Season 1 Episode 9 – Maximizing CEREC Use for Advance Procedures

Full Episode Transcript

With Your Host

Dr. Tarun Agarwal

Welcome to T-Bone Speaks with Dr. Tarun Agarwal where our goal is to change the way you practice dentistry by helping you achieve clinical, financial, and personal balance. Now, here’s your host, T-Bone.

T-Bone: Alright guys, welcome back to another episode of T-Bone Speaks. I want to thank you guys for listening. I know that we have many choices in life and we appreciate that you choose to listen to our podcast. Before we get started today, I would like to ask you to do a couple of things for me. Number one, it would mean the world to me if you would go on to iTunes or Google Play and leave a review for our show so that we can try to reach more people. Number two is if you could do me a favor and make a post on your social media accounts about how much like – if you don’t like the podcast, please call me directly. But if you do like the podcast, it would be great if you could go on your social media accounts and share it with your friends because we are trying to reach a broader audience and make a bigger impact.

So, I’m Dr. Tarun Agarwal. I’m here with my co-host.

Chuck: Hey, good morning. This is Chuck McKee.

T-Bone: Chuck who is still not on Facebook.

Chuck: Still not on Facebook.

T-Bone: At this point, I think you’ll never going to get on Facebook, Chuck.

Chuck: If I cave in and jump on Facebook, will you really respect me anymore?

T-Bone: Yes.

Chuck: No. I’m just not going to do that. [crosstalk]

T-Bone: I guess you don’t want your territory to go down. You don’t want to communicate with, whatever. That’s not what we are here to get into today, okay?

We are joined today with another live member today. We have Dr. Benjamin Nemec here with us today. Benjie, how are you doing?

Benjie: I’m doing well. Good morning.

T-Bone: That’s good. Why don’t you have a little more energy. This show is about energy, for god’s sake. So let’s pick it up a notch. [Laughs] Benjie is our trainer here at 3D Dentist for our CEREC program, our Maximum CEREC Program. We want to take this opportunity while he’s here training our group this weekend to have Benjie on for an interview. We were just having a random conversation yesterday about using CEREC for more advance procedures within the practice and, you know, I always look to Chuck and why are people doing that; what’s holding the dentist back, and we had a great conversation and I said, “We need to stop this conversation right now and too bad, we didn’t have mics on ourselves because it would have been an unbelievable episode.”

So I wanted to come back and try to recreate that and just kind of talk.

So Chuck, what are we going to talk about?

Chuck: We’re going to talk about full mouth restorative dentistry with CEREC.

T-Bone: Now, when you say full mouth, you refer to literally top and bottom? Does that mean one arch? Does that mean, maybe 10 teeth, eight teeth? We’re talking about, would you say probably better, more complex care?

Chuck: I would say 10-20?

T-Bone: Ten to 28 teeth within that ballpark.

Chuck: Right. And we’re going to talk about, is it really worth it doing it with your machine?

T-Bone: Is it even possible with your machine?

Chuck: And you know – and again, I always ask the question, just because we can, should we?

T-Bone: Okay, and that’s what we have Benjie here for. Benjie, I think you are surprised yesterday when we were talking that he was regularly doing this types of cases, number one that’s one part of the issue is, do we have the patient base for this and then number two, can we do it with our machine? Is it really practical doing it with our machine. And I think you were a little surprised when Benjie talked about how he is doing it with the machine and how he’s found a way to make it predictable and enjoyable.

Chuck: Yeah, that was something I honestly had known him for about an hour at that point and as you guys hear, he’s a pretty conservative person and when he was telling me he was doing a couple [crosstalk]

T-Bone: Is that just because he is from Texas?

Chuck: No. It was just – a lot of times…

T-Bone: Yeah, you’re saying he’s a conservative like, politically?

Chuck: [Laughs] You know, often when you hear people doing this much full mouth rehab, a lot of times there’s some folks who have some pretty big egos to do this. You’ll find that he’s very, very humble and a lot of folks who do this are doing maybe one a year with their machine or not. He’s doing a couple cases a month and to be honest with you, I was pretty blown away by that. In my typical day, one of the biggest things with CEREC I hear is folks get a little hung up on Quadric dentistry and the reason being is – how often do you really get to do a [Quadrant of all laser crowns anymore?] It seems to be, one [4:01 inaudible] and what I’ve been trained on through the years is, this is a great single tooth machine. This machine is designed in its purest moment to do single tooth dentistry, maybe one or two crowns at a time, whether that be with implants, whether that be a surgical guide or just doing a simple [4:19 inaudible] Here we are doing 10-20 units at a time. That’s pretty impressive. We’re just talking about some members who’ll get into it in a minute about his workflow, so again, this is one that I’m going to listen a lot more than I’m going to talk today because it’s just that I was blown away.

T-Bone: That means you’re going to be quiet. That’s unusual for you.

Chuck: Especially after three cups of coffee this morning.

T-Bone: Three cups. I want us all to – who’s listening – if you’re non-CEREC owner or if you’re a CEREC owner and you say, well, I don’t have the patients for that. I don’t have the time-patience or patients for that. I want you to listen with an open mind. I want you to listen with an open mind about what’s possible because we want to impart a different way of doing this and what we want to do is debunk the myths about this. And quite honestly, selfishly, I want to learn more about this because this is an area of CEREC that I’m not using it to its fullest potential.

So Benjie, why don’t we talk to you for a little bit and let’s get to know you a little bit and go from there. SO Benjie, talk to us about you, where are you from, briefly, what your practice is like and then kind of what you’re doing.

Benjie: I practice in Austin, Texas where I’ve been for the last 18 years. That’s come by fast.

T-Bone: That’s why you have no hair on your head.

Benjie: Well, just like you.

T-Bone: I have hair today. I didn’t shave.

Benjie: [Laughs] You have fuzz on your head. I won’t call it hair.

T-Bone: Thank you.

Benjie: So my practice, obviously has grown over the course of those 18 years, but the biggest focus that we have is patient relationships. It’s asking questions of our patients in interviews to really find out what their long term goals are and I think that’s where getting beyond the one season, two seas as Chuck put it, I think that’s where it comes in is talking to patients really about what their goals are and finding out what their value system is for their mouth. And in that progress, the insurance questions most of the times get eliminated pretty quickly.

T-Bone: Or they become less relevant.

Benjie: Exactly. The people really use insurance a lot of times to make decisions for them and when they’re not confident in the decisions they want to make. So what we do is ask questions in a way that allows us to get beyond that barrier with patients and those objections. A lot of people think that doing quadrants or doing veneers or doing full mouth are only for people who can afford it, financially stable people and I will tell you that is most of the times not the case. People will find a way to pay for things in this country that they value and it’s asking the questions that get you to find out.

T-Bone: So are you saying that your practice is full of – not full of rich people necessarily.

Benjie: Correct.

T-Bone: Okay, so you don’t have a practice where literally, everybody walks in as a millionaire.

Benjie: Correct. Absolutely.

T-Bone: Okay. And Benjie – okay, I’ve known Benjie for several years now so some things that struck me about Benjie is, one, is that you’re very humble and a very good clinician, despite how you look and your golf games is slightly worse than mine. [laughs] I did beat you at when it really matters than [7:47 inaudible] number two, I kicked your butt. I’m just saying every other time it didn’t matter I wasn’t in the mood. I wanted to give you some freedom there but you built a practice that is truly insurance independent and I know I’ve been a big proponent of many practices taking insurance but I would say that you built a practice without insurance. So, talk to us about that decision, how you got there and how does that work for you.

Benjie: Well, how I got there was just the aspect of – I personally have moral or ethical problem charging people different fees for the same service and I don’t have the mentality where I can do something of less quality. I’m a perfectionist by nature, believe in doing things the best of my ability that comes from father. You give a 110% in everything you do. And so, I had a problem charging a different fee for someone based upon whether they had insurance, didn’t have insurance, etcetera. So my mindset was no my fee’s my fee. I do things to the best of my ability and I charge a fee that I feel comfortable if the patient walks in, two years, five years, ten years down the road and I don’t like that restoration and what not, I have the flexibility to replace it at no charge to the patient if that’s what I feel like. SO, that’s where my thoughts on that came into play was I wanted to do something that I’m morally and ethically felt would make me happy everyday to do and that to me is not what the insurance model does for us.

T-Bone: You started as fee for service and you maintained fee for service through that time?

Benjie: I started the only insurance that I was on at that time was Delta because of the University of Texas and the fact that they – that Delta was their plan and I thought, well I’m in Austin, I’m down the road from the University of Texas, I need to accept that to survive and I was on that plan for less that two years before I had to get off.

T-Bone: Now, what do you do as a non-insurance office to differentiate yourself to get these types of cases, to get patients to say yes. You said a lot of interesting things at the beginning. You didn’t lead with price. You didn’t lead with being the best clinician, you led with sitting down with your patients and being relationship based and I think that’s an important that I want our listeners to hear about, is that, even in our practice, many would say that as a PPO practice, we probably do more advanced dentistry than many practices do and people say, how do you do that? And I say, you establish a relationship with patients. You help them choose the best. So talk to me about – just kind of expound them that a little bit if you don’t mind.

Benjie: You know I think that you’re absolutely right. I think doing more dentistry on fewer people each day is based upon establishing those relationships. It’s based upon talking about wants, not telling people what they need. That’s always been my philosophy as dentistry is optional. It’s a luxury in this country. you go around the world and particularly if you do any missionary dentistry, you see that most countries they don’t have modern dental care and those people get along pretty darn well.

T-Bone: You don’t need teeth to live. Bottom line.

Benjie: No. You don’t need teeth to live.

T-Bone: You can gum it and live a good life.

Benjie: Yes, you can. So from our standpoint, that’s how we treat things and we make sure our patients understand that I don’t want any more dentistry on you than you want to do but more importantly I don’t want do any less dentistry on you than you want to do. And it takes having a relationship and it takes having a conversation to be able to find out what patients really want from us and we ask a lot of questions to be able to differentiate what is important to them, what is their value system and how the pieces of the puzzle are going to fit together for that patient because the last thing I want to do is to do a bridge or some implants on the patient. We had done with fats and now they say, “I’ve always wanted to straighten my [12:02 inaudible]. I wanted to straighten my teeth.”

T-Bone: Those implants don’t move. [laughs]

Benjie: Yeah, those implants don’t move.

T-Bone: God willing

Benjie: Yeah, so, how do you avoid that? You have a conversation in the beginning and you look future focus from day one with the patient and truly understanding what their long term goals are and even if it’s not something that they can do in the next year or two or ten, at least if we understand where they’re wanting us to take them with their mouth, then we can make a plan from day one that’s going to get them there. And it goes with finances as well. We’re very flexible financially on how we can help people work towards those things.

T-Bone: So you’re flexible like, people can pay you when they want, how they want. They can put a check in the mail?

Benjie: No. I mean, we’re flexible from the standpoint of we’re flexible on payment plans whether they’re smaller in office payment plans or an outside source like care credit or Wells Fargo, you know, there’s certainly also what we call lay away plans that we do in our practice where people put away money towards procedures over time and we treat them as they cache enough funds and that’s also one of my big proponents of CEREC. CEREC gives you flexibility financially that not having large [13:13 lump fees?] allows you to do is it allows you to segment out procedurally things and sometimes do things before the money comes in if it just makes more sense.

T-Bone: Before the money fully comes in.

Benjie: Right.

T-Bone: Inflation has had some skin in the game.

Benjie: Yeah, absolutely.

T-Bone: You know, if I would boil down what you just said and I believe in this philosophy completely it’s what helped me get to where I’m at in the insurance environment is, I would boil down everything you just said into the word, trust. And ultimately, patients want to buy things, patients want very good for themselves and they come in often times they wall in front of them because they think you’re trying to sell them something and you said a lot of great things that you said. I don’t want to do any more dentistry that you need. I don’t want to do any less dentistry than you need or want and I want to understand what your long term goal is. And to me, that is trust. That is that trust that you build with somebody when you say to them, this is what you need to do. This is what you want to do and you have a relationship with me and your trust that I’m not going to tell you stuff just to make it up.

I think that ultimately that boils in. So Chuck, before we segue way into CEREC, do you have any questions on the philosophical part with Benjie? You’ve been the first person I’ve talked to on the podcast that we’ve invited on that is a non-insurance provider and I always say, – I come across sometimes as being insurance proponent like you should take insurance and that’s not what I mean at all. I mean that it’s much easier not to take insurance often times and build a general practice but insurance gets in the way of building – sometimes building the practice that you want but I also believe that you can build a practice that you want under insurance. But Chuck, do you have anything to add there?

Chuck: Sure. Just a couple of quick things. I cover a pretty big geographic area in our state. That sounds funny talking to someone talking from Texas, but part of the demographics I cover, I have the poorest county in the state and I have one of the more lucrative areas to live and a more affluent. So many times I hear people say, “Hey, Chuck, this is Raleigh. This is not like where we are.” And then so many times I’m in Raleigh, I hear people say, “Hey, look, everyone here is on PPO. It’s not like your folks down east where these are all rich tobacco farmers. So, [15:35 inaudible] we’re always looking for an excuse because most of the time it’s us, right?

Benjie: Absolutely.

Chuck: So talk to us, do you think, I mean you’re in a grey area – it’s Austin and everyone loves Austin.

T-Bone: It’s Austin weird, by the way.

Chuck: So, how much of that do you honestly play into your success and the other thing is, because I know we need to jump into the meat of this but, and this doesn’t really matter, but what do your peers think about you locally? Often when you’re a trainer and you have a great practice, often, a lot of folks they’ll throw a few darts at you. So, tell us a little bit about that as well.

Benjie: Well, the first question to me is pretty simple and you answered it. It’s mindset. One of my dearest friends practices in a little city called Borger. B-O-R…

T-Bone: Is that booger?

Benjie: No, Borger. It’s like you took booger and border and kind of replace some others. So, B-O-R-G-E-R. If you want to Google Map it, look it up, it’s in the far northeast candle corner of the panhandle of Texas near Oklahoma border, very blue collar town, very tiny town and Texeco has a large plant there. All of his patients are very blue collar.

T-Bone: So you say Texeco plant not Texeco executive office.

Benjie: Exactly. And all of his patients are – 80% of his patients are connected to that plant so we are talking very, very blue collar people and not people who are making six figure salaries, what not, spouse combined. So from that standpoint, like I said, someone who is very meats and potato practice, he does most stuff in house, his fees are higher than my fees. We kind of jokingly have a little bit of a fee contest. His fees are higher than my fees, he works basically, 135 days a year max, has a million dollar plus practice. Everything is paid off. His overhead runs a little under 30%.
So this guy does crazy stuff. When the banks need money in town, literally, I mean, I’m not lying. They come to him, sometimes to help support loans for other locals. It can be done anywhere and the key is relationships. We have the same practice philosophy where we interview our patients. We spend a lot of time upfront talking to patients and finding out those things that we discussed. He’s also a CEREC dentist. He’s also a [17:50 dentist] as well.
We share some of those things too, but the main thing that we both do is establish those relationships and know the questions to ask. More importantly our staffs, really, it’s not about us. It’s about our front desk initiating that conversation, following it up in the hygiene room and the hygienist taking it to another level so that by the time I come in the table is set, the plates are laid out, we are ready to go to dinner so to speak with that patient and I’m ready to then talk to them about their wants. And I’m not having to point out internal photographs with [18:26 inaudible] and bad decay and try to convince someone they need something because that is what leads you to [18:33 inaudible] club, single tooth dentistry and that’s all you do and patient tells you pick the worst one doc, that’s where I want to start. That’s the game I don’t want to play.

I want patients to have ownership of their mouth. It’s their teeth. It’s their decision to make it. It’s not mine to make and the moment I start making decisions, I own it. And so if something starts to bother them, it’s on me, it’s not on them so, like I said, we share that same philosophy and it can be done anywhere. It can be done in the big city where you have dentists and I have a lot of dentists all around me or it can be done in small town where there’s two dentists and one guy charges $2000 a crown and the other guy charges $380 a crown because that’s what it is in Borger, Texas. I can tell you who the better is in Borger, Texas from my experience with Daryl.

T-Bone: You know; I’d like to add one more thing on this. And this comes again from my insurance mindset. There’s nothing wrong in taking insurance. There’s nothing wrong in accepting lower fees. What in my opinion is wrong is making that your life and not making attempt. You may not succeed but not making an attempt to get to where you want to get to.
Now, Benjie has a clear defined role of what his non-negotiables are, what he wants for himself and what he wants for his practice. If many of us want a practice that we have a crown of the year club and the filling of the year club and take care of one tooth at a time, then by all means, do it. But if you’re looking for something more in life, whether that’s a greater practice, whether that’s greater professional satisfaction, whether that’s greater finances, whether that’s greater vacation power or time off then you got to do something different than you’re already doing. And that’s what of the things I love about having you on is that we can show a different side of things. Things that are different from what I typically talk about.

So Benjie, in seguewaying into CEREC and things.

Benjie: One other thing before that…

T-Bone: Yes, go ahead, absolutely.

Benjie: I guess one of the questions [crosstalk]

T-Bone: Oh, I interrupted. That’s typical [laughs]

Benjie: Kind about how I’m looked at in my own community and obviously, I can’t know what every doctor thinks about me, but that’s one thing that I think. I do know is, most of my reps come to me for their dentistry whether that’s [inaudible] implant [reps?], etc. I think that says something and I have several dentists in the community that come to me for their dentistry as well, several specialists, specialists that send their staffs to me and what not. I think that speaks a lot. T-Bone said that I tend to be pretty humble and once again that goes back to my father. But I am very open to the community. I get cases, like, I got one last night on Dropbox from patients in the area who struggle with a case. I’m very open, just like T-Bone is, very open to helping people out. It’s not about them having to pay me to do it. Once we meet and once you learn something from me, I’m available full time. So, like I said, I think that there’s a good [crosstalk]

T-Bone: Be careful with that statement.

Benjie: Yeah [laughs]

On my time, since I’m a [21:46 inaudible] I’ll get to it on my time, but I always make time to get to it.

T-Bone: And listen, on that note, I think as speakers, as trainers, we always get a bad wrap within our community and by other people that I call them haters. I call them jealousy and it’s not that we’re bad people. I’m a very firm and upfront and just – this is who I am person and you’re more humble and quiet and nice compared to me but ultimately, I think what people don’t see is those things that we achieve whether it be speaking, because everybody wants – not everybody, many people want to be speakers, many people want to be trainers but what they don’t see or sometimes don’t realize is the toll that it takes on your life and what it takes to get there.

None of these things are ever handed to us. Not anybody that I hang out with that I know, it’s things that we earn, it’s things that we continuously put effort into, like how much time do we spend putting together programs? How much time do we spend making ourselves available? What is the sacrifice to our family for this? For example, and I don’t want [22:56 inaudible] down this path but I want people, those that are jealous, or those that are haters, what is the sacrifice? For example, in my case, I’m out of my family forty Friday and Saturdays a year. Forty. And when people say to me, “Oh, you only work three days a week.” I’m like, yes. I’ve chosen to work three days a week in my one job so that allows me the flexibility and freedom to work for two days a week in my other job.

I think people miss that. It’s unfortunate that we get this. So let’s get to the CEREC stuff. Chuck, I’ll have you take the lead on the mindset and what the naysayers or the people that have question about this are asking.

Chuck: A couple of quick things and we talked about this a little bit yesterday, so again, I have a great clientele, great group of people but so often I’ll see CEREC is good enough for first year stuff. I mean – I’d see some just awesome, awesome dentistry. So too often I see when we jump every three, four, five units, it seems to go a different lab and sometimes even a higher level lab, right? And so, when I talk to doctors about using their machine a little bit more and I hear, “Chuck, it’s not worth my time.” This is a great bread and butter machine. Eighty percent of my work is posts here. Eighty percent of my work is A2 or C2. It’s a machine for that and it has changed my professional life. I believe in this technology. I’ve built my whole territory on it too. In saying that, but it seems like when we jump over three or four units, I hear doctors say, “You know, I can just take an impression. My assistant’s going to do everything else. It doesn’t take any more of my time.” And my challenge has always been, well, why don’t you schedule differently then. If it’s truly, we’ll get to a point where you’re three or four units it’s not taking my – it’s taking more of my time, what are you doing? Just because you’re not in the room doesn’t mean you’re being productive. So I did a little bit of math on this and we can go back and forth, but I was pretty conservative that when you get into an aesthetic lab, we’ve all heard the four or five-hundred-dollar unit, it’s what [24:59 cyclops charge?] And we joke about that, that’s because they know they have to do it twice. But let’s just do some quick pencil math. You told me yesterday that of these cases you do a couple of these a month, some are 10 units, some are 20. Typically, on a 10 year case issue, you do all on the same day. When we talk about that, that’s about a six-hour procedure, beginning to end, which is, I was blown away by it. And you really messed up my math when you told me that. So I did a little pencil math on that and if you have a really good lab that’s charging $250 a unit, that’s $25000. I’ve worked closely with lab technicians and I’ve seen how long that takes them to do 10 units and that’s probably six hours of time. So then I looked at your time and broke down with your fee, you’re producing about $25000 an hour at that fee in six hours. That’s remarkable.

So is it worth your time to keep that in house because you’re really only saving on a 10 unit case, $2250, back out $350 in CEREC supplies, so you’re sending $19000. Tell me a little bit about that. That’s what I think most folks struggle with. Is it really worth your time to do it yourself? From the work that I’m hearing about that you do and you see, obviously, you [26:09 inaudible] there but I think the majority of dentists, they don’t feel comfortable enough with their own aesthetics when they get past first pre molar, right? Wouldn’t you agree?

Benjie: I mean; I think that where all these starts is what we talk about earlier. The conversation with the patients will lead you to do a more front tooth dentistry, first off because we tend to have systems that build back tooth dentistry, and I agree. CEREC is a phenomenal quadrant machine, in my opinion or even less obviously a single unit machine where anything beyond that comes into play as one in the conversations with the patients and finding out what they want. But second off is a good wax up on the [26:54 inaudible] and so, all of my big cases, everything I do in CEREC is off of copy mode, partly for the sake of occlusion. Partly for the sake of predictability and so I do use a really, really, good wax up done by a lab to facilitate my workflow.
Even though that tend to be the case, typically takes six hours on the high side, my time, chair time is usually four hours or less and then middle there is where you can either do it yourself. You can have a really good assistant that’s trained or in my case, I have a local lab that I pay a very small hourly fee to come in to enhance aesthetics on a more challenging aesthetic case.
That said, those are usually the smaller guys, the single units, or the two units, or the four units where it becomes more challenging. I actually found once you get into the [inaudible canines] typically patients want things all the same color. They don’t want a lot of enhancements on the teeth. They don’t love the halo effect and we have materials that are naturally going to give a little bit [28:07 inaudible] in the incisor, such as Emax, NT and the props are conservative enough and some of the dynamics in CEREC like increasing spacer, etc. allow the cements to do some work for you and the [28:19 thirds?]. From that standpoint, honestly, that two hour window is kind of two hours of prep using my wax up to [provisionalize?] the patient to see what things look like to work out a [28:32 closion?] and to work out functional movements. Then we scan that in and then the next two hours are just milling and my assistant just doing glazing, because that’s all they need on them. They just need a layer of glaze because that’s really all the patients want and then the last two hours are seating and then doing some final finishing and honestly, most of the time I book an extra two hours or I book two hours typically doesn’t take me [28:59 inaudible] for these guys. An hour, an hour and fifteen and then we have some extra time for my assistant. We send them home at an immediate bite guard that she will make kind of at last time. So my time in that six hour window is usually around three hours, three hours and fifteen minutes, three and a half hours at the most.
And so in between that – certainly yes, absolutely, I can do other dentistry and even bump up that $25000 an hour rate significantly more, but the biggest factor is once again the patient. The entire practice is around the patient and this is about the patient. It’s about the patient experience. Patients don’t want to have to go home with temporaries.
They don’t want to have to worry about them falling off especially when they’re on their front teeth. And certainly, we do temporaries in a way, even when we don’t do things in one visit but the temporaries don’t come off, the patients just don’t – they don’t love the thought of temporaries. I mean, first and foremost, and that’s another objection that some people have to having this type of dentistry done particularly someone whose come in and they’ve got 20 year old veneers and they remember how terrible the temporaries were 20 years ago. It’s hard to convince them to say, “Well, no, no we can do temporaries now that are nicer.” That’s always in the back of their mind. So if we can tell them, “Hey, we can now redo that procedure. We can update it. You had it done 20 years ago when A2 was white.” Now they want Bleach Three or Bleach one, even.

T-BONE: That’s toilet bowl.

Benjie: American standard, toilet bowl white as we call it. And we can do that in one procedure predictably you don’t have to worry about temporaries. You don’t have to have sensitivity while you’re on the temps because you don’t have prep sealed well. All those different things. You got to avoid drinking anything dark, etcetera. So, from that standpoint, everything I do in my practice is about the patient and it’s about overcoming objections which is what we have to do every day to do the dentistry we want to do. And you said, 10 or 20 years, I mean, I do 28-unit full mouth reconstructions as well with the CEREC machine and that’s – even with a real challenging aesthetic case, I may decide to send out the upper front eight and the lower front six but restore behind that with CEREC. And that’s a huge savings. Even if you just do the molars with CEREC and have a lab do second by the second by, that alone is a huge savings and it’s nice when the patient comes back for delivery that you don’t have to give a full block on both sides of the lower and lose the ability to work with function at that point. So there’s a lot of different ways to utilize CEREC in this process.

T-Bone: Okay, you said a lot of things there that I forgot three quarters of the things I want to talk about. [Laughs] But there are a couple of things that stuck out to me on this, one is, I want to go back and I want to reset our mindset on what we’re talking about, okay? So Chuck, without just roughly – Chuck and I talked about this, we would say, what would be a person, a dentist, typical dentist, what is their goal for what they want to produce per day?

Chuck: Most of the time I see, everybody strives for the million-dollar practice. Let’s talk about that. But to do a million to a million three and collect that you need to do on average about $600-$800 a day.

T-Bone: So we would say that most dentists strive somewhere between $5000-$7000 in production?

Chuck: That’s correct.

T-Bone: Okay. One of the things people say is, you said earlier that your dentists say to you is, ” Hey, I simply don’t have the time or it’s not worth my time to do these case. It’s easier for me to send these to the lab and I would say, absolutely correct. In the current practice model and philosophy that you have because if you’re trying to do multiple hygiene checks, multiple columns, squeezing in patients, doing emergencies on the side, then absolutely this doesn’t work, okay. But what first has to happen is your mindset has to be that, you know what, and this goes back to our episode that we had earlier about integrating new practice and new procedures into your practice. The first thing you have to do is say, “Listen, I want to do this.” Because your patients want this, by the way. Your patients want single visit work as long as there’s no functional and aesthetic compromise, which we can show you how there’s not functional and aesthetic compromise. Patients want the work and what I’m saying is, stop doing this on regular work days to begin with. Start with by making a special day that you come in and this is what you do. Now imagine, let’s call it a 10 unit case. Now, Benjie, I know your fees are probably higher than most, but let’s call it a eight unit case or 10 unit case, let’s even say that’s $1000 a unit, which is unbelievably reasonable for a fee. That means your production and collections for that day is going to be $10,000. So if our goal is $5000-$7000 a day, we’re already beating that. And imagine what it’s like to have one patient and have that time. Let’s say it’s not even six hours. Let’s say we take an entire eight hours to do a case. You have a two-three hour break in between. You get to visit with your patent. You get to have a relaxing day. I mean, I don’t think I’ve – as it overly hard a day, actually.

Benjie: No.

T-Bone: And the key I think, what really scares them is people just don’t admit they don’t know how to make the technology work is what it really boils down to. The other thing that you said that I want to take a few minutes on is, you talked about shading, essentially. I think we have this – our own internal mentality that we need to make these restorations have gingible staining and incisor crack lines and incisor halo and all these different things, correct?

And really, patients don’t want that. They want basics.

Benjie: Yeah.

T-Bone: So the finishing is really more about contours, a little bit of anatomy and making sure the tooth is nice and polished very well and glazed. I think those things are the things that we have to keep in mind and you talked about bringing a lab tech in for your one or two or three-unit case. He’s not talking about posterior work. He’s talking about those single centrals, those two centrals, make it easier for those things. Why do we have this feeling that we need to do everything? Bringing experts allow us to do that. So we have about 10 minutes left and I want you to talk about how you’re doing full mouth cases with CEREC. So tell me, the mindset, the sequencing, the advantages when your patient doesn’t have all the money. Your patient don’t have $35000 all at once to do it. How are you leveraging the technology to add this procedure to your practice and within your practice.

Benjie: Well, I think the biggest underutilized feature of CEREC is articulation. And we’ve discussed this and you’ve posted a case online showing patients the articulation feature and that goes even further, particularly when you’re dealing with full mouth and especially now that we have the ortho software to be able to do the dual buckle bite which if anybody from [35:56 inaudible] is listening, we need to get the dual buckle bite feature and the regular software so I don’t have…

T-Bone: They’re listening.

Benjie: Yeah. [laughs] So, from that standpoint, I will have a patient comes in that maybe is complaining about wearing down their front teeth and their front teeth are getting shorter, they’re aesthetically – they’re in their forties and the third or more of their front teeth are gone and they want veneers. And if all I do is put veneers on them without addressing the crucial issues [crosstalk]

T-Bone: What got them there?

Benjie: What got the there, they’re just going to break it off and wipe it out. And trust me, I did that earlier…

T-Bone: No matter if you use Zirconia? you use Emax? No matter what material you use, they eventually either break or pop off.

Benjie: Yup, or wear their joints out, one or the other if it’s a female. So from that standpoint, I have a patient that comes in and whether they have occlusal pain, TMD type symptoms, or whether they have a wear issue that’s bothering them then I will scan them and they’ll wear those software and I will export that file into the regular software and use the occlusion feature to show them their ecclusial compass and the functionality of their bite and where they have interferences etcetera and then from my sample and when the patient sees that on the cell as some people like to say, is a bad term in dentistry but we are always selling ourselves. The cell is complete. They can see it with their own eyes versus getting out an articulator and what not and they’re just confused. When they see it on the computer screen, they know it.

T-Bone: So you utilize… I don’t mean it. I want to make sure that we reinforce this point. You utilize a technology so that patients are becoming part of the diagnostic process. In other words, you are not just telling them you have occlusal interferences because nobody – like I don’t even know what the hell that means. So I know my patients don’t know what that means. You’re using the technology to show them their bite, show them how their teeth fit together and show them this. And for those of you that are right now saying, “Well, I don’t have the time to do this, and that is why you stopped doing single tooth dentistry.”

Benjie: Right!

T-Bone: So, what I would say is when you identify these patients in your hygiene chair, put them on your Thursday or Friday that you designate as your complex case day so that you can diagnose these people properly and not try to fit it in to your busy day schedule.

Benjie: Yeah.

T-Bone: Sorry, keep continuing.

Benjie: Like you said, I mean, it’s about the patients. So if you cram that into a time that you’re in a hurry then it’s not going to be about the patient at that point in time. So yeah, absolutely, bring them back in a dedicated 30 minute to an hour window and spend that time with them But it’s showing them that and then I’ll take in a step further from the standpoint of having another file where I do prepless overlays typically on the lower molars, they tend to wear off fast and the upper molars sometimes on both and lingua veneers on the lingual of the upper back teeth, I mean the upper front teeth, lingual of the upper front teeth. So I’ll show them what building up their teeth will look like in a very conservative manner.

T-Bone: So that’s about recreating the centric stops…

Benjie: Exactly. And interior guidance.

T-Bone: in treating their interior guidance and their vertical.

Benjie: yup, and eliminating posterior interferences and providing proper posture disclusion, etcetera. I’ll show them that and I’ll say, “Well, this is kind of where we start.” This is kind of a diagnostic phase. If you want to go down this road and see what the results will feel like and then I’ll let the patient decide and talk about numbers or ask them, “What do you think, something like this would cost? and when I get a feel of what their budget is…

T-Bone: So you ask them?

Benjie: Yeah.

T-Bone: What they think…

Benjie: What do you think it’s worth to you, etcetera? Then that gives me an idea of, “Okay, are we talking about…”

T-Bone: So if they say $150…

Benjie: Yeah. I’m just kidding [laughs] Then I’ll give them a [40:03 inaudible] by Garter, tell them to go to Walmart and pick up a Baygon. But, no, we’ll get into that conversation because I don’t want to waste their time or my time, honestly.

T-Bone: So you qualify the patient by simply asking them what they – how much they plan for this or what they think something would be some cost and that way, you don’t go down the road of doing all these work to somebody that can’t afford it.

Benjie: Absolutely. [crosstalk]

And doing that digital workflow in CEREC, once you learn the process, I mean, it literally takes fifteen minutes or less. A lot less time that it takes mounting this other models and the expensive sending it out for a wax up. You’re basically doing a virtual wax up in the software without costing you a lot of thing. And like I said, 15 minutes of time typically is about all it takes me to do and so from that standpoint moving forward, then we can talk about based upon their budget on how we work this out and whether it’s staging. And for some people…

T-Bone: Talk about staging to me.

Benjie: Well, staging, you know…

T-Bone: Do you have to do full mouth case all at once, prep all [crosstalk] the upper arch, prep all the lower arch.

Benjie: Absolutely not. No. Absolutely not.

T-Bone: Okay, so this can help you make it more affordable for your patients. To steal a line from what Chuck has talked about who stole it from somebody else is, “Our patients didn’t get here overnight. We don’t have to fix it overnight.”

Benjie: Exactly

T-Bone: And I think that’s the biggest challenge for these cases – these full mouth rehab cases is that the patients are – we tell the patients that it’s all or none.

Benjie: Right

T-Bone: And what you’re saying, by leveraging technology we don’t have to do it all or none.

Benjie: Correct

T-Bone: So talk to me about that.

Benjie: Well, I mean, it’s two thing is I think a lot of dentist aren’t comfortable with bonding and so they’re afraid if they don’t wrap the teeth 100% with crowns

T-Bone: 360 degrees

Benjie: That they’re not going to get something to stick so the only way to do that is to cut the tooth down in order to even do a restoration on these patients. And you don’t have to do that. We can bond, whether it’s just a simple composite or whether like what I prefer to do, use the technology to melt out a composite wax a little prepless overlay then micro [42:06] the tooth and bond it on top or bond it on the lingual of the upper anterior and work through that functionality issue there and then we can move from that to replacing things as fast as the patient wants or as slow as the patient wants. But first, we have to work out occlusion and we have to get them if they’re having joint pain, we have to get their joint pain to subside and so, that’s the first step and then the second step, we can go as fast as they want or as slow as they want and I do – I have some patients that say, I want it all in one day and sometimes I can do that, sometimes it takes two visits to do. But then I have some patients that say, “Well, this is going to be $30000, $40000, $50000 worth of treatment. If we’re talking about maybe some implants for some missing teeth…

T-Bone: Or paying a butt patient

Benjie: Or patients that’s more challenging in more ways than one. Then, like I said, they may not be able to afford that and they need to branch that out over couple of years or so. And we can do that. I mean, that’s the beauty of the technology is, we can and a copy model

T-Bone: So now that you work, so hear this everybody, you’ve worked up the occlusion. You setup the occlusion in the machine and one of the challenges that we face with many of these cases, at least I faced is you work out all these stuff in the provisionals and the model phase, and the provisional phase and then you send it to a lab and then it comes back totally different. And what you’re saying to me is, by leveraging technology, we can avoid that from happening.

Benjie: Absolutely.

T-Bone: Because you just essentially copying what you’ve worked out and the machine will reproduce exactly what you have.

Benjie: As long as you’re doing things in segments and whether that’s segments and when it’s segments of time or whether that’s segments and one or two appointments, doesn’t matter. It’s the same process. It’s just broken out and how the patient can afford to do it.

T-Bone: That’s interesting. So Chuck, do you have anything else to add or questions?

Chuck: You know the biggest thing – I’ve seen a lot of surgery here and with a lot of surgeons, I noticed that, we’ve got a little bit of a threshold with a patient on time. It seems to be about three hours, three and a half hours. The patient gets a little squirly, it’s just uncomfortable, they’re open a long time and we do [44:13 inaudible] downtime in this kinds of cases. So, that’s a long visit. That’s a really long visit. So a couple of things come to mind when I hear this is, once you’ve prep the tooth, we always joke and say, that’s an open wound. Right?

Benjie: Yeah

Chuck: it is just wreaking havoc of just things going on and an increase sensitivity. That’s what really hurts us with CEREC early on when it used to take forever to do a restoration. So we ran into that and the other thing is, what about the patient’s experience? Sure they’re leaving with immediate teeth and that’s while we have Starbucks and next day air, that’s where we live and that’s what people want. But is that really realistic? Is that uncomfortable? I mean, that’s a long time for demo. I mean, so what do you do there to help with that?

Benjie: In those 10 unit cases we started with, I mean, like I mentioned we’re going to do some preps and then we’re going to put the provisionals on because that is going to become our reverse copy procedure where you prep first and then you scan in the copy second, which is your wax up, which you’ve taken with a putty [45:13 inaudible] you’ve injected in the mouth. You’ve worked out function and you’ve made sure the patient is happy aesthetically with lipline and things along those lines. Then you just leave the provisionals in while you make the restorations and then as the [45:27 inaudible] drops down, you go back in the treating room, re-anesthetize the patient, remove the temporaries and then bring in the restoration in the trial fit and deliver.

T-Bone: So what can you do to make the patient comfortable because that’s a long visit?

Benjie: Well, I mean I think there’s several things, obviously. There’s products like Nitrous Oxide, Newcom, we use a lot of Newcom in our practice. That works well. And then for some patients or – a lot of patients, actually.

T-Bone: Sometimes for the dentist

Benjie: [Laughs] we will do sedation dentistry. Now the problem, the only issue with sedation dentistry is the aspect of the patient not being involved in the approval of that final product and so, they sign a waiver

T-Bone: Or they come back for a second visit, to deliver.

Benjie: Yeah, or they come back for second visit. They’re one or the other. Either they sign a waiver that they’re approving it off of the model but not being able to see a visual of the mouth, unless there’s things like spaces and wear. A lot of times we can do a trial and a pre visit. We can go in there and use the putty mate to put it on their teeth. But if we’re talking a lot of crowning…

T-Bone: Essentially, no prep type things.

Benjie: Exactly. There are ways around it for a lot of cases. For some you can’t so the patient has to decide but my full – If I’m doing a true full mouth case, typically those patients are completely sedated. In particular, a lot of them do involve procedures like implants where in the here and there. We’re talking about a lot of full mouth cases and that’s another reason for me to segue way into a lot of what T-Bone does and he also taught me guided implant surgery. And that’s why I wanted to get into it because I’ve had these full mouth casts and some of them needed implants.

And the implants were holding up the restorative aspect of it. So this way, I do the implants. I control the process. I’m not waiting to get them back from a specialists, etcetera. And so to me it just adds to that experience and the pure number of times patients has to be submitted which is not just for health reasons but mainly for financial reasons for that patient. The better I can do them. And that’s where ZEREC to me is it’s powerful tool to begin with is in providing single visit dentistry for sedation dentistry.

T-Bone: That’s what got me into CEREC. We’re doing a significant amount of sedation. My patients like, I mean, I have to come back and get numb or – because that’s what they don’t want to begin with, right?

Well, you know, Benjie, we’ve talked about a lot of stuff. I’m a bit disappointed that we didn’t get into the technical aspects of CEREC. I would love to do that, so if you don’t mind, what I would like to do, while I have you for two days, I’m going to have you back on and you and I, I think Chuck you won’t be available, let’s draw it out and let’s walk through the technical aspect, in words, obviously we don’t have the software. What you’re doing to walk through a full mouth case from beginning to end, from the diagnostics, from the model work to articulation, to the diagnostic bite stops, to prepping teeth, then doing the biocopy to segmenting it out. I will walk through the technical aspects of it. And for our CEREC owners, I think – that listen to the show, I think that would be great for them.

Would that be fair to ask of you, it’s not really a choice you can say no to, by the way.

Benjie: No, absolutely.

T-Bone: Chuck, I want to thank you guys and in wrap up to this, I know what any of you are thinking, you’re saying, this is out of my league. Benjie can do this in Austin weird. He can do it because he has patients who have money. He can do it because he doesn’t take insurance. And what I’m telling you is that we’re doing this cases, not at the level that Benjie is doing in the terms of the quantity and not necessarily with CEREC because I haven’t allowed myself to go there. Quite frankly I haven’t taken the training to be able to do this. So, I know what you’re saying. Those are all excuses, quite frankly and I always try to give people disruptions’ and the disruption is, listen, “Get off your butt and do something different.”

If you’re interested in this type of work, if you say it can’t be done and other people are doing it, that means it can be done. And that doesn’t make – Benjie, is not special. His golf game is not that good, okay? And he’s not special in any way. [crosstalk] Not everyday, most days.

His game, you know his game, he’s not that special. Other than the fact that he’s a constant lifelong learner. He do not walk out into dentistry, get his CEREC machine and being able to do these things. He’s consistently learning. He’s consistently sharing. He’s consistently pushing himself and that’s what we don’t have enough of internally.

So until our next episode, I want to thank you for joining. Again if you need to get in touch with me, it’s www.tbonespeaks.com. I’ve added a new segment in the podcast called, #AskTBone where you send in questions and I’ll try to do it eight to 12 minute podcast episode. I’m trying to record those on the drive to work, by the way. And then if you need to get in touch with Chuck, it’s www.askchuckmckee.com and if you need to get in touch with Benjie, Benjie how can people get in touch with you?

Benjie: Best is my email address which is Dr_Nemec@yahoo.com

T-Bone: And you have a Facebook account. Can people meet you there?

Benjie: Yes, for Benjamin Nemec.

T-Bone: Okay so they can friend you and you friend them back?

Benjie: Absolutely, yes.

T-Bone: And then, obviously, we didn’t into the workshop but we’ll talk about that in the next episode.

Thank you everybody and I appreciate your time.
Thanks so much for listening to T-Bone Speaks with Dr. Tarun Agarwal. Remember to keep striving for excellence and we’ll catch you on the next episode.

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