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Podcast: Should you consider starting a second – or third – practice?

Hello and welcome to Ascent Dental Radio. A program dedicated to the balance between the clinical aspect of healthcare and the business of healthcare. And now here is your host, Dr. Kevin Coughlin.

Kevin: Welcome to Ascent Radio. My name is Dr. Kevin Coughlin. You’re listening to Ascent-Dental-Solutions, where the focus is on knowledge, training, education and development.

This podcast is brought to you by VOCO Dental Supply, one of the largest and best dental materials company in the United States. Originally from Germany, but have headquarters in South Carolina, and I want to thank them for sponsoring this podcast. I also want to thank Mr. Doug Foresta and his podcast company, Stand Out and Be Heard. Without his expertise and mentoring, this podcast could not be possible. What he’s done for my professional business and my consulting business I cannot say enough about.

With no further ado, I have some questions today about a topic that seems to be getting more and more attention and more interest in the dental community. And that’s corporate dentistry, in particular, MSOs and DSOs. Why don’t we start with the first question?

Doug: Sure. Thank you, Kevin. Great to be here with you. My first question for you is — there was an article recently about how to know if it’s time to create a second practice. If you’re a solo practitioner, when is it time or what are some considerations? So my first question for you is, if I’m a solo practitioner, maybe I’ve been in business for five years or so, what are some of the considerations that I should think about when thinking about the idea of potentially starting a second practice?

Kevin: Since this podcast is only roughly 20 minutes, I will do my best to stimulate your interest. But keep in mind that I have been practicing and still practice dentistry every single day, Monday through Friday. I have 14 offices and I have gone through the trials and tribulations and these questions in my own mind and still do to this day. In summary, my first recommendation would be to think long and hard about what your end gain is.

Are you building additional practices to sell to a DSO or MSO to get the maximum value down the road? Are you growing because your facility is just over utilized and you’re no longer efficient and effective and you’ve decided that you’ve been so successful at one practice you want to continue and grow your business with another location?

Those two general questions would drive my answer when I’m doing consulting to dentists all over the country. And that is, what is it you’re trying to obtain? To cut to the chase, my personal opinion dealing with hundreds, if not, thousands of dentists over the last 35 years is that most are interested, whether they know it or not at the beginning, to get the best return and the biggest return on their investment.

Meaning that if one practice is successful and the second practice is just as successful, the investment and the return on your investment will be significantly better than just selling one solo practice. I’m going to assume that if you’re not aware of it you ultimately will come to the conclusion that the more successful practices, and the better the processes and procedures, the more valuable this entity is to a potential purchaser.

When we talk about potential purchasers, depending on the number of practices you accumulate and run successfully, your value will go up, but the number of individuals interested in that practice will go down. For the average dentist to be able to afford and purchase three, four, five, ten or fifteen practices, I believe there are few and far between potential purchasers.

So in most cases, you will ultimately be leaning towards a DSO or Dental Service Organization, which by definition are run and owned by dentists, or an MSO, Managed Service Organizations. Which no matter what we talk about, not matter what we think, in the real world, they’re run and operated by equity partners, venture capital groups that hold the money, that pull strings and ultimately the decisions for better or worse.

With that being said, my learning curve taught me that you should never expand into another location, unless your first location has excellent processes and procedures. That means infrastructure is in place, you have adequate staff at your front desk, you have adequate chair side assistance, you have adequate dental hygienists and you have adequate, and let me emphasize this, hardware and software controls. The older you are, the greater the likelihood that your return on investment could be much less.

I look at this very much like anything that you do in the market. You can afford to lose almost everything in your 20s and 30s and you still have plenty of time to rebound and be very successful financially, in your 60s and 70s. But when you start this type of aggressive expansion, the money and time effort when you do it in your mid-career to late career, sometimes may prove out to not give you the best return because of the significant amount of money you’re going to have to invest and the significant amount of time.

So for those listening to this podcast in their early 50s or late 50s, make sure you fully understand the financial and the emotional time commitment of opening up additional practices and what you can expect for your return on investment. Unless you’re an incredible superstar and you can get that practice up and running, profitable, with an EBITA of at least $300,000 to $400,000 within 12 to 18 months, you may find that your return on investment may not benefit when you put in the amount of risk and effort.

Doug: And that’s the other piece I was going to ask you. Have you seen dentists who have gone for it, so to say, and it hasn’t worked. What do you do if you try it and either financially it’s not doing the way you thought it would or it’s just not for you, like you decide this is not me, what then? I guess would be the question.

Kevin: You deconstruct. I would say, take the practice that’s the weakest and unload it as quickly as possible to an associate or a dental broker. You may lose a little bit of money in the process, but my opinion is there’s no reason beating a dead horse. Bad is bad and usually, the longer it takes you to make a decision, the more costly it is and the worse it is in the long run. So I would say, cut your losses as soon as possible and unload that practice as quickly as possible and focus in on your initial practice and continue to build it and consider it a learning experience.

Obviously, with proper mentoring and coaching from someone like myself or other experts in the area, what ideally you want to do is avoid the mistakes that people like me have made so that you’re the most effective and most profitable with the least amount of stress. And it’s like anything, reduce your learning curve will increase your chances of success not only emotionally but financially.

Doug: One of the things I was going to ask you as well, Dr. Coughlin, is that is this something that is even talked about at this point in dental school? That’s what I think is so important about what you’re doing. Is this something that’s even discussed, that I would learn if I went to dental school?  

Kevin: I know starting in 2006 I started lecturing at Tufts School of Dental Medicine in Boston Massachusetts. At that time, I was not aware of any of the schools in the Unites States really addressing the business component of medicine and dentistry. I think with the average school debt of about $267,000, the time commitment, the loss or opportunity cost of spending four to six additional years of training and education and with a high debt structure, it is absolutely imperative that these young practitioners get basic business knowledge either from people like myself or I’m happy to say I see that the schools  in order to keep their accreditation are now mandated to offer between 18 and 22 hours of practice management before these students graduate from dental school. So more and more I see this drive to educate and inform these young practitioners so that they can minimize their errors and maximize their potential.

Doug: Thank you, Dr. Coughlin. I really appreciate you taking the time to share your words of wisdom and perspective from someone who, as you said, owns and operates 14 dental practices.

Kevin: Right, and they’re certainly practitioners out there that have more practices than me and have been just as successful or more successful. I’m happy to share my trials and tribulations and I’m pleased to present this on Ascent Radio and I want to thank VOCO Supply Company for sponsoring this podcast and our previous podcasts. And special thanks to Mr. Doug Foresta and his podcast company, Stand Out and Be Heard. Without his expertise and production acumen, we would not be able to present this on a weekly basis.

Thank you so much for listening. This is Dr. Kevin Coughlin. You’ve been listening to Ascent-Dental-Solutions, with a focus on training, education, development and knowledge. Thanks for listening and I look forward to talking to you soon.

Podcast: Nick Raithel on how to promote your dental practice by writing a book

Hello and welcome to Ascent Dental Radio. A program dedicated to the balance between the clinical aspect of health care and the business of health care. And now here is your host, Dr. Kevin Coughlin.

Kevin: Welcome. You’re listening to Ascent Radio. My name is Dr. Kevin Coughlin, owner of Ascent Dental Solutions. I want to give a special thanks to Mr. Doug Foresta and his company Stand Out and Be Heard. Without his expertise in podcasting and the production of this podcast, this could not occur.

Today, we have a special guest. This is Mr. Nick Raithel. Nick has a claim to fame and the excellent background in how to help the dental profession and health care profession in general promote themselves, their business and their expertise by using the written word.

The ability to use books to convey a message and to improve a marketing strategy. Nick is owner and CEO of the company Content Corps. Nick has been at this for many, many years and has written the book in how to create a 7-hour book.

Nick, thank you so much for taking time from your busy schedule to talk to our profession about this unique way and how to improve a marketing strategy and a message that most of us in health care profession don’t think about. Thank you so much for joining us. Give us a little bit of background about your company and how you got started.

Nick:    Absolutely. Thank you so much for having me here, doctor. It’s a pleasure to be on your show. I really have a lot of respect for that. I think you’re really helping out our profession in terms of just educating and empowering people. So for starters, just thank you for that. Keep up the good work.

With respect now to what you were asking with kind of my own background and my sort of service, my offerings, what we’re doing really with the 7-hour book is we have a system that allows any dental professional to create their own professionally published book. And with that book, establish their authority, establish their credibility and really position themselves apart from other dentists in their market.

Kevin: I could tell you that I wished I knew about your expertise and your company. As you know, I’ve published three books. One of them; Your Tooth is Killing Me, the other is Business, Processes and Procedures Necessary for a Successful Dental Career and the third one Just Enough to Be Great in Your Dental Profession. And the hours, the time, the drudgery of producing these three books, I would say, most in the health care profession would say it’s not worth the time and effort.

But with your process and procedures, you’ve streamlined it to make it much simpler, much more efficient and effective. Describe a little bit about how that’s done.

Nick:    Absolutely. One of the biggest things people don’t know is that working with us, doing our system, only requires a grand total of seven hours of your time. That’s it. And with that, you’re not doing any work beyond just talking to us over Skype or the phone in a series of conversations. That’s it.

So you don’t have to do any of the writing or any of the review that would normally be required in doing a book. You’re certainly not sitting alone, as many book producers know, alone at a desk having to write anything for hours and weeks on hand. You don’t do any of that. You just talk to us over the phone or over Skype, we walk you through some questions — a framework we have — and your book gets created from there.

Kevin: Nick, once that book is created, how does it get out into the public? Are you using an outside publishing or does your company take care of that also?

Nick:    We take care of it through various publishing services we have partnerships with.

Kevin: And would Amazon be one of those services or do you use other services?

Nick:    Depending on the author, Amazon could definitely be one of those services, but we are unlimited in that respect.

Kevin: For those listening that may not be familiar with what it takes to be an author, although you’ve really created a very effective and efficient means, I can tell the listeners that not hundreds, not thousands, but multiple thousands of hours were spent developing my books. And I can tell you that that time and energy probably could be much better spent using Content Corps and Nick’s process and procedures.

I can also tell you that — well, why don’t I let Nick — about the advantages of having a book with your name and you’ve published it, the affect that it has on credibility, speaking engagements, what it means to our patients base when they see that their dentist or health care provider has the expertise in which to put something in print.

Nick:     Sure. Kevin, I think that a good place for listeners to start with this is to understand that a book makes you more than just another dentist. More than just another health care professional. With a book, you have a chance to take the knowledge, the experiences, any insights you have that make you unique and the unique way in which you see the world and show that to people. Do you ascend above the competition?

Kevin: I could tell you Nick, that I’ve had the privilege to listen to you on other podcasts and one of the take-away messages that I never really thought about, but when you’re forced to talk about a subject, whatever that subject is, in our case it’s health care or dentistry in particular, you actually learn more about the subject. You become engaged. I believe you become more of an expert.

I know during my research and listening to my thoughts and writing down those thoughts, you actually become, not only more engaged, but more knowledgeable about the subject. Do you find that?

Nick:    Yeah, I definitely do find that. I think that frankly, one of the best ways is to understand your business, if you view your dentistry as a business per se, or just to understand it as a craft. If you’re looking at dentistry as a craft and you’re a professional practicing that craft, one of the best ways to do it is a book. Because it forces you, as you’re saying Kevin, to kind of get outside of your head and look at it from different perspectives and really understand it better so you can communicate it better.

Kevin: One of the quotes that stuck with me when I was listening to you is what’s perhaps one of the most important assets we have as health care professionals and dentists in particular. Your quote was really, I thought, astounding. You basically summed it up by life experiences are probably our best property, our best asset. And when you start to write a book or use your particular system to write and publish a book, those life experiences are re-engaged, they’re re-ignited.

I can tell the listeners that a day doesn’t go by that I don’t get an email or a phone call regarding questions about a book. What did I mean by this, did this really happen? Et cetera. And it’s opened a whole venue of contacts and networks that I didn’t even realize or understand.

And I can tell you that from my own personal experience, not only does it give me great pride, but you touched on it; the patient base and the team members of my business, which are close to a 160 employees in 14 different offices here in the Massachusetts area, it does give you that extra credibility that I think deep down they’re saying, “Jeez, he could have been doing so many other things and he took the time to write his thoughts down to provide education and mentoring for new generation and the existing generation out there.”

When you do this, I don’t want to put you on the spot, is there an average fee or cost from start to finish Dr. Smith or Dr. Jones connects with your company Content Corps, what is the length of the process? I know you mentioned that through Skype or phone call it’s roughly seven hours of speaking and then your team takes those words and puts them into a book. How long is the process from your company after you’ve received the content to complete the project?

Nick:    Certainly. As I’m sure you would imagine, it’s really going to vary depending on the client themselves. The very first step though is for us to determine if someone who’s thinking about this, if what they have in mind and their ideas really are a fit for our system. Because a lot of people do want books and a lot of people really should go out there and create books, but what they’re thinking may or may not be a fit for our system. So we always just want to make sure that it is and that begins with a simple 20-minute conversation which people can schedule by visiting our website www.contentcorps.net.

Kevin: And is there a charge for that 20-minute consult?

Nick:    No, that’s completely complementary. We want to hear your idea and there’s absolutely no fee for that.

Kevin: Are you comfortable giving a range of what individuals could expect in an investment? I know that time is roughly seven hours, but an investment for the individual to create this book?

Nick:    That’s the kind of thing that, again, is really going to depend on the individual themselves and if it is a fit. So I would encourage anyone who’s curious about that, just to kind of go to our website and have a look and see if it’s something they might be interested in. And then from there, if it was, we would again determine if it was a fit and go from there.

Kevin: Nick, with your expertise and background, is there a general number of pages that seems to be the best? We know in the podcast industry that roughly a 20-minute podcast is considered ideal because it’s the average commute time in a car for most people in the United States. But for a book, is it 50 pages, 100 pages, 150, 200?

Nick:    It does depend on the person themselves and their own specific goals. I think above all, that is what this comes down to. This comes down to goals. What are your goals in producing the book? And then from there the number of pages will be determined by the content that will be used to produce and to fulfill those goals.

Kevin: That’s a nice segue. I know when I first started for the listeners, so many times I’m asked, “Why? Why did you do the book?” And I teach at Tufts School of Dental Medicine in Boston, Massachusetts and I teach practice management. These young men and women are getting prepared to graduate and they really don’t have business experience, business acumen. They’re not sure how to apply for a job, what to look like in the job.

I continue to do the same course over and over again and one of the students and faculty said, “You really should put this in a book.” And I said, “You know what, this is a very efficient and effective way to get the message. Because in a 90 minute lecture, sometimes you can’t cover all the basis.”

Nick, as we’re getting close to coming to an end to this podcast, you’ve mentioned your website, is there a phone number that you’d like to share with our listeners?

Nick:    I think the website really is the best place to start. With that website www.contentcorps.net, I think that’s the best place.

Kevin: As far as a response time for our listeners if they’re webbing into your company today, this week, you get back to them within 24 hours, within a week? What’s the turnaround?

Nick:    We have a very quick turnaround. So if you’re filling it out, we’d be getting back to you quite soon.

Kevin: I know as we come to a close, something that sometimes we’re a little uncomfortable talking about or a little outside our comfort zone, but when we do podcast, when we do webinars, many times those are difficult areas to monetize. There are ways to monetize them and I learn week after week with my expert Doug Foresta on Stand Out and Be Heard. But with the book, it’s a very easy way to monetize because you can sell those books or you can use them for marketing purposes, which also generates a stream of income. Would you agree or would like to expound on that?

Nick:     I would and I would say that not only are you selling the book, not only are you using it in your marketing, but a book really can be kind of your gateway into other things and other ways of monetizing. For example, using a book to launch your speaking career, using a book to launch your coaching career, if you want to get into coaching; dental coaching or business coaching. You can really use it to create many new avenues of revenue for yourself.

Kevin: Nick, I can’t thank you enough and I thank the listeners again. And special thanks to Mr. Doug Foresta and his production of this podcast. You’ve been listening to Ascent-Dental-Solutions and this is Ascent Radio. My name is Dr. Coughlin and our focus is on knowledge, development, training and education.

Mr. Nick Raithel and his company Content Corps and The 7-Hour Book, I strongly recommend to our listeners to consider his expertise and consider taking the time to put your thoughts down in writing and I think you’ll enjoy it and hopefully you’ll enjoy it as much as I did. Nick, thank you so much for taking your time. I appreciate this evening’s podcast with you.

Nick:    Thank you so much for having me, doctor. It’s been a pleasure.

Your website is only as good as your SEO

If you’re a dentist then you probably have a website. It might even be an awesome site. But here’s the thing, it doesn’t matter how much blood, sweat and money you’ve sunk into, if prospective clients can’t easily find your site then it’s not really doing you any good.

So how do you get them there? Try typing ‘dental office’ into Google right now along with your town or city and see what comes up. Is your website there or is it someone else’s?

To ensure your site is near the top of the Google search rankings (the goal in local search is #1), you need to work on your SEO. Search Engine Optimization is the method web experts use to make sites appear at the top of search results and get your business found by potential patients.

Given the number of practices competing for new customers local search is becoming a big deal and it’s only a matter of time before every practice starts to optimize their sites for maximum exposure.

I recently spoke to a guy named Mike Pederson about it. Mike is the CEO of Dental Boost, a cutting-edge dental SEO company for both solo and group practices.

He told me it all comes down to coming up with the right ‘buyer-intent’ keyphrases that people use on Google to find dental practices.

Typically, most dental practice’s keyword phrases number about 20. Mike Pedersen’s company has developed around 500 such phrases. However it’s about more than numbers. The better your phrases and search terms are, the more chance your practice has of rising up through the rankings.

Of course if that’s all it took then everyone’s practice would be at the top of the searches! There’s more and you should look into a company like Mike’s to give you some guidance. .

So is it worth it? Every penny!

Outside of word-of-mouth, web searches are the best way for people to find a new dentist.

Although a good marketing campaign also helps, making sure your business name is tops in web searches is a basic necessity, the digital equivalent of having a lighted sign in front of your practice.

Podcast: David Wolf on the power of communication

Hello and welcome to Ascent Dental Radio. A program dedicated to the balance between the clinical aspect of health care and the business of health care. And now here is your host, Dr. Kevin Coughlin.

Kevin: Good afternoon. You’re listening to Dr. Kevin Coughlin and Ascent Dental Radio. Today, I have another super guest for the next 20 minutes for another amazing podcast. Ascent Dental Solutions is focused on helping the dental community market themselves, improve patient relations and just improve their bottom line.

I would be remiss if I didn’t mention Mr. Doug Foresta. He has helped produce over 50 podcasts for me and without his intellect, his expertise and his stick-to-itiveness, we wouldn’t be here today.

As important, if not more important today, we’re dealing with communication issues which to me, are the fundamentals of success in any business, but in particular, my area of expertise: dentistry.

Today’s guest is Mr. David Wolf. He’s been creative director and producer of content for radio, TV, film, podcast, audio books and multimedia. His clients are Amblin, Universal, Disney, Discovery Channel, South West Airlines, children’s medical centers, Kidney Care, Miller Brewing, Budget Rent a Car, Frito-Lay, Pepsi, McDonalds, Texaco and the list goes on and on.

You may be asking yourself, why would the dental profession be interested in having an expert like David speak? I can only tell you with 35 years of practicing dentistry, owning 14 dental offices, 160 employees that the single most significant thing that I’ve seen over the years is the ability to communicate with your team members and your patients.

And without any further ado, David’s going to introduce himself and tell us what he’s seen over his number of years in this field and how he can, perhaps, improve our ability to communicate with team members and patients.

David, thank you so much for taking time from your busy schedule to speak to our audience today.

David: You are most welcome, Kevin. Thank you.

Kevin: Give us a little bit of background about what you’ve sensed and what you see as far as communication in health care, but in dentistry in particular.

David: That’s a fascinating subject because it’s infused by years of producing talent, singers, speakers, musicians in the context of pure communication which is music and audio for advertising and communications and training films so my perspective is somewhat skewed to the entertainment preparation or production side of the business.

As an observer of those who I’ve encountered in the medical profession and also in dentistry, and we were talking offline about this is as well, I think that because of the nature of the work and the nature of the type of minds that enter those fields, I think from a personality perspective they tend to be very scientific.

And I would check this with you to see if you agree, I know you’ve been in the industry for more than 35 years. Would you agree that most of the folks, it seems to me, tend to be more, let’s call them introverted. They’re really measured by their grasp of technology and emerging technology in dentistry. And then with that emersement, they are then almost tasked to come up for air and talk to mere mortals as they’re sitting in the chair ready for a procedure. Do I have this right?

Kevin: I think you hit the nail right on the head. We’re all somewhat prone to these idiosyncrasies. We focus on the minutia. We focus on infinitesimally small areas of the human anatomy and many times we lose sight of the actual patient. We’re not actually listening to what they’re telling us or what they actually want.

And I think in today’s competitive market in medicine, in dentistry, the ability to be able to connect, what I call BLT; you want your team and your patients to believe in you, you want them to like you and you want them to trust you. And in order to accomplish that task, there are certain areas of expertise that you bring to the table that maybe you can help our listeners learn from your teaching standpoint.

David: Absolutely, and I appreciate that. You hit it on the head with BLT because at the end of the day, what I’ve learned, if I’ve learned anything in my 30 or so years in the communication space, is that for the most part we’re emotional beings. And the communications and this connection that we make, the belief, the like and T was trust, forming that foundation in a relationship, it’s all about emotion.

So how do we communicate emotion in a world that is somewhat technical and there is sometimes a clock running and there is a procedure to be done and there is a lot of preparation?

It almost, from my perspective, might require that the practitioner almost compartmentalize a bit, and as I said earlier, come up for air and understand that okay, now I’m going to speak to this patient in emotional terms. I’m going to use my voice in ways, almost the tone — one of the things I do is I coach people around the use of their voice. I call this program The Power of Voice.

There are some fascinating things about the voice that despite the fact that we use it for 80 percent of everything we do, no matter what business we’re in or vocation or avocation we’re in, we rarely think about it. We just assume, oh, this is my voice, this is what I’ve been given and born with and I’ll just use it however I can use it. But very few people really think or exam or even practice simple aspects of their vocal mechanism. And I think some of this could apply to the practitioners that are listening here to better understand how their voice affects the emotions of the patient in the chair.

Kevin: I would tell you that some of the things that I’ve seen is in my particular organization, we see over 938 new patients a month. And over and over again I hear the same thing; how come no one ever explained this before? How come no one ever told me this before? And when you’re talking about the inflections in the tones, in your voice, I would tell you that over and over again I hear the same thing and that is, “I didn’t notice any empathy. The practitioner explained the A, the B and the C, but there was no inflection, no empathy, no real concern. It was a matter of fact. They need A, they need B, they need C and the cost is D.”

I think many times we as clinicians miss that connection that people, as you mentioned, they want that emotion. They want to know that you care. They assume that you already know how to do the A, the B and the C, that you’re clinically astute, but what they really want to pay for, what they really want is you to connect with them emotionally and understand why they want what they want and how come they need what they need.

And that’s been my 35 years of experience and sometimes, myself included in this, we miss that because we’re on the clock or because we’ve done it so many times.

Are there specific tips or training drills that you can suggest for the whole health care? But I believe it applies to anyone who deals with people.

David: I think you’re right. I’m glad you asked because I have a lot of notes ready for us today around some specifics. We’ve been kind of nibbling at the edge of this.

We’ve established that it’s an emotional connection we need to make, but how do you do that with your voice in the context of a practice? And by the way, I would say also Dr. Coughlin, that this applies to speaking too in public, it even applies to guys like you and I that do podcasts and Doug that are on mic technique. It really applies to a lot. And I’m a student of this stuff. I’m working on it all the time even though I help others accomplish it.

So here it goes. I have a list of things I like to call the Elements of Voice and that includes breathing and tone, melody and pitch modulation, word formation, rhythm, pacing, phrasing. And then this thing we call filler words which may not as much relate to this emotional content that we’re talking about with respect to empathy, some of these traits or some of these elements of voice absolutely do inform the emotional content of our voice.

If I may, maybe I’ll demonstrate a few of these things. What’s amazing and again, I’m a student of this as well, as you pointed out here after even 35 years we’re always students, so few of us have really thought about how we breathe. Unless you’ve played trombone or some wind instrument in a band when you were in grammar school or high school, no one ever taught us that we really need to breathe from our abdomens.

And almost think of the abdomen as a balloon and the first step in breathing is not the inhale, but the exhale. So what we’re doing is we’re clearing [exhales], we’re exhaling out as much as we can — there will always be some air in our lungs because that’s what is required to keep them inflated — but to clear the lungs out to a comfortable level and then allow them organically or naturally to re-inflate.

What I’ve been practicing lately as I’ve got more and more into studying this is putting my hand sort of right around my navel and really feeling the expansion of my abdomen in a way that may feel a little silly. And many of us are weight conscious so if you’ve got a little belly you’re like, “I’ve been taught and conditioned socially to hold in my stomach all the time.” So for me that was a little bit of a I work on my weight, but push the stomach out as you exhale and really pull it in so it’s lower than your chest.

What happens when we, so much of us project or create the stream of air that our vocal folds use to create sound, we tend to focus in our neck area and in our chest area. And so where this folds into what we’re talking about with empathy is that if there’s enough sufficient breathe to support the stream of air as you talk to a patient or as you’re talking to someone in public, I believe that that support that you’re providing, your vocal tone, will feel more soothing to the recipient. So that’s just one example of breathing.

Kevin: I could tell you David also another thing that I saw is the physical presence of a dentist or any health care provider in their cubicle or operatory. I’ve been a student, not as astute as yourself, but I videotape a lot of the presentations that occur in a medical setting. And one of the things that I noticed is often the practitioner is standing and the patient is sitting and immediately you’re creating a dominance. I strongly recommend that you take a look at not just the tone and the breathing, but the physical space that you’re in and try not to impinge by being too close or too far away.

I talk to my students, my staff, my team members and say, “Try to be eye-to-eye contact. Try to stay within an arm’s length or three or four feet from the individual and talk eye-to-eye rather than looking down or looking up at them.” Would you agree with some of those comments?

David: Absolutely. We can’t ignore the fact that communication is multidimensional. And so in a room with a patient, or with anyone for that matter, a very high degree of adaptivity to what they’re comfortable with is called for here. And so in a world that is very procedurally driven, which is the world most of you live in, I think, in the medical space, you almost have to step out of that and suddenly become highly adaptive.

Now, I may have that wrong. It may be that even though you’re dealing with known anatomy, you go into a mouth or a cavity or a gum periodontal situation, you may have a whole lot of adaptiveness that’s required in order to treat. I may have misspoken on this, but these levels of sensitivity about hierarchy and body language are all a part of the communications process.

Of course, I’m focusing on the voice, which is only one component. The visual, yes. Bottom line is I absolutely agree with that premise. It’s a total communications process.

Kevin: David, are there actual courses out there that you teach that can give more instrumental techniques? Is there ways that people can touch base with you to learn some of these tactics that really, I hate to say, we try to sell to people? But in the world that I live in, we’re all selling something and in my opinion, selling is good providing it’s done ethically and honestly. I’ve never looked at selling as bad. I think I’m selling myself on this podcast.

You’re selling your techniques to people. But so long as they’re done with the idea of providing value and a service and to improve the way we connect with people, I look that as something very good and I appreciate the expertise. How do they get in touch with you? How do they reach out to learn more about these techniques to improve their accepting the patient and the patient accepting them?

David: Thank you very much. I appreciate that, Dr. Coughlin. By the way, I listen to your podcast regularly and I know that really you’re sharing great and valuable information that you believe in. That’s what I’m trying to get to there. So thank you for including me in the fold there. The way folks can get a hold of me and learn more about this program I call The Power of Voice is they can reach me at www.podcastandradio.com.

There is a contact me area or page on that site. There is also a little bit of an explanation about The Power of Voice. I do coaching. I’m developing a course that will be ultimately sold online as well and a lot of exciting developments around all of this is as an adjunct to my background. So thank you for inviting me in.

Kevin: No David, thank you. For our listeners here, sometimes I like to digress from the technical aspects because I think sometimes more important than the technical aspects of health care is the people aspects of health care. And I think we take with a grain of salt what we should probably spend more time on. And that’s patients come to us to listen to explanations, options, the risk, the benefits and the alternatives.

And unfortunately, if we’re going to provide the highest level of care and service, the ability to communicate, the ability to connect and the techniques to make us better at it are many times completely overlooked in the health and medical profession. And bringing experts like David wolf and his programs to our listeners, I think, is a great boon to our profession and to our patients.

David, with your expertise in the creative director and producer, we need people like you in our health care profession to make us connect better and more efficiently with our patients and I can’t thank you enough. Please, don’t hesitate to reach out and get to David at smallbizamerica@gmail.com.

You’ve been listening to Dr. Kevin Coughlin, Ascent Dental Solutions, where the focus is on knowledge, consultation, training and development. And in closing, my great thanks to Mr. Doug Foresta, Stand Out and Be Heard. Without his expertise, this podcast would not take place. Thanks again and I look forward to speaking to everyone soon.

Podcast: TMD and what patients and dentists need to know

Hello and welcome to Ascent Dental Radio. A program dedicated to the balance between the clinical aspect of health care and the business of health care. And now here is your host, Dr. Kevin Coughlin.

Kevin: Welcome. This is Dr. Kevin Coughlin. You’re listening to Ascent Dental Radio, where the focus is on knowledge, consultation, development and training. I believe this is the 40th podcast that we’ve been doing and it wouldn’t be possible without the special help of my production and consulting guru, Mr. Doug Foresta. His company, Stand Out and Be Heard is responsible for the webinars and the podcast and I always like to give a shout out to think him very much for his expertise and his talent in this regard.

Today, we have a topic of temporomandibular joint. For most of the listeners you’ve been hearing me and listening to me focus on the business of dentistry, but I want you to know that I am a clinician and have been practicing for 35 years as a general dentist in all areas of dentistry.

Over and over again I get questions and comments about Temporomandibular Joint disorders or TMJ and I thought today’s podcast might be valuable to the listeners on how do we treat TMD issues and what’s going on in the field. I’m proud to say that I’m going to have some questions asked to me today. Those are general questions and if you have specific questions, you can reach me on www.ascent-dental-solutions.com. I’m very good about checking and getting back to you with specific questions. Doug, what’s your first question?

Doug: Thank you, Kevin. It’s a pleasure to be here. My first question for you is what is TMJ or TMD? Can you explain what that is?

Kevin: For the lay patients listening to this podcast, TMJ stands for Temporomandibular Joint. It’s the acronym for the most complicated joint in the human body and it’s located right in front of your ear canals on the right and left side. For the clinicians listening, we refer to the problems, the signs, the symptoms of temporomandibular joint as TMD or Temporomandibular Disorders or Dysfunction and there are a slew of them. Many times, the patient will come into the office and say, “Dr. Coughlin, I have a TMJ issue.” And my response is everyone has a TMJ, but not everyone has TMD issues. Hopefully, that answers that question.

Doug: Thank you. What are some of the patient signs and symptoms then of those TMD issues?

Kevin: I would say, in my 35-year career working pretty much five days a week, sometimes six days a week, a day has not transpired where a patient or an employee or team member hasn’t said, “Dr. Coughlin, I have pain, stiffness, popping or clicking in the joint region.” And when I say the joint region, I’m referring to the temporomandibular joint. Generally, the complaints are pain and discomfort and a limited range of motion.

I would say to the clinicians out there I have been doing expert evaluations for insurance companies for close to 30 years and the vast majority of the cases I review are TMD disorders and over and over again, I feel that the records that have been taken by the diagnosticians, the dentists in particular, are less than adequate and could be greatly improved by following some simple rules. I would strongly suggest to the clinician that on every single patient you document Range of Motion, ROM, not only vertically, laterally, but also protrusively.

This means, you have the patient open vertically as wide as possible without causing any pain or discomfort and for the average adult that should be close to 60 millimeters. If you want to save a lot of time and a lot of aggravation, generally, if you take your hand and use your forefingers and put them on top of each other and place them from the incisal edge of the upper anterior teeth to the incisal edge of the lower anterior teeth, you’re going to get about 60 millimeters. If you eliminate your baby finger, that will be about 50 millimeters and that would give you a good indication that the patient’s range of motion vertically is within normal limits.

Laterally, you have the patient bring their jaw all the way to the right and then all the way to the left and generally, that should be about four to six millimeters right and left to be an adequate range of motion laterally. Protusively, you’d like to see the patient move their lower jaw forward, at least, 6 to 10 millimeters anteriorly or protusively.

I would strongly recommend prior to the removal of wisdom teeth, prior to any orthodontic care or any extensive treatment where the patient’s jaw is going to be open for any significant length of time, let’s say more than 30 minutes, make sure your charts document range of motion.

The next item that I think is critical is during this range of motions, you want to document if the patient has any deflections or deviations. A deviation simply means when the patient is opening their mouth vertically, the jaw deviates either to the right or to the left and does not come back to the mid-line. This is an indication when the jaw deviates to the right that more than likely, the temporomandibular joint on the patient’s right side is not functioning properly.

Just going back to some basic anatomy and physiology, the first 25 millimeters of opening, the temporomandibular jaw rotates. After 25 millimeters, it translates down and forward. So when you see the patient’s jaw deviate to the right in this particular exercise, you know that the left TMJ is rotating and translating properly, but the right TMJ is not and it’s a pretty good indication that that joint is not healthy and is not in a correct position. And usually, the culprit is the meniscus or the disc that separates the temporal bone from the mandibula bone.

The next documentation would be a deflection. This simply means that the jaw upon maximum opening deflects either to the right or to the left, but comes back to the mid-line. So the opening is almost an S-shape. This means that the joints are not working properly. But in most cases, the disc has been recaptured and it allows the jaw to come back to the mid-line. Whereas in a deviation, that disc is not allowing proper translation and is most likely not being recaptured.

The critical thing here in this particular podcast is to give you a few simple inexpensive tips to improve your diagnostic records and your diagnosis and to help your patients and also to protect you since in my 35 years of experience, most patients have some temporomandibular joint signs and symptoms prior to dental treatment.

And then the dental treatment triggers the episode of pain and discomfort and the patient immediately associates it as a dental problem that was caused by a dentist when it actuality, the problem was predisposing. But because the records are inadequate in the documentation of range of motion, deviations and deflections have not been adequately documented. How about another question, Doug?

Doug: I was going to say, I know I was doing it as you were speaking, I could picture our listeners moving their jaws back and forth as you were talking about that. What are the treatment options for TMD?

Kevin: The first thing that I would tell our clinicians and for patients listening is you’ll never get success unless you have a proper diagnosis. And you’ll never get a proper diagnosis unless you have appropriate dental and medical records. The fundamentals and basics are a thorough medical history and a thorough dental history. To augment those two bits of information, I would strongly recommend that there be a complete clinical palpation and exam of the head and neck region, with emphasis on the medial and lateral pterygoids, the temporalis and masseter muscle, which are the four major muscles of mastication or the muscles responsible for chewing and function.

Palpation of these muscles, which start almost if you could just put your finger above your ear and move it forward in the shape of a question mark, you’ll be palpating the posterior middle and anterior temporalis muscles on the right and left side above the ear.

From there, you will go down and palpate the masseter muscles and if you clinch your teeth together, you’ll feel a bulge in front of your ear and those are typically the masseter muscles. Those are the two large muscles responsible for a large majority of the pain and discomfort.

During the palpation examination and the clinical examination, tenderness to these four muscles of mastication usually indicate that there’s a muscular problem and a muscular cause of the patient’s pain.

Also, you’ll find customarily, the patient will complain of tension and stress headaches, many times sometimes misdiagnosed as migraine headaches, and they’re really caused by the clenching and squeezing down of the upper and lower teeth together. And that constant aggravation causes spasm in these muscles which cause pain and that pain emanates from around the ear, in the head and neck region.

Next, you should have upper and lower diagnostic impressions so that we can see what your teeth look like and how they function. On top of that, I would suggest radiographic examination so we can determine the health and the condition of the temporomandibular joint. Typically, this would be a cephalometric view or a panoramic view and sometimes, we can even do a temporomandibular joint view. The more views, the greater the likelihood we’ll see damage and injury to the joint.

We can sometimes, depending on the severity of the problem, we may want to augment these diagnostics tools with an MRI or a CAT scan. But in most cases, for this particular type of podcast, I would function on the easy reversible treatments and diagnosis first to distinguish is the joint problem purely muscular or is it what we call internal derangement or intracapsular disease where there are some orthotic condition and the disc is not in its proper condition.

And there is sometimes, and actually many times, a combination of both problems, which makes the treatment in the diagnosis sometimes confusing and difficult.

After the proper diagnosis is done and records are done, generally, the treatment are broken into phase one and phase two types of treatment. The phase one treatment is simply to get the patient comfortable. And if it’s a muscular problem, we can many times test this by putting you on a pharmaceutical medication called Flexeril, generally, 10 milligrams, either in the morning or at night or a combination of both, to see if the patient’s signs and symptoms decrease. If they do, you’re pretty clear that you’re dealing with a muscular situation.

The next thing, in my 35 years of experience treating TMD disorders, is what we call Anterior Misguidance. You’ll find that your patient occludes or contacts the anterior teeth prematurely. Generally, these people tend to be very good looking in nature and generally, their teeth appear to be straight, but their upper anterior teeth are vertical. They have very little angulation and the angulation on the upper anterior teeth should be closer to 110 degrees.

And in most cases these upper teeth are up and down vertically so when the patient’s lower jaw goes into occlusion or opens and closes, the anterior teeth hit prematurely, causing the mandible to move backwards, irritating the ears, creating tinnitus, ear aches, neck, upper back pains and a tingling in the joint and just general discomfort.

A quick test for the patients and clinicians is to put your index finger lightly on teeth 7, 8, 9 and 10 or your upper anterior teeth and tap your lower teeth gently. If you feel a vibration or fremitus in that region, it’s a pretty good indication that the patient is suffering from anterior disclusion or malocclusion.

And a simple task would be to create some type of orthotic, sometimes referred to as a Night Guard, even those that’s inappropriate, to not allow the upper and lower anterior teeth to touch. Keep them out of occlusion and determine how the patient responds. If they immediately feel that they no longer are getting headaches or the headaches are reduced, the range of motion improves and their joints are no longer tender, then you know you’re dealing with some anterior misguidance. And you can correct this problem in phase two with some adult orthodontics.

Doug: Let me ask you this, Dr. Coughlin, the question that I think especially for patients would want to know, what is the cost generally of these treatments?

Kevin: I’d like to get as much as I possibly can, but that’s probably unprofessional and unethical. In fairness, it’s an excellent question. But generally, the diagnostic records will probably range somewhere between $175 and $650. As far as the actual treatment is concerned, the orthotics or the temporomandibular joint appliances and generally I would recommend one appliance for the lower jaw to be worn during the daytime and then an upper appliance to be worn at bedtime so you don’t wear both appliances simultaneously, what you’re trying to do is balance the jaw and keep in mind that this treatment approach is reversible.

It’s basically a phase one type of treatment to make sure your diagnosis is accurate and you’re providing value and care to your patient. Those orthotics can range from anywhere from about $850 to $2,250 per appliance and in most cases, the patient will need two appliances.

The course of care and treatment during this phase one is anywhere from three to six months and the patient is generally seen about every 14 to 21 days for adjustments and checks. Those visits are broken into short, medium and long, and the visit fees will range anywhere from $45 to $95 per visit. Please, keep in mind, I never hesitate to quote fees or recommend fees to give the audience some general guidelines, but the fees are general and they will be determined by the individual providing the care and treatment.

That is generally phase one type of treatment. If we find that the patient has responded and they’re doing quite well, their signs and symptoms have been eliminated or significantly reduced, a fair number of patients go into what we call a Phase Two type of treatment.

The phase two treatment is instead of wearing these orthotics day in and day out, we try to use a combination of orthodontics, prosthodontics to align, level and rotate the teeth to the new jaw position so that the orthotics or appliances are no longer necessary. That type of treatment can run into the several thousand dollar category. In most cases, the orthodontic care can run anywhere from about $3,850 to about $7,200 depending on how much and how we’re going to move these teeth.

In some cases, if the patient has a beautiful dentition with little to no dental disease, I will push the patient and guide them more towards and orthodontic type of treatment. If the patient has significant restorations, existing amalgams, composites, crowns or fillings on the teeth, I many times will suggest using a prosthetic type of treatment rather than orthodontics. The reason for that is the patient gets a double whammy. Not only does their jaw feel comfortable and their bite feel correct, but the cosmetics are improved significantly.

And in some severe cases, the patient will need a combination of both treatments. Keep in mind the physiology of the human body we cannot move the jaw indiscriminately as far as we want or as needed in some cases, and in those rare cases, a surgical approach is sometimes needed.

And that’s categorized as orthognathic maxillomandibular facial surgery. These are cases where positioning the jaw, even with the most up-to-date orthodontic care and prostatic care is not adequate. We actually have to surgically reposition the upper and lower jaw to the get the patient in that phase two success.

Doug: Would that be covered by insurance?

Kevin: In most cases, in my experience, once you’re going into the surgical phase, in most cases, that would be covered by your medical insurance because there would be a letter of medical necessity and no longer will your dental insurance be involved. I should comment a little bit on the fee structure for the dentist and for the patients listening to this podcast; my personal opinion is temporomandibular joint of TMD issues are medical issues.

The debate is the medical insurance feels that it should be billed through dental, the dental feels it should be billed through medical. But make no mistake about it. The temporomandibular joint is a joint and it is a medical procedure and a medical treatment, in my personal opinion, even though in many cases the individuals best suited to treat these most common problems are dentists.

Doug: That makes a lot of sense. I really appreciate it, Kevin. Thank you so much for sharing on this important topic of TMD and what people need to know.

Kevin: Thank you, Doug, very much. I just want to leave the listeners with what I call the 3 Ps. I would strongly recommend as you see your TMD patients, look for the 3 Ps. The first P is what was the patient’s precipitating event? It’s either going to be macro or micro trauma.

The second P is why are they predisposed? The patient usually will have a class two division one or a class two division two, malocclusion or a recessive mandibula or retrusive lower jaw. The third is what’s perpetuating the problem? So the three Ps are Precipitating, Predisposed and Perpetuating.

The perpetuating problem is TMD patients typically are clenchers. They’re constantly over exercising and irritating the muscles of mastication. When you can identify the three Ps and are comfortable with those 3 Ps, then you’ll probably have an excellent result in treatment and the patients will be happy and you will find that the treatment of TMD can be extremely rewarding and very cost-effective once you understand the basic principles.

You’ve been listening to Ascent Radio. My name is Dr. Kevin Coughlin. If you have particular questions, don’t hesitate to reach me through my website www.ascent-dental-solutions.com.

My special thanks to Mr. Foresta, whose company is Stand Out and Be Heard and is responsible for the professional production of the webinars and podcasts that you’ve been listening to. Thank you very much and Doug, thank you for your questions.

Podcast: Lisa Norton on how dental hygienists can improve efficiency and effectiveness

Hello and welcome to Ascent Dental Radio. A program dedicated to the balance between the clinical aspect of health care and the business of health care. And now here is your host, Dr. Kevin Coughlin.

Kevin: This is Dr. Kevin Coughlin. You’re listening to Ascent Dental Solutions. This radio podcast is brought to you by VOCO Dental Supplies. As usual, we’re here to talk about different areas of the dental profession and today, I have a special guest. Her name is Ms. Lisa Norton. She represents VOCO Company, but she has a unique background. She graduated from Albany State University in New York and then went on and pursued dental education in dental hygiene at Forsyth University.

She practiced dental hygiene for many years and then for a variety of different reasons, got into the consulting business. And as all of us know in the field of dentistry, there is no more difficult department to manage and improve upon than the dental hygiene department.

All of our dental individuals struggle with some of these issues and we hope that with Lisa’s expertise and the background of her exceptional company, she’s going to offer values to today’s podcast.

Lisa, thank you so much for joining us on this podcast. We’re excited to have you here. If you were to tell us over the years of experience as a dental hygienist and a consultant for VOCO, what would you say are the top problems in most dental hygiene departments?

Lisa: I think hygienists are faced with multiple time constraints. There is a lot of expectation from the dentist that they’re going to be able to take radiographs, treat the patient, educate the patient, reschedule them, treatment plan for them in a very short period of time.

One thing that I feel helps to increase efficiency in this area is to streamline their systems or work with the hygienists to eliminate some of the extraneous conversation, use paperwork that can streamline the protocol and better communicate with the patients. So when the dentist does enter the treatment room, they’re ready with what needs to be addressed by the dentist and have the back-up of what they’ve already discussed with the patient.

Kevin: In your opinion, with your background and expertise, what do you think the ideal timeframe is for a hygiene patient, if there’s such a thing? Do you recommend 30 minutes, 40 minutes, 60 minutes, longer than 60 minutes? Do you recommend scheduling by procedure? We have almost 20 minutes so you should be able to answer this fully and completely for our listeners.

Lisa: That’s a loaded question and I’m sure there are a lot of people on the other end listening to this waiting with bated breath on what my response will be. I think it’s really different for every practice. I think that depending on what the expectation is from the dentist and how large the practice is, what is expected to be accomplished within the appointment time, all those things need to be taken into consideration. I think that depending on what the patient is appointed for will depend on the time that the hygienist needs.

I think the first thing the office needs to identify is what they’re trying to achieve within that appointed time. Once that’s identified, then the office should sit down as a team to evaluate how much time is going to be effective and efficient. And then able to achieve what the hygienist is trying to achieve, what the doctors are trying to achieve, what the administrative staff is trying to achieve.

Multiple systems are in place and each one has to be addressed. Because the hygienist may present treatment that then has to go out to the treatment coordinator who has to address what the costs are, what the fees are. All those times need to be taken into consideration.

I think it would be unfair for me not knowing what the practice is to throw out a time. I can only speak from my experience where I worked on a 10-minute increment. We had a lot of freedom to appoint what we felt was necessary.

If I had a perio maintenance patient that required only a deep cleaning for that day but wasn’t required an exam or radiographs or was due for periodontal probing, I could see them in 30 minutes. That was me having the autonomy to book that patient on my own, but all offices have very different systems in place.

Kevin: As a practicing general dentist myself for 35 years, some of the problems that we all face is Mrs. Smith and Mr. Jones have been given a 60 minute slot and, of course, their dog got hit by a car, their child came down with a fever, they cancel and now you’re trying to find the appropriate patient for that appropriate time. I think we all struggle with this. Some of the processes and procedures that I’ve put in place that may not be politically correct — it’s what I call profiling — is the patient a one, a two, a three, a four, or five?

One means they’re the gold card. They’re the American Express Gold card. They have no insurance. They actually have been pre-approved by a soft credit check and we know those patients are prior approved. So no matter how badly the periodontal need is, if the individual does not have the financial funds, they’re probably not going to fulfil the treatment plan that’s best for them. So we do a soft credit check to determine the financial situation which is generally done through either Wells Fargo or Care Credit.

The second is categorizing the groups of patients. In our particular practice, we have five groups. Group 1; they have no insurance. What we consider the Gold Card. Group 2; they’re over the age of 65. As a general rule of thumb, usually your home is paid for, your kids are out of college and generally you’re in a retirement mode and you can finally take care of your own needs.

Type 3; you have insurance, but that insurance allows you to balance bill. Which is almost a dinosaur in today’s dental market, but they’re still out there. Type 4 are government assisted plans. These plans the government usually reduce your fees by between 60 and 70 percent, but you’re guaranteed a fee. And generally if you fill out the forms correctly, you’re going to be paid within 45 days.

Type 5 are those groups of patients that have insurance, but do not allow us to balance bill that patient. Or if we do balance bill, we’re taking a reduced fee because the dental office has signed up on a contractual basis that they’re going to provide us with X amount of patients, but for that luxury they’re going to reduce a reasonable and customary fees.

This way here the hygiene department knows from a financial and didactic stand point the profile of Mr. and Mrs. Smith before they go in. What are your feelings on that? And I hope you say positive because we’re on air.

Lisa: I will say I worked in two different types of practices: one which we only participated with two insurances and one we participated with many insurances including GHI, which was all the government state workers were signed up for, which was very slow reimbursement.

We were faced with either only presenting what we felt the insurance would pay for or presenting to the patient their actual need and allowing them to accept or reject treatment. The way that we did it was we created a system where the fee was placed at the bottom with all of the therapies included. That included the fluoride varnish, that included each quad scale, that included oral irrigation.

During that visit where they were assessed based on their periodontal probing that they were a moderate periodontal case, if they were a GHI patient, they were shown what their payment was going to be in total, including the co-payment which were procedures that were not reimbursed by their insurance.

Which were out of pocket payment because they were not covered by GHI. Yes, it was a reduced rate, but it was — as far as time, we were able to achieve a very effective treatment within a shorter period of time, a 50 minute time where typically it might be 60 minutes or an hour and 10 minutes. Just because we had the protocol and the procedure in place. Sometimes even less because we used the paperwork to streamline the efficiency of that chair time. And then when patients returned, we could rebook at a lower time frame. I would say I’m probably in agreement with you in the sense that time was taken into consideration, but we were able to shorten the time by streamlining the process.

Kevin: You’re more efficient and more effective.

Lisa: Absolutely.

Kevin: I want to get into some nitty-gritty. It’s amazing to me the number of sealants that aren’t done on premolars and second molars and first molars. The amount of fluoride that’s not offered to our geriatric patients and to our adult patients. I’m amazed at the number of ancillary procedures that are so critical to overall dental health and care and the outcome of our prostheses that can be implemented by a well run hygiene department.

Can you go into some data, some procedures, some materials that you find that are extremely helpful for most hygiene programs?

Lisa: Absolutely. One thing when I enter an office and meet with the hygiene department for a lunch period, typically, I’m there to talk about some of the systems I’ve used in the past, but also materials that my company offers to implement into their protocol. I try to work with the ADA risk assessment forms to help the hygienist use a framework in which they’re able to present fluoride to their patients. Again, we go back to streamlining the protocol.

The ADA recommends about 80 percent of your practice should be receiving some type of fluoride adjunct therapy. Many practices aren’t even aware of what their baseline is. So when we start to ask or I start to ask the hygienist, “Typically, who are you offering fluoride to?” They’ll say, “All kids.” And they don’t necessarily take the risk into account. When we introduce or when I introduce the ADA risk assessment, they’re able then to see this is an objective opportunity for me to say to my patient that they’re presenting in my chair at a high risk. And I’m going to recommend an adjunct therapy.

Often, hygienists, I think, are faced with a struggle of selling product or selling procedure and not just administering care. This takes that subjective part of their presentation out of it. And now they’re using an objective form, which is the ADA, which almost everyone is aware of. And it’s add a little of validity. Not that it needs to, but it does.

Kevin: More importantly, it’s showing value.

Lisa: Absolutely.

Kevin: In the professional healthcare systems selling has a negative connotation.

Lisa: Absolutely.

Kevin: But value has a positive connotation. And over and over again in my 35 years, I’d be a hypocrite if I didn’t say I’m interested in bumping my revenue. I’m interested in improving my numbers, increasing my profit. I would be wrong if I said anything else, but it should never come before patient care and service.

So if you’re selling a product that isn’t delivering value, then I think you’re a charlatan. If you’re not selling a product and recommending a product that provides value, then I think you’re not doing your job as well as you should. And the profession needs that.

Can you talk specifically about some fluoride products that you’ve seen some phenomenal results with VOCO, in particular?

Lisa: Absolutely. Profluorid Varnish is a varnish that is very well received in hygiene practices. The application goes on clear, it’s very thin. The flavors are great. We have caramel, melon, mint, cherry and now bubblegum flavor so it offers a wide range of option for hygienists. Plus, it’s at a very competitive price point. You think about when you’re offering a fluoride varnish to a patient and you’re a little bit over a dollar application, it takes less than a minute to apply. And you’re offering your patient a service and improvement in their oral health. And you’re increasing your hygiene production, as you just talked about. So it’s a win-win.

Kevin: This fluoride product by VOCO, is it applied by a brush or is it applied by a swab or is it up to the hygienist and doctor to decide what works best?

Lisa: It actually comes with a brush. It’s packaged with the brush and has a little well so it’s very easy to use. It’s unit dose. And we also have tubes available. If doctors are concerned about the waste, there are tubes available with all the flavors.

Kevin:  Do you recommend that the area be isolated, such as an isolite or a dry shield?

Lisa: No. Actually it sets with the saliva. Sometimes it will go on a little bit easier if you take a 2 by 2 and wipe the teeth and then just you swipe the tooth. You do not have to cover every surface. It does become available in the saliva afterwards. So not every surface needs to be covered.

Kevin: And home care instructions; are the patients supposed to avoid eating or drinking for 15 or 20 mins or can they go immediately to resume their diet?

Lisa: They can eat and drink. We ask that they avoid anything hot liquids or anything hard and crunchy. If it in the geriatric population, at the end of the day, we ask that they avoid alcohol for four hours. And the recommended time for it to be left on is about four hours.

Kevin: As far as ADA codes, what would be the code that our listeners would be using?

Lisa: It would be the varnish code which is 01206.

Kevin: And that code that you’re talking about, does the ADA do it by quadrant or by individual tooth? Do you know how our listeners would build this? For example, if we’re going to isolate the lower right quadrant, 28, 29, 30 and 31, is that billed as four individual surfaces or is it billed as just one varnish treatment?

Lisa: There are more than one code you can use in this situation. If you’re doing localized areas, there is a desensitizing code. My apologies that I do not have that on me and I don’t want to mistaken the number for you. There is a code that I could do some research on and get back to you as far as desensitizing. So if you’re working in a specific area, there are per tooth codes that can be used. But the 1206 code is for the whole mouth for a varnish treatment.

Kevin: Okay, very good. As far as sealants, I know VOCO has some different sealants that are available. Could you speak to that?

Lisa: Right now, we just have the Grandio Seal. It’s a 70 percent filled sealant which is a great opportunity because that high filler allows for increased wear. It’s going to hold up longer. It goes on very easily. We have a non-drip technology. So in the syringe, you don’t pull back on the syringe to stop the material from flowing out. When you stop pressing, it stops flowing. Hygienists can really appreciate this type of application because they’re not required to pick up a explorer afterwards to tease the material through or have to call the dentist in to adjust it down because it’s too high.

Kevin: My name is Dr. Kevin Coughlin. We’ve been listening to Ascent Dental Solutions. This is about the 60th podcast that we’ve produced and I have to give thanks to Mr. Doug Foresta who his company, Stand Out and Be Heard, without his expertise and his knowledge in podcasting, I certainly couldn’t do this on my own. And I like, at the end of each episode, to thank Doug for his expertise.

Today, I wanted to introduce VOCO and their ability to provide value, not only because of their products, but their ability to bring people into your office, train those people and help them to add value to our care and our service that we’re already providing. I could tell you that our company Bay State Dental had a 115,000 patient visits in 2016. And I cannot tell you whether it’s large or small, you need proper processes and procedures and a well-trained team to support your organization.

What I particularly care about with VOCO is their ability to come in and do lunch and learns to provide expertise to the staff that many time we as dentists don’t have that expertise. We should, but many times we’re confused on the new products, we’re not sure how to use the new products, and many times we don’t have a baseline.

Experts like Lisa can come to our practice and help us improve, more importantly than our bottom line, but our care and service to our patients. Lisa, I can’t thank you enough and your company VOCO for being here today. I’m sure we’re going to be having you back. Thanks so much for your expertise.

This is Dr. Kevin Coughlin. You’ve been listening to Ascent Dental Solutions. Thank you all for listening and we look forward to talking to you in the next week.

Podcast: Mike Pedersen on improved dental SEO

Hello and welcome to Ascent Dental Radio. A program dedicated to the balance between the clinical aspect of health care and the business of health care. And now here is your host, Dr. Kevin Coughlin.

Kevin: Good afternoon. You’re listening to Ascent Radio. My name is Dr. Kevin Coughlin, owner and operator of Ascent-Dental-Solutions, with an emphasis on knowledge, consultation, training and development. I’d like to give special thanks to Mr. Doug Foresta. He has produced all of my podcasts with Ascent Dental Radio and Ascent Dental Solutions. His company is Stand Out and Be Heard and I just always want to thank Doug for his excellent production.

Today, we have a special guest. His name is Mr. Mike Pedersen. Mike is the CEO of Dental Boost. It’s a cutting-edge dental SEO company for both solo and group practices with a focus on the dental market. Mike has been in this business for over 17 years with an emphasis on online marketing and six years, he’s been working exclusively with dentists.

His agency is able to help clients dominate all of their locations in Google organic searches. They’ve also provided custom high-converting dental websites. Most of the dentists out here listening and health care professionals realize that a website and a mobile app is part of our marketing program, but Mike takes it with his company, Dental Boost, to a whole new level.

Mike, thank you so much for taking time from your busy schedule. Can you give us a little bit of background about the particulars; why you saw this niche, why you decided to get involved with this particular aspect of the dental business?

Mike: Kevin, first off, thank you very much for having me on your show. I’m honored and it’s very much appreciated. Instead of going after the normal approach for dental SEO which is city dentist, city veneers, city Invisalign, city sedation dentistry, those are very general terms and the unfortunate thing is everybody else is going after those terms. And if you’re in a big city, you’re talking about hundreds of dentists going after that term.

Well, that chance of that one dentist, even when they hire an SEO company, the chance of that one dental practice ranking in the top three organically is pretty slim or none, even after one year, Kevin. One year of investing in SEO, the chances of ranking in the top three are very slim, depending on the competition.

So what we decided to do was, do our exhaustive research to find out what kind of what we call buyer-intent dental keyword phrases are people typing in Google for specific searches. And we came up with some staggering numbers, absolutely staggering. The first number we came up with from kind of a general standpoint was 577. The typical dentist when they hire an SEO company goes after all of their services and they tap on the city and then they’ll go after city dentist, city cosmetic dentist.

So we typically see that the approach with all dental SEO is about 20 keyword phrases. We’ve come up with what we call Phase 1 SEO. We’ve come up with over 500. And when we tell our dentists that, they’ve never even heard that number before. It’s kind of like, “What is that? I mean, 500?” And they don’t think we’re serious. And then when we give them our references and they talk to some of our dentists that we’ve done it for, then they start believing that we do what we say we can do.

The exciting stuff for us is the back end, we’ve got a proprietary system we use that’s Google friendly that makes it through all the updates. But the neat thing that we’re able to do is from a robust standpoint, we’re able to not only go after the city the dentist is in, but all the surrounding areas up to five. And so what we’ll tell our dentist is, “Hey, what are the areas you draw your patients from outside of your city?” And they’ll name a bunch of areas. And it could be neighborhoods, it could be outlying towns, things like that. So now we’re going after five to six locations per dental practice.

When we do that, now you’re talking about ranking for upwards of 2,500 keyword phrases for your dental business. And that’s called pure domination in dentistry. Pure domination.

Kevin: I can tell Mike, you’re quite an athlete. I don’t know if our listeners understand what your previous background was in athletes, but I can tell with your desire, your drive and just your overall excitement with your business, Dental Boost. For some of our listeners, even the word SEO, Search Engine Optimization, may be foreign.

For those dentists not as, let’s just say, digital savvy, my understanding is that there’s close to 13 billion Google searches very month. And out of those billions of searches, is it true that the majority, 50 to maybe 75 percent are coming on mobile devices and can you discuss with our audience how that’s changed?

A typical dentist like me who’s been practicing for 35 years, I used to think if I have a website, I’m doing online marketing and I’m free to go. But in reality, experts like yourself realize we’re probably throwing our money into the wind and not getting much of a return on our investment. Could you address that for us, Mike?

Mike: Exactly. And you said something that’s very important when it comes to Google search too is we call it Voice Activated Search or Voice Search. Where people are on a mobile device, and they will talk into their phone — they use SIRI a lot for Apple devices — but they’ll get on Google and they’ll type in “cost of veneers, Portland” or whatever it may be and they’ll start — voice activated search is exploding.

And when you think of voice activated search, which is what we optimize for in our SEO campaign, people don’t talk in general terms. They talk as if they’re talking to somebody right in front of them. And when they do that, you’re talking with three, four, five words so that they get a really defined search result.

And that’s another benefit of our approach, is that mobile search is exploding. And you’re exactly right, it’s over 50 percent on mobile now and growing.

So people are spending more and more time on their mobile devices, including shopping, which Kevin you and I, I don’t know about you, but I’ll speak for myself. I’m 53, tech savvy obviously, running my agency, but I’m old school. I’m not about to make a purchase on my phone. I’ll do it once in a great while, but I don’t think the user experience is very good on a little phone to make a shopping purchase. But a lot of the younger millennials, 25, 30, 35, 40 year olds, they’re doing everything on the phone now, everything.

So you make a very, very good point and it’s a great reminder for me to tell the audience that voice activated search is exploding as well. And that voice activated search is not somebody saying Portland dentist, you’re saying, “Looking for male dentist in Portland, Oregon.” They’re talking into their phone, is what I’m trying to get at. And if you don’t optimize your website for a mobile search, you are losing a huge percentage of people that are using mobile to search for a dentist.

Kevin: Mike, let me just follow up with another question. I know you’ve been doing this for a long time. I know that your clients have been over the top satisfied with the service that you and your company have been providing. But how do you track the results? At the end of the day, when you take on a client, how do you track so that we have objective data to determine the return on investment with your company?

Mike: Great question. First and foremost, we always send ranking reports every month. And that is just hard core data to show if we’re performing what we promised we would perform, which is ranking higher in organic search. Number one as an SEO company, we’re hired to rank our clients higher in Google organic. That’s number one. That’s right off the top. So every month we send a ranking report. We just sent one the other day to a client and this is pretty damn exciting. Kevin, honestly, this is unheard of in dental SEO. This particular client had 973 top three positions in Google. 973, can you imagine?

Kevin: Absolutely fantastic.

Mike: Yeah. So first off, we send a ranking report. Second, we’re going to look at the traffic boost that our services are bringing that particular website. So we’ll go into Google organic and we want to see an increase in traffic. The increase is going to be incremental each and every month because as we rank more and more buyer-intent keyword phrases, that traffic is going to keep going up.

Unfortunately with the old style of dental SEO, traffic hardly ever goes up because it takes so long to get those rankings for those general terms. We’re able, with our robust proprietary back-end system we use, what we’re seeing on average is the first month ranking report we send a client, they have over 200 top three positions in Google is our average right now, after only four weeks of working with us.

Kevin: Mike, if you don’t mind telling the audience, you talked about the organic search. What’s the inorganic search when it’s associated with Google?

Mike: Great question. It’s called Google AdWords. Google has continued to show us something. As SEO experts, we’ve seen this happen more and more, but they can always go so far and then people will stop using Google, which is this; you will see the first page of Google with more and more ads because that’s how Google makes their money. But if they sabotage that and they can’t, there’s no way.

There’s a lot of people that say SEO is dead. Well, they don’t quite understand SEO when they say SEO is dead because if Google littered the whole front page with ads, people won’t use them anymore and Google as big as they are will go away.

People hearing this might say, “That’s crazy, they’re a 50, 60, 80 billion dollar company,” there’s been many multibillion dollar companies that disappear and we can name them over and over and over again. If Google littered the first page of their website with ads, people would leave them. There’s no doubt about it. So people that say SEO is dead, they’re uninformed.

But when we talk about organic and then what’s left is called Google Ads and also the map section, and Google is even taking more of that away. The map section, that little box on the first page when you type like a city dentist, it used to be seven positions in that map. Well, good old Google didn’t like that that map took a big section of the page one for a search so they cut that down to three. Good old Google, rumor has it, it might cut that down to one and throw an ad in there.

So as you can see, Google constantly is trying to, without getting in trouble, put more ads in there. So Google ads typically are the four positions on page one and the top four positions on page one as well. So top and bottom, that’s eight positions of ads.

But let me tell you something, Kevin, about ads and especially with those dental support organization owners that are listening to this audio. If you want to play the Google ad game per location, you are talking about thousands and thousands of dollars per month to get an ROI because it takes a lot of investment to gain the trust with Google to lower the cost per click. But even when you lower the cost per click, you still might get a lot of clicks, but that doesn’t necessarily mean you’ll get a phone call or a new patient.

So we’ve done some research and we’ve found out a number that I want all the listeners to understand, and it’s this; we have found out through research and studies that Google AdWords only send 10 percent of all website traffic to a business. Hear what I just said again; Google ads only send 10 percent of website traffic to a business.

That means if that business, whether it’s a dental practice, a DSO with 50 locations, if you are not doing any kind of organic optimization, you are leaving 90 percent of the potential traffic on the table for all those locations. Ninety percent!

Kevin: That’s huge.

Mike: That’s a big number.

Kevin: Mike, I was wondering if you could share with the audience in your business experience Dental Boost, without getting too specific, whatever your comfort line is, but for the dentists out there, large groups, solo, corporate groups, what generally can they expect for an investment to get your expertise to help them grow their business, improve their position on Google? And at the bottom line, you want people calling the office and you want to convert this tracking to new patients for your business.

Mike: Are you asking what our fees are?

Kevin: Generally, how do you charge the dentists that are listening? Is there a set fee, a monthly fee, a start-up fee and then follow up fees? How exactly does your company run in that regards?

Mike: We’re pretty standard, but what we do, especially the offering that we have with this buyer-intent and hundreds of phrases we go after, we’re priced about right in the middle of what most credible dental SEOs charge. But remember, most dental SEO companies are using the old method that takes six months to a year to see any kind of result, any at all. That is true. That’s a fact. But what we don’t want to do is we don’t lock our clients into contracts.

We’ve heard horror stories and I dealt with a lot of clients. I’ve got one right now, a solo practitioner out of Seattle, no names mentioned because I love them to death. They brought us on and his previous company basically will not let him go and they’re trying to extort a bunch of money from him.  

We don’t want to do that. We don’t lock our clients into contracts. With a thirty day notice, they’re out. They give us a thirty day notice, they’re out. But we do have an agreement because we have a formal agreement that lets them know what they can expect from us and the investment per month and that kind of thing, but we do not lock clients into like a 12-month contract, 18-month contract. If clients aren’t happy with what we’re doing, they can leave within 30 days. So that’s one. Really we’re proud of for that one.

Secondly, we don’t have start-up fee, we don’t have this fee, we don’t have that fee. We typically have a monthly retainer that our clients hire us on. That monthly retainer never changes unless they want to add on more services. And Kevin, I didn’t even get into all the stuff that we’re doing that’s getting really exciting for a lot of our clients, what we call add-ons and keyword clusters.

And I can tell you that a little bit, but for the investment it’s basically just one fee per month for SEO and depending on how competitive the area is, if you’re a solo practitioner, we’ve got kind of a baseline we start with as far as investment. It’s definitely not in the low end. If you’re looking for hundreds of dollars a month, we’re not the company for you. That would be another company that you would want to call on. It depends on the competitiveness of the city or the investment for our services. But our services only fluctuate $300 to $500 from top to bottom. So it’s not a real massive increase, if somebody has got a city that’s 500,000 we don’t like triple the cost, we just incrementally go up.

For a DSO, we basically cut each location in half. For example, the ideal situation for a DSO, so if the DSO owners are listening, please listen to this; Google is looking more for brand recognition now. No longer do you need individual websites for each one of your location. And I would strongly recommend against that. Have a brand that has all your locations on one website. That makes it consolidated, that makes it more cost-effective. And for us, now we can treat it not as separate accounts, like we would have to with each website, now we can treat it as we’ve got an initial investment for location one and then location two through the rest of them, we cut in half basically.

So it becomes way more affordable when you look at the investment with each location as its own business, even in a DSO, it’s still its own business but in this umbrella of a DSO, we cut it in half. So we feel like we’re very accommodating for a DSO to cut that price in half for each and every location after the first one.

Kevin: I can’t tell you how much I’ve enjoyed and I’m sure our audience has enjoyed listening to your expertise as CEO of Dental Boost. Your particular interest and expertise to dentist is a credit to you and your company and it certainly will help us who struggle trying to find new patients and how to handle this new world of digital marketing. Can you tell our audience the best way to connect with you ; a website, an email, a phone number?

Mike: Sure, absolutely. One thing I want to say is there are a couple of dental practices on the east coast that have the name Dental Boost. Our company name is The Dental Boost. Because if the listeners just went to Google, they’re going to find a couple of dental practices back east so we want to make sure the word “the” is in front of that. The website is www.thedentalboost.com. My email address is mike@thedentalboost.com. Our business number is 866-500-1414.

And Kevin, I want to say one last thing too that’s really important to the listeners, and I love doing this, by the way. Anybody that’s seriously interested in doing this, we really don’t want anybody just trying to just kind of pick our brains and not have an intent into possibly hire us. I do a personal thing we call a Digital Assessment.

That Digital Assessment is I will do a screen share of my computer with all of your online presence. If you’ve got ten locations, if you’ve got one location, I will pull up all your different web properties and I’ll analyze them right there in front of you on your computer screen. You’ll watch me click around. I did it with you, Kevin.

Kevin: You’re not kidding. And for those listening to us, it was an extraordinary eye-opener. The time and energy that Mike and his company put in to evaluate, in my opinion, is worth a pile of gold.

We’re not experts when it comes to marketing. We’re experts in the web. My personal opinion is talk to the experts like Mike. Have them get you straight and narrow so that you get the best results and you don’t waste money and time. Mike, is there anything in closing that you’d like to tell our audience?

Mike: When you make a decision to invest in your practices, you own a business. So it is an investment. A lot of dentists we talk to really kind of fret over I don’t want to spend this much money or I can’t spend that much money. It’s an investment in your business and because everything is online now, I would strongly recommend giving serious consideration to investing in a digital marketing program for sure, whether it’d be with our company or another company. But other than that, Kevin, I just want to thank you so much. I’m very honored to have been on this call with you and I thank you very much for that.

Kevin: Right back at you, Mike. We’ve been listening to Mike Pedersen, CEO of The Dental Boost, an expert in online marketing, but in particular, search engine optimization to get the best bang for your dollar.

My name is Dr. Kevin Coughlin. You’ve been listening to Ascent Dental; my company, Ascent-Dental-Solutions, with a focus on knowledge, development and training and education for the dental community.

I also would like to close with a thank you to Mr. Doug Foresta who produces each and every one of our podcast and his company Stand Out and Be Heard. If you’d like any additional information in how podcast can help your business, give me a contact at www.ascent-dental-solutions.com.

Thank you everyone for listening. And I can assure you we’re going to get Mike Pedersen back from The Dental Boost to talk about the inorganic along with the organic portions of SEOs. Mike, thank you again and thanks to our listeners. I’ll talk to you soon.

Dental implants growth tied to technology advancements

Although pioneering techniques have always been a part of dentistry, I must admit it’s been fascinating to watch how one in particular has evolved throughout my career.

I’m talking about dental implants. When I did my first implant back in 1983, it took three hours to get a single tooth in place. Back then the process included drilling into the bone to test for bone quality and quantity. The theory was that good bone density meant a good prognosis for a successful implant.

Since then I’ve done thousands of implants and the process has developed quite a bit.

Today, using cone beam technology we can plan the surgery in great detail. The cone beam allows us to check for quality and quantity of bone, height and width of bone without any invasive drilling.

Putting the technological advances in the procedure aside, it’s hard to overestimate how important an advance like implants are to the quality of life of patients. Even a patient with no teeth can have them all replaced.

It used to be a very time consuming and expensive process for a fully edentulous patient. Prior to cone beam technology, patients would wait weeks for treatment prep and planning to be completed. The prep has been since dramatically compressed over the years, resulting in a quicker and much less expensive procedure.

There are some companies such as Implant Concierge that are rather handy for dentists in that they handle all the post cone-beam scan work and create a plan for the dentist to work from. These are online processes that eliminate office work in terms of merging, segmenting and thresholding for the procedure.

What I like about such companies is how they allow dentists to integrate implant work easily into their practice without  stand-alone software, and the learning curve that it involved for everyone in the practice.

Outsourcing this type of work is a good strategy to increase your service offerings without impacting your current business. And because it expands the scope of your practice, it is good for client retention, referrals and your bottom line.  

So if you feel your practice is not growing as fast as it should, consider all the options.

Podcast: Bret Royal of Implant Concierge on benefits of implant surgery

Hello and welcome to Ascent Dental Radio. A program dedicated to the balance between the clinical aspect of health care and the business of health care. And now here is your host, Dr. Kevin Coughlin.

Kevin: This is Dr. Kevin Coughlin. Thank you for listening to Ascent Radio. My podcast is Ascent-Dental-Solutions. My name is Dr. Kevin Coughlin, a practicing dentist since 1983. I want to give congratulations to Doug Foresta, Standout and Be Heard. Doug has been helping me produce this podcast for the last several months and he can be reached at dougforesta@gmail.com.

Today, we have what I consider one of the leaders in the industry, Mr. Bret Royal, Founder and CEO of Implant Concierge. If you haven’t heard about it, you will hear about it in the near future. Bret is here to talk about the advantages of Implant Concierge, which I’ve learned firsthand.

He established seven businesses all related to the implementation and utilization of cone beam technology and guided implant surgical services into the dental market. As CEO of Implant Concierge, LLC, he’s built one of the largest CAD/CAM guided manufacturers in the world while focusing on service, simplicity and affordability.

With no further ado, I’d like to introduce to you Mr. Bret Royal, CEO of Implant Concierge. Bret, thank you so much for taking your valuable time to speak to us and the dentists all across the world about the advantages of guided implant surgery. Give me a little bit of a background about why you started your company and how your company is doing right now.

Bret: You bet. First of all, Dr. Coughlin, thank you so much for having me on Ascent Radio and on your podcast. It’s truly an honor. I really am excited to be here. My company was founded originally as a dental imaging center along with myself and 42 other dentists in San Antonio. And it was right when cone beam CT was coming out, it was pretty new and expenses of buying a cone beam CT unit, obviously, was not a smart economical decision at the time.

So myself and a few other dentists here in San Antonio went in as partners and opened a really nice state of the art dental imagining center focused on treatment planning and dental implants. Because of my network of surgeons across Texas, we went from one imaging center to ten relatively quickly in about three and a half years.

From the very beginning, the cone beam CT was fascinating, but what really got me excited because of my dental implant background was taking the cone beam CT images and creating a virtual surgery and presenting that to the doctor and as well to the patient to help improve the case acceptance and also just the quality and predictability of dental implant surgery. Over the years as the business grew and the services were becoming more and more popular, we really needed a way to take our business from local region dental imaging centers where we were provided really robust services to more of a national platform, even a global platform. That’s how Implant Concierge was created, is how can we take what we currently do but provide it to many more dentists across the United States and not just where we’re located.

Implant Concierge was founded on things that we had already been doing, but putting it online and making it much more simplified and taking all the time away from the doctor to free up the doctor from having to buy software and spend a ton of time sitting there working with DICOM files, merging, segmenting and also doing all the thresholding, and just simplifying the process and building a communication tool that will allow doctors to work together to make the process very multi-disciplinary and also very simple.

That’s my background and it’s been an amazing growth over the past ten years. Implant Concierge is averaging about 3.8 new dentists per day since October 2014. So it’s been a wild ride, but it really matters because I think the services are what many dentists need as they embark upon providing implants for their patients.

Kevin: I can just digress a little bit that I placed my first implant in 1983. At that time, I scheduled almost three hours to place that singe tooth implant. Over the next 34 years, I’ve put in literally thousands of dental implants. And only until the last five to seven years that I realized that — because this podcast goes out everywhere to non-clinical people, to clinical people, to the public in general, you may not realize this, but when we first started placing implants, we would drill a hole into the bone and check for the quality and quantity of bone. If it feels dense, if it felt strong, that was a good indication that the implant would be successful. Those pioneering days, I’m happy to say, are gone by the wayside.

Today, with cone beam technology and your company sophistication of software and guided surgery, we can now basically do the surgery virtually before we ever start the treatment on Mr. or Mrs. Smith. The cone beam allows us to check for quality and quantity of bone, height and width of bone. Why don’t you take a couple of minutes and explain to our audience some of the advantages and sophistications of using the virtual treatment plan before the actual treatment plan?

Bret: You bet. Many, many dentists go into a case with a lot of concerns about the anatomy and the amount of bone. As you said, the cone beam CT was powerful and fine giving us the bone quality and quantity upfront so at least now we know. But on top of that, now we can go ahead and we can place the implant. It allows us to avoid challenging outcome of situations, whether it’d be the sinus or the nerve, we can also place the implant in the ideal restorative position.

And really this is the key, I think, for many dentists whether you’re a specialist or you’re a general dentist placing the implants, you want to be able to plan and place the implant in the ideal restorative position so that at the end of the outcome you have a tooth. You don’t have a crown on top of an implant.

Using the software, we can place the implant in the ideal position. We’re using the crown-down philosophy, using that restorative crown as our guidelines and then maximizing the bone to the implant position and size, the length and the width. The software allows us to do that. Taking the diagnostic cast or the patient’s digital dental model and merging it also gives us the soft tissue and so many other parameters to consider while we’re placing the implants.

Once we have that virtual surgery completed, now we can take it to the next step and take the virtual surgery and utilize that to design a 3D surgical guide that utilizing CAD/CAM and 3D printers we can now print a medical grade surgical guide that can be used that takes our virtual plan and then it turns it into reality into a surgery.

Kevin: I know that we have a wide variety of listeners with a diverse degree of experience. Basically, if you walk us through, from my perspective, we have tooth-supported surgical guides and bone-supported surgical guides. In simple lay terms, some people have no teeth and we’re replacing all of their missing teeth with dental implants and other people have a wide variety of teeth still present and we’re replacing just a single tooth.

Can you explain the process, the procedures and how Implant Concierge works through the completely edentulous patient, the patient has no teeth at all, so that our listeners get a firm idea of the power of Implant Concierge and the tremendous success rate by following the correct process and procedures?

Bret: You bet. And I think if you go to our website, we have these protocols listed out to review and look at a step one through five process. But ultimately, the dentist would simply start the case at Implant Concierge and let us know which teeth are missing. In this situation, all teeth would be missing. And also on another chart, they let us know where they ideally would like to place the implants.

Once that’s completed, the Implant Concierge is going to get the dentist the exact specifications and rules, the workflow, so to speak, as far as exactly how to do it.

The number one step on a fully edentulous patient or someone with no teeth is to have a well-fitting hard reline denture. Once we have that denture, we can go ahead and use they call them X-ray markers, but it’s really a one millimeter lead ball that’s on a sticker and they’re actually for mammograms.

So we go ahead and we take six of these X-ray markers and just stick them randomly to the patient’s denture. At that point, utilizing the doctor’s cone beam CT scanner, we’ll go ahead and scan the denture with these X-ray markers on them and then we’ll very carefully take the denture and position it near the patient’s mouth. While the patient is wearing it, they’re also given a CBCT scan. Essentially, the patient was scanned one time with the cone beam CT unit and the denture was exposed twice.

Once those two scans were taken, it’s generate a file called DICOM. That’s what cone beam CT generates, is a DICOM files. Both those data sets or DICOM files are uploaded directed into Implant Concierge’s HIPAA compliant communication portal. So they’ll go and upload us the files. Once we have those, it’s a matter of utilizing software to match them back together and then using a tool called Thresholding, we can literally threshold the difference and create the soft tissue model.

From there, once we have that soft tissue model, we can pretty much do anything we would like to do. And we utilize the denture, the soft tissue model and the bone to meet with the dentist to finalize the final positioning during that virtual implant planning or VIP session.

It really is magical how simple it has become over the years. This used to be a very time consuming and also a very expensive process for a fully edentulous patient. Now, a fully edentulous patient is one of our easiest cases that we can do, believe it or not.

It’s come a long way in a matter of two, three years, saving that patient weeks of waiting for the diagnostic tools and treatment planning to be completed as well as a ton of costs that can now be minimized from not having to create really expensive scanning appliances. So this dual scan protocol, using the X-ray markers along with the patient’s denture is just a wonderful advancement for the patient and for the dentist.

Once that meeting is done, Dr. Coughlin, at that point we go ahead and we build a surgical guide that matches the intaglio surface or the denture so it fits just like the patient’s denture did. And then at that point, the dentist can go ahead and do a very efficient surgery.

Kevin: Just for our listeners out there, these little millimeter microdots or mammillary dots for radiopacities, you can order these through your local surgical supply house or I believe Implant Concierge can also order these radiopaque dots also. Another quick for individuals are make sure when Bret explained to you, you’re better off taking the denture with the diagnostic radiopaque dots and scan that first, then put it in the mouth rather than vice versa.

Because once that prosthesis is put in the mouth, sometimes the saliva and moisture can loosen up those radiopacities and you like to keep them in the same place. Am I correct on that, Bret?

Bret: Yeah, that’s a great tip. So step number one definitely would be to scan the denture out of mouth first with the markers and then carefully put it into the mouth. As far as the purchasing location, if you just type in “one millimeter X-ray markers” you’ll have a whole plethora of medical supply companies. Or if you buy from Implant Concierge, we have created a little package where you get a box of 110 of these markers for $40, that includes shipping, as well as the protocol sheet as well as a little sponge because you want to position the denture on top of a sponge or a form on top of your CBCT scanner.

So it’s almost like a little scanning kit for your dental assistants to follow along very precisely. It’s a little bit technique sensitive when it comes to taking the cone beam CT X-ray so having these protocol sheets right there for the dental assistants who will be taking the X-ray is very helpful to avoid any issues or poor scan quality.

Kevin: Bret, can you talk a little bit now about the patient who’s dentate, someone who has a multiple number of teeth but may need one, two, three or four additional teeth replaced and the sequence on that?

Bret: You bet, Dr. Coughlin. Providing a surgical guide for a patient who currently has teeth or what we consider a partially dentate patient is also extremely simple. The workload depends upon the technology that the dentist currently owns. Once again, you start the case at Implant Concierge and then follow the protocols.

The first thing that we’ll need is to take a cone beam CT scan of the patient. What’s nice about this is that no scanning appliance is necessary or a radiopaque template or a special bite guide. Nothing is really required. All we want is a simple separation using cotton rolls of the upper and lower maxilla and mandible teeth.

Once you have a simple separation, sometimes people will even use a bite stick and lay it across the occlusion table just to create a little bit of a separation. At that point, once you have the separation of the teeth, go ahead and take a CBCT scan so there now we have our DICOM.

You directly upload that into Implant Concierge and then if the dentist does not own a digital impression technology, then they’ll go ahead and take an alginate impression and then pull up a really nice accurate diagnostic cast and then ship us the diagnostic cast. Once we receive the diagnostic cast, we’re going to go ahead and digitize it using an optical scanner and create a digital file of that diagnostic cast. And then we turn that digital file into what we call a .stl (dot STL).  

If the dentist owns an intraoral scanning unit or a digital impression unit, that’s wonderful because the dentist can take a quick impression of the arch of interest and upload the STL file directly into Implant Concierge and within minutes, Implant Concierge will have the DICOM of the CBCT as well as the digital impression.

And then we’re off the races of merging and planning the case for the dentist. It’s either a cone beam CT plus a diagnostic cast, or if you have a digital impression, take a digital impression and upload that directly to Implant Concierge. So the workflow for partial is very simple.

Kevin: I know all of this information is on your exquisite website. But if the patient is partially edentulous and has a good fitting partial or removable partial prosthesis, do you want that partial in there when you do the cone beam or would you prefer that that be out of the mouth?

Bret: That is a great question and a lot of dentists they make the mistake. You do not want to have the partial in the mouth when taking a cone beam CT scan. The reason makes a lot of sense; cone beam CT scan does not like metal and most partials have some type of metal framework built within or the clasp.

So those clasps create all kinds of scatter or what people call noise on the cone beam CT. When you scan a patient, make sure everything is removed from the mouth. However, that RPD or the Removable Partial Denture, is so valuable for us for planning.

So whenever you send in your diagnostic cast, if the patient has an RPD, go ahead and take a second impression, what we call a pick-up impression of the patient wearing their RPD and send that in also. So now we have two diagnostic casts; one of the patient with their missing teeth and then one of the patient wearing their actual RPD. Because that gives us the actual reality or the actual positions of the restorative teeth and where you’d like to have them.

Once we know where the restorative teeth are at and we know the bone, we can do an amazing treatment planning that’s extremely accurate, once again, using that crown-down philosophy. So the RPD is a very useful tool.

Kevin: Am I correct if the patient doesn’t have a removable prosthesis if you’d advocate a diagnostic wax-up? So you’d send the impressions or I should say the pod accurate models of the edentulous area and then you would do a diagnostic wax-up so that we’re helping you where we want the occlusal plane, the path of insertion, the emergence profile, et cetera. Am I correct on that?

Bret: That is correct. This becomes a situation where you kind of have to make decisions. If we’re only missing one or two teeth, my team, they’re very well trained, they’re all dental assistants and also lab technicians, we know where teeth belong so we can virtually place a tooth in the right position to give us that crown-down philosophy.

However, if you’re missing a long span of bridge of teeth, maybe like say three plus teeth in a row, may four teeth in a row, then it’s really powerful if the dentist would send us I want the teeth to be in this exact position. So a lot of dentists what they’ll do is they’ll go ahead and do a quick wax-up in their lab or have their lab create a wax-up and send us that diagnostic cast with the wax-up on it as well.

If the dentist does not want to do a traditional wax-up, that’s not a problem. We have some very powerful software where you can send us the diagnostic cast as well as the upper and the lower end by registration and what we’ll do is we will virtually merge those files together and we’ll do a virtual articulation and then we’ll create a virtual wax-up that’s going to be extremely accurate, just like your lab would do on the bench with the articulator.

It is actually a huge advantage if the dentist does send us a wax-up because that way, we can make sure we use the crown-down philosophy. Having the doctor’s wax-up is always going to be superior versus someone else’s because you guys know exactly where you want that tooth.

Kevin: Mr. Royal, I cannot explain as our listeners know listening to me for several months now doing this podcast, I only endorse companies that I believe, like and trust in. My association with your company what has just been to me over the top is the care, the service and the ability to want to train us to provide a better care and better service for our patients.

Bret, can you tell us your website and how the doctors listening can get in touch with you to ask additional questions or order from your to get started with Implant Concierge?

Bret: You bet, Dr. Coughlin. I just want to say once again, thanks for having me. I also want to say my whole vision, my whole goal is to make guided surgery because I think it’s so powerful and so wonderful and as simple and affordable as possible. That’s what  I think we’re based upon.

I think we’re one of the few companies that actually provide this level of service and support. So I’d love to give you my contact information so that way your listeners if they want true service and a guided surgical company, I hope they give us a call. We can help them out to provide that predictable solution that they’re looking for as well as the confidence.

Our number is 866-977-2228 and the website address is www.implantconcierge.com. The easiest way is to call us, someone will jump on your computer with you, give you all the protocols and we’ll even review your cone beam CT scans before you upload them to make sure that they’re of great quality and scan correctly. Whatever we can do to help out, we’d love to be there for you.

Kevin: Mr. Royal, thank you very much and I know your company is going to go nothing but straight up, the service, the care, the expertise over the top. I know how busy you are. I can’t thank you enough for taking the time.

You’ve been listening to Ascent Radio. Again, a shout out to Stand Out and Be Head by Mr. Doug Foresta who’s producing this podcast. A special thanks to him. That’s dougforesta@gmail.com if you’re interested in podcast and the power that it can provide for education and knowledge.

My name is Dr. Kevin Coughlin and you can contact me at www.ascent-dental-solutions.com, with a focus on education, training, development and knowledge. Thanks again for listening and I look forward to talking to you in the near future.