harder. Just rise to the occasion and achieve your own dental destiny.
MD: Those are great words of inspiration. But you must run into dentists who really don’t want to do what you’ve just said. They don’t want to have to be a leader and don’t want to have to run a business. What’s the most common question you get from dentists at lectures or via emails? Is there one thing that dentists hit you with all the time that you can almost count on getting at least once a week?
HF: Yes. That is staff problems.
MD: I wonder if most dentists in America are nodding their heads yes in agreement.
HF: Yep, that’s the most common question I get. How do you deal with dysfunctional staff? And the answer is so easy: You fire them as fast as you can. But they just don’t seem to have the guts or the perseverance or they’re scared that fired employees are going to talk bad about them around town. But building a winning team is probably THE single most important thing you can do in any business. I mean, Southwest Airlines hires on attitude and trains for skill. All the other airlines want an impressive resume showing skill; Southwest Airlines wants a happy, personable person.
MD: And I would guess that Southwest Airlines would pride themselves on hiring on attitude, but I would assume that they are definitely going to fire based on attitude as well, right?
MD: I mean, you might not be the sharpest employee there, but as long as you’re happy, outgoing and you look like you love to work there and love the customers, then you’ll be OK.
MD: Alright. Well, Howard, thanks for your time, I really appreciate it. We’re going to direct everyone, if they haven’t already, to go to dentaltown.com, log on, get an account. It’s free. Find out what you’ve been missing. What you’ve been missing, which is only the best post-graduate education you could ever hope to get in dentistry. It’s almost “Dental School 2.0.” Now you’re not just learning from part-time instructors, you’re learning from other full-time, wet-finger dentists who have been in the same trenches you have been in and may have some answers to the problems you’ve had. So again, thank you for creating something like Dentaltown, Howard, and I look forward to seeing you on there.
HF: Thank you very much for your time, Mike. This has been a real honor.
Dr. Howard Farran is a noted international lecturer on faster, easier, more efficient dentistry. As founder and editor of Dentaltown, Hygienetown® and Orthotown®, which collectively are mailed to 38 countries and more than 215,000 dental professionals, Dr. Farran’s impact on dentistry has been widespread. For more information about Dentaltown, visit dentaltown.com. Contact Dr. Farran at email@example.com or 480-893-2273.