Episode Transcript
[00:00:06] Rob: Welcome to the Evolution of Dental Podcast, brought to you by Evolution Dental Science, where we share the stories of the people and the technology shaping the world of dentistry. Today our guest is John Madden. And John, I hear congratulations are in order!
[00:00:20] John: So yeah, recently I got a merit award for outstanding achievement from the National Association of Dental Laboratories. What I later found out is it was for some work that I did with the American Dental Association and the NADL, about like kind of occupational awareness, because we have this ongoing trend in dental technology where there's fewer and fewer technicians. And the technicians that we do have are less and less formally trained, and they're more trained on the job than they are in schools. And so, you know, we're trying to advocate and bring people into the profession. But also just recognize that it's getting more difficult to attract employees and attract people to this career. You know, because there's not a formal pathway. And if we don't have a formal pathway, then people that are young in life don't feel like it's a real option for them to define the rest of their life. Right. And so I just do a little bit of work trying to, you know, encourage people online. Explain how you would take this as a pathway, like how do you access these tests? How do you figure out how to do this as a career? And, yeah, just a whole lot of encouraging people to investigate that. And to, you know, look at dental technology as a possible career choice.
[00:01:47] Rob: Absolutely, man. That's brilliant work, especially considering that you specialize in removables and removables is probably the one that struggles the most in attracting new technicians in my experience. So it seems like a pretty good segway: Why digital dentures?
[00:02:05] John: Hehe, yeah. Well, I can't say, uh well, there's, there's two, “Why digital dentures?”, right. There's “why digital dentures” for me. And then why are digital dentures important? And I'll start with the first one. Why digital dentures for me. So, like I said, just like I do all that encouraging of other people online and like trying to highlight this as a career choice. You know, I was kind of finishing up college, and I was working at a dental school, just kind of like cleaning floors in the lab. And, this guy that I work for was a removable technician, and I said, I think this is pretty cool. I want to try and do this. And then comes the question, how? Because there is no school in Minnesota to learn how. So I learn pretty well just by absorbing from other people like you would with any normal trade program. You show up to work and you learn as you go, and it just turns out that that's a way better scenario for me than most other people. I like to learn a little bit, take a lot of time to digest it, go and study it on my own and come back and try to add to it. Right. So the “why digital dentures” for me was I was learning how to do traditional removable work, and just at the same time I saw digital dentures. The very first digital dentures. And I said to myself, well, if you're going to do this, the digital denture is going to take over all of your work and you need to be 100% committed to that. So that's what I did. And what I observed very early on, like 2012 maybe, you know, I was like, this is how it's going to be. And I just knew that instinctually. So that's why digital dentures for me is, it was a matter of survival, but also just a matter of a way to affect change , right?
[00:04:05] Rob: Right.
[00:04:06] John: Like I, I had the ability from the place in time that I was at, to have a different affect than people that came before me. If I paid attention to that really closely and put in maybe a little bit more effort than a person should, hehe, into digital dentures, right? So but when I think about why digital dentures, I also think, you know, why digital dentures. What is it about digital dentures that is better than the way we were doing it? And so you kind of have to do an analysis of what's wrong with the way that we make dentures. Now or not now, but.
[00:04:44] Rob: Then.
[00:04:45] John: Then. In the analog session-
[00:04:46] Rob: Some people still “now”.
[00:04:47] John: Yeah. Some people still now. And there's a lot of quality to that. And like, I don't deny the quality of that process. What I do pay attention to is what was broken in the system. And the system is, in the United States and this is an American problem like it is almost exclusively. I mean, it's a worldwide issue, but the problem we have is almost exclusively American. And that problem is, is that the way that we manufacture the denture, but also the way that we clinically approach the denture is really rooted in something that was done in like the 1930s. Right? All these methods that were built upon, all the textbooks that were written were based on a system of technology that doesn't exist anymore. When these textbooks were written, people still made plaster impressions. They didn't even have VPS when a lot of these methods were written. Right. When these methods were written, they didn't have dental insurance. People paid cash. When this method was written, they didn't have scanners or 3D printers or any of the possibilities that we have now. This method was written and has become obsolete, but our approach to the denture didn't change. And so we came upon an opportunity to change the entire approach to the system. The system of producing 6 million dentures in the United States every year. So now we have all these problems. We have dental insurance that has eroded what we get refunded, we have an opportunity to use scanning to enhance the speed of that system. We have all these other things, and we really haven't harnessed them and coordinated with, you know, academia to really make a solution for people. And so when I look at it, I'm like, why digital dentures? Why digital dentures is because we have a really big problem, which is, clinicians can't afford to do dentures anymore. And they're not excited about doing dentures. They don't understand that dentures are the gateway to implant dentistry. They don't understand the possibilities. And what's exciting to me is it's a totally unwritten book and I get to help write it. And so it's like a tremendous honor. And also just an exciting place to be in history. Okay, that was more than you bargained for, but.
[00:07:08] Rob: No, no, that's exactly what I was looking for! Because in fact, there's aspects of that that I certainly hadn't really taken into account. Most of, I mean, to be fair, I'm more of a fixed technician than I am a removable technician. I've done maybe two dozen dentures. You know, all of them digital, by the way. So like you were speaking to all those methods up until very recently, 2012, maybe 14 or so. I mean, you started to have people like AvaDent you know, and Andy Jakson bringing that to light, but generally 3D printers really weren't quite up to it. Milling machines were not efficient enough to really crank out a denture and the software. Just kind of wasn't there yet. What about the production process with digital dentures now, do you really feel makes it a very viable option?
[00:07:54] John: Yeah, I do want to say that is viable. I, I want to add to that and I want to say that it's an incredibly fast moving target. Every nine months there's like another material that's out there or another version or another generation. And so I've been making digital dentures. Yeah. For 12 years, something like that. But the sheer volume of possibility becomes very confusing for people, in a commercial sense. Right. So really when you look at the digital denture as a product, you need to offer a full solution which includes customer education. Right. You need to say, “This is how I make a denture”, and part of that is educating the customer. Part of that is collecting the records and having the equipment, and part of that is producing the object. And ever since then, it’s just every year is a different climb to, like, make my own version of the best denture that I can make. You know, the Ivotion milled, the PolyJet printed denture. Those are the exciting things now, because when I look at what's a high quality denture or a high quality digital denture, I want it to be monolithic in nature. I want there to be no adding teeth to a base.
[00:09:23] Rob: Yeah. I'd like, if you don't mind, can you speak to that a little bit? Because I've seen some notes from you that I thought were pretty interesting about the discrepancies between, a monolithic denture you design and it shows up in on-scene one way versus a two part printed base and teeth, and it shows up with-
[00:09:37] John: Right.
[00:09:38] Rob: Well, anyway. Yeah, yeah. Please tell me more about that.
[00:09:41] John: This is what we learned really early on with AvaDent. And the big revelation with AvaDent when they came up with the XCL-1 and XCL-2 milled denture, was the idea that you could have a design file, and then your manufactured output was almost exactly like that design file, or as close as humanly possible. And that was the very first instance of that, because when you have this monolithic assembly, you have the potential for perfect occlusion or no clinical occlusal adjustments. The reason needs to be to complete the denture faster, in 2-3 appointments, because that’s where it really becomes affordable for the clinician to keep offering this service. So basically this is the “why” of why I like those PolyJet printed dentures. So for me, I was in love with the AvaDent monolithic denture. The problem with that is your bottleneck is in milling. You have at least 2.5 hours in, to one object, possibly more, maybe as much as 6.5 hours, depending on what equipment you're on. And you might end up with a denture that is exactly like the design. And so this is like the apex for us because clinically, you're delivering a perfect denture. But what happens if you don't do all those things? Basically, you have a milled denture that's going to take a lot of time. So you need to move into 3D printing. When you move into 3D printing, we were using vat printing. Right. We're using DLP and SLA style printers. And then you're assembling the two parts and there's no oversize milling option here. So those dentures are always out of whack. There's always a discrepancy. There's always what we would call an assembly error. And that assembly error results in an increase in VDO. That's what you see in this slide here. There's kind of like a halo where, you're noticing maybe like three quarters of a millimeter difference. Because of your glue gap setting, because of excess resin in this assembly or whatever. Well, when you add that to two arches of dentures, that's a millimeter and a half, or two millimeters of open occlusion. Now that's costing us time. That's costing us clinical time, which is the big no-no.
[00:12:14] Rob: Yeah, that's chairside at that point.
[00:12:16] John: That's what we want to avoid at all costs. That's the most expensive time. You're using 3D printing as a tool to increase output through-put and efficiency. But you're eliminating all those occlusal discrepancies. And so you're able to make a near-perfect object over and over and over again at volume, and reduce the machine time to, we'll just say, conservatively, a third, but more likely a fifth. Right?
[00:12:47] Rob: Right. Especially since some of these printers, you can manufacture more than one denture at a time. That does lead me to wonder, though, what kind of results have you seen from, say, monolithic vat printing? You know, just standard resin printing. Say it's all printed in tooth shade, and then the gum portion has been shaded either with stains or with something like EasyGum. How do you feel about those?
[00:13:09] John: So, we do quite a bit of those as temporary dentures. And that is one philosophy. Right. And here is my sticking point with that philosophy. The premise is this is a try-in. And we're going to assume that we need to do another denture right. But why did we make that assumption? The assumption is something is going to be wrong, and so we're going to need to correct it down the road. Well, the first thing that comes to my mind is how often does that actually happen? Is it 30% of the time, 70% of the time, 90% of the time? What I've found in practice is that 30% of the time, with the proper education with the clinician, I can get to a final denture in one step. So then if I delivered a white denture or a temporary denture at that appointment, that's really a disappointment, because now I need to schedule another chair time, to deliver the real denture. Well, now that we have full color dentures, what is the difference between the try-in and the final? Nothing. Absolutely nothing. So you have the opportunity just out of the equipment that you chose to produce and deliver a denture at least 30% of the time, one appointment sooner. Can you imagine, trying to calculate the cost of that to a 400 office DSO? Where in 30% of your denture visits, you're able to shave off one of their appointments. just by delivering a color denture where you would have delivered a try-in. This is a massive outcome, tens of millions of dollars!
[00:15:00] Rob: It's an easy calculation to make there with a good calculator.
[00:15:03] John: Yeah, when you calculate the system… In my weird world, my weird focus is to always start with calculating the benefit to the system and not myself, you know, so in my mind, yes, I deliver the white monolithic denture as a try-in. I would prefer to change the mindset to deliver a colored denture on that try-in appointment every time. But that's not everyone's mindset, so… hehe.
[00:15:35] Rob: That's kind of why I ask, because you have a unique and very powerful perspective, and you've clearly been in this from the formation of a lot of the digital denture ethos here. And so I know a number of, I wouldn't say the majority of, but I definitely know a number of technicians that are printing a monolithic denture, like out of the white material,
[00:15:55] John: It’s the most common.
[00:15:56] Rob: And then they're using, like, GC stains or like, EasyGum from Harvest or something like that, and delivering that as a permanent denture or a final product.
[00:16:05] John: Sure… yeah…
[00:16:06] Rob: And I was wondering what your opinion was on those kind of work.
[00:16:08] John: Ah, okay. Yeah, I wouldn't do that. Haha!
[00:16:10] Rob: Haha! I wouldn't do that!
[00:16:14] John: I mean, I've done that. I've done, you know, composite colored dentures, plenty. You can make composite colored dentures that last a long time. I think you want to be aware of if you're actually using a try-in resin for that. That's not advisable. If you're using an actual permanent resin for that, like, let's say like Rodin Sculpture, or something like that.
[00:16:37] Rob: Right. Specifically that resin is what I've seen a lot.
[00:16:41] John: Yeah. Then you're talking about something different-
[00:16:43]Rob: I’m curious, what's your thought process behind the “don't do that”? Or why that’s not a-
[00:16:48] John: Yeah.
[00:16:49] Rob: Why that's not a viable option there.
[00:16:50] John: I don't think it's not a viable option, but I think it is confusing to the clinician. Right. Because the clinician could receive a white denture from someone and they would be getting what is a try-in resin that's meant for less than 24 hours in the mouth, right. And then you could get a denture from somebody else, another laboratory that is Rodin. Like a nice high impact ceramic filled resin that is expensive and worthy. But these two things look very similar. It would be very confusing and easy to make an assumption that one is just like the other. And the reality is that try-in resin is going to absorb a lot of moisture and get pretty foul pretty quick. Whereas, this white, Rodin sculpture is a totally different animal. Right? So, yeah. I'm not, you know, if you have good communication and your customer is extremely educated, maybe? But I would be very careful to educate them on the difference between these objects. Like I said, it goes back to something we said earlier, which is, there’s so many options and it gets very confusing very quickly. And if you operate in generality, you can make mistakes.
[00:18:16] Rob: Right. And as you said, so many options. There's an old saying that all of the options is none of the options because of just analysis paralysis, decision, indecision.
[00:18:27] John: Yeah.
[00:18:28] Rob: And speaking of the myriad of options available, what do you feel is more viable with the partial world these days or flippers?
[00:18:38] John: Wow. Okay. This is deep, deep waters.
[00:18:42] Rob: Deep waters!
[00:18:44] John: You know, we have some options for digital partial, right? And I think the very first conversation that you want to have is, what's the purpose? Why are we going to do a digital partial? Again, much like the complete denture space. I think from a clinician's perspective, the biggest problem is having confidence in success. They've had a lot of bad experiences with partial dentures, either fitting or patient satisfaction or mistakes or bad metal frames or whatever it may be. They don't want to do it. In a lot of cases, it's a scary subject matter. You know, I had a customer call me this year. A newer dentist. He's 4-5 years in, and he said, you know, I didn't want to do partial dentures until we started doing these acetals because I had so many bad experiences with trying to adjust metal frames for hours, and the patients weren’t happy. And that's a lot of different things. But it comes back to these three categories we talked about: education, clinical records, and manufacturing. And when you get into that manufacturing, the digital partial space is almost entirely about materials, like you said. All these materials are out there. But we need to talk about what those materials are for, almost exclusively for flexible partial dentures. And in this new context, like flexible partial dentures as a replacement for acrylic partial dentures. And in the US, acrylic partial dentures are like, you know, same word treatment partials or like partials where the patient is wearing it because it's cost effective and they're most likely going to lose more teeth. Because what we see with this very specific case, which is the most common, like 70% of the partials in the US are acrylic partial dentures. So, you're making this acrylic partial denture, and what you see is people add on to it all the time. They add a tooth here, they add a tooth there, they do a repair, a clasp breaks, and all of a sudden you have this 12 year old acrylic partial denture. That's really where these resins get challenged. Can that last 12 years? And then the other question is should it last 12 years?
[00:21:38] Rob: That's what my immediate thought was. Should that last 12 years? Especially considering the cost of production on the printed resins, and-
[00:21:45] John: Yeah, yes.
[00:21:46] Rob: Printed resin partials where as, yes you can just reproduce it more or less. You know, you can take the scan and maintain the tooth positions and maybe adjust it to fit, you know, whatever's changed in the patient's mouth. But, you know, your traditional partial, you don’t realign a partial I mean, you can but like again, should you?
[00:22:04] John: They do it way too often. Yep.
[00:21:19] Rob: And way too often. And then there's also the introduction of, something that we're doing a lot more of is 3D printing, chrome cobalt and 3D printing titanium substructures, partials.
[00:22:18] John: There's kind of this premise in the partial denture world, like, is this even worth studying, or is this even worth looking at? And the thought is in the argument, maybe the false argument, is that, hey, we're not going to need these because people are just going to do implants.
[00:22:43] Rob: I feel like that is a very false argument. That strikes very close to home. I'll tell you what, though. It strikes very close to home because my mother, who is a diabetic, has had two failed implants. It doesn't matter at this point why, but specifically, like, she's still in a partial. And bottom line, she's afraid of getting an implant after two bad experiences.
[00:22:54] John: I would be too.
[00:22:56] Rob: She doesn't really have the bone structure to support, you know, more implants. So there's definitely a market for the partial denture for, maybe not a huge market, maybe not everybody. But there's definitely I mean, you don't want to leave some people out. And that's the bottom line. I think that saying that everyone's just going to get implants and move along is probably leaving out more than just my mom.
[00:23:17] John: Yeah, definitely. And I feel like that grows. Right. Because you might have a medical complication like in her case, but more so you're going to have a limitation in what solutions are available to you through your insurance. And that's really what I see is the limiting factor for people. And this is cynical of me, but I always assume that insurance benefits are only going to get progressively worse, and that people's ability to afford these things on their own is also only going to go in one direction. And so when I look at this, again, it's just much like the denture problem. We need to make x number of these in the United States. We have fewer and fewer people that know how to do it really well. We have an increasing demand with population growth and with our ability to afford different solutions. This is becoming more dominant instead of less dominant. And then also when people get implants, they're wearing these digital partial dentures in that space until the implant integrates in a lot of cases. Because a lot of the partials that I make and I do in the digital realm, I mill acetal partials, that's my go-to quality partial. So if I can offer that high quality option, that's what I'm trying to offer. But a lot of those are going over single implant sites, on like a 8 or 9, you know, until the patient is ready to get the tooth restored and uncover the implant. So, yeah. I don't think they're going away, is my point. I did put a lot of energy into studying it. I do think the major trend and the thing to be aware of in that space is that we are kind of blending these lines between treatment partials and acrylic partials and flexible partials. And the reason for all that is clasping. There is not a way to digitally design a wire clasp for a partial. Well, there is a way to do it, but nobody does it. And so, a good portion of my patent work was on how to do that, how to make wire c-clasps in orthodontic and retainer appliances and in partial dentures digitally.
[00:25:39] Rob: For those who aren't really familiar, I mean, like myself with some of the challenges with making a metal clasp on a digital partial. What are those failure points that you're seeing?
[00:25:48] John: Okay, so what most people would do is, let's say you're using Lucitone 199 to press-pack or cold cure a flipper right now, like you're doing it the old way. With all these technologies, you know, like the reason AvaDent was beautiful is they're able to produce something that was 1 to 1 comparable. This denture that is made analog and this denture that’s milled digitally look pretty much the same, and they fit the same purpose. This is the same thing that we're trying to do with partials. But it's a lot more complicated. And it goes back to what we talked about before: assemblies. Remember, we talked about monolithic assemblies, right? Well, now with partials you can't have a monolithic assembly. You have metal parts and you have acrylic parts and you have all this. So you want to make an acrylic partial denture that looks just like the flippers that have been sold for the last hundred years with wire clasps in them. And the reason for the wire clasps is they're adjustable. And unlike a lot of the resins we have now, the flexible resins, they don't age out prematurely at two and a half years. They don't become brittle, they don't absorb water, they don't do any of those things. So we're looking to add wire clasps just like they were. Mostly because people want something that looks exactly like they're used to. So when you do that, then you're looking at how do I make a library of clasp parts? How do I sort that library to fit a tooth? And then how can I assemble a flipper really easily? Without a stone model? And the answer is, you just make a huge library of different clasp options that can be used in software. You find a way to automatically sort them, and insert that into your denture. You can press pack or now you can do the exocad quick snap.These ones were custom made. But when we went from this, we started making them as a stock library. So basically those clasps would be integrated as a stock library and just fit underneath the white part of the tooth, it vmakes a little sandwich. And then the denture on the other side here is, you know, what you would see mostly coming from most labs where you had the acrylic wing clasp in the front or the horn clasp in the front. So, like I said, the problem with this is those horns eventually wear out and break. And like I said, a lot of these appliances are being strung along for God knows how many years. And they just meet their, you know, they just meet their fate a little bit sooner than you'd like.
[00:28:33] Rob: Right. Which is a struggle for a lot of these clients because many of them are just, they're not necessarily medically enabled to receive an implant. They're just financially disadvantaged, we'll say. And, you know, I've seen a lot of shelters out there even try to give out partials to these poor people. They’re trying to manage to eat as best as they can. And then what they have is, like you said this 12 or whatever year old partial hanging out and just clinging to life. So how does that compare to some of the acetal partials you say you've been making lately? So why acetal? And, what makes that different?
[00:29:07] John: So, now we're going to do an acetal commercial. I guess.Hehe.
[00:29:12] Rob: It’s not a commercial if it’s the truth!
[00:29:14] John: No, it's the truth. The advantage with acetal over maybe the light-cure printed ones? So acetal is a disc and it's milled, and its strength characteristics outperform that both in the flexibility and in the strength. And unlike the light-cured resins, that flexibility doesn't really change as much over time. And when you compare the two, you would say it doesn't change, hardly at all. And so the disadvantage to acetal is that it's all white. And in order to make a “monolithic appliance”, you're not really making a monolithic appliance because it's colored in a composite like you see here. So I’m coloring these, I’m adding composite, and then the failure point for acetal is, will this color last? And the answer is yes it will, with proper surface restoration. These are OPTIGLAZE and GRADIA, but my more recent ones, that is Rodin Glaze. What I noticed about the Rodin was the quality of that surface finish. The time that it takes for that to start absorbing common contaminants. You know, when we do start to migrate into those metal frames, you can have the titanium milled or the chrome printed, and I've been, you know, doing that for, I don't even know, 26 so, 16? 15 [years]? And, just great results. But you're limited- you were limited until 2021. So, like, going back and doing the rest of the steps analog. Now you have that QuickSnap. You have the BEGO Complete product, which is another kind of assembly device, or assembly aid, that allows you to just build it theoretically without a model. I find with the [exocad] QuickSnap, you really do need the model in some cases. And there's little, you know, limitations and boundaries to each one.
[00:31:27] Rob: But do you have a preference between the two?
[00:31:32] John: I won't say hehe. I think like most things that we talked about, I think the story isn't completely written yet. And the reason I say that is, because, again, we talked about the main problem. The main problem is there's not enough people, there's not enough interest in doing this. Even the people inside of dentistry say, hey, this isn't going to be around forever. We're going to do implants because they're excited about that. But when you look at prevalence, you're like, hey, how many dentures are made, how many partials are made, and then how many implant surgeries are done? Do you have any idea? It's like less than half a million implant surgeries done in the US every year. And I'm not going to say that that's not growing. It absolutely is. But when you put that next to 6 million dentures and like however many partials, for each denture that is made, there's seven partial dentures made.
[00:32:30] Rob: Really, I had no idea the ratio was that far. So there's seven partial to every denture?
[00:32:35] John: When you want to talk about prevalence and then opportunity to make an impact, that's why my focus landed here. I'm like these are things that are going to get paid for. They're paid for by insurance. People need them. There's not enough people to make them. And then, you know, how do you start to solve some of that? Because my solutions ended up, you know, as far down the rabbit hole as, you know, patents on how to robotically assemble partial dentures, you know, like, so you're like, sure. You're like, how are we going to make this with fewer and fewer people? We have to use all the tools. We have to use AI. We have to use robotics. We have to use material science. We have to use systems analysis. We have to do the whole thing. And that's the only way that you're going to have an outcome. And you might as well do it now because you're already rewriting all the rules, right? They wrote a partial denture textbook, which is McCracken's. That's the one that I have. It’s a common textbook. They didn’t have acetal! There's no acetal in there. There's not even a flexible partial denture in that textbook at all. They don't even mention Valplast. So it's like you have the opportunity to rewrite the whole, what is my whole world. Why not?
[00:33:50] Rob: Absolutely. And one of the things that you keep going back to that I think is probably commonly overlooked, especially from the technician side, because we're pretty far removed from the direct process of the billing, is the insurance policies. But at the end of the day, it really defines a lot of the work that we do, whether we recognize it or not. At what point did you start to pick up on that? And how has the I mean, clearly, it's been something you've incorporated directly into some of your work. What do you think would be a good path to learn more about that? And how did you come to discover that?
[00:34:28] John: Hehe, Okay. Well, so I worked at the University of Minnesota, and there was like, it’s hospital style dentistry. Right. It's like, you know, six floors and each floor is, you know, we'll call it 120 chairs of dentistry, like 120 operatories. And you're just like, enmeshed in it. And when I was learning all of this, the idea for me was, I can't do 240 chairs worth of dentistry every day. As a technician, I can't be responsible for doing 240, you know, work for 240 people. But I can do what I can. So then you need to eliminate what will be most cost effective and what wouldn't be. And so the cost analysis became critical, but also the cost analysis to the clinic. So if you have an operatory open, how much does it cost to open an operatory for an hour, $140. How much does it cost to do this procedure? If we did this here in-house, how much would that cost versus sending it out? What's the time cost versus the dollar cost? And then you know, you start thinking like that really early on. And you're thinking about, you know, gosh, when you look outside of here, so much of this is just like people are operating with blinders on, doing things out of habit instead of out of having a really good, firm grasp of the cost analysis. And so I just came about thinking about it in a different way. Do I know the billing codes? No. Absolutely not. Can I tell you where to find them? Yes, I can. Is it confusing to dentists? Absolutely. They take, you know, entire like classes on it. Once they leave dental school, they'll hire consultants to teach them this stuff like a major DSO will have a whole group of people that are just responsible for that. So you want to be aware of what this cost is to your customer because you're just a part of a big system. And that system includes what insurance values your work at and what your customer values that at, and you have two customers. You have the patient and the clinician. So I just look at that whole system. And when I look at the system, I kind of see costs differently than maybe some other people.
[00:37:12] Rob: Yeah. I mean, again, it's a huge component of the system that easily gets overlooked. And to be fair, a lot of the doctors and a lot of the clinicians and technicians, their whole world is right here in front of them. And, you know, sometimes picking yourself up and appreciating all the other components that go into it, especially like the reality of the insurance, which is one of the most real things to the patient other than the restoration or the prosthetic itself. I hadn't really considered quite how it fits directly into partials and stuff. So that's a really cool insight. I don't think many people have made that. That connection is as much as you have here, and it's a very real world, you know, aspect of this.
[00:37:58] John: I'm lucky to have had some other business ventures where they got me outside of that box quite a bit, and they were like, really. You want to look at dentistry like, how many people can you help? And that's not my natural state. My natural state is like, I want to make these, like three cool dentures today. And I want to, like, think about esoteric denture theories and like, and the future of making these objects in mass. But the reality of that is you got to get out and you got to meet the guy that owns the DSO. You got to talk to him about what his concerns are or like what he needs. And then you can frame what you're doing, because if you haven't networked and you haven't understood all the stakeholders, then you can't really effectively solve a problem, I think.
[00:38:57] Rob: No, that seems absolutely correct. And again, looking at it from a systems analysis point of view is I think not as common as it possibly should be and, probably should be, not possibly. That it is all one big environment with all these components that work together. They're not individual islands and the insurance being a part of this system. At what point did you start to appreciate it as a system? So you say working in the hospital and having hundreds of chairs that you couldn't get to. So how did you overcome that? I mean, you said you were looking at it as a system then because you saw and appreciated the mass of production that had to be met. How did you overcome that challenge?
[00:39:41] John: I think, you know, very, very early on, what happened was, I was trying to bring in digital dentistry equipment. Right. And they were forcing me to- They said, no, we're not going to do that. We're not going to buy anything. And I was like, well, we really ought to do this. And they kind of, they didn't force me, but I was like, I'm going to do a cost analysis and prove them wrong. So I kind of did that with custom abutments. I said, this is what custom abutments are costing you. This is what you could save on it. And then it kind of cascaded from there. And then when we started to digital dentures with AvaDent. Yeah, it kind of changed my mindset. I was like, these are more expensive. But what was happening was we were saving four appointments. And so it was like, holy crap, we're paying more for this denture, but we're not opening this chair seven times. And every time you open a chair, it's $139 or whatever it is. And so you're really saving about $600 by doing this more expensive denture. And so, you know, that's really where the cost analysis habit came from... You know, I was really engrossed and involved with that value chain of digital dentures. And just to like to have that realization. But also to see for many years the organizational outcome for the university just based off of that small observation was like, Holy cow, we're saving this time. And it's not just an organizational outcome. It's like a societal outcome. Right? Because you had patients come in from four hours away to come to the university because, you know, it's elites and like, they want to do that. That's what they want to do. And you're like, boy, I just saved them, an eight hour, you know, round trip. Four times. I just saved that person, like, a day of their life. Like, you know, you have an actual outcome by harnessing the technology. And if you're not doing the cost analysis and the systems approach, you wouldn't even notice it or observe it. And it's simple as an individual to just overlook that. But if you're overlooking those things at the organizational level, boy, that's a great way to go bankrupt. You know? And if you're doing that and you're in the technology field, that's a great way to become obsolete. So really that system's approach comes out of survival. But also just again, being at the right place at the right time in history.
[00:42:23] Rob: Right place at the right time. What about the future of this do you find exciting? Like, obviously we talked about JetPrint dentures a little bit. We talked about the monolithically milled dentures. Where do you see some of this stuff going? What are you most excited to see change in the next, say, 5 or 10 years?
[00:42:41] John: Five years. I'm excited about AI design.
[00:42:45] Rob: AI design.
[00:42:46] John: But I think we get really excited about AI design. So one of the companies I'm involved with is Voyager. We built our own denture software, like, you know, like exocad and like 3shape, but it's our own. We wanted to use that information for our more complex stuff. And we did. And so we built, like a cloud based AI that designs full arch hybrids. So if you're a dentist and, and you're paying for a designer and you're, like, waiting four hours to get a design back during a surgery, that sucks. So this does it in like 12 minutes, and it gets you a printable design back in like 12 minutes. It's like cloud based, you know, server based. So you just upload your pic or your iCAM or whatever. It aligns all of it for you, and then just boom sends you back your printable prototype, for your hybrid surgery.
[00:43:45] Rob: Wow.
[00:43:46] John: And in doing all that kind of stuff. What I realized is the AI design. You know, people are fixated on AI replacing jobs or replacing humans. And I'm fixated on AI collaborating with humans. And, how can we have an AI if it's not built into a usable workflow? Right? Like if you didn't see the problem in the workflow bottleneck, if you can see the bottleneck in the workflow and you weren't a master of the workflow, then you couldn't build a useful AI to solve and relieve that bottleneck. So, basically what we did was we built that really cool. I don't know, it's not really an agent, but, it's like a, you know, AI tool to help you in that very specific dental situation.
[00:44:44] Rob: And not to mention, like earlier, you were saying that there are fewer and fewer dental technicians going into the field. So how are you going to do it if more and more people are needing dentistry? How are you going to do more work with fewer people if you don't have some kind of technological assistance to help the technicians that are there?
[00:45:01] John: It’s a workflow tool. We have this very specific workflow to do hybrid surgeries. And we just built this tool that aids in getting that done faster, and more reliably. And so that's really how I see AI. Where it really gets interesting, what’s interesting is when you see how AI and robotics go together. So when you look at the ways that AI can affect our lives, and the way that robots can affect our lives in dentistry specifically, you have to reinvent the way we assemble things. You have to reinvent the way machines create things, because the way that we think about it now is retro-fitting it for the way humans made things, which is not efficient.
[00:45:54] Rob: Right. No, it's a complete mind shift, completely different approach. Absolutely. And whether it's additive or subtractive manufacturing, at the end of the day it doesn't matter. You have to make the systems rise to the occasion, and you rise or fall to the level of your systems. Right.
[00:46:10] John: I will say this. I will say that traditional dental software is not going to be able to keep up. I think exocad has done a really good job of it, trying to keep up. But what's going to happen in the next ten years with assembly of partial dentures, assembly of hybrids, assembly of locator dentures and, you know, mesh supported dentures. The software can't keep up. The software isn't made to do that. The software is made to simulate what we did in wax, and it's a fatal flaw. I just think the pace at which you're going to have to move over the next ten years is going to be pretty rough. So, so, yeah, AI just like, kind of overcoming some of those problems is going to be a huge part of, of solving, you know, some of these high volume laboratory operations.
[00:47:18] Rob: Absolutely. That makes a lot of sense. And either the software companies are going to rise to the occasion and incorporate these tools, or they're going to be surpassed by other companies that invent them.
[00:47:28] John: Yeah, they'll be put together. I mean, you're talking about a lot of different problems, too, because like I said before, it's like, you know, making 100,000 partial dentures a year is a different problem than making three a day or like ten a day or whatever. You know, these are very different budgets and different price points.
[00:47:52] Rob: Truly. Yeah, truly. And so if we have younger people listening to this, where would you recommend they go to get started if they wanted to dive into the future of digital partials, digital dentures? How would they embark on that journey, if you had to do it right now, today, where would you start?
[00:48:11] John: I mean, the lowest hanging fruit is to start with flexible partial denture design. Right? I do think you want to, at the end of the day, have a really great background in CAD, basic CAD, CAD, whatever. Understanding how many different, or, you know, learning many different types of CAD so you can understand the similarities, that run through all of them. And so that's where I would start. I would learn every type of CAD that you can possibly learn, but really dive deep into those textbooks and learn those, metal framework design theories.
[00:48:55] Rob: As schools start to adopt the digital dental workflows and the digital dental philosophies, what about the analog world should they remember and appreciate to incorporate into their curriculum?
[00:49:08] John: Yeah, this is deep. This is close to home. So, yeah, I've spent, you know, 18 years in formal dental academia. The principles that a lot of this are built on are, you know, you can't skip them, you can't skip over these things. And a lot of those people would consider analog principles. So I think from the dentist's perspective, I would say, you know, you’ve got to take an impression. You have to be able to take a VPS and alginate, a denture impression, large bridge, fixed impression, and you have to be able to do that well. And you need to be able to mimic that with a scanner. You need to figure out how to do that. And that's the tough part is because not everybody in a dental school is going to be able to teach you how to do that. You're going to have to pursue that information. And that's kind of the fun part for me. And I find that most people don't find that very fun. They paid a lot of money for an education. They'd like to get it. From the technician side, what should technicians know, analog versus digital? Like, you know, like a trade school. What are they going through now? I think trade schools are having trouble getting equipment. Getting equipment in the door and supporting that with faculty, just like dental schools are. They're a little bit more successful at it. And the students are excited to learn that technology, as you would expect. What I would say is that in my own experience, I was really blessed to learn those things side by side because I can move fluidly in and out of them, you know? And it's kind of like someone being fluent in, like, sandscript or something like that, or like Latin. But just to be able to have your mind move like this through them, is such a big deal. And it made such a big difference when people measure my value, they're like, oh, oh, this guy's not just, you know, whatever. He actually knows this stuff. So I would encourage people to read old textbooks and understand the techniques that they're doing in those old textbooks and understand the steps and the workflows that were germane to that time. And then when you are going ahead and trying to, you know, determine your own path, like, how am I going to use this scanner digitally? How am I going to use this? You can remember all those steps because each one of those steps was for a reason. They weren't just nonsense. And so as long as you're understanding the principles baked into those steps, now you can translate it. Because here's what I do guarantee is there is not a digital textbook. If there is, it is constantly evolving and incomplete. So you're the one that's going to write it. And so go out there, read those old textbooks, make sure to respect the information and the steps and to ingrain them into what you do. And then see if you can replicate their intent with your new equipment.
[00:52:36] Rob: Gotcha. That sounds like excellent advice. And John, where can people find you online?
[00:52:41] John: Oh, I'm on Facebook and on Instagram, @disruptivedentistry.
[00:52:47] Rob: Disruptive dentistry. John Madden, thank you so much for your time today. This was amazing, a wonderful conversation.
[00:52:52] John: Thank you. Thank you. I had a great time!
[00:52:56] Rob: Same! And thank you, all of you out there listening. Thank you for joining us for the Evolution of Dental Podcast. Please remember to like, subscribe and share this show with your friends. And remember, never stop evolving!
