EforAll Lynn Winter 2020 Cohort

The EforAll Lynn Winter 2020 Cohort is coming together and Metatooth will be part of it! EforAll’s Lynn Community offers twice-a-year business accelerator programs and “pitch contests” focused on nurturing local entrepreneurs. Core values are Inclusivity, Empathy, Collaboration, Respect, Performance, and Drive. Entrepreneurship for All began in Lowell-Lawrence, MA as Merrimack Valley Sandbox in 2010.  It is the brainchild of Jaishree and Desh Deshpande, with initial funding through their Deshpande Foundation.  It has since expanded across communities in Massachusetts and has recently welcomed Longmont, CO to the fold.

It’s already been helpful to participate in the application and interview process. Interviewers and application reviewers have highlighted questions and prompted reflection on my motivation and goals. The core of the program is twice-a-week workshops over the next 12 weeks. Mentor matching happens at program start and mentors meet with entrepreneurs over the course of the following year. Participants are expected to leave the 12 week workshop period with a 9-month plan to grow their business.

There is a lot of moving parts in any operation. I’ve previously relied on SCORE and the Greater Lynn Chamber of Commerce for business questions and advice. I plan to go back to that well, too!

Thanks to the staff & volunteers of EforAll Lynn for their attention during the application process. How are you engaging with your local community to strengthen your business and achieve your goals? Tell me about it in the comments!

custom-night-guard development

Night Guard Design

Night guard design is done! Read about my scanning experience here.

I am using FullContour, LLC for design services. Super easy interfaces, works well with STL files. I use “design approval” but I am not sure I would make any changes. 2mm occlusal, 1mm buccal/lingual. Shallow trim. Can’t wait to evaluate the fit!

What’s your night guard design preference? Tell me about it in the comments!

dental-lab review


SHINING 3D’s AutoScan-DS-EX is an entry-level desktop dental scanner.  Their website describes it as cost-effective and at $5,000 it is. For that price, you get structured white light, two cameras, a swing arm & turntable, a collection of mounting jigs, calibration plate (more on that later), a USB drive with software, a USB dongle for licensing, and a package of Blu Tack.  You will need an Intel Core i7 processor, NVIDIA GTX 750 graphics card, and Windows 7 or later. Check out Metatooth’s setup!

I had two problems setting up. Each were quickly addressed by my supplier, Bayshore Dental Studio, and SHINING 3D Dental Support.

1. The software version on the thumb drive was not able to connect with the scanner.  I was sent a Google Drive link to download version 2931. It would have been nice to get this information ahead of setup, but it was quickly resolved. The customer service rep used Team Viewer to review my machine, this happened over night for me, given their location.

2. Take off the protective plastic cover before trying to scan the calibration plate!

The case entry form will be familiar to exocad users. I haven’t had reason to scan more than impressions. Additional scans were needed to fill holes; the default scan paths did not give complete coverage. Hopeful for a way to change the scan paths or possibly issue arm/turntable and capture commands to the scan server itself.

Any other AutoScan-DS-EX users out there? What has your experience been? Tell me about it in the comments!


NGINX Heroku WordPress

NGINX, Heroku, and WordPress combined. This website is powered by WordPress on Heroku. Details on configuration are here.

My next #DevOps task is to add NGINX in front of the WordPress application. In the future, this could be used as a load balancer. Until then, NGINX will reverse proxy the requests to the Heroku application instance.

To start, I spun up a virtual machine running Ubuntu on Amazon’s EC2. Check out how to install and configure NGINX here. Make sure to open your firewall to HTTP & HTTPS traffic!

I encountered two major issues:

  1. The request passed by NGINX through the reverse proxy was not being understood by Heroku’s application stack.
  2. Once the application stack properly handled the request, WordPress’s response triggered a redirect loop.

Reverse Proxy

Heroku’s stack uses the host of the request to route to the appropriate application instance. The originating Host value is (in my example) ‘’. Heroku shouldn’t respond to this. Turn off the app’s Custom Domain feature if it does. Update the reverse proxy to set a new Host header that Heroku will respond to.

server {

    location / {
        proxy_set_header Host;

    # configure SSL here

Redirect Loop

Setting the Host request header got Heroku’s attention, now WordPress responds to that request with a redirect loop. I encountered this problem while trying to configure an HTTPS-only WordPress installation. The way out of the redirect loop was to update two more request headers and then to use those headers in the WordPress configuration. Here’s the new section of wp-config.php

if ( $_SERVER['HTTP_X_FORWARDED_PROTO'] == 'https' )
        $_SERVER['HTTPS']       = 'on';
        $_SERVER['SERVER_PORT'] = '443';
        define('FORCE_SSL_ADMIN', true);

if ( isset($_SERVER['HTTP_X_FORWARDED_HOST']) ) {

That gets WordPress to not redirect to https on these proxied requests, but only if the request headers of X-Forwarded-Proto and X-Forwarded-Host are specified. The NGINX configuration now is:

server {

    location / {
        proxy_set_header Host;
        proxy_set_header X-Forwarded-Host $host;    
        proxy_set_header X-Forwarded-Proto $scheme;

    # configure SSL here

That’s how I got NGINX, Heroku, and WordPress to play well together. Next task is to use an upstream for the proxy_pass directives. What’s your infrastructure layout and what did you learn along the way? Tell me about it in the comments!


Docker Ubuntu 19.04

Docker on Ubuntu 19.04 is a cinch. “Dockerizing” an application is a great way to ensure you understand it’s dependencies. I always forget this last bit when setting up a new machine.

sudo usermod -aG docker username

Otherwise, I recommend this Medium post by Grigor Khachatryan.

It turns out that LAMP Ubuntu 19.04 is the most popular Metatooth blog post. Can’t argue with success. More #DevOps posts forthcoming! I’ll certainly keep posting about teeth and technology, too.

What other “crowdsourced” finding has surprised you recently? Tell me about it in the comments!



SmileDirectClub IPO

SmileDirectClub and it’s initial public offering is in the news. The numbers cited are astounding: revenue of $423.2 million in 2018; 700,000 customers since 2014; $945 million addressable market; $393 million in funding (Shen, 2019).

Legal and regulatory hurdles remain. SmileDirectClub is suing the state dental boards of Alabama and Georgia to remove the requirement that a licensed dentist be present for the 3D scan of the patient. Arkansas has a law, co-written by a state representative who is also a dentist, that requires in-person exams before a doctor can treat a patient remotely.  If the attorney general of that state takes action, expect a lobbying effort by SmileDirectClub (Mandelbaum, 2019).

The question remains: can you collect enough data to make a treatment decision (for example, start clear aligners or referral to a local orthodontist) remotely? If it’s really not possible, then more innovation is needed to make it so. Teledentistry provides a way to bring better oral health to under-served regions. The technology and infrastructure built to disrupt the orthodontic industry should have a side benefit.

Align Technology Inc.’s 17% stake is looking pretty good. What other disruptive startups have backing by industry leaders? Tell me about it in the comments!


Shen, Lucinda. Fortune (August, 16, 2019) Brace Yourself: SmileDirectClub Is the Latest Unicorn to File for an IPO Accessed August 23, 2019.

Mandelbaum, Robb. Bloomberg Businessweek (August, 22, 2019)  A Tooth-Straightening Startup Runs Into Resistance Accessed August 23, 2019.


Open Formats and Protocols in Dentistry

Open formats and protocols in dentistry first appeared in the 2000s. They grew from the need of dental laboratories to integrate equipment for digitizing study models, designing dental prosthesis,  and manufacturing those products. Many software systems are “walled gardens”, where everything inside the walls are manicured but there is no way to access other gardens.  Of course, outside the walls the landscape is *not* manicured, so a robust integration method is needed. The “gardens” in this case were the Dental CAD/CAM systems of the 1990s.

Dental laboratories pressed for open integrations so they could make effective outsourcing decisions about how to manufacture these products.  Dental CAD customers demanded ways to manufacture their products using the tools or partners they determined was best for their business. Performance tuning for specific equipment may still be needed, however the issue of connectivity between different vendor’s CAD and CAM is no longer an issue.

The same market forces that drove open formats and protocols between digital dentistry tools are now coming to bear on dental imaging and business software.  Some dentists are demanding it in the pages if Inside Dentistry:

Dentists should not be beholden to any company for the ability to access and use their data in the manner that they see fit. (Jablow, 2019)

Improving patient care while meeting the demands of the dental insurance industry will drive this move to open connectivity. For the patient that would be portability of dental records and image.   If market forces are expected to be efficient, then artificial barriers to patient choice need to be reduced.

The application of machine learning algorithms to dental imaging improve the accuracy of diagnosis, which could create demand for earlier interventions as well as reduce unnecessary ones [1].

Lastly, open formats and protocols will lower integration costs for the dentist [2]. Administrative costs are one of the largest drivers of dental (and overall healthcare) costs. In this way the dental industry will take a lead from dental lab owners in demanding  connectivity to improve patient outcomes.

How is open connectivity impacting your business? Tell me about it in the comments!


[1] Shah, Agam, AI Can Lead to Lower Dentist Bills, Wall Street Journal (July, 16, 2019) Accessed 2019-07-19

[2] Jablow, DMD, Martin, Digital Dentistry Data, Inside Dentistry (July 2019) Accessed 2019-07-19



dental-lab manufacturing

Terry Lorber mentioned on IDT Weekly

Metatooth’s Terry Lorber is mentioned in Episode 26 of IDT Weekly. IDT Weekly highlights articles in the peer-reviewed Inside Dental Technology publication. IDT is a resource and learning tool for dental laboratory owners and managers. This month’s issue (July 2019) includes a Continuing Education article entitled “Does it Scale?”, by Terry Lorber.

The article covers a range of topics, from the mundane (for example, network topology) to the more philosophical (for example, lean manufacturing). The aim is provide concrete examples on a number of ways to bring the latest business technology to the dental lab. For inspiration, the author looks to examples from his experience in dental startups, where the growth expected by investors must be supported by robust and reliable information systems.

Need help with integrating dental & business technologies? Contact us to find out more. Do you have examples of scaling information systems for dental manufacturing? Tell me about it in the comments!



Lean Manufacturing and Kaizen

Lean manufacturing is a term and concept that grew from the heralded Toyota Production System of the 1970s. Toyota was able to up-end the North American car market by becoming efficient at building high-quality cars (Roos, et al., 1991). Lean manufacturing encompasses many practices for identifying and removing waste from the manufacturing process. These concepts are beneficial to startups, small businesses, and large manufacturers.

A kaizen event is a 2 to 5 day effort focused on one business process or workstation. The kaizen team should be made up primarily of the team members who conduct the process under scrutiny. You may start with 5S: Sort, Set in Order, Shine, Standardize, Sustain. Safety is job one! After the workstation is in order, document the process. Make note of every step. Measure the process. The goal is to remove waste, not to speed-up the value added steps.

Look for repetitive tasks that don’t add value. Can they be automated? An example of waste is duplicated data entry. Strive to enter data only once into your master database or lab management system. Look for ways to export/import to downstream workstations as needed. Traceability is not just a requirement the FDA places on medical device manufacturers, it is valuable on it’s own as a tool to reduce errors and improve quality.

Make a change and re-measure. Repeat as necessary. Celebrate your team and their improvements at the end of the kaizen event.

Interested in learning more about how to hold a kaizen event? Contact us for more information. Have you held a kaizen-like event? Tell me about in the comments!


Roos, Daniel, Ph.D.; Womack, James P., Ph.D.; Jones, Daniel T.: The Machine That Changed the World : The Story of Lean Production, Harper Perennial (November 1991), ISBN 0060974176, ISBN 978-0060974176

dentistry review

Teeth and Oral Health in America

Teeth and oral health in America is a complex issue, which invariably means class is involved. The mouth is part of the body, but for reasons that remain unclear, dental colleges were created separately from medical colleges. This silo-ed approach to education has been mirrored in the way dentistry is delivered, separate from physical care. The real economic pressures that have created our current healthcare crisis are also shaping the way oral healthcare is delivered. Mary Otto has authored a book investigating the oral healthcare landscape.

The Story of Beauty, Inequality, and the Struggle for Oral Health in America

By Mary Otto
291 pp. The New Press. $26.95.

This book was brought to my attention by a recent article on dentistry in The Atlantic. Otto covered oral health for the Washington Post and is now the oral health topic leader for the Association of Health Care Journalists.  She’s contributed to and while Teeth is a scholarly work supported by ample notes, it remains highly readable. It was reviewed in the NY Times Sunday Book Review after it’s publication in  2017. The topics it covers are just as relevant in 2019!

The state of one’s teeth says a lot about one’s economic status. The same economic forces that have driven the uptake of cosmetic dentistry also make it harder for oral healthcare to be delivered to under-served populations. Initiatives that could help deliver oral healthcare face opposition from dental associations. These initiatives typically involve allowing dental hygienists to provide (unsupervised by a dentist) cleanings to school children in “dental deserts” or expanded licensing for dental therapists.  These are policy changes that can and do work, but push back from organized dentistry has been hard.

One example given is in the case of Deamonte Driver, whose death from an infected tooth drove the State Children’s Health Insurance Program debates of the aughts and the Affordable Health Care debates of the teens. It seems like the simplest solution to providing access to oral healthcare is expand the pool of practitioners who can provide these services, but the fear that dental hygienists could threaten the dentist’s business model is a powerful block to these kinds of changes.

What role does technology play?  I offer two avenues:

1. Technology providers need to continue to innovate with new products and therapies. Advancements in endodontics, implantology, and (yes!) prosthetic therapies provide avenues for dentists to provider better and more effective care for their patients.

2. Technology must continue to reduce costs. Not only is cost reduction attractive to technology providers, it also creates the margin space for therapies that were first developed for the premium market to be made available to the value market.

What role do providers have in improving teeth and oral health for under-served populations? Tell me about it in the comments!