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Office Visit: Dr. Joshua Nagao by Kyle Patton, associate editor

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Categories: Practice Management, HR and Accounting;
Office Visit: Dr. Joshua Nagao 

by Kyle Patton
photography by Takashi Sato

Dentists spend most of their working hours inside their own practices, so they usually don’t get many opportunities to see what it’s like inside another doctor’s office. Dentaltown’s recurring Office Visit profile offers a chance for Townies to meet their peers, hear their stories and get a sense of how they practice.
From graduating first in his class clinically at The Ohio State University to being recognized as a top dentist by his peers in Tucson, Arizona, Dr. Joshua Nagao's success has seen no rest.

Before leaving dental school, Nagao found himself shadowing a prominent oral surgeon keen on showing him the ropes. He took that knowledge and ran with it. Today, as an instructor with Implant Pathway, Nagao teaches the ins and outs of implants in continuing education workshops.

Back at Designer Dental, the practice he took over in 2016, production has climbed and climbed— to the point Nagao is planning to double the size and scope of his practice. With an impressive (and growing) collection of technology and a core of staffers who’ve been on the team since day one, Designer Dental serves as an example of what a fee-for-service office can accomplish.

In our exclusive Q&A, tour Designer Dental while Nagao talks about creating a practice on pace to hit $2 million in production, why dentists shouldn’t sleep on offering sedation, which tech investments were worth the spend, and more.
Office Highlights
NAME:
Dr. Joshua Nagao

GRADUATED FROM:
The Ohio State University

PRACTICE:
Designer Dental,
Tucson, Arizona

PRACTICE SIZE:
2,500 square feet; 5 general operatories, 1 surgical suite

TEAM SIZE:
9

How did you find your way into dentistry?

I always knew I wanted to end up in the medical field, but didn’t know exactly where. Growing up, I had an affinity for business and working with my hands, so when I shadowed one of my mentors who was a dentist, I found it to be the perfect fit. I loved that it involved medicine but also cosmetics, and potentially more business involvement than would be associated with traditional medical doctors. I was lucky to grow up with a close friend, Dr. Jarron Tawzer, who also had the goal of becoming a dentist—and did— so we were able to push and encourage each other.


While you were still in school, you worked with a prominent oral surgeon. How did this experience alter your career trajectory?

It was the most formative experience in my dental career. A bit of back story: I had finished my graduation requirements during the third year of dental school, so I wasn’t assigned any more patients in the clinic and it was basically up to me to find something to keep me busy until graduation.

Luckily, an oral surgeon I’d been volunteering with invited me to shadow at his office when he found out I was looking for opportunities. I ended up working with him for about four months. During that time, I was able to perform most of the procedures offered in his practice.

This was a small, rural oral surgery clinic, so the most common procedures were extracting wisdom teeth, full-mouth extractions and removing grossly decayed teeth. Nothing fancy—no implants, no all-on-X cases, no cosmetic oral surgery—but I was able to get very proficient with all the other areas of surgery that are the hardest to learn: laying a clean flap, repairing a sinus, taking teeth out atraumatically, suturing, aspects of general anesthesia, etc. This experience made me the dentist I am today and greatly influenced my choice to pursue a focus in implants and surgery.


In a short period of time, you’ve gone from implant student to implant teacher. What’s key to adding this (or any) additional service to a doctor’s toolbox?

I’ve been teaching at Implant Pathway for the past 3½ years—in fact, I started as a mentor there just three years after graduation—so I’ve seen hundreds of doctors learning a new skill set. I also do a significant amount of private, in-office mentoring for doctors who have higher skill sets. Based on what I’ve seen during that time, I think a lot of it comes down to teachability: No matter where you are in your skill set, there is someone somewhere who can teach you something.

I like to have the mindset that I could go to an intro implant course and if I haven’t learned something, it’s my fault. Whether doctors come to Implant Pathway, hire me for private mentoring or attend a lecture, the ones who seem to be the most successful afterward are the ones who are humble, ask questions and are there to learn. The ones who try to argue a point or prove they “know more than you” don’t seem to find success.


You’ve gone through rigorous steps to become certified in IV sedation. What led to this decision, and how has it worked out for your practice?

A large part of my decision was based on the experience I had at that oral surgery office with general anesthesia. I saw how nervous patients were to come in and how convenient it was for them to be sedated. I learned I didn’t want to practice without the ability to sedate in my office.

Since then, intravenous sedation has become a huge part of my practice. We get the chance to see and help patients who have huge dental fears or have sometimes avoided visiting an office for years. The ability to sedate in our office has led to larger cases, and the opportunity for other dentists in my area to refer to us. I would say doing IV sedation has had a larger impact on the growth of my practice than almost any other factor.


 Tell us about your current practice, its history and the surrounding community.

Even during dental school, I was looking for an office to purchase. Early on, I knew I wanted to own my own business. I found an exceptional fee-for-service office in Tucson that had been started by Dr. Stephen Sailer.

Dr. Sailer was Pankey-trained, so I learned a great deal from him while we worked together. I purchased the office about six months after I graduated from dental school and slowly grew the surgical procedures done in the office. Today, we’re about half surgery and half general dentistry.

When I took over the office, we were producing around $600,000 a year; now, we’ve grown to where we are just under $2 million. A huge part of that growth is because I have been able to keep basically all of the staff that was here on day one.


You made a decision early on to invest heavily in technology. What do you have under the hood? Was it worth the ROI?

Technology is my favorite! I love having new and exciting technology in my office. I think part of this goes back by to my Asian heritage: I love electronics, gaming, etc. I would say a majority of the technology we’ve invested in has had a huge return on investment.

The latest system we acquired is the Amann Girrbach Ceramill Motion 3, a five-axis ceramic mill along with sintering and glazing ovens. This allows us to fabricate full-arch zirconia prosthetics that connect directly to multiunit abutments in our office.

I also have the SprintRay Pro55 and Pro95 printers (along with the wash and cure system) and a full Carestream suite of technology, including CS8200 CBCT, a CS3800 intraoral scanner, CS2400 handheld X-ray units and CS1500 intraoral cameras.

Digital design is an important part of my practice, so I have the full Exocad CAD software suite.

I think my favorite pieces of technology are my cameras. I have a Sony A7 III and a Sony A7R V mirrorless cameras with a variety of lenses and lighting setups for everything from intrasurgical photos to portraits. These photos serve many important uses, including patient education, case presentations, publications and lectures.


Where do you imagine dental offices will be 10 or 20 years from now as far as treatments offered?

My guess is that technology is going to make things more efficient, more affordable and more comfortable for the patient. I expect most restorations will be able to be made chairside and 3D printing of materials will overtake the market, eliminating most milling by expanding into full ceramic and zirconia printing capabilities.

I imagine intraoral scanning will improve to the point where scanners will be able to differentiate between tissue, blood and tooth so subgingival margins can easily be detected without cord or laser troughing. These scanners will likely also be able to measure perio pockets, eliminating probing, and will become very efficient at shade-matching.

Artificial intelligence will become a huge part of dentistry. Radiographs will likely be put through algorithms to detect carious lesions. CBCT imaging or some variation will likely get to the point that extraoral images will be all that’s required to efficiently diagnose, as opposed to intraoral sensors. It’s an exciting time to be in dentistry because most if not all of these ideas are already in development.

One sad thing I do foresee is that 20 years from now, we will still have many offices practicing exactly like they do today despite the advances, just like we have many offices today practicing with the same techniques they did 20 years ago.

Top Products
Carestream Dental CS8200 3D. I would not practice without this CBCT technology. Between improved diagnosis and providing the ability to safely plan surgical procedures, there may not be a more important piece of equipment in my office.

Amann Girrbach Ceramill Motion 3. This five-axis puck mill allows us to fabricate myriad restorations in various materials in-office, which helps control costs and gives us the ability to customize final restorations.

Exocad DentalCad software. This software designs everything from single crowns to full-arch restorations. One of the things I find most valuable about Exocad is that designs can be quickly updated.

SprintRay Pro S 3D printer. I have two SprintRay printers, and they get used every day. If you are looking to move into the digital world, 3D printing technology is a must. We print models, wax-ups, shell temps, and even toys for my kids once in a while.
How has your FFS structure translated to practice expansion?

We’ve been blessed to continue growing every single year since I bought the office. We are actively looking for a larger space—the goal is to double the size of the office and add a partner dentist who can manage the day-today dentistry while I focus on larger cases and surgery. The space will also house a lecture hall so courses can be taught and at least two large surgical operatories that are large enough for observation.

I will admit that sometimes being a fee-for-service office is scary. I have patients who have been coming to me for a long time who let us know they’ve decided to find a dentist in their network. That never feels good, but we have found many times they come back after a few visits because they didn’t get the same level of service.

Being a fee-for-service office has allowed me to treat patients according to my skill set and style, instead of being limited to what an insurance plan covers. It allows me to see fewer patients every day and really focus on treating the entire mouth, not just individual teeth. People laugh at me because I always say my ideal day is to see two to four patients and really focus on comprehensive treatment.


What’s your advice for docs who want to transition away from insurance?

It’s a tough situation, without question. On one hand, practices can do really well on a PPO schedule: I know a lot of dentists who do great work and have full schedules while being in-network.

I think it mainly comes down to how you want to practice. For doctors who want to take more time with patients and get into treatment plans that center on treating the whole mouth instead of individual teeth, I think it’s great. I can see why it would be terrifying, though: Dropping insurance plans that you’ve been in contact with for a long time comes with the risk of losing patients.

My advice would be to start slow. First, hire someone to negotiate the fees on the plans you are contracted with. Many times, you can improve your reimbursements.

Then, drop the plans that lose you money. If there’s a plan that pays you $10 for a prophy, drop it—stop saying yes to losing money. Drop a couple of plans a year if your end goal is to get to full fee-for-service, but also recognize that people are willing to go to that type of office because they expect a higher level of service and attention.


What does the future hold for insurance plans?

It’s a messy situation. We have DSO companies and insurance companies sponsoring and funding dental schools, and I think that’s a problem. When huge for-profit organizations are having a tremendous influence on the future of dentistry, with profits and pleasing shareholders as a primary motivator, both doctors and patients suffer.

It also makes it much more difficult for smaller, independent offices to compete because they don’t get the discounts on supplies, equipment, etc., that big companies get. I do think there is a place in dentistry for DSO offices and insurance, but they are becoming heavyweights.


Walk us through your management style.

I’m probably the most laid-back “manager” you’ll ever meet. My office manager has to be the enforcer because I’m the kind of person who just wants to get along with everyone and be their friend.

That being said, I believe my team respects me because of that relationship: They know when I do call them out or ask them to change something, I’m serious. I think any management style can be successful—you just have to surround yourself with people who can fill in the traits you don’t have.
A before and after of an anterior case by Dr. Joshua Nagao that involved immediate extraction (socket shield) of Tooth #9 and anterior veneers.
BEFORE
Office Visit: Dr. Joshua Nagao

AFTER
Office Visit: Dr. Joshua Nagao


What kind of cases excite you the most?

I love cases that are hard: Front-teeth implants, in particular, have been something people specifically travel a long way for me to do. Out-of-state dentists have called the office because they heard I do a lot of them.

I’m a also huge fan of tissue aesthetics, and even have said if I were to go back to school, I’d do perio. (I know, that’s crazy. I never would have said that before.) That’s part of the reason I really like anterior implants. They are hard, but if you do them right, nobody will ever know that a tooth is an implant.


What’s a trend in the profession you love?
I love that treatments and technological advancements are pretty much all centered around the patient. We have technology that makes things more efficient, less expensive and more comfortable, benefiting the patients in the end.

I also really enjoy seeing so many young dentists finding out what they love in the field. It’s so rewarding to see passions ignite and imagine the possibilities of where these colleagues may end up in the future.

The best thing in dentistry is that there are endless options. If you like surgery, you can do surgery; if you like ortho, you can do ortho. My advice is to find what you like. Find what excites you and become the best at that. If you don’t love what you are doing, you won’t want to do it.


Give us a snapshot of your life outside of practice.
It’s crazy! You’ll find me chasing or chauffeuring one of our three kids to gymnastics, soccer, etc. Most days, my wife, Lacey, and I have to divide and conquer to get kids where they need to be.

I love old Japanese cars. I have a 1993 Acura NSX that is a blast, and I’m currently rebuilding a 1970 Datsun 240Z. When we actually have time, we do love to travel and prefer somewhere with sand and water.
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