So I’ve had more than my share of sleepless nights of late and my sleep cycle always revolves around what is going on in two areas:

1) My relationship with my wife and kids.

2) What’s going on in our business?

The great news is that Bridget and the kids are healthy, happy and they give me more love and joy than I ever expected to experience in one lifetime! The good news is that I’ve finally resolved the big issue that’s kept me up night after night after night for the last couple weeks…

That’s right. You guessed it. I’m going to fully embrace Invisalign in all my practices.

I’m certain that those who know me well and even those who have only casually observed what I’ve been up to for the last decade will raise an eyebrow at this turn of events.

“Burris, that doesn’t make any sense!! You’ve railed against Invisalign for years and now you’re doing a 180? You’re worse than a politician!” I can hear you saying. And you’re not wrong in one model of the universe where belief possession is the norm. In that model, we know what we know and do what we do because it’s RIGHT and to change or to admit the world has changed is tantamount to admitting we were wrong and that we are a failure. Most of us orthodontists see the world this way so take comfort in the fact that most of your peers agree with you.

I can’t argue. I’ll stipulate to all you are thinking.

I have been against doing Invisalign in my practice for a long time because I couldn’t reconcile the additional cost, the additional equipment and the cash flow issues with my practice model. However, if you’ve paid attention at all then you already know that I’ve changed my practice model tremendously in the last couple years – so this move isn’t out of line when you think about it. For starters, long before it was cool I decided to go aggressively direct to consumer in my marketing to reduce reliance on referrals from dentists. Once I had grown large enough and had become diversified enough to be self-sustaining, I decided to bring hygienists into my Ortho offices in an attempt to increase access to care while growing my business. I’m sure I don’t have to tell you how that went over with the local PCDs. Fast forward a couple years and we are now Arkansas Dentistry & Braces and we have dentists, oral surgeons, pediatric dentists and hygienists in house alongside our orthodontists. Last week I dropped my specialty license in the state of Arkansas to level the playing field and make it legal for me to see hygiene and ortho at the same time. No one, especially the dentists, thought I would ever do so. This week we made the decision to go all in with Invisalign… You see the pattern here? Do my “wild and crazy antics” make more sense in this larger context? I sure hope so because it’s scary as hell out here on the cutting edge.

I usually keep my blog posts short but I know you want more detail on the reasons I’m making this move because we are, by nature, detail people. Remember you asked for it!! Here is the short list of things I’ve been mulling over for the last 8 years. The facts and thoughts that culminated in this week’s big decision:

  1. There are 300 million people in the US, and a study in 1996 (before the clear aligner market was in existence) found that 49% would not consider going to see the orthodontist because they don’t want braces. Of the 150 million who would consider braces, only 2 million people start treatment each year. That’s about 1.3% of the people considering braces who actually end up getting them.
    • It seems that orthodontists are clawing and scratching for our share of the 1.3% of possible patients because braces are our appliances of choice – the DOCTOR’S choice not the patients’.
    • This tends to give doctors a sense of scarcity instead of abundance.
  2. The latest numbers available show that the orthodontic industry has grown 11% in the 5 years (going from 2.6 million annual starts in 2009 to ~2.9 million annual starts in 2014) while Align has grown >110% in that same time.
    • Realizing that within the ~2 million annual starts in North America, Clear Aligners were 15% of the business in 2009 and in 2014 that number was 20% – what % of all orthodontic starts do you think Clear Aligners are now and will be in 5 years? Will it be 30%? Or will it be 50%? How well positioned are we to capitalize on this changing market trend? The size of the pie is growing, while the clear aligner share of the pie grows as well. And why shouldn’t I get more than my fair share of that?
  3. The national trend is consistent. GP referrals to the orthodontist have declined over the last 5-7 years and the rate of decline is accelerating
    • The cause doesn’t appear to be that they are doing more Invisalign – Align’s business with the GP’s isn’t growing as fast as we all think
    • Pediatric Dentist practices increasingly are taking on in-house orthodontists and therefore referring out less (or not at all).
    • Straightwire is becoming more popular among PCDs
    • DSO’s are playing a significant (and growing) role in reducing the GP referrals in the market (every GP practice that they purchase is one less referral source)
  4. When OrthoClear entered the market in 2005-2006 there was a measurable impact on the percentage of Clear Aligners in the overall orthodontic market because there was more BUZZ in the marketplace as a result of increased competition. All current indicators lead to more growth in clear aligners: Orchestrate, ClearCorrect, Smile Care Club, etc.
  5. In a 2011 Harvard Business review article titled “Reinvent Your Business Before It’s Too Late”; it recognizes the importance of innovation (or reinvention) before the business plateaus in order to stay ahead of the industry/competition curve.
    • The article notes that “making a commitment to reinvention before the need is glaringly obvious doesn’t come naturally. But that’s exactly when to take action.”
  6. There are several examples of major brands that have been wiped out by technology changes in their industry. Here are 4 Reasons Kodak, Blockbuster, Blackberry, Yahoo & Other Major Brands Fail:
    • Inability to acknowledge the change in their business/industry
    • Inability to react to changes and innovate
    • Inability to stay ahead of the times – not adjusting to the marketplace or technology of competitors.
    • What Got You Here Won’t Get You There
  7. Innovation and patient demand DO NOT care about Dr. X in ABC town. Demand drives the market.
  8. I’ve reduced costs in all areas of the practice and now my goal is to drive top line growth (a la Michael Raynor) and skate to where the puck is going (a la Wayne Gretzky)
  9. Invisalign is a category creator and spends millions each year creating demand and driving that demand into practices… why not leverage this?
    • I have GPs in place and Invisalign will cater to the GP side, which is mostly adult patients.
    • Doing Invisalign allows me to get bodies in the door for Ortho and convert them into a hygiene patient and treat the necessary restorative issues over the course of the patient life cycle.
    • Invisalign is applicable to and desired by the masses- most adults don’t want braces and not every adult needs a crown or implant yet 74% likely have crooked teeth.
    • I’m looking for practice growth on the GP side. Invisalign will be essential. Practice growth begets practice growth and bigger PCD practices means more Ortho referrals.
    • Increase conversion- patient preference plays a role in conversion.
    • Enhanced patient experience which increases in office referrals – Patient is sitting up in chair and short visits offer doc ability to make eye contact, build rapport and drive a positive culture in office.
  10. Efficiency/Scale
    • Less chair time increased starts without the need to increase fixed expense (associates) – hopefully this will make up for my lab bill and the time I have to spend on the computer.
    • Ability to control the treatment time and keep cases on track despite turnover or different doctors working on the same patient. Avoiding overtime is a constant struggle, as you know.
    • Ability to have aligners delivered in hygiene or by a GP. I’m just a PCD in Arkansas now after all!
    • Fewer emergencies
    • Invisalign works well in rural and remote offices and reduces the days that I have to have an orthodontist there.
    • Improvements in scanner technology and Invisalign mechanics make using Invisalign much easier and more effective.

I could go on but I won’t.

Bring the thunder tell me why you agree or disagree and why my assessment and action plan are wrong. Help me find the best practices I’m missing and point out the holes in my thinking so I can avoid missteps. Life’s an awesome adventure. Glad you’re along for the ride. I’m not afraid of dentists or big box dentistry doing Ortho… They should be scared that I’m doing Invisalign and dentistry!

11 thoughts on “Fear

  1. Can I ask just a fundamental question that is on my mind about myself and the inner fire that drives us. We strive to ACCOMPLISH, meet and exceed goals…to what end? Our own self gratification…’look what I did and awesome I am’

    Where does this get us, more stress, less than desirable sleep patterns and the feeling of never being content with where we are.

    Ive struggled with this as you know Ive created a highly effective and efficient practice that continues to demamd growth.

    Money is not a motivator anymore, as a matter of fact I’m finding it quite insulting to my family and friends. Of course we share and give however in the eyes of the working class someone who works 3 days a week making 7+ figures is very unusual.

    When do we stop this vicious cycle of abtaining more just because we can. Definitely a truly American Spirit and I celebrate and admire people of great success, especially when self made like yourself and the visionary icons such as Elon Musk.


  2. One of the best things I learned from Anthony Robbins was “Turn frustration into fascination.” What a perfect example you have outlined in your article. Paradigm shifts happen so quickly. Being in touch with what people want and find a way to make it happen. Thank you for sharing your proactive and well researched plan.

  3. I think just about everything you say is correct. But you don’t need to justify your actions. Your business, your decision. And I believe a smart one.

  4. We are lucky to be in the career we are in because we have this choice between two good options: money and freedom. It’s up to the individual to strike the balance that works for them. What you do has inherent value to other people. That’s why you make 7+ figures. You are obtaining, but you are also providing. You are providing value to people. It should never feel insulting or something to be ashamed of.

  5. Hey buddy- I think it all depends upon the motivation. If growth is simply for growth’s sake or , as you said “look at what I did”, then it might be an unreasonable goal. A goal motivated by external forces. But if the motivation is to serve more or serve better, then the growth is rooted in something greater. Look within to find the answer, Great Master!

  6. Well said! I attended my first Invisalign course in 2003. I was fresh out of hygiene school, but I remember being inspired. Not by the results at that time but by the vision of the future. As a dental hygienist, effectively treating patients in aligners makes everything easier chairside and most importantly it gives our patients a better experience and excellent outcomes. These patients are happier, their tissue is healthier and they just plain smile more. I know personally I would be far more productive as a hygienist seeing 4 Invisalign patients vs. 2 bracket patients….and that makes my job easier and more enjoyable! Thanks for sharing!

  7. Ben, with continued innovation in terms of materials and attachments and such, the technology will progress and probably become the major provider of orthodontic mechanics in the next 10 years or so. With folks like Jonathan showing us how they use the technology to push the envelope, and others willing to share ideas and show cases, we will see the demand grow even more. Align’s direct to consumer marketing is much more focused than that of organized orthodontics and they have the budget for it. Embrace the change, grow with the change, your practice will become much more efficient and if I put in a plug for a new text for neophytes to learn more, go to Quintessence Publishing: Schupp and Haubrich Aligner Orthodontics; Diagnosis, Biomechanics, Planning and Treatment. Typical German excellence! I am just enjoying it now. Best jump we have made in my 38+ years of practice!

  8. It’s all relative Brandon. Some people look at what you do and think you should settle down because you’re working too hard and you have plenty. But others might think you have a long way to go. Same goes for all of us. We can never know what’s in the hearts of others so I don’t even try to divine it any longer. It doesn’t matter to me – to each their own. I do what I do because I like it. I don’t do things I don’t like to do. That’s freedom.
    I also love to learn, grow and improve. Every day. It’s fun to me and it’s rewarding. That’s fulfillment.
    I get to spend an incredible amount of quality time with my wife and kids. We are very close and make memories daily. Nothing brings me more joy and love then my family time but family, work and everything in life touches. Life is much more like spaghetti than waffles! You can’t neatly separate aspects of your life like the rooms of a house or be a different person depending on who you’re around and be happy long term. It’s a myth. You gotta be you! Your true self. And you gotta discover who that is. Also, I want to model for my kids what it took me so long to learn. I want my kids to see that you can find something you enjoy and get good at it and do well – then it’s not work at all. I don’t even differentiate between weekdays and weekends. It’s all the same to me. I do all I do for my family and with my family. That’s purpose.
    Then there’ are my practices and OrthoPundit and and and the speaking events, and all that. I consider these endeavors all the same. I find no greater joy in life than helping others get what they want. Watching someone realize that they have it in them to grow and improve and succeed is the ultimate experience and it’s my drug of choice. I’m high on life and the result of my life’s work will be thousands of people who are better off than they were before they met me. That’s legacy.
    Finally, my life didn’t start off too great and, as a result my attitude was very negative for a long, long time. In my mid 30s though I realized that I had a choice and I could be happy and productive if I only decided to be so. I’ve lived more in the last 6-8 years than I did in the 35 preceding. I live more in one morning than most people do in a month – not because I’m better or smarter or particularly clever – but because I have worked hard to find out what I’m good at and what I like and how I can get better by reading constantly and seeking out and learning from peers and my betters. I would love to live to be 100 but I can honestly say that if I was told I would die today I would not be disheartened. Life is about quality because that’s all we can control. No one knows when they will hop off this rock no matter how fit. You see it all the time. Seize the day in all aspects of your life! No matter how well we are doing, we can always do better – with our spouse, with our kids, with our patients and with our friends and peers. People think you have to sit still and be quiet to show you’re satisfied. That’s not true at all. I’m extremely satisfied with my life but I’m also hopeful and eager to learn more and do more today. That’s life man! Live it to its fullest in whatever form you choose and don’t judge how others live theirs. Have a great Sunday!

  9. I started SDC back in August and I’m very happy with my results so far. I’m on a 16 tray treatment plan and currently on tray 11. Prior to starting SDC I wore braces for 5 years but you would never know with the way my teeth shifted over the years. I’m excited to finish in the next 3 months!

  10. Good for you! Happy it’s going well and excited you’re going to get the smile you deserve.

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