Episode Transcript
[00:05 - 00:25] Rob: Welcome back to the Evolution of Dental Podcast, brought to you by Evolution Dental Science. We explore the stories of the people and the technology changing the world of dentistry. Today's guest is an iTero guru, an expert in the field of the developing technology surrounding imaging. Doctor Josh Austin, welcome. How are you today?
[00:25 - 00:40] Josh: I don't know if I'd use any of those words. I think the thing I'm most an expert in is obscure sports references from the 80s and 90s. I think that's probably where my expertise lies. But I appreciate the very kind words. Thank you. How are you?
[00:40 - 00:42] Rob: I'm doing well. Happy to have you here.
[00:42 - 00:43] Josh: Happy to be here!
[00:43 - 00:48] Rob: So, what got you started on this journey with sports trivia and iTero?
[00:48 - 01:28] Josh: So sports trivia starts by, I grew up in a time period that most listeners of this show probably won't have ever heard of, called the 1980s. And in the 1980s, we didn't have this thing called the internet. And so you had to fill your time with things like reading sports magazines, watching one game a week on TV, reading the back of baseball cards, things like that. And so that's where all that esoteric knowledge comes from. Forget anything about teeth. I forget that stuff immediately. But I do remember that Chris Sabo, hit 264, for the Cincinnati Reds in 1989. So important information to know for sure. I just made that number up. So if that’s right, it’s just pure luck! Just pure luck.
[01:29 - 01:31] Rob: So how'd you get started with iTero, though?
[01:31 - 01:51] Josh: Yeah. So iTero, that's a much more interesting story. So, you know, I've, I've been in the digital game, in it since like 2008, and it started with not even the iTero scanner. It started with a scanner you might remember, and some listeners might remember if they're OGs in digital, called the 3M™ True Definition Scanner.
[01:51 - 01:57] Rob: You had a 3M™ True?! With the powder spray? Hey, yeah, there you go!
[01:57 - 04:23] Josh: With the powder spray and all of this, and it was monochrome. It would take eight minutes to scan a quadrant. And it all started because I just didn't like- one of the things I struggled with in dental school was taking master impressions. Like, it just, you know, it just was always a struggle for me. And so I was like, there has to be a better way. And of course, I saw, you know, early on we had like the Cadent iTero, the foot pedal iTero that first came out. And it was like producing this milled model versus the True Def, which produced this SLA model, stereolithography model. And I was just like, oh, I like reading. The technology is like SLA- are more accurate than a milled model. And that's when we were scanning and making a model off of it, and then just making a traditional crown off of a model, just like with a stone, except we had created it digitally. And so I had that scanner for a while and it, you know, you see immediately like the better fit of restorations, the better fit of aligners when you're able to actually get a full arch scan but it was just cumbersome, right? It was just wonky. And eventually the True Def, they stopped developing that scanner. They never did anything additional. And so I was like, at some point I was like, I need to find something different. So we tried everything else out and we tried iTero and my team all thought the iTero was the easiest to scan with, and so that's what we got. And that's when we started going, and it was just like everyone else using an iTero. We scan for crowns and bridges and it’s like cases and that was it. But there was one day in my office, this is like 2017. I had a lady and she's an older lady and she didn't bring her hearing aids that day, and she had broken like 14 or 15 or had a crack or something like that. I was trying to explain to her that she's going to need a crown and she just couldn't hear me. And so I was like, I don't know what else to do. So like, we took an intraoral camera and you couldn't like- the mirror on the internal camera was fogging up and it had spit bubbles on. It didn't get a very good picture. So I told my hygienist, “scan her with the iTero, let me show her the iTero”. And it was like despite her not being able to hear anything, she could see immediately on the iTero. And it kind of gave me this idea to start scanning everybody. And so in 2017, we started scanning every patient that came in the door with iTero. And it’s still what we do today, everyone who walks in gets a scan, and that's the basis of our patient communication. And our new patient experience in the office starts with an iTero scan. Everything starts there and then we go off from there and use all the other tools to try to talk about treatment.
[04:23 - 04:32] Rob: So you say you're using it as much as a tool to convey a visual, as anything else then to communicate with the patients, like seeing is believing.
[04:32 - 05:57] Josh: It's far more valuable for me for that, than it is as a replacement for polyvinyl siloxane and impression material. I mean, that's what it does. It generates more dentistry in the practice. And it's certainly big cases and esthetic cases and full mouths and implants and all that high value stuff, but also just stuff like class twos and carries and nightguards and Essix retainers and all of that. I mean, it just generates more dentistry. Does it take an extra two minutes to do a scan? Yeah. Does it cost me a sleeve chip? Yeah, for sure. But, as we like to say, in the Molis Coaching world, we don't step over dollars to pick up cents. We don't step over dollars to pick up pennies. And so I'm not concerned about the two minutes of time or the $2 scanning sleeve because it just produces so much more dentistry. When patients can see what we see, they say yes to treatment. That's that's all, all it is. And, you know, photos are fine, photos are good. But at the end of the day, a photo is a static, two dimensional image with no context to it versus like the richness of a 3D scan. Especially today, with the beauty of what intraoral scanners do, whether it be the iTero or the Trios or the MEDIT i900, or any of them. They all produce these really photorealistic scans, and patients look at it, they see it, they understand. And when they see and they understand, they say yes to treatment. So that to me is like, that's the way to use a scanner. It's far more valuable for that than it is for, you know, instead of squirting goo around a prep.
[05:57 - 06:09] Rob: Yeah, that sounds much more relatable. How else has incorporating the scanner into your practice changed? Like, what are some things you did before that you no longer do? What are some things you do now that you didn't do before? Because you scan everybody?
[06:09 - 08:12] Josh: Yeah. So the first thing when you start scanning patients and talking to patients about it, like in the hygiene room, I would say. Either at their recall or the new patient exam or whatever. You have to talk less, like I have to do less explaining when they can see. Right. If a picture is worth a thousand words, like how many words is a scanner? It's like a million, right? It also makes my exam time go down because again, I'm not talking as much. Right. Dentists are great. Dentists are great at talking in circles and talking patients out of treatment. I see it all the time. And so that's one of the workflows that changes. But then once you have the scan, what we're finding is all these scanner companies, doesn't matter who it is. They're all building these software tools on these scanners that have nothing to do with creating restoration. They have everything to do with communication. Right. So whether it be carries detection technology, there's like five scanners in the market now that have carries detection. Whether it be, what I call change monitoring, the ability to take a scan in one day and take a scan a year later and show what's changed, to sort of observe for things like wear and recession and teeth that are crowding or spacing. And then the ability to do outcome simulation, right, the ability to take a patient, take a scan and then show them what it would look like if they were to do esthetics, what it would look like if they were to do orthodontics, what it would look like if they did both right. So using all those different tools, just like quickly and easily, at a couple of fingertips, can make a difference about where a conversation goes, and give a patient, you know, ideas about what is going on in their mouth, what can be addressed, what's changing in their mouth, and then what is possible. Right. That's kind of the biggest thing. So I think just having- once you have the scan, once you have that STL data, there's so much stuff you can do with it and they're giving us more and more tools, the scanner companies, and they're really putting a lot of development into this, in order to make us realize that these scanners are not for making crowns. Yes, they make crowns. Yes, they can scan for a bridge or an implant, no problem. But it's so much more than that.
[08:12 - 08:27] Rob: Do you have any- It's so much more than that. And do you have any examples you can think of, like… because you're a big believer in, as I understand, minimally invasive dentistry, do you have any examples of how that's influenced or cases that you've used to transform somebody's cosmetic experience?
[08:27 - 09:46] Josh: Yeah, for sure. So, I mean, minimally invasive is great, right? Like I always use the idea that, like while there is a terminology of something called the no prep veneer, the cases that are no prep or like so small, right? There's very few of those people. But if we use the treatment tools that we have, we can make cases more minimally invasive and we can move to a position where maybe we have to prep less off of a tooth. And so we can use ortho in a lot of those cases. And so I can use a simulation to show somebody where their bite is hitting, like, hey, you know, you’re edge-to-edge right here. If you want to do some repair of those edges and correct that asymmetry from the wear that you have, we gotta get some space from somewhere. If I don't I have to prep a bunch of your tooth away and I can show them that kind of modeling. And then I can show them, hey, after eight months of alignment, look where your teeth are now. Now we can just add to your teeth, right? By using these simulators that are on the scanners now. And so those types of situations are situations that come up all the time. And I always say this like, if a patient will grant me the gift of patience, I can move them to an area where we have to remove less of their enamel. Right? Am I, like, you know, I talk to-
[09:46 - 09:50] Rob: You mean literally move them. You're saying orthodontic, yeah, orthodontic aligners.
[09:50 - 10:46] Josh: Orthodontically move it, right? Yeah. And I'm the first to say, like, I like prepping teeth, you know, I mean, I love prepping teeth. I love the smell of enamel as it flies, you know, through the operatory off my handpiece. But there's a time and a place for it, right? When we have ugly enamel, we have discolored enamel. We have old restorations, and we have decay. But if I have pretty teeth, you know. But they have some unevenness, they have some asymmetry or whatever, we can do some ortho first. We can, you know, we can make the outcome better. In one case where we really talked about it was the case that was just published in the Journal of Cosmetic Dentistry in November of last year, a case where we had some spacing, uneven, incisal edges, altered passive eruption. And so we did a combination of orthodontics with Invisalign. We did some crown lengthening, and we did ten no prep veneers. And it actually ended up winning the AACD Case of the Year last year.
[10:46 - 10:47] Rob: Wow!
[10:47 - 11:15] Josh: And you know- I felt so bad because it won the Case of the Year for like crown lengthening and veneers. But like I didn't really do- I didn't even pick up my handpiece like they were literally no prep veneers. So it was like, actually, the award doesn't go to me. The award goes to my lab tech who made the veneers. All I did was glue them on you know, but it was about the moving teeth into a position first, so that we could be no prep, because you would have never been no prep had we been in the position he was at before.
[11:15 - 11:17] Rob: That's beautiful. Wow, Case of the Year. That's pretty impressive.
[11:17 - 11:19] Josh: I mean, it's, you know…
[11:19 - 11:36] Rob: Just to have, I mean, just have the vision to bring it there in the first place because that's the big difference, as you were saying, is the difference between cutting unnecessarily, teeth that are already beautiful, you know, versus just changing the position so you can put them, set them up for success.
[11:36 - 13:32] Josh: Well the digital tools are what's giving us the ability, right? Like, you guys are obviously like huge exocad, proponents and part of your business is exocad licensing and all that kind of stuff. And exocad gives us tools to be able to analyze [things] like, hey, where we are, where are we now, you know, what would the thickness of ceramic be? All that kind of stuff. And now those tools from exocad that help us with that are being incorporated into another product that Align Technology sells called Invisalign Smile Architect. And so there's tools from exocad in that so I can kind of plan the orthodontic case with a vision of like at the end where our, you know, how much reduction, how much is addition, all that kind of stuff. So it's the digital tools that give us the ability to visualize this, versus the old days of like having to sit at a lab with a model and, you know, in a pot of wax, you know, and having to manually wax all this stuff up and just see where you got right versus now, like, you can just do it all with a mouse before you ever pick up a handpiece. And that's the difference is just like using all those tools. That's why what you guys do with your laboratory and your digital part of your business is so great because it gives dentists those tools. And my wife is that, I mean, I practice with my wife, we're a customer. We bought exocad from Evolve, and she works up cases all the time in exocad for me. And one of the great things that I think you guys do, which I really love, and this isn't supposed to be a commercial for you guys, just FYI. But, like, she can hop on a Zoom call. She can schedule a Zoom call with a designer any time. That all kind of came with the license of the exocad. So, it's just those tools, right? The more digital tools we have, the more we can play in these games with like- All right, where does the tooth need to be in order for me to get this facially driven outcome right? And the more tools we have, the easier all that’s gonna get, and the faster and more repeatable it's going to become in all of our practices.
[13:32 - 13:37] Rob: Using the tools to plan out the cases before you even touch any of the teeth.
[13:37 - 13:48] Josh: Exactly. That's the point. You know- that's the great thing. Now, do you happen to know the ortho and how you're going to move the teeth that way? Yeah, for sure for sure. But I know a couple guys that can help you learn how to do that.
[13:48 - 13:52] Rob: How's that? First off, who can help you learn how to do that? Hehe.
[13:52 - 15:05] Josh: I mean, I'm biased because I teach in an ecosystem, named Molis Coaching. And so Molis Coaching is the number one, leading platform for GP education on Invisalign clear aligners in the world. It's named after a guy, Ryan Molis, who's the world's leading GP provider for Invisalign. And it's like Spear Education- It's a website with a library of videos. And we have live events too. But you go through all the videos and you, really from soup to nuts of, you know, the idea of aligners in your practice all the way through how to execute ClinCheck, how to use elastics, how to use IPR and attachments. And I mean, it's literally everything about how to work with aligners in your practice. And it all just comes from the need of like none of us were taught ortho very well in dental school. We were taught that there is something called orthodontics, but you don't need to worry your pretty little head about it. Send it to an orthodontist. And so you've got to learn ortho from somewhere. And, so, having somebody to teach you that, you know, specifically for clear aligners, I think is important. Are there other great Invisalign educators out there? Yes, for sure. David Galler is great. Christina Blacher is great. Corey Anolik is great. A lot of great people.
[15:05 - 15:13] Rob: That's awesome. And so working with the coaching, how has that influenced the way you approach dentistry? Has it changed anything in the way you look at things or how you communicate with patients?
[15:13 - 18:48] Josh: So when I started teaching for Invisalign, I was teaching just iTero stuff, how to get great scans for crowns, bridges, implants, restorative stuff. I had no interest in Invisalign. I did zero Invisalign cases as recently as 2020. I would just say “you need ortho” and I'd send them somewhere else. And a good portion of those people just never go because it's another place. And so at some point I realized, like, I need to learn some of this stuff and that's where the whole thing started. And within a short period of time of consuming as much of the clinical education about clear aligners I could find, I find myself much more confident in it, much more willing to take on cases, which meant I was talking about it more in the practice, and it was something that I was seeing all the time, like where ortho could help me out. And I would argue it's about three quarters of my restorative cases could benefit from some orthodontic alignment. So we talk about it a lot. And where energy flows, momentum grows. Right. And so that started growing the practice. And now orthodontics is like 40% of my practice, which would have been unheard of. And as I started doing more than I or, you know, as I learned more, I started doing more, which meant I had more cases and could help other dentists. And really, when I joined Molis Coaching the faculty-my role on that team is all talking about how you can use ortho to improve your restorative dentistry? And so, Smile Architects is a tool that we use a lot for that. And that's kind of my role. So I'm sort of like Steve Kerr on the 1990s Chicago Bulls. Like, you know, I'm not going to get any rebounds. But you can bring me in to shoot some threes and that's how I kind of have one job on the team. And so, I've been able to kind of just focus on that, but what it's allowed me to do is become much more confident in my patients who just need orthodontics and treating those patients in-house. Now we do class twos, we do class threes. I'll use elastics, we do “teens” now, we do palatal expansion. Like it just sort of starts from there. And so what you start seeing is you know dentists are really great. We're really great at diagnosing carries and perio because we have tools to diagnose those things and we have tools to treat them. Right. If someone comes in with carries, we have something to fix it, and it generates revenue for the practice, which is good. But malocclusion is the one disease that most dentists are totally fine with saying, “looks good see you in six months”. And the reason I know this is because most dentists don't have articulating paper on their exam kits. They have mirrors and explorers and radiographs or whatever, but they don't, they're not looking at bite. They ask the patient to bite down, but they're not looking at that. When you start scanning everybody now you can start visualizing malocclusion. And when you have a tool to treat malocclusion, you can begin taking malocclusion as seriously in your practice as you would do carries and perio. And what you find is that your patients are treated better. You're treating a disease that is much more prevalent now than carries in perio. And it is something that I think is great for the patient and it's great for the practice. And many dentists sleep on malocclusion because we don't have tools to treat it. And that's because dental schools don't teach ortho. And so you didn't have the ability to treat it, referring it out. And that's always kind of a barrier. So, what it does is, when you start becoming comfortable adding this to your practice, your patients are going to be treated better because of it. And, they're going to be treated more comprehensively. And I think that's the goal.
[18:48 - 18:59] Rob: Treated more comprehensively, absolutely, because it sounds like I mean, if you're treating 40% of your patients now with orthodontic work, that means that to me anyway, that tells me that that was there all along and.
[19:00 - 19:01] Josh: It's all yeah, it's always been there.
[19:01 - 19:09] Rob: If it’s true for you, then it's probably true for others. And it sounds like it's a pretty approachable thing that you can get into with the modern tools.
[19:09 - 19:41] Josh: Yeah. And when you can visualize occlusion with somebody after a scan, you know, you just hit the Occlusogram button, and it shows them where they're hitting. What you're gonna start seeing is people, a lot of people hit on two teeth in their mouth. A lot of people have big red interferences on one tooth, and the rest of the teeth don't touch, but they are nailing their front teeth, or they're hitting on their incisal edges. And now that you can demonstrate that to a patient and show them where they're hitting and where their occlusion is, now you're stimulating that conversation. You're getting a patient interested in treatment, and then the energy begins to flow from there.
[19:41 - 19:49] Rob: Have you ever had patients that looked at that and were still resistant to treatment or hesitant about it? And how do you overcome that?
[19:49 - 23:26] Josh: For sure! Absolutely. Patients say no all the time, say no all the time. And you got to be good at hearing no as a dentist right. I went to college in the 1990s. And this is before there were dating apps. So, you used to have to, like, go actually talk to women at a bar or whatever or at a party. So I'm really good at hearing, no, because I used to hear it every night when I was in college from various women at the University of Texas. I would ask them out on dates and they all said, no. I'm good at hearing no, no today doesn't mean no forever. No, today means no today. But it doesn't mean we don't inform people of what their diseases are. It doesn't mean we don't tell people what their what their oral condition is and what we see. And I get it, like ortho doesn't fit everyone's lives right now, the same way a full mouth rehab doesn’t fit everyone's life. The same way an all-on-four doesn't fit in everyone's life. Like there could be a time in the future that is right for that patient. So if the time is not now, fine. We'll wait with you. We'll clean your teeth. We'll make sure you don't have carries. We'll make sure you don't have perio. But we're going to talk about it every time. And I understand that not everyone has the means to do it right now. You have no idea how- 42 year old mother, she's got some wear, she's got some recession. Her teeth are wearing down, her teeth are thinning. But, like, I get it, she's got a 14 year old who just started ortho. She's got a 16 year old that just finished ortho. We got college coming up in a year and a half. Like, you know, you just have to be okay with the fact that not everyone is going to say, yes, let's start today. And that's fine. That's totally fine. It's just part of the it's part of the deal. And what I would like to do is make patients understand that they have an issue. You know, I want to inform them of that issue. What they choose to do with that information is theirs. I'm kind of a libertarian. I'm not like a weird, crazy, like, sovereign citizen libertarian. But at the end of the day, I think, like your teeth, your choice. You get to make the decision. But when it does fit in their life, we're here for them. You know, we're here. And that happens a lot. Most of the patients I do comprehensive dentistry on, they don't walk into my office with money falling out of their pockets, you know, in asking for the treatment there are people that have been in my practice for years, and we've talked to them about it ten times. And for whatever reason, the day that they say yes, that was their day. I don't know why. You know, maybe their aunt just died and they inherited 50 grand. Maybe they just got a big bonus at work. Maybe they finally got their kids off their payroll. I don't know, but, you have to be okay understanding that not everyone's going to jump right in on this, and you have to help patients along. Tell them what you see. Tell them what you know, but don't judge them for not making the decision that you would make. I got told by an oral surgeon that I need two-jaw surgery, that I need maxillary and mandibular advancement. And, you know, like, I don't know. Would you say yes to that right away? Like, I've been thinking about it for, like, two years, you know, could I say yes at some point? Yeah, maybe. But, like, I'm not going to just say like, oh, yeah, I need both of my jaws operated on and under general anesthesia in an operating room? When can I say yes, when can we start? You know, like, there's not always going to be that super clean yes. And that's fine. That's where dentistry is. You build relationships over time, and that's what keeps a dental practice going is you talk to patients about it, you help them through as they break teeth, you know, always keeping them informed, but letting them know that there's, their decision is theirs. But we're here to help them. And at some point, most of these patients will get to a point where it's their time, and then you take care of the case then. So, yeah, you're not going to get a yes from everybody right away. And that's fine. If you did, you wouldn't have the time to do anything. You'd be only doing, you know, these big cases, or, you know, 80 hours a week. And then you'd be complaining about that. So, you know, it's a privilege to be a long term provider for a patient. And this is kind of what happens over time is that you treat patients through their life.
[23:26 - 23:32] Rob: Treat them through their life, they don't always say yes, but at least you get to keep them informed. So it's their decision to make.
[23:32 - 23:38] Josh: Absolutely, yeah. That's what our role is right. You know, inform them and let them make the decision that's best for them on that particular day.
[23:38 - 23:44] Rob: As I understand you also have done some lectures with Jennifer Bell. Is that right? How's that collaboration been? And what’s been interesting?
[23:44 - 25:32] Josh: Yeah, I love Jen! JB's one of my favorites. So, Jen and I teach a course together, along with Karla Soto and Matt Hicks called CDI Comprehensive Dentistry with Invisalign. And it's a two day course. We're really talking about how you use Invisalign aligners in a comprehensive treatment plan. Where does that fit when you're restoring teeth and moving teeth for a position’s minimal prep, how do you set up your ClinCheck, how do you talk about it with patients, etc. And Jen is one of my favorite people in the world because [she] and I are both pragmatists. Like, we both are the first to admit that, like, you know, I'm not [Dr] Michael Apa. You know, I'm not prepping $5,000 veneers on influencers and Hollywood actresses all day. You know, I do class two composites. I do single crowns on number 18. You know, I, I have crowns that break. I have, you know, restorations that get recurring decay. I'm a regular dentist, but I have this part of my practice that’s become that because of the tools that we have, and here's how we use them. And so I love working with Jen. She's great. We give each other a hard time because for many years, I was like the Invisalign guy that didn't do much Invisalign right. And so I was like a gold level provider, which is kind of lower down. It sounds great, but it's lower down on the totem pole. And this past year we hit platinum for our practice and Invisalign. And Jen texted me and she's like, she was mad- She was mad at me because now she's the only one on the stage that's like a lowly gold level provider, and everyone else is platinum above. And so she was mad that I made the jump to platinum, but I was like, hey, you got to join Molis. And then you can get the platinum too, you know? So I love her. She's amazing. We're both doing a presentation this year at the American Academy of Restorative Dentistry. Have you ever heard of the AARD meeting?
[25:32 - 25:34] Rob: Yeah, yeah, but for those who haven't, please.
[25:35 - 26:48] Josh: Yeah. So it's in Chicago. It's the same week as Chicago Midwinter and it's been around for like 100 years. And there's only 165 living members. So for someone to be invited to join the organization, someone has to die or retire. And so in order to join, you have to attend as a guest a certain number of times. You have to present, and then you have to go through this whole nomination process. I mean, it's probably easier to be appointed as Secretary of State than it is to get into this organization. And both of us are presenting what they call a projected clinic, which is an 18 minute presentation at this year's AARD. And so we were both kind of going through this stress together of building this 18 minute presentation because it has to be 18 minutes. If you go 30s over, they will literally turn your microphone off and push you off stage. So it's got to be a tight 18 minutes. It has to have a certain number of literature citations. It has to show dentistry. It has to have all these like specifications. And so it's an interesting process to go through again. So she's my girl.
[26:48 - 26:54] Rob: That is- I had no idea it was so exclusive and specific 18. Not 17. Not 19.
[26:54 - 27:43] Josh: It’s insane. I mean, if you finish a little early, they're fine with it. They just definitely don't want you going 19, like that is for sure. It is the elite of the elite. I think that Diana Tadros did one last year and she did so well. And she did a lot of her stuff from the Drip course. And so all the exocad design stuff taking three patients doing mockup smiles and then getting them to say yes to dentistry from that, then doing the dentistry and all that. Diana was so great last year. Her presentation is pretty- I would say progressive is the word I would use. You know, it's a lot of video. There's some music and stuff like that. So I wasn't 100% sure how these 78 year old prosthodontists would enjoy her Drip style. They seemed to love it. They seemed to love it. She did a great job. So I'm just hoping I can be as good as Diana was last year.
[27:44 - 27:50] Rob: I'm sure you'll do great. And so you've got some upcoming classes you said as well with Dr. Karla Soto.
[27:50 - 28:56] Josh: Yeah. So it's coming up in August of this year, and it's a course that we're doing through Molis coaching, and it's called Fusion. It's a lot of the same ideas that come from comprehensive dentistry with Invisalign, but it's the next step. So it gets really into our ortho setups for our pre-restorative cases. Prep design, provisionalization, 3D printing of provisionals, some design stuff, laboratory communication, occlusion. That's my role is to teach occlusion in this course. And it's like I have to boil occlusion down to one hour, which I don't know how I'm going to do. So I've got to figure all that out. And, then really, we're going to spend a good couple of hours on how each of us do consults, because each of us do consults differently. And I frequently say this: it doesn't matter how good you are at prepping teeth, if no one ever says yes to a crown, what does it matter how good your preps are? It doesn't matter how good you are at Invisalign, or at ortho. If no one says yes, what does it matter? Like you could prep veneers like Michael Apa. And if no one ever says yes, it doesn't matter.
[28:56 - 29:00] Rob: What is your approach to getting them to say yes if you can share.
[29:00 - 30:43] Josh: Absolutely. So it's using the tools of the scanner that we have now and relying on simulations and so, in the iTero world it's called Invisalign Outcome Simulator Pro. So what we can do is we do a scan and then we can take a photo with an iPhone. Very easy wide smile photo. And then we can quickly within 2 or 3 minutes show them what their teeth would look like in a 3D model mode, with either ortho or ortho and restorative dentistry. And we can also do in-face visualization. So basically show them that photo of themselves, what they would look like if they just aligned their teeth or if they align and restore their teeth. And now we have the ability to take a short video, a 30 second video or so, and we can show them in the video what they would look like of them talking, laughing, smiling. If they did alignment or if they did alignment and restorative dentistry. And when we go through that path and I have a way that I have a pattern, I go through a sort of road that I take them on, and then I unveil to them this photo of themselves, what they look like. And then we go to the video in this moving, dynamic image, it gets people interested and that's it. So, I mean, if I just sat there and used words to talk to somebody about aligning teeth and restoring them, you know, I bet we'd get a 5% case acceptance rate. But when we do all of this visualization, if we include a year after, for case acceptance, our case acceptance rate jumps up by like 35%. So it's a pretty spectacularly moving thing.
[30:43 - 30:50] Rob: So it sounds like you're using the tools to tell a video kind of story to the patient to show them where to go. So. Right.
[30:51 - 33:53] Josh: Absolutely. Yeah. For sure. And then the nice thing is, after I go over all this and we're sitting in my console room now where I do that where I go where I have a big TV on the screen. We go over all of that stuff right.So somebody comes in for cleaning. Now I'm talking to you about Invisalign and veneers. They're going to go home and need to talk about this with their spouse, their partner, their wife, their husband, whoever. So you got to send them home with something. Car dealerships do this, right. If you go test drive a car and you don't buy it that day, they give you this really nice folder with all the information about the car and the financing terms and all this kind of stuff. Right. So we now have a deal where we can share with them what's called a scan report, which has a bunch of still images from the scan and from the simulations with a QR code. So they take their phone, hold it over the QR code, it pops, it loads up on their phone. That way they can take it home and show their wife or their husband or their side piece from the Coldplay concert. Whoever, whoever they want to show. No judgment from me. And now we can share this video with them via text. And so we text them the video, we send them this report in the QR code, and so they can take it home and have a discussion. Right. And so I think a lot of times we as dentists, first off, we're really bad about overwhelming patients with this big long treatment plan from Dentrix or OpenDental or whatever that has 10,000 ADA codes on it: D-4381 D-2692 whatever. And then this technical description about what it is and the fee and whatever. And it especially for a comprehensive case where you turn ortho and crown lengthening and veneers and this it's only three pages long. I mean that's like giving somebody the scientific specifications of an engine when they're trying to buy a car. Like, no, Mercedes Benz doesn't do that. They give you a sheet that looks like a really great picture of the car and then like the features that come on it in plain English and then the price, that's it. Right. And so I think dentists are really good at complicating it. So what we try to do is we try to bundle stuff together. So my favorite procedure to do is Invisalign and four veneers. It's my favorite procedure to do because it's pretty easy to do the Invisalign, the veneer procedure. Like I can prep four veneers and scan, photograph and provisualize them in under two hours. Seating four veneers is easy. Much easier than 10 or 12.And when we give a treatment plan to somebody, it doesn't say like number seven. I don't even know what a veneer code is… 27, 81, whatever it is. Number 827, it doesn't have any of that. It just says alignment X number of dollars veneers, X number of dollars. It's two lines. That's it. And it's all bundled together and it's bottom-lined. Bottom line, stop overcomplicating it. Make it easy.Just bundle it all together. Make it all one fee. Figure out what your fee is for that kind of case. But in case you want to. And then bundle it together and make it easy. So when you give somebody a treatment plan, it is easy for them to read, digest, take home and know what they're getting.
[33:53 - 33:55] Rob: Give them one target to aim at.
[33:55 - 34:26] Josh: Absolutely, absolutely. The number of times that I used to give people a treatment plan that had like core build up with pins, tooth number three, core build up with pins, tooth number four, core build up with pins, tooth number five for all 28 teeth. And then the restorations on each one and this and that. And it was just like a mess. I mean, it literally is like giving technical specifications to someone who's buying a car. Like they don't need it. They want to know what color it is. Does it have tinted windows? Does it have power steering? That's it. We're ready. Let's go, let's go. Make it easy.
[34:27 - 34:47] Rob: That seems like really good advice. Again, just make it very digestible. Bring it down to the bottom line. On target. They're looking to pay the price anyway right. So why not just boil it down to here's your target. Here's what you have the budget for. Not split it up into a dozen different little subtotals that are all going to be incorporated into the same at the end anyway. I really like that-
[34:47 - 35:02] Josh: And make it seem like we're nickel and diming them, right. Like it's so it's and it's just it's above their head. They get overwhelmed. And when they get overwhelmed, the human tendency is to just not make a decision, to just push it down the road, like, I don't have mental space for this now. Let's think about this another time.
[35:02 - 35:03] Rob: I’ll worry about that later.
[35:03 - 35:06] Josh: And the other day doesn't come.
[35:06 - 35:10] Rob: Yeah. And then tomorrow. And there's always the day after the day after the day after next.
[35:10 - 35:11] Josh: There's always something the next day-
[35:11 - 35:25] Rob: It’s gotten so much worse in the time in between. And meanwhile they're coming back and you're taking additional scans and monitoring the progress and saying, hey, this is continuing to get worse. Yeah, but it's continuing to add up and I just can't think about that right now.
[35:25 - 35:37] Josh: That's exactly right. There's so much else going on. Make it easy. This is how much it's going to cost to take care of you. It includes alignment and includes a restoration of your teeth and everything you need along the way. Make it easy.
[35:37 - 35:43] Rob: Make it easy. Bottom line and keep them in communication as you said before, let it be their decision. We keep them informed.
[35:43 - 35:46] Josh: Yep. That's it.
[35:46 - 35:58] Rob: Speaking of informed, there's a new technology with iTero coming out that I was not really aware of up until very recently called Near Infrared, something like that? NIRI? Can you tell me a little bit about that? Oh you’re in it, yeah.
[35:58 - 38:32] Josh: So we've had NIRI for a few years on the scanner, and what NIRI does is it carries detection technology. So as one of the cameras in the iTero one now, basically transluminates teeth with infrared light and what we find is teeth with carries, the carious lesion, will absorb more light, more infrared than hard sound tooth structure, which bounces more off. And so, you can actually see, in a little window on the scanner, these little, like, white spots. It's really good at detecting inner proximal carries. It's like class two’s, especially incipient ones that sometimes are too small to show up on bite wings. You can see this, like white spot in the marginal ridge. So it's really great at tracking decay. We've got pretty good data on it. A multi-site multi-nation study of around 6000 patients shows that it has the same sensitivity and specificity as perfect bite wings. The problem with bite wings, which are great, but bite wings, oftentimes you have overlap in the contacts if the sensor in the X-ray head isn't positioned just perfectly. And with intraoral scans you really don't have that. So it's a great adjunct to bite wings. And we never tell anybody not to take radiographs when you need them. But it doesn't emit any ionizing radiation. So let's say for like pregnant patients that's a great way to keep you know, abreast of any carries. It could be happening on a patient that you're not going to take radiographs on. And it's great for seeing more than what a radiograph can show you. There's another, the Trios family of scanners has fluorescence technology. And I think they're 4,5, and 6. And so it's using the same sort of idea, just a different technology where it uses fluorescent light on the teeth. Areas with carries absorb more of that fluorescent light so they appear darker on this view, on this filter, on the scan. But that tells us, this goes back to what we started talking about at the beginning, which was like, why would they put carries detection tools if they wanted you to buy a scanner and use it just to scan crowns? Like, I don't need caries detection when I'm scanning a crown, I remove the carries. That's why we're doing the crown. I'm scanning the crown so the lab can make a restoration for it. But if they're putting carries detection tools in they’re telling you where they want you to use the scanner, and it's not in restorative dentistry. It's on the new patient experience, the recall patient experience. It's informing and educating patients. So they say yes to treatment. That's really what it's about. And that's where it comes from.
[38:32 - 38:37] Rob: It's looking further down the road… to see what's coming.
[38:38 - 39:29] Josh: So all these tools: outcome simulation, change monitoring, carries detection. This is all, you know, what basically makes it is that your intraoral scanner is the digital hub of your practice. And so you end up collecting this massive data on all your patients, which is really, really nice to have around, you know, for all kinds of different reasons. I've had patients where somebody fell down and broke their front teeth. In the past, I'd be free forming those composites. Right. Well, now I've got a scan on them from their last visit, so I 3D print the model. Can make a putty matrix, and then I can basically rebuild their teeth in composite exactly how they were before they broke them. Really cool. I would never be able to do that if I didn't have all these hands on patients throughout their journey through my practice.
[39:29 - 39:34] Rob: Is there anything else about having the archive data that surprised you or come in handy like that?
[39:34 - 40:31] Josh: Yeah. For sure. So, like, I had a patient this week, who broke her tooth. Has a partial. In the old days, it'd be like, I don't know what. Am I going to send the lab the partial for a few days so they can wax up the crown or whatever, like, no, it's like I just sent the lab the scan from six months ago, this is tooth number three, tooth three broke but it's an abutment for the partial. Here's what the tooth was like before it broke. The day they came in, the tooth was already broken, so I couldn’t do a scan of it then to do a pre-treatment scan to match. The tooth was already broken. So I had the outline of the scan from last week or from last month, six months ago or whatever sent that to the lab. They were able to duplicate that with exocad doing a big, like a bio copy basically. Milled out a crown that was the exact same shape and contour of their tooth before. So the partial just slides right in. It makes all those things way easier when you have that long term data on patients.
[40:31 - 40:34] Rob: And you just keep scanning every time they come in.
[40:34 - 40:56] Josh: We scan most adult patients once a year. So what we like to do is we like to line up to where they're either getting a scan or radiographs on their visit. Only at one visit are they getting both, and that's their new patient visit. They get both a scan and X-rays but otherwise it alternates from there. So scan, X-rays, scan, X-rays, scan, X-ray, throughout their hygiene recall appointments.
[40:56 - 40:59] Rob: Gotcha, but you do keep it basically an annual record of them and that way-
[41:00 - 41:01] Josh: Absolutely. Yeah.
[41:01 - 41:06] Rob: If situations like this arise or anything else unforeseen, you have something you can fall back on and reference.
[41:06 - 41:06] Josh: Absolutely.
[41:07 - 41:11] Rob: And as you said before, you can monitor the movement of the teeth as well to see-
[41:12 - 41:13] Josh: Yeah, or ware, or gum recession.
[41:13 - 41:13] Rob: Yeah, exactly.
[41:14 - 41:32] Josh: And show them, and that’s why I’m saying, I show them like, hey, look at your gums here two years ago. Look at your gums today. See how they've changed. We got to do something about this or it's going to get worse. Right. And then they can see it. They can own the problem at that point because they see it with their eyes. They don't notice it because they don’t look at their gums every day. If they do, maybe they don't.
[41:32 - 41:34] Rob: But nobody sees the grass grow.
[41:34 - 41:52] Josh: Exactly. That's exactly what it is. That's exactly what it is. So it's just a great tool for all of these things. It's really amazing how much you can do with this data. And at the end of the day, it just comes down to getting patients educated so that they say yes, educated patients say yes. The bottom line, that's what it is.
[41:52 - 42:02] Rob: Where would you say would be a good place for your regular GP to dive into this so that he can start educating his patients on this and incorporating some of these techniques into his practice?
[42:02 - 42:48] Josh: Yeah, start scanning your patients. That's where it starts. Start scanning your new patients. And then slowly add in your recall patients, as time allows and as you get more used to it, that's really it. Just take your next ten new patients, scan them with your scanner, and just see if they say yes to treatment more than the people that you don't scan. It's going to be yes. And once you see that, it's like game over, you want to scan everybody. And then the dynamic changes. But you got to get your team on board. And so, you know, how do you eat an elephant? You take bites, right? So start with new patients. That's the low hanging fruit. Those are the ones you need to try to maximize anyway. And that's the easiest to start with. Once you do that then it's easy to start growing on your recall patients as time allows, and as they come into the practice. Just start with your new patients.
[42:48 - 42:53] Rob: That sounds like a great place to start. That's so exciting. Thank you so much for being a part of this.
[42:53 - 43:40] Josh: Yeah. No thank you guys. Thank you guys. I, I, like I said, we're a happy customer of Evolve and we've there's literally not a day that goes by that we're not using exocad for something. Sometimes it's as easy as creating a model. Sometimes we've, you know, got a patient who needs a bridge, who's missing a tooth and we want to make a nice provisional. So we, you know, build the model with a pontic on it or whatever. Like, sometimes it's silly stuff like that. Sometimes a full smile design, all kinds of stuff. But, having exocad in your practice has really become a really important tool for us. And so, I thank you guys for, for, being involved with Diana Tadros’s courses, and getting my wife set up with our whole exocad setup. So it really does make a huge difference in the workflow to practice.
[43:40 - 43:46] Rob: It's such a powerful tool. And we appreciate you being a part of this. It's very exciting.
[43:46 - 44:49] Josh: I'm just a paying customer man, and happy to do it because it really does. You know, you look at it like an exocad purchase and it's not inexpensive. But you guys do offer a lot which I have never heard of anybody that you can just jump on with a designer. You know, schedule on there or Calendly link or whatever and get on and have them help you design something. The support is amazing. You guys remote it in and set everything up. It was super duper easy. But it's an investment that pays off. And if you're catching all this internal data and you have a tool like exocad, that really makes that to where you can do things that you never imagined you could do, and you can do them quickly and then add on the 3D printer from there. Whichever 3D printing workflow you have, the missing key is the design in the middle, right? And so, you guys have a whole number of options and a suite of solutions for that. So, I just appreciate you guys being a, progressive voice in the world of digital dentistry and bringing digital dentistry to everyday dental practices like mine. It's appreciated.
[44:49 - 45:06] Rob: We appreciate you being a part of it. It brings it down to, bringing better care to the patients, connecting with the people who, at the end of the day, are receiving the treatment through the whole reason that we're doing any of this right. We're trying to bring better restorations, better treatments, less invasive treatments, if possible.
[45:06 - 45:08] Josh: Yeah, yeah. And more predictable.
[45:08 - 45:14] Rob: More predictable. Absolutely. And you said you've incorporated 3D printing into your practice as well.
[45:14 - 46:16] Josh: Yeah. We have a couple 3D printers that we’re running. So we have a SprintRay Midas, so we can print restorations pretty quickly. About ten minutes for Crown, five minutes or so for an inlay or an onlay, seven minutes for a veneer. We have a Pro2 where we can print models, night guards, surgical guides, shells, things like that. Bridges, all that kind of stuff. So we're using them kind of for long term provisionals, the restorations we do, or like the inlay instead of a composite, you know, inlay or a big, big, you know, or surface composite will print a composite onlay, using the Midas. I would love to see some more evolution in the materials that are available for printing restorations and have them add some more strength and wear, capabilities and all that, but we'll get there. You know, we're early on in that, in that journey, of these 3D printed materials, it will only get better. But again, like, if I don't have a design, I can’t print a restoration. Right. So like, the design is the missing link in the middle. People have scanners. People have printers. But exocad in the middle is what makes the two work right?
[46:17 - 46:20] Rob: Absolutely. What good is a canvas without a paintbrush? Right?
[46:20 - 46:26] Josh: Exactly right. Exactly right. I guess you could be Jackson Pollock and just use your hands. But it gets messy.
[46:26 - 47:29] Rob: Not if you're trying to match eight and nine. Hehe!
[46:29 - 46:34] Josh: Yeah, you can't do that. You can't do that. You can't do that.
[46:34 - 46:39] Rob: And speaking of places to start, where, where can people find your courses? Where can they find you online?
[46:39 - 48:09] Josh: Yeah. So if you're interested in the Molis Coaching fusion course, go to moliscoaching.com. There is a tab that says Live Courses. I think fusion is the second one listed. That's a great thing if you're looking at really growing that ortho-restorative part of your practice, incorporating ortho with your restorative dentistry, to get better outcomes for patients and be more conservative. You can always check my Instagram, @joshuaaustindds. And then I do a lot of courses with Invisalign. And so a lot of times I'll come to a local area, and, you know, do a study club. I do a lot of Seattle study clubs. I don't know if you guys are familiar with them. And I don't know if I'm breaking news or. I don't know if I should say this, but let me say it this way. I just joined the faculty of a major education restorative education center/platform that many of the people may know. And there will be some announcements about that coming forward. So watch my Instagram for that. But, hold on, I got- it's education. I'm sorry. So, that should be coming soon. So, there will be about 8 or 10 courses a year, at this education center that may or may not be in Scottsdale, Arizona, where you could come learn ortho-restorative, intraoral scanning with the iTero Lumina. And how to maximize that for restorative scanning and for consultation purposes and for records and all that stuff. So lots of places to find me.
[48:09 - 48:24] Rob: That's so exciting, man. Wow, it sounds like you're really on the edge of all this, though, and it's really cool to hear your voices from both teaching and in the real world. Putting these practices to use, with real patients in real-time.
[48:24 - 48:26] Josh: Sweet. Well, thank you guys. I appreciate it.
[48:26 - 48:48] Rob: Thank you. And thank you, everyone else for watching. This has been the Evolution of Dental Podcast. Remember to look for us on all the podcast platforms. Remember to like, subscribe, share the show with your friends and never stop evolving.
