Dentistry Uncensored with Howard Farran

How to perform dentistry faster, easier, higher in quality and lower in cost. Subscribe to the podcast: https://podcasts.apple.com/us/podcast/dentistry-uncensored-with-howard-farran/id916907356

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Howard Farran:

It is just a huge honor to be sitting in my home and having one of my rockstar idol role models Dr. Anne L. Koch come all the way over to my home. On Dental Town she put up six courses in endodontics. You're the most viewed endodontist on Dental Town. Let me read your bio. Dr. Koch received both her DMD and certificates in endodontics from the University of Pennsylvania. She is also the founder and past director of the post directorial program in endodontics at the Harvard School of Dental Medicine.

Following her clinical and academic career Anne created her own successful technology and development company, Real World Endo, of which she was CEO and president. Although Dr. Koch is no longer actively involved with Real Word Endo, her passion still burns brightly. Women's issues in dental medicine, and diversity challenge as a whole are key points of interest. Accordingly Dr. Koch is very involved with women's issues and organized dentistry as well as maintaining a faculty position at the University of Pennsylvania School of Dental Medicine. Dr. Koch also maintains a position at a senior fellow with Penn Medicine. You have to be the most accomplished endodontist on earth. If someone said, "Who's the most accomplished," it'd be either you or Steven Kohn.

Anne Koch:

Okay, well thanks. I greatly appreciate that. First of all I'm thrilled to be here with you Howard. I was so thrilled to do the keynote with John Coise who was a classmate of mine. Back in 1973 I was KOC, John was KOI. We sat next to each other for four years in dental school. I've known John for 44 years. That was great, great time for me at the [inaudible 00:01:46] meeting. We just had our 40th reunion two weeks ago at Penn. A couple of things to update the CV, I'm thrilled to be back engaged with real world endo. That really pleases me completely to be back involved. Another thing I made a very significant contribution to the University of Pennsylvania. When I transitioned there were a couple of years where things were pretty challenging. Nobody had really done this. Certainly no one at my level had changed gender. Even though I thought I had done it pretty successfully in many different ways it wasn't so easy. Then Penn reached out to me. They actually had an unofficial Anne Koch day at the dental school. I met all these wonderful, wonderful students.

I stepped up and I made a very significant donation and two weeks ago they had the official dedication of the Anne Lauren Koch room. It's a big room. It's a big, big room. It's a very large lecture and seminar room. I'm so completely thrilled to be able to do that. Listen, I'm going to be very honest. Having a room named after you in an Ivy League school is way cool. Don't let anybody kid that it's not. It's way cool. There's something here far more important. I'm having another plaque made on the inside of the room. This room has been gifted to acknowledge the existence of LGBT students, residents, faculty, and staff. At the end of the day you've seen my presentation, Howard. I show a wonderful picture of me with a bunch of people from Penn. They're LGBTQA supporters, allies, students. At the end of the day I say to people, "Look at this picture. Look at the diversity. Look at the heterogeneity. Most importantly of all look at the humanity." That's what it's about. That's what it's about for you and I as healthcare providers.

That's what it's about the people out there who are viewing this or listening to this. It's a privilege to be a healthcare provider. At the end of the day there's no room for bigotry and prejudice. You and I both know what goes on whether its sexual orientation, racial, whatever, who knows, there's really no room for that as a healthcare provider.

Howard Farran:

Well said. I've had so many emails over the years about this podcast saying they so love that I mention that my little brother Paul, who's seven, eight years younger than me, he's gay. They always say the same thing, "I'm a gay dentist in a small town in the south. I'm so fearful that someone will out me because it would just be a nightmare." I'm like, "Dude, it's 2017. You can't let people know that you're gay [crosstalk 00:04:35] Texas and Alabama?"

Anne Koch:

Yeah, and the transgender thing has all of a sudden blown up, but a number of years ago, and I transitioned gender back in 2013, and I was 63 years old when I did that. That was right at the beginning of this explosion of this transgender thing. I've just written a book for Rutgers press. That should come out this next year. The name of the book is It Never Goes Away; Gender Transition at a Mature Age. It's a little bit of a cautionary tale because things have gotten way ahead of themselves. Where they've gotten way ahead of themselves has been on people over 55 and kids less than 18. There's legitimacy to both sides of that, but there are a lot of people coming in who really have to basically be better informed, think more clearly, more circumferentialy through the entire process. For us as dental providers I'm now starting to get feedback from dentists. Wait a second all of a sudden I've gone from zero trans patients to 20 patients. Listen to this Howard, this is amazing. I got a phone call maybe two months ago.

I've gone around for the last two and a half years to many, many medical conferences, being a keynote, talking about my transition, my own personal experiences, transgender health. I got a call and it was from a pediatric dentist at a very well known children's hospital in the Midwest. He introduced himself and that was terrific. I said, "Why'd you call me?" He said, "Well, I was given your name, that I should speak to you about this issue." I said, "Fine. How can I help you?" He said, "Listen, I came here to this hospital 22 months ago. There was a transgender outer lesson program. We had 18 patients. 22 months later, as I speak to you tonight," it was on the telephone. He said, "We have over 600 patients." What the heck is going on? When we're starting to see that kind of input into our patient population into our patient pool people have to try to figure out is there any special things that we need to do? Is there any type of accommodations we have to make. I think as dentists it's much easier working with that population as compared to our primary care physician friends.

That's not particularly difficult for them, but that gets into blood panels, hormone administration things like that. For us in the dental world I think the thing dealing with transgender patients is first of all you want to create a welcoming environment. I think you and I both agree we went to create a welcoming environment for any human being, but especially these people. I think one of the things here with this is creating forms in your office that express gender identity. What is it now? Google has 19 different terms or something, one of these groups. I'm really big on gender affirmation and gender non-conforming. I think far too many young people, less than 18, far too many people over 55 go a surgical route. I think there's a lot of other options for these people, but that's another discussion. First, as dentists we want to create a welcoming environment. Have forms that properly reflect your gender identity. Have gender neutral bathrooms. That's a no brainer. I think you want to have a staff that's trained a little bit in how to ask these individuals questions. Don't pepper them with trans questions.

Here's the most important thing when working with transgender individuals, which I have found. Do not assume anything. Just ask. I think one of the things is, I remember when I was transitioning and I did it at Boston Medical Center. I had some good fortune of being able to go through the women's primary health clinic at Boston Medical Center. I would be sitting there, and this was before I had the final surgery and all that stuff, but I kind of looked like what I do look like now. Maybe a little bit thinner. I remember one day this young woman comes out, this young Spanish woman, there was five ladies and myself. She goes, "Kenneth Koch." Nobody ... I don't know who ... She goes, "Kenneth Koch." Nobody moves. Then she bellows out, "Kenneth Koch." I raise my hand and I said, "Come over here." I said, "First of all, to you, it's Dr. Koch." I said, "Secondly, what we're going to do is we're going to make this an educational experience. What I want you to do is I want you to write my name in front of the chart, Anne Koch."

She goes, "Well, your insurance card doesn't have that name." I said, "They don't have it right now. They're going to have it very short, but I want you to write my name." She goes, "I can't do that." I said, "Yes, you can." She said, "Well, I'll have to speak to Dr. Segal," who was my primary care provider. I said, "Absolutely, let's go over and speak to Dr. Segal." We go over in tandem to speak to Dr. Segal. Of course what does Jenny say immediately? "Write the name on the front of the chart." That's just being a little bit considerate. It's being a little bit forward thinking. That's the way working with these patients. I think Howard, for our dental colleagues when they're working with trans patients when you treat them with respect you're going to be stunned at what grateful appreciative patients they're going to be. A lot of these people have had a really, really tough ride. For me when I wrote about it, it was a little bit different. I had a lot of life experience. I think have an intellect. I have resources. I had an image of what I wanted to do and I was never dysfunctional. This was just something I thought about. I was very functional. I was very successful doing what I had done.

My world changed when I had a squamous cell diagnosis at age 63. I realized I had been compartmentalizing this my entire life. Flip all the card over. I've got to do it, and that's not particularly uncommon with older people. For me I was never dysfunctional. I never thought about suicide or anything like that. It was always there since I was four years old and when mortality hits you be it a car accident, or a cancer diagnosis there are certain things you want to do and I just felt I had to do this, and so I did it.

Howard Farran:

Just to be specific every dental chart should ask if they're male, female, or-

Anne Koch:

Gender nonconforming.

Howard Farran:

Just gender nonconforming.

Anne Koch:

Yeah.

Howard Farran:

Is there a hyphen or just gender nonconforming.

Anne Koch:

Gender nonconforming.

Howard Farran:

Explain really what that means.

Anne Koch:

Well, what has happened this is a whole generation. This has been an amazing thing. I think this is terrific. Basically, you know what this means? If you're a guy and you're an effeminate guy it's okay. If you're a young woman and you're kind of butch it's okay. What happens gender nonconforming there are a lot of young people, especially, that's not exclusively but let's say especially less than 40, who they don't identify either as male or female. They identify as themselves. In fact the terms of pronouns they will use very often the pronoun they. When I'm speaking or communicating with medical schools many times I'll see emails come with peoples name. They talk about preferred pronouns. Like, Howard. Hi, I'm Howard. Preferred pronoun he, him. I'm Mandy, preferred pronouns she, her. Then somebody Tye, preferred pronouns they, Z. That's just something. This is how things change. This is how generations change. What I like about, not just gender affirmation. I like this idea that gender is a continuum. It really is not black and white. There's so many things that you and I grew up we saw it as black and white, good and bad. That's not really the way these people see themselves.

I've done videos for Dental Town on the endo restorative continuum. I like the concepts of continues because there's a connotation. There's an implication that is somewhat fluid and you can move along. I've met some gender nonconforming people who somedays present more as a guy other times they present more in a feminine way. They're happy as long as they're productive. That's their vibe.

Howard Farran:

I just appreciate so much how you had the courage to be a role model, to come out and make this public. Was it frightening? Did you fear a backlash, non acceptance?

Anne Koch:

Probably because I was-

Howard Farran:

Were you afraid major endo companies would want to have nothing to do with this?

Anne Koch:

Well, the interesting thing was I think that was some other peoples concerns. My concern initially was, wait a second. I've done so many different things for people. I've been out there. People have known me. They're going to understand that I'm basically the same person. That was a miscalculation. That's why I took a couple of years to get things to come around. For me I miscalculated how toxic it was. One of the things, to me, that was so interesting was that I thought, and I talk about this in a book, I thought the people that I knew for 40 years would be my strongest allies. Well, it's not necessarily the case. What happens those people somehow felt they had been duped, that I wasn't honest with them all these years.

I was completely honest with them. It was just something you compartmentalized. That was a little bit of a surprise that the people who I thought would standup and have my back they really didn't. As I talk about in the book, and as I show in my lectures, and I do show pictures as you know, when I went through some of this facial plastic surgery the only support I had going through this entire thing was a stuffed mouse. I remember lying in the hotel room, up in Boston, after being dismissed from the hospital, with [inaudible 00:14:51], bandages, and the whole nine yards. I remember sitting in the hotel room looking at myself all swollen and black and blue thinking what the hell did I ever do to piss off so many people that I hear I am doing something so important and my support system is stuffed mouse. That was amazing to me. I couldn't believe it.

Howard Farran:

Was that rock bottom?

Anne Koch:

Rock bottom was even after that where people who kind of almost a little more purposely were working against me and different things. It's one of these things where I think if I didn't have such a strong personality, and I do have a strong personality, it would have been really tough to handle. I'm trying to think, what did I do? You should be happy for me. Someone should be saying to me, "Oh my gosh Anne I'm so happy that you did this. Oh my gosh it took a lot of courage" instead of trying to burry me. That was the rock bottom after that stuff had been done.

Howard Farran:

You were saying friends and colleagues. What about family? Where they [crosstalk 00:15:55].

Anne Koch:

Oh that wasn't particularly supportive at all. My brother, who was a great brother growing up, but he and his wife are quite religious and I never had any children. His thing was, "I'm supportive." I said, "Well, I don't think you're really supportive." It was kind of like, "Well, I'm supportive because I don't want you to go to hell." What kind of support is that? I don't think that's particularly supportive. What was really interesting was that I had to pull back. It's like taking a five yard penalty with the Phoenix Cardinals, Arizona Cardinals. Take a five yard penalty, drop back, do a time out, suck on some pressurized oxygen and try to figure this thing out. It took me a good two years of just trying to figure out what's going on here. Yeah, I was doing some things in the trans community, but I wanted to get back into what my love is, which is my specialty, which is dentistry and endodontics. My whole world changed in the summer of 2015. I had gone to the University of Pennsylvania for many years, played sports, worked in the dining service, got married on campus there.

I get an email from the alumni office that they had been at the dental school and that they found out I had changed my name and no longer lived in Palm Beach. I had a home down in West Palm. Beautiful house, I had a beautiful home in the end of Long Island. When I saw that email I realized oh my gosh they know. I'm going to call them, so I called them. The next day Howard, I get an email that is still the most stunning email, to me, I've ever received in my life. Like you I've received lots of emails. It was the most loving, heartfelt, warm, humanistic email I have ever received in my life and it was from Sing Cook Kim, you know the endodontic surgeon, Sing Cook Kim who had been a mentor of mine at Penn. It was amazing. What happened was that when I saw this email and he invited me down to Penn I went back and they had this unofficial Anne Koch day at the dental school with all these kids. He acknowledge all the different products and techniques I had developed and created.

They were using some of these at the school. They didn't even know I had developed them, which was wonderful. That led to my association in a much closer way with the school. It led to me stepping up and making a donation, which I was very proud to do. I ended up amazingly being elected to the board of overseers for the school and I'm very, very involved with the veterinary school as well. As far as I'm concerned University of Pennsylvania really became my family. University of Pennsylvania, to me, I'm a ferocious defender of how terrific the entire university is. I think the dental school has really set some great standards. That really changed my world. What happened is you kind of get your mojo back. I'm a person who spent a lot of time in the water. I still love being on the water. Worked my way through dental school as a commercial rod and reel fisherman out of Montauk. Still love making fishing rods and all that kind of stuff.

It took me a couple of years to get my sea legs because the blow back was just so much in extreme of what I anticipated. The good news is a lot of the people who initially were stand offish just didn't want to be the first. You know that's kind of human nature. When people I had known, partners people like that, people involved with some of the different companies I work with in endodontics and in dentistry, once a couple of people realized wait a second this is the same Dr. Koch everybody's come back. That's pretty unique in the trans world. What I'm really very happy about is, as I said, I'm very happy to be back with a real world endo. I'm happy that Dr. Nassay, who I'd chosen to replace me as CEO and president, we're doing a lot of things together. I think Dr. Brave and Dr. Nassay did a good job of keeping things going. I think that's a lot to be said by that.

Howard Farran:

Is it going to be the Anne and Allie show now?

Anne Koch:

Yeah.

Howard Farran:

[crosstalk 00:20:36] Anne.

Anne Koch:

Yeah, A and A.

Howard Farran:

Will he still be the president or will you?

Anne Koch:

Yeah, no, no he's doing that, and Dennis has served for a number of years as the trustee, one of the trustees with us, and I appreciate what Dennis did. Dennis graciously stepped aside and I came into the position that he had, had. In retrospect we kind of both did some things that we wanted to do. I had a wonderful relationship with Dennis, as you know. I can still consider him a friend. One of the things that made our relationship work Howard, was that we were very different. Maybe it turned out a little more different than we both would have thought, but that's what made it work. I had things that I could do well. Dennis had things that he could do well. I think at the end of the day maybe things that worked out the way we both, maybe hopefully, would have hoped for. I can't speak for Dennis, but I can speak for myself and so-

Howard Farran:

He retired?

Anne Koch:

Yeah, he's retired now and from what I heard, I don't really have much communication with him, I understand he's doing well. I think that's terrific. Of course Allie, I think is happy to have me back because everybody's different. I think with Dennis and I when we were doing all our courses what made it work was a yin and yang. It was a total yin and yang situation. With Allie it's also a yin and yang. A little bit different yin and yang. Dennis was a little bit more reserved.

Allie's a little bit more of a different generation, more with tech stuff. I'm, like you, out there. It's funny because years ago people would say something like, "You're kind of high maintenance." I said, "Absolutely not high maintenance. Complicated." There's a difference, but I'm very pleased where I've gone through with this trans thing. I think I've done a lot of good at these different medical meetings. First of all medical world does things very different than dentistry. It's like 10 minutes, you get 10 minutes. I'm not doing 10 minutes. If you want me to show up I've got to do at least 45 minutes. Preferably an hour to an hour and a half.

Howard Farran:

For your lecture?

Anne Koch:

Yes, absolutely.

Howard Farran:

Now, is your lecture that you just did at Townie, is that going to be a course on Dental Town? Is Howard Goldstein going to make that a course?

Anne Koch:

Well, if you want to I'm very happy to put up a course with something, or having a course where we do-

Howard Farran:

Well, did they tape the one you did?

Anne Koch:

Yeah. We're going to work through that. I'd love to work through that and make that a course.

Howard Farran:

One of the reasons I really didn't want to podcast you because your story is the pictures, the visual.

Anne Koch:

Right, it's a graphic picture.

Howard Farran:

It's such a better story. In fact if you get anything in this podcast you got to log onto Dental Town to see the story. The way you pictured and show that whole story, what an amazing presentation.

Anne Koch:

Thanks. That's resonated. I've been a number of places. This year I did ADEA which is the American Dental Education Association. I was one of the keynotes. They haven't had a keynote speaker who's been a dentist in years and years. The other keynotes were the CFO of Google, the first black female astronaut Hillary Rosen who's a CNN political commentator, and Anna Navarro who is a Fox TV political commentator. They were the other keynotes. Rick Valachovic who's the president, wrote an amazing review of the whole meeting. He thought that I was the most charismatic of all the keynotes. That's the feedback of the meeting. I'm so thrilled about that and they taped that. It was really a big deal for me and that morning I did two lectures for ADEA. I did a keynote at night, and I gave a 90 minute presentation in the morning to a packed room. At the end of it I had a standing ovation. I've had that at a number of medical conferences. For me that's really incredibly, incredibly satisfying. That's kind of like coming full circle. That's a big deal.

Howard Farran:

Yeah, democracies are so brutal on the minorities.

Anne Koch:

Oh, I mean listen one of the things that taught me was that all of a sudden I had a totally different appreciation for black and brown. I had a totally different appreciation for lesbian and gay individuals. There's many, many transgender individuals who kind of lead a life as trans individuals. To me that's not what I did. To me was about being a professional woman. I write about it in a book that my goal was to be at a University of Pennsylvania alumni function as a professional woman. That's my goal. It's funny when I show up, they see me show up, and they think, "Uh-oh what's this upper east side bitch going to be talking about?" Then after 10 minutes they realize, "Oh my gosh she really cares." I totally care. My style is my style. Everybody has their own style, but I do care. One of the things that's been a wonderful sidebar to this for me is I'm back into athletics. I had walked away from big time athletics. I couldn't handle the locker room. When I transitioned I got back into it.

I won the Northeast Senior Women's Tennis Championship two years ago. I don't play like a guy. I probably lost 60% of my strength doing this, which is an interesting thing people don't talk about. I like playing tennis. I play tennis really well. In the course of doing that I beat, at the time, the number one senior women's player in the country. I was really pleased about that. Does anybody know? I have no idea. I have no problem saying to people. If somebody asked me I'd say, yeah, but you don't go around saying to people, "Hi, I'm Anne Koch. I'm a transsexual woman. I was a guy for 63 years." That's not a good way of starting conversations either with a woman or a guy. I played like any other woman and happened to win it. It's very gratifying to me and here's one of the things; I walked away from big time athletics because I couldn't handle the locker room. In high school there was never a team bus that was going to leave Smithtown high school without me on it. I was all Long Island in two sports.

In college everybody's all this, all that, all whatever. It's a whole different game, but now I find myself in women's locker rooms. I belong to a beautiful tennis and beach club on Cape Cod. I have girlfriends who come up to me and they'll say to me, "Listen Anne, do you have a couple minutes? Can I speak to you about 10 minutes about something?" It's always about business. They're looking about starting their own salsa business. They're looking about starting a pie business, or a home catering business. They know I have a lot of business experience and that's incredibly rewarding to me that someone is-

Howard Farran:

Well, Real World Endo is a serious business.

Anne Koch:

It's a serious business. That was one of the things with-

Howard Farran:

That's bigger than anybody's individual endodontist practice.

Anne Koch:

Absolutely, and it was bigger, and you could ask Dennis the same thing. One of the things is I have tremendous remembrances of what Dennis and I created. We created a whole big thing. It was a big deal and Dennis would say this, I believe we were the biggest continuing education company in the world for a while. We did a lot of courses.

Howard Farran:

It looks like we'll be knowing each other for a longtime. My sisters tell my little gay brother that he's going to hell for eternity. [crosstalk 00:28:29] go to heaven with eternity with my boring sisters or go hang out and party with [crosstalk 00:28:35].

Anne Koch:

Well let me-

Howard Farran:

Paul is absolutely the sweetest, nicest, thoughtful person in our entire family. Has done everything for everyone, and he's the guy going to hell.

Anne Koch:

Well, yeah and again what happens is that people have to realize, and I think most gay and lesbian people now realize, and transgender people, that, that's not going to happen. People sometimes get buffaloed. Especially younger people. One of the things that's really become an issue for me is somebody referred to me, when the transgender hell things, as the accidental activist. I'm definitely not an activist, but what I am ... I have this preface in my book. In the book I talk about that I don't represent the far right agenda, nor do I represent the transgender agenda. I'm looking for veracity. I'm looking for the truth and that's the space that sweet to me. For me I talk about things in transgender health because I had been a very unique individual in that I was both looking through the prism as a patient, as well as looking through the spectacles of a healthcare provider who had seen more than 32,000 patients, so that was pretty unique.

Howard Farran:

You've seen 32,000-

Anne Koch:

In my career I probably saw more than 30,000 patients.

Howard Farran:

You've done 30,000 root canals.

Anne Koch:

No, no I did pros for 14 years.

Howard Farran:

Oh, that's right.

Anne Koch:

I've done thousands and thousands of crowns.

Howard Farran:

Oh, that's right. You're a prosthodontist and an endodontist.

Anne Koch:

Not an official prosthodontist because I never got the degree, but there were a couple of guys like us in the Air Force. I was Chief of Pros at a number of bases. I also was head of all the lab work for all the Air Force for all the Pacific. I used to actually take my dyes and I would ditch them with a 15 blade underneath a microscope. I was serious. All the endodontic products that I have developed, and what Dennis and I developed at Real World Endo, and we reverse engineered from the final prosthedontic result. I have to tell you a funny story, before I get into women's issues, because I want to talk about women's issues. Gosh, this must have been eight years ago, nine years ago I get a call at home, I was living on Long Island, from a very, very famous New York City Manhattan Prosthodontist. He calls me at home, he's surprised that I answer the phone. He introduces himself and I knew who he was, and said, "Hello." He said some nice things about Dennis and I, which was great, and about the endo-sequence system.

He said then, "You know I'm doing a lot of root canals. I'm doing a lot of endo in my practice." I said, "Really?" He goes, "You're mad." I said, "No, I'm not mad." He said, "Really?" I said, "No. It makes all the sense in the world to me. If you're doing a crown prep and a tooth blushes and becomes pink that's cooked. Do the endo." I said, "If you do a crown prep and you turn away, and you turn back and it's brown or purplish that's thrombosis. Do the endo." One of the great articles I ever got a response from was an article called, Do the Endo Dude. I said, "No, I'm not mad." He goes, "Really?"

Then he got kind of defensive, and this is a big guy, he said, "I'm only doing anterior teeth and premolars. I'm not doing molars." I said, "Well, if you were doing molar endo as a prosthodontist in New York City you should have your head examined." He said, "No, I'm just doing premolars and anteriors." I said, "Fine." He said, "You're not mad?" I said, "No." He said, "Oh, there's another thing." I said, "What's that?" He goes, "I can't believe how much money I'm making doing endo." I replied, "Now I'm pissed." It makes all the sense in the world, Howard.

Howard Farran:

When did you write Do the Endo Dude?

Anne Koch:

That was for dental economics back, I'm going to have to say 2002, 2003.

Howard Farran:

Man, you should re-update that and print it in Dental Town magazine.

Anne Koch:

I'd love to redo it. I'll do that. Absolutely.

Howard Farran:

It's a very common question that the young kids have.

Anne Koch:

Years ago with the [inaudible 00:32:09] require we talk about, I would never do crowns on lower anterior teeth without having it devitalized. One of the things I talk about in lectures that's so true, especially for the young dentists listening, is to do six units across the front. I don't care whether they're laminates, I don't care whether they're laminates, I don't care whether single units, and number 10 is close. Mrs. Jones complains so much about the price of this. If you tell her that she needs a root canal it's another $900, whatever. She's just going to go crazy and drop the entire treatment plan. Then you go into evasive action. You put [inaudible 00:32:42] a temporary you try this, you try that. I've done all that stuff. At the end of the day here's what you have to do. If the tooth is close and you think it may need an endo do the endo, dude. I've been on both sides of a tooth.

You are never, ever going to have any patient who enjoyed being told that they needed a root canal. You are never going to have any patient who enjoyed being told that, "Excuse me sir or ma'am your treatment plan just went up another $1,200, $1,400." While they don't understand this or they don't like hearing this they understand it. They don't like it, but they understand. You don't do the root canal, you cement all the units, then you've got to go in through their beautiful new crown and do a root canal on number 10. God help you if break the porcelain you bought yourself now a really angry patient. The whole key thing here is yes, they're not happy to hear the news, but do the correct thing. If it's going to require endo do it now, because they will understand it.

Howard Farran:

I sometimes think they worship pulp. You see all these people talking about these elaborate pulp [crosstalk 00:33:45].

Anne Koch:

Yeah.

Howard Farran:

What do you think about pulp capping in general?

Anne Koch:

No, I think first there's a couple of things with pulp capping. One of the things that's going to be interesting is that bio-ceramics is the real deal.

Howard Farran:

Why?

Anne Koch:

Because of the physical properties of the materials. Bio-ceramic is like a bone cement. In other words bio-ceramic when it is set and it's driven by the moisture in dentinal tubules, which is what 40%. It's a hydration reaction so a hydration reaction at the end of the day is going to spin off water, which continues to drive the reaction, but the other thing it spins off is hydroxyapatite. Hydroxyapatite is a big, big deal. What that does it allows us also to get bonding. It helps us close the gap between the sealer and gutta percha. Also in terms of a higher PH, in terms of being bioactive, in terms of spinning off hydroxyapatite the BC sealer, the bio-ceramic is a great pulp capping agent. What I like to do with pulp capping, and this is changing the game with pulp capping, what you do with BC putty you have to understand with bio-ceramics what changes the setting time is the particle size. BC sealer, and this was a big thing that Dennis and I wanted, we wanted to have it ess than one micron. You can push it through a tuberculin syringe. That's BC sealer.

The repair material is a little bit larger than one micron and the putty's a little bit larger than that. The facet is even a little bit larger. Anyway, but still a very small particle size. What you can do with an exposure, if it's an accidental mechanical exposure, first of all disinfect the are with some hypochloride. You can get hemostasis. Hemostasis Howard, is the first thing you have to do. How can you get that? One of the things I've always liked to do is take a small exquisitely sharp spoon excavator, you make a little slice, and you hear the pulp suck back into the chamber. That stops a lot of the bleeding. If you want you can put some peroxide on a big tuft of cotton or you can put some sort of hypochloride on it, but you can get hemostasis. Once you get hemostasis I want you to place the BC putty on top of the exposure.

Howard Farran:

Who makes this?

Anne Koch:

Brasseler makes the BC putty. You put that right on top of the exposure and then give that about 10 minutes to set. You don't have to send the patient home with a wet cotton pellet like MTA. Give it about 10 minutes to set. Then what I want you to do is I want you to put a glass ionomer on top of it. Use any type of glass ionomer. You can use Vitremer, I don't care, Fuji whatever. You put the glass ionomer on top of the BC putty material, you're going to get a bond, and then what you do is you etch the glass ionomer, then you totally restore it. Boom too easy, single visit. That's what you do with exposures. Now how do I feel about mechanical versus carious? This is going to be a very interesting topic. This is an opportunity for a multi million dollar product if anybody can develop a product that can evaluate the pulp as to how much penetration we have with the bacteria. The dental pulp likes to compartmentalize things and it compartmentalizes inflammatory cells.

A lot of schools now are starting to see the pulp does a pretty good job about compartmentalizing bacteria. What happens if you have a pulp, even an adult patient that's not really contaminated, for instance like a mechanical exposure, adult pulpotomies we're finding now work. That's going to get us into a whole other issue in endodontics about ethics. In other words, do they need a pulpotomy, or do they need a full total pulpectomy and opterated of the reticular tooth structure? Very interesting thing. Keep an eye on that.

Howard Farran:

Where do you think it's going to go?

Anne Koch:

I think it's probably going to go in the place where it's going to be based on the contamination. I think it's also going to be probably you're going to see more adult pulpotomies come forward in the next five years. You're probably going to see an increase in the price of pulpotomies. I was at an endodontic study club and I said, "Listen I trained residence. They're $500,000 dollars in debt." What do we have here? You have a $1,800 root canal or you have a $150 pulpotomy. One of these well known dentists said, "Make a pulpotomy $1,000." He didn't say that jokingly and I didn't take it jokingly. I don't have an answer for you. I don't know where this goes. I can tell you that everyone's getting some preliminary results. I think of years ago indirect pulp caps. Indirect pulp caps don't work. We found that indirect pulp caps do work. I think we're going to find out in certain cases that pulpotomies on adults can work, but I think what's going to be key is now we determine the bacterial infiltration of the tooth, of the chamber. At this point in time we haven't seen that.

Howard Farran:

One of the saddest things when I got here to Arizona is the Medicaid, the state access. They paid the filling for peto was $3 more than the extraction and almost four out of five moms will tell me, "Well, it's cheaper to pull it." You're like, "Yeah, but you don't have a tooth for three bucks."

Anne Koch:

Right. Let me tell you why this is the second coming of this for me. I graduated from dental school in 1977. The first year I worked in west Philadelphia in a health clinic. Honestly I was the only white person I saw the entire year. I didn't even see many Spanish people. It was an African American area, African American students. It was mainly a lower income and at the time the department of public assistance in Philadelphia Pennsylvania going DPA did not pay for any endodontic treatment. I had all these young kids coming in and I realized if I continue to excavate the decay I'm into the pulp. Goodbye tooth. We had been told at Penn that indirect pulp caps don't work, so I figured screw that. I'm going to do what I think is the right decision. What I was doing I started doing indirect pulp caps. Listen to this I was doing it with Dycal, Dycal right. Then I found out something. You know what I was finding out? They worked.

My idea was if I could buy a couple of years maybe this individual would have a job, maybe this individual's parents would be in a situation where maybe they had some come kind of insurance or something. I was trying to buy time, but I realized that oh my gosh the indirect pulp caps work. It had to be two, two and a half years later all of a sudden dentistry changed. Forget what we said about indirect pulp caps. Indirect pulp caps work.

Howard Farran:

Why did the Dycal work?

Anne Koch:

Just because it was calcium hydroxide covering and it was able to stop somehow, or rest, or do something to that bacterial penetration and it was working.

Howard Farran:

You think it was because of the PH?

Anne Koch:

PH, yeah PH. Just like what calcium hydroxide ... a lot of endodontist, including myself, have done the majority of the cases single visit. There were cases that I never did single visit. I would do multiple visit, but the [inaudible 00:40:54] of choice, especially necrotic teeth, is calcium hydroxide. The reason it's calcium hydroxide is because the PH. The PH is about 12.8, which is the same as the bio-ceramic material.

Howard Farran:

Anne, podcast audience are younger.

Anne Koch:

Yes.

Howard Farran:

People our age are reading textbooks and going to conventions. One of their most common questions is they're so confused on one step versus two step. Some people say if there's any [inaudible 00:41:19] it's got to be a two step. It seems to be an extremely common question on Dental Town.

Anne Koch:

Yeah-

Howard Farran:

Are you a one stepper or a two stepper?

Anne Koch:

Well, first of all probably of all the root canals I did in my career, probably 65% were one visit. 35% to 40% were a two visit. If a tooth was vital and there was no infection obviously that's a one step. Even with some necrotic teeth I would do, if it was asymptomatic, in one visit. It's easy to say, which cases would I not do a one visit root canal on. If I ever had a mandibular posterior tooth, meaning a mandibular premolar or molar, if it had an area and it was symptomatic, and symptomatic to me means pain and or swelling, I would never do that in one visit. Here's why; If I opterate that case and that tooth blows up, and I have to IND it, if it goes to the lingual side ... because I can't establish [stringe 00:42:19] through the tooth because I've already filled it, if it blows to the lingual side IND on the floor of the mouth is a plain mess. The floor of the mouth is very vascular. I don't want to be sticking a blade there.

If it blew to the buckle side trust me INDing near the mental foramen is a tight short type of situation for men and women. You're right near the mental foramen you don't want to nick the mental foramen when you're going down a bone with your blade. That case of mandibular posterior teeth, they're necrotic but symptomatic, didn't do in single visits. If I had a case that was draining, there was active pus coming out, I'd never do that in a single visit. Even if it has a fistular, which is kind of like natures safety valve. I still wouldn't do that in a single visit. If you have a tooth that's draining a lot I would take the rubber dam of, have the patient use warm salt water rinses, warm to hot salt water rinses, for five to ten minutes. That would bring out a lot of the drainage. Go back in and if I could close the tooth I would. If not I'd bring them back, but I would never do that in one visit. If the tooth is draining you can't do that in a single visit.

Another case silver points that are symptomatic. If somebody came in with a silver point case that was asymptomatic, even if it had a little bit of an area, I would one step that. If they came in with a silver point case that was symptomatic, again being pain and or swelling, I never did that in one visit. Those teeth are really dirty cases. When you pull out the silver points, and a great way for pulling it out for the young people is to use a hedstrom. Get a hedstrom hand file and gauge into silver, which is a soft metal, and you pull it. Out comes this silver point that's going to be black because all the corrosion products, right along your hedstrom hand file. I wouldn't do that in one visit. Another case that I wouldn't do in one visit, if it was going to take me an enormous amount of time. Let's say you've got a patient and you're in Chicago and they've got to fly to Johannesburg South Africa the next day, and they need the root canal done, don't go into a marathon appointment, like three hours.

First of all everybody should be using bite blocks when they're doing posterior endo. The bite block they should be using is not the NBA oral surgery large size. You're going to disarticulate your patient. Only use junior or child size bite blocks. You put it in the upper side of the arch and people do fine. If you have a marathon appointment in endo and you don't use a bite block, when you get done, you take off the rubber dam apparatus and then you say to the patient, "Okay Howard, you can close." You know what the patient says? They can't close. They've slid out past the immense and now you've got to grab their mandible with two hands pull it to you and then put it back up. It just goes back up into the joint very easily. Those are cases where you shouldn't be doing a one visit endo procedure.

There's other practicalities. Even as a management person if someone's never paid you for previous root canals why would you do a single visit? Think about that. People will do fine with calcium hydroxide. That's your own business decisions and we people make that. For me the big thing is in terms of symptomology, pain, and or swelling, and whether they have a lesion or not. I know endodontists who do everything one visit. I never subscribe to that. I know endodontists who do everything two visits. I don't subscribe to that. I think it's kind of a case by case thing.

Howard Farran:

They're also confused on the market. There's so many file systems.

Anne Koch:

Oh my gosh yes.

Howard Farran:

On [inaudible 00:45:54] they want me to ask, "What do you use?"

Anne Koch:

First of all this is going to be obviously a biased answer to me because Dennis and I created the endo-sequence system. For me-

Howard Farran:

Who sells that?

Anne Koch:

Brasseler sells that.

Howard Farran:

Brasseler sells all your inventions and patents?

Anne Koch:

Pretty much now, yeah. There was one thing I had created years ago for Sybron called SmearClear. SmearClear it's basically EDTA with a couple of surfactants. What it does it removes the smear layer and opens up the dentinal tubules. I like SmearClear still because if you're using a bonded endodontic filling technique like BCC sealer, if you're using a bonded opteration technique it really helps to open up the dentinal tubules. When you do that not only are you getting a chemical bond to the wall you're getting a mechanical bond.

Howard Farran:

That's sold by Sybron.

Anne Koch:

By Sybron.

Howard Farran:

Which is owned by Kerr, which is owned by Danaher.

Anne Koch:

Danaher, right. That's called SmearClear. That's a great product I think.

Howard Farran:

Does Brasseler, do they sell that direct or through dealers like Patterson [crosstalk 00:47:06]?

Anne Koch:

Both of those companies sell it direct. Brasseler is a direct company. I believe that Sybron is still a direct company.

Howard Farran:

Really, Sybron's direct?

Anne Koch:

I believe they are. They may have changed now because they've had some different changes of ownership.

Howard Farran:

It's interesting because in Dentsply supply, which is now married Sirona, Dentsply Sirona they're endo division, their Tulsa dental division sells direct. All their other ones go through dealers.

Anne Koch:

Right, and one of the things I've had in the past was, I was involved with that many years ago, was the fact that there was an idea the endodontics and the changing nature of instrumentation and opteration required more education on behalf of the sales rep. I think in the dental industry there's a little bit that distributor reps a little bit more, and the direct companies have sales that have more of an educational component to their job.

Howard Farran:

We see that in implants too.

Anne Koch:

Yeah, right.

Howard Farran:

Implants, the rep only talks implants and endo.

Anne Koch:

Right.

Howard Farran:

Your file system [inaudible 00:48:07] Brasseler is the endo-sequence?

Anne Koch:

Right, endo-sequence and that was all reverse engineered from the final prosthodontic result. The big thing about endo-sequence and Allie, Nassay and I just yesterday completed a great course for Smile brands. All these young dentists-

Howard Farran:

He was down in town [crosstalk 00:48:24].

Anne Koch:

Yeah, down in town. Yes, in Scottsdale. What all the young dentists were just agawed at was the synchronicity. One of the thing I'm very proud to say was back in 1994 I had the first endodontic program, first postdoctoral endodontic program to use full shank rotary files. The first endodontic program to use rotary files was UT San Antonio. They used the Light Speed. Steve Senure and Carlos DeRio were ex-Air Force guys. They had the Light Speed, which is an oil drilling tip. Steve and Bill Wild they had the company. They were the first rotary instrument out of the gate and it was at UT San Antonio. The Light Speed is a very short head. It's like a Gates Glidden, but at Harvard I was the first endodontic postdoctoral program to use full time a full shank rotary file. We used the series 29 profile at the time. There was no books like rotary files for dummies. We had to learn everything on the tape. We learned as we went along.

My residents, I had five residents that first year myself, but one of the thing I learned very quickly was oh my gosh we can get predictable shapes. Constant tapered rotary files create a constant shape. A variable endodontic technique every canal is shaped differently because the taper's are differently. That's why variable tape has always been associated with a thermal plastic technique. I started planning around in Boston in 1994 with single cones, glass ionomer. I found at the time that if I used a o-4 taper the hygienic fine medium cones were a pretty good match. If I used an o-6 taper the hygienic medium cones were a match. Eventually once I created Real World Endo and I started to play around with gutta percha I changed the molecular weight of gutta percha. I made it stiffer. By changing the molecular weight we made it stiffer. I realized I can have a gutta percha cone and now if I lasified this, laser verify it, it can match the preparation exactly just like a post.

I used to go around saying to people what's the best post drill in the world? It's the last rotary file. Also, for all my endodontic residents I always taught them to use a rotary file like a post drill, straight up and down. Not going around the anti-curvature. When I would finish with a 30-o-4 or a 25-o-6 it was a 30-o-4. It wasn't a 31-o-4 or a 31 and a half. It was the 31. I had precision with my preparation. I can now get laser verified paper points, laser verified gutta percha cones to match. Then I created a custom made post system that matches it precisely. As I say to people there's lot's of endodontists who've done many more root canals than I have. There are endodontist who have done 45,000 root canals. I can't believe that. I don't know of any endodontist who's done more crown and bridge than I've done. I've done thousands and thousands of crowns. [crosstalk 00:51:35]

Howard Farran:

At Brasseler you have the endo-sequence, you have the files, the paper points, the gutta percha all absolutely match?

Anne Koch:

And absolutely the post as well. It's the only post system that doesn't weaken teeth because it's bonded.

Howard Farran:

Can I tell you something weird about post?

Anne Koch:

[crosstalk 00:51:55]

Howard Farran:

You said there are kids that are $500,000 in debt. They're not going to do a $150 pulpotomy when they can do a $1,400 root canal. Do you know why Japan went to self etching for their bonding and we went to total [inaudible 00:52:09]? We did the false four, the rinse, all that stuff. Japan went the self etching because the insurance system in Japan they just get 10 minute appointments. They're not going to do any system that takes long. With the post, when I was in UK, France, a lot of European countries, the fee for a molar root canal is $100, but they get another $100 for a post. They'll put a post in every single canal. They have to, because $100 doesn't even break even for a molar root canal. Insurance systems determine a lot of technology.

Anne Koch:

There was a fellow and he's at one of the universities I recently was at. I kind of forgot which was the university. His name is Steve Morgano. Steve's a prosthodontist and he had been up in Boston for a number of years at the VA. He was at Harvard for a year, that's where I met him, and then he was at BU. He wrote an article in the 90's in the JPD, Journal of Prosthodontic Dentistry, about why people in Massachusetts, why dentists in Massachusetts, use a post. Why do they place a post. First of all for people that don't know Massachusetts is very energized about dentistry. Dentistry's very active. The general dentist, the Massachusetts Dental Society, we had our own insurance company EDIC, they're very engaged. Steve got a tremendous response on his questionnaire. The overwhelming response by dentists in Massachusetts why they place a post in a tooth was it's a code.

Howard Farran:

[crosstalk 00:53:39]

Anne Koch:

One of the things in the military I did probably thousands of abutments where I did an intraradicular core build up. What an intraradicular core build up is, for our younger viewers, that's where you have a tooth that's had a root canal and you basically, for instance on a maxillary molar, take three to four millimeters of gutta percha out of the pallet or canal, take one to two millimeters out of the two buckle canals and then we would condense our core material into that. It used to go Howard, you used to condense amalgam.

Howard Farran:

Sure.

Anne Koch:

Then we were condensing tie core, Barry's gum. You remember that? That was the good material. That was called

Howard Farran:

Barry-

Anne Koch:

Musican.

Howard Farran:

Tie core's Barry Musican's?

Anne Koch:

Yeah, right. Yeah. What happened was that was what we called an intraradicular core build up. They don't weaken the tooth either. The problem is in the civilian world it's very tough to get paid for that.

Howard Farran:

Is Barry your buddy?

Anne Koch:

Not really. I know Barry. I think Barry's a friend. I see Barry. I haven't spoken to Barry in a while. I used to see Barry at all the trade shows. You have to realize I'm just getting back on the circuit. It's really fun for me because last year, which was 2016 that was the first AAE I had been to since 2012. People were pleasant and stuff and I think a lot of people didn't even know who the hell I was. It was kind of like you're the nice looking blonde, or pleasant blonde, whatever term you want to use. That was fine, but they didn't know who I was. Then all of a sudden over the course of the last year the words leaked out. When I went to the AAE this year and I gave two presentations. One was on the bio-ceramics, the real story, and the other one was treating the transgender patient. Think about that. The AAE, I'm speaking at the AAE on treating transgender dental patient. Anyway, I felt, and part of me in modesty, I felt like a rockstar.

I had so many people coming up to me saying hello and hugging me. Very quickly I established that if you're going to come up and say hello to Anne Koch you have to hug. You have to give me a hug, and it worked. I think part of this is they realized how comfortable I am with my own skin and it makes them comfortable. One of the things is it's okay to laugh. There's a lot of people that I have enormous sympathy for in the trans world. They don't seem particularly happy and they've been so stressed out. They have such the difficult life. Fortunately for me I've been able to do this in a way that I've been able to keep myself pretty much intact. Part of this is having a sense of humor. I guess about a year and a half ago when I first started getting back lecturing I was giving a lecture in Massachusetts to an audience.

There were a lot of people there who I knew and they were okay. There was some people who didn't know me and I could see they were a little like, "We don't know how to react." Then I said to them [inaudible 00:56:37] being here I said, "Understand one thing. There is nobody in dentistry who understands change like Anne Koch understands change. Everybody laughed and realized it's okay to laugh. Absolutely it's okay to laugh with me. That's different laughing with somebody than laughing at somebody. Nobody wants anybody laughing at them. It's okay to make some different things. When I say nobody knows change like me that's meant to be funny and it's fine.

Howard Farran:

What do you think your biggest [inaudible 00:57:03] will be? You've had so much on the endo, so much on social issues.

Anne Koch:

It's really kind of interesting because one of the things that's my big interest outside of endodontics is women's issues. There have been people who've been physicians who've transitioned and they kind of disappeared. Wait a second you were a physician, and you transitioned, and now you're working in a CVS? That's not quite right. No knock against anybody working in a CVS, but what I've done, which I'm very, very proud of is that I was at a level in endodontics and I went away and transitioned, fought through whatever I had to fight through. Now I'm back up to where I was before. That's not done, hasn't really been done too much in the medical field. There's a couple of people who are transsexual surgeons who are transgender women themselves, but one was always been in that world. The other one had been successful as a guy. A bit of a legacy that I've been able to show people that you can come back and reestablish yourself. For me I'm really pushing the women's issues, because I can't believe now how difficult it is for women to get things accomplished.

It's so funny because when I speak to women, and I have a lot of female girlfriends, and back in Cape Cod where I live most people see me as Anne. I was a tall blonde woman. If people know or if people ask I have no problem, no hesitation telling them. There's another part of my life where I'm going around the country speaking on transgender healthcare so everybody knows. With women I couldn't believe how much more difficult it si for women to get things accomplished in medicine and dentistry as compared to an old white guy. I have the unique of being a successful old white guy. Now I'm hopefully successful as a mature white woman, but one of the things is that when I look at this there are differences. I'm trying to address those issues. Misogyny is worse now, I think, in medicine. I mean dental medicine, veterinary medicine, dental medicine than 1973. Part of this is different people coming from cultures where misogyny is not only tolerated, it's promoted. That can't go on like that. It can't work like that.

I find myself Howard, now being a magnet for young women from a lot of Asian countries, Middle Eastern countries, India. They stick to me like Velcro and I'm very proud to have them. I'll stand in front of the gun for you ladies. I like being that kind of banner carrier. I have no problem doing that. You know what's so funny is all women, and women will tell you this, all men don't know how to multitask. Absolutely correct. A guy give him a can of beer, a remote control, they're watching ESPN, done. What women don't understand about guys is guys do something so much better than women. One of these things is prioritizing. If you give a guy four or five things to do as you know men do a calculus.

They do a calculus like how is this going to effect me? How is this going to effect my image? How is this going to effect me financially? How is this going to effect me going forward? Guys do a calculus where I'm going to concentrate on this, and they blow off the other three things. Women don't do that, but guys do that, and guys get things done. My experience has been women, the female CEO's I've met kind of think like a guy in that you can't do everything. Sometimes you have to make a decision. You've got to concentrate on this. I'll come back to the other one's maybe at a later date, but you've got to go with this.

Howard Farran:

Why do you think the United States has never had a woman president and the Fortune 500 is 95% men?

Anne Koch:

I think there's two different things on that. I think that the Fortune 500, I think that's going to be changing. I think one of the things in the past that men could get away at the end of the day, kind of always holding the kid card over women, that women aren't fully committed because they want to have a family. I know women where that's been very difficult when they've had kids and have a life that it takes away from their job and [inaudible 01:01:18] fully. I know a lot of women who don't have children and never plan to have children are just as dedicated. I think you're going to see some changes. Also in the past you had women, and if their husband or partner, but generally a husband, if they were transferred they would go with the husband. What happened all of a sudden they brought that chain of continuity was broken. They were working their way up in a company all of a sudden it's gone, because now they're working on the west coast not the east coast.

Howard Farran:

I've seen this situation in my backyard. The man is making $60,000 a year. The women has an established practice it's [crosstalk 01:01:55] 750-

Anne Koch:

Right, guy leaves and they leave.

Howard Farran:

She's making 200, gets transferred to Seattle, she's bawling in my front room. She has to decide to follow him, which she did-

Anne Koch:

All the time. Happens all the time.

Howard Farran:

It's like why don't you just tell that dumb idiot that since you make three times more ... and she says, "Well, it's emasculating to him that I make three times as much money." I say, "Well, tell him not to think about that when he's vacuuming."

Anne Koch:

Right. I like that. I like that.

Howard Farran:

I mean it's tough, because you can't tell them to go. They got kids. It's just so sad.

Anne Koch:

Well, it's really difficult. Guys can play the intimidation card, guys play the family card. Guys play the family card against female associates on the medical and dental side all the time. I have to tell you a funny thing. I used to have a little club in Boston, which I no longer have. It was mainly female professionals. Only about nine or ten people. They were basically seven young dentists, two physicians. They just knew me as Anne. We would meet in a restaurant. One night I'm there and there's always an alpha female or an alpha male in every group. The alpha female in this group was a young Korean woman who's a dentist in Boston. We're talking about some stuff for about a half an hour. Then she goes and she says, "Listen Anne," she said, "I don't think I told you this, but we were all talking in a parking lot before we came up tonight, that you've had such an amazing life. You've done so many things. We all realize that we think that you probably know men really well. Can we speak to you about men?" I said, "Yes. I think I know guys really pretty well."

We talked about men and of course two of them were treating guys who were total dead ends, like get rid of this guy stat. Listen honey if it's not working for you now it's not going to get better with time. It's kind of fun for me. Then I've had other women where, and especially with my tennis friends, where they'll be talking afterwards. Just understand for all the men out there with a girls night out you can't have a guy. One guy ruins the dynamics of any GNO. If you have a couple of women, you know it's your wife, your girlfriend, whatever, and they're having a girls night out, don't go and crash it. It doesn't work. I was with a couple of girlfriends and they were saying, "Gosh, Anne you have such insight into men. It's amazing." Then they said, "Oh, that's because kind of your field. Your field is so male dominated that's why you have such a keen insight into men." That's the story you want to go with it, going with that story? It is different. It is Mars and Venus. I think it's not so easy.

I think relationships are really, really difficult and this is a great lead into my own personal relationship. I think my wife, who's Japanese, and transsexual people in Japan have been there for gazillion of years. They have no problem. Buddhist countries see three different sexes. It's very different than I the United States. She knew about it. I had written her a letter before we got married saying that I don't think this would be an issue, but there's a possibility that this could be an issue that I've always felt like being a woman, so it was no surprise. What happened, what really I think threw her over the edge, was the response of my friends. My friends were like, "Oh my God, the sky is falling." This is the end of the world that will push this little Japanese woman over the edge where I've got to have a divorce. Having a divorce in Florida is an expensive divorce.

Howard Farran:

Why? Why Florida?

Anne Koch:

50%.

Howard Farran:

Yeah.

Anne Koch:

Fortunately she was gracious enough to understand I was trying to don't focus on 50%. Just focus this is the number that's incredible. The good news here is that she's come back. Actually a couple of summers ago she was visiting me-

Howard Farran:

She came back from Japan? Back and forth?

Anne Koch:

No, part of the settlement she now lives in a gorgeous, drop dead, 37th floor ocean front condo in Hawaii. She likes the lifestyle, she's doing it, but she's become ... still remains a great friend. I would be less than honest if I didn't say I wish I could repair that situation so it became a eight month, four month thing, or maybe a six and six, because there's great companionship. We still enjoy each other's company when we're together. Who knows where things go. Really what pushed her over the ledge initially was just the fact that she saw all this exaggerated response. I think she thought this must be incredibly toxic. I'm like, "Wait a second."

Howard Farran:

What percent of that came from religious people?

Anne Koch:

I have found, with my own thing, religious people are impossible to judge. I had some people who, like my brother, thought maybe I was going to go to hell. I had some other religious people who were incredibly supportive. I found no correlation between political parties. I had some liberal democratic friends who I thought were going to embrace this. That wasn't the case. I had some people who I know as very right wing people who thought that they were going to get at it, and they were incredibly supportive. It's really hard to predict where that support or where the non-support's going to come from.

Howard Farran:

It's sure a lot of people who are very conservative are conservative in financial, but liberal in social [crosstalk 01:07:30].

Anne Koch:

Like libertarians.

Howard Farran:

Yeah.

Anne Koch:

You can do what you want to do.

Howard Farran:

When you talk about women's issues it almost makes me want to cry, of the women dentist. I don't want to get into politics and religion and all that. She was in the Middle East and when their country had a revolt when the new group of crazies found out she was a women dentist who had male patients they killed her.

Anne Koch:

Right.

Howard Farran:

I posted her picture. Can you imagine being a women dentist getting killed for treating a male? God.

Anne Koch:

That's why one of the things in the last few years in the states I think there's been a tremendous amount of improvement in terms of LGBT issues. I have a lot of gay friends. My gay friends are great, great fun for me. It's always kind of fun because my gay friends say, "Well, we don't say you're fabulous unless you really are fabulous." I take that as a great compliment from my gay friends. I have a number of, obviously of course, lesbian friends. The way I've looked at this, the group that was many, many light years behind was the whole trans group. There's many, many more challenges associated with that group. At least finally I think that group's being viewed in a little bit different light. The reason I go around to medical conferences, and again, in terms of I have found most trans people I have met have gone back into a transgender nonconforming world. That's not me.

I live in what people would refer to as a perfectly maybe straight world. I don't consider it straight. Massachusetts is a regular world. Massachusetts has no bearing if you're gay, straight, lesbian, or trans, so I just lead my life. I lead my life hitting tennis balls. I like having a drink sitting on a boat in the fall, hair back, sweater, and corduroys having a gin and tonic. That works for me. Giving and endodontic lecture works for me.

Howard Farran:

I'm going to go back to women's issues and the fact that so many women, that'd be the majority and then a few gay, tell me that they don't like going to their study club because it's a good ole white boy club. I've had African American dentists, gay dentists, a lot of women dentists. What's your advice on ... you think you should be talking to the men saying, "Hey, this is what they're feeling." You can argue facts, but you can't argue feelings. If you think you're a good person, but minority black, minority women, minority gay, transgender are afraid to [inaudible 01:10:14] to come what would you say to all the people in study clubs where they're all a bunch of white males?

Anne Koch:

Well, one of the things here is that they really kind of ... one of the things that's happened, and maybe this is a bit of the legacy, I lecture Howard, very similarly to how I lectured as a guy. I never was tethered to a pole here. I walked around a room. When Dennis and I would go overseas Dennis would be at the front of the podium, I'd work the audience like Jerry Springer. Who knew. I should have been a [har-mon-ger 01:10:42], but it worked and it gets the audience engaged. I lecture as a women and there's very few women who lecture the way I do. I really make it personal. I'm out in the audience. Unfortunately I have found women to be more conservative in terms of how they're lecturing. Of course it's a tough deal for women because if you come across a little bit too aggressive they're not going to be viewed as being feminine and stuff like that. It's really tough for women to find that sweet spot for them.

For me, and especially in the past having done a lot of the commercials and modeling I realized it's not gender specific. If you can get out and you can rock it and do things that's personality based, not so much gender. I'd like to see more of these clubs bring in women as lecturers. I'm going to be doing a lecture with Lynne Brock who's an endodontist down in Alabama. It's for the Mississippi dental association. Here are these two blonde women, two endodontists, we're going to be doing this lecture. She's not a wallflower and I'm not a wallflower, and we're going to rock it. I want to see more of that happen, but in terms of good ole white boys clubs, that kind of stuff, yeah that exists. I think that's going to be awhile before that totally changes around, but there's a couple of things here that's different. It's an age related thing and you see it in schools now, especially in medical schools, the awareness of women's issues. The awareness of gay and lesbian issues. Don't hang old Dr. Kohn because he said a joke.

Just [inaudible 01:12:24] things have changed. It's the younger guys in their 40's. That's the group that has to understand that this kind of bullshit no longer goes. It's a different time. People have to work through this. They have to speak to their members like, "Wait a second. Times have changed." You know and I know in education times have changed. It's really tough getting millennials to come out to a conference. Guys your age, my age, people in their 40's, but you get this 28, 32 it's tough to [crosstalk 01:12:53].

Howard Farran:

Some of it's just insane like Chicago made winter. February, really? Is that your favorite time to visit Chicago?

Anne Koch:

No, but that's no male meeting that has a big attendance. What happens also there's a group. You have to realize this group is so comfortable with technology. It's the proverbial Thanksgiving dinner and the cousins are texting each other across the table.

Howard Farran:

You've lectured around the world.

Anne Koch:

Right.

Howard Farran:

When you lecture in Germany they have beer, and wine, and food. Have you ever been to a lecture in the United States where there were beer and wine?

Anne Koch:

No. What Dennis and I used to do this, we used to do dinner lectures at Real World Endo. We would actually have a free buffet dinner and enjoy the dinner while we're talking. I'm walking around while you're having a croissant and I'm speaking about brown ceramics.

Howard Farran:

I think it's funny how these big meetings attendance is drifting down, but it's not down enough to where they're willing to start making any changes.

Anne Koch:

I think I saw a welcome change this year at the Long Island dental meeting. I had a lecture slot that was kind of a grave yard slot, meaning 6:00 to 9:00. What was really interesting was that I got a chance to spend time at that meeting. The evening before it was packed, because they had so much food and drinks. They had white wine, red wine, Prosecco, beer, all kinds of different ethnic foods. Oh my God it kept everyone in house.

Howard Farran:

You know what's the funniest thing when you say New York? I grew up in Kansas. We're always told New York City's the biggest city in America, and there is no New York City.

Anne Koch:

Right.

Howard Farran:

When you go to New York City and you say, "Oh, do you live in New York City?" "No, I live in Manhattan. "No, I'm in Brooklyn." "No, I'm in Queens."

Anne Koch:

Staten Island.

Howard Farran:

There is no New York City. You'll never meet a dentist in your life that says, "Yeah, I live in New York City." It's kind of funny that way, isn't it?

Anne Koch:

That's what makes New York so much fun. You have all these different things, but I think it is a challenge for dental education. I think the dependency upon technology, the type of [daw-nt-s 01:15:00], the sim labs, the animation. You know the sim lab doesn't grab your hand piece, so that's a challenge for us. It's really the truth. I know case based learning very well. Case base learning works if the students are really motivated.

Howard Farran:

I want to ask you a personal question and then an endo question. To me it's so confusing growing up in Kansas. The Koch brothers are the most ... there's four billionaire brothers-

Anne Koch:

One of them-

Howard Farran:

It's Koch.

Anne Koch:

One of them lives fairly close to me on Cape Cod.

Howard Farran:

He was the one kicked out, right?

Anne Koch:

I don't know which one it was, because I know one brother went to MIT, and the other brother went to MIT as well.

Howard Farran:

That reminds me, you went to Harvard.

Anne Koch:

Well, I went to Penn but then I started the endodontic program at Harvard, yes.

Howard Farran:

Did I tell you my favorite Harvard, MIT joke?

Anne Koch:

No, please.

Howard Farran:

Someone's at the grocery store and the sign says, 10 items or less, and he has 12 items. The clerk says you're either from Harvard and can't count or your from MIT and can't read.

Anne Koch:

Be careful what you say when you say that in Cambridge.

Howard Farran:

MIT's known for their math and Harvard's known for all their social ... They're going to see your K-O-C-H and some are going to say Koch and some are going to say Koch. Why are there two different sounds to the same name?

Anne Koch:

Well, the real German pronunciation's is Koch, which means cook in German. Koch is kind of a little bit, even in Pennsylvania, Dutch in the Amish country and stuff. That's the main thing. They pronounce it as a Koch a little bit more like Koch. The anglo pronunciation of it was Koch. It's kind of interesting because it's by the heritage that's a German name meaning cook. There's a lot of other people with Polish names, Russian names, where they've shortened it to Koch. Like Kochinski to Koch, that kind of stuff. Koch now is not just German. There's a lot of variation. Ed Koch, think of Ed Koch in New York City. He was the mayor.

Howard Farran:

Your last name means cook.

Anne Koch:

Right.

Howard Farran:

Are you a good cook?

Anne Koch:

Let me tell you about this one of the things I ... at this point in my life, after going through everything I'm going through, I don't fake and I don't do a false modesty thing. There are some things I know how to do. There are some things I know how to do well, and there are some things I'm totally clueless about. If you want me to cook really a restaurant quality rib roast I'm clueless. Now, fish, seafood I know how to do that stuff. It was so funny because last year Sing Cook Kim, that person I had mentioned earlier, he came up to visit for a week and I showed him how to open oysters. You have to realize this is a world famous micro-surgeon. He's a DMD, Ph.D, MD type guy. Anywhere he goes, or even anywhere I go with micro-surgery courses they just assume you've been trained. Dr. Kim, Dr. Koch you've been trained. They're not impressed, but the fact that we can open oysters they're so completely totally impressed.

Howard Farran:

That was one of the best decisions I made. I had three of my four brothers living here, or all four, bachelors. We hired a cook. What was her name? Anne or-

Male:

That was when I was going to college in Flag.

Howard Farran:

Oh. We brought in a cook. She came in and I think we had 10 lessons. Everybody went to a different level of cooking. I want to ask you another question before I let you go, thanks for staying over time. My guest are supposed to stay an hour. You're already at an hour and 20. Here's a big dilemma that I want you to put on your mom hat. They come out of dental school, they're $350,000 in debt.

Anne Koch:

They're lucky if they're 350 and not 500.

Howard Farran:

You have to be good in sales to sell bleaching, bonding, veneers, these big cases, these rehabs. They're shy and they're introvert, but endo they're in pain. They're begging you. They're like, "Can you help me?" Almost half the graduates that walk out of dental school say, "I hate endo." I've had so many people, one of them said to me, "I'd rather be taken out in the backyard and beat with a stick then do endo." It's a $1,000 and insurance pays 80%, and the patient's begging you to do it. What do you say to that 24 year old?

Anne Koch:

I guess I put the sunnies on as the unknown endodontist. I put the sunnies on as fun because a lot of times with my residents we'll have pictures with the sunnies. It makes me think of that old lady who's on the cards, you know the lady with the glaucoma glasses. You have touched into something that is right in my wheel house. One of my biggest things that I have no problem speaking how I feel, and ever since you've known me I've always been that way. In the past my big complaint was about undergraduate endodontic education. People would say, "Anne," at the time it was Ken, "Don't get so upset. It's no different than orthodontics." Wait a second. There's a huge difference. In orthodontics there's no such thing as an emergency. There's an inconvenience. You lose an elastic, maybe you broke an arch wire. It's not a catastrophe. It's an inconvenience. In endo you can have somebody a week out of dental school, they're working for their first job, somebody comes in with a cellulitis and their eye's closed. That's a whole different procedure. The idea that you're not taught a lot of endodontics in undergraduate education is not the same as ortho.

I'm here to tell you every endodontic graduate program in North Americ is excellent. They've got great men and women as residents. They do a terrific job teaching and promoting endodontics, but especially teaching. The graduate programs are great. Where there's enormous variation in endodontic education is on the undergraduate level. I was at UNLV on Friday. They have some students who've done more than 50 molars as an undergraduate dental student. 50 molars as an undergraduate dental student. I've been to also many places where recent graduates come out they did one or two teeth. Sometimes they never did a tooth, just typodonts. There's enormous variation. One of the things that I used to have at my residents at Harvard, and I said to them very quickly, "Before you, as a graduate student as an endodontic resident, can take a case from an undergraduate student and do a surgery or a complicated case, you have to find a replacement case for the student."

When I put that edict in place it got a lot of barking and chirping. I said, "There's no discussion here." They said, "What do you mean Dr. Koch?" [inaudible 01:21:31] Dr. Koch is pretty reasonable. How come there was no discussion? It was so obvious to me. Here was my answer. "They also paid tuition." I think it's terrible that undergraduate dental students are not getting the exposure in perio, and in endo, and they stay restricted to endo, that they deserve to get. The thing to me is what has happened now, this is kind of interesting, I just had a conversation this morning will Allie Nassay. I see an opportunity for Real World Endo, and for Allie and myself teaching basic, generic endodontics.

Howard Farran:

I wish you'd do it online at Dental Town.

Anne Koch:

We're going to do it online in Dental Town.

Howard Farran:

Anne, tell me this, 30 years ago today I graduated 30 years ago. May 11th 87. When I was in dental school 30 years ago we had six full time endodontists. The class size was 120. There's a dental school up the street from here, has one board certified endodontist. How can one guy teach the whole damn school endo?

Anne Koch:

Well, that's a problem. This is a problem when you get into dental education in terms of how can they recruit faculty. Full time faculty's very difficult to recruit. Obviously in endodontics it's just like I have never been at any DSO ever. I've never lectured at any DSO where they did not try to hire me. It has nothing to do with me personally. It just has to do with I'm an endodontist. Schools have to make an effort in bringing some part-time people. In running a graduate program a school is only as good as your part-time faculty. Now if you have a dental school that it only has an undergraduate endodontic component, no post-op program, you've got to bring in some part-time endodontists to help out on the undergraduate level. I totally believe in that. Again, one of the things for me is that the pendulum is now swinging back. Will Giannobile was a perio resident at Harvard when I was running my endodontic program. Let me tell you what I did. When my endodontic residents were doing an endodontic surgery, you know who was assisting them? Joe Feralini's perio residents. When Joe's periodontal residents were doing perio surgery you know who was assisting them? My endo guys.

Howard Farran:

Nice.

Anne Koch:

That way you get an appreciation for what the other person's doing. Anyway, Will Giannobile was a perio resident with Dr. Feralini. Will now is the chairman of periodontology at the University of Michigan. He's also the editor of the journal of Dental Research. That's a serious journal. Last May he had an article talking about failure rates with implants visa vi endo and perio mucositis, peri-implantitis, things like that. That started the swing. Now what we're seeing, we're seeing this big swing coming back towards dentition based prosthesis. In Boston its gotten so out of control now that endodontists are telling the perio guys and the pros guys, especially the pros guys, "I can't save it. It's fractured. I can't save it."

It's gone from one extreme where somebody had a short fill one third the way down a canal of being attracted and having a fixture place, to now where prosthodontist are trying to have endodontists save teeth that are fractures, that need to be extracted. As we go more into this dentition based trend it's really incumbent upon young dental graduates, young general dentists, young restorative dentists to understand what endodontics can do, what endodontics can not do. I think it's an opportunity for them. I see this as a great opportunity for Allie and I to teach generic endodontics to reach a lot of young dentists.

Howard Farran:

Another stressful question a lot of endodontists have is whether or not they should learn to place implants. What is your view on an endodontist?

Anne Koch:

Well, it's interesting because when endodontists first starting treating implants I said to them I said, "Excuse me, have you ever had a patient come back and say to you, or you have a patient in a chair, 'Well I'm not going anywhere, the temporary's not right.'" They said, "Well, no. I never did any restorative or any kind of prosthedontic dentistry." I said, "Well I've had. If you're going to be doing implants you have to understand placing an implant to me is pretty easy. It's a lot easier than doing a mandibular molar apicoectomy." The big thing, and you can offer your opinion, but the big thing to me about implants is soft tissue management and treatment planning. You can't have little dark triangles between six and seven, and seven and eight, and eight and nine. You can't have that. Your [inaudible 01:26:11] the management of the papilla. That's something that a lot of endodontists that I've known in [inaudible 01:26:17] didn't have any background in. Yeah, placing a fixture is pretty easy, and I understand that. I think it's up to the individual, but if you're going to be placing fixtures as an endodontist I want you to understand keenly soft tissue management and treatment planning.

Howard Farran:

I want to-

Anne Koch:

Does that make sense to you from your perspective?

Howard Farran:

Yeah, absolutely. Thanks for staying overtime.

Anne Koch:

Are you kidding me.

Howard Farran:

I've been going over.

Anne Koch:

Don't ask Anne Koch a question, off I go.

Howard Farran:

I'm greedy on your time. I see these young millennials are a half million dollars in debt. Every time they want to take a course they got to get in a jet airplane, fly across the country, stay in a resort, drop three grand a weekend. I think it's crazy. What I used to do is just walk across the street or drive and I would ask these specialists if I could assist them. I saw there were two types. Half of them were hope, growth, and abundance. They'd say, "Come on in." Half were fair and scarcity like, "Well, if you want to have it done right give it to me." What do you think about these young kids who are sitting in a town and they see these specialist, but they're scared. They don't want to knock on your door. This is what they say to me, "They don't want me to learn because they want the money themselves. Why would they teach me?" What would you say? What would your advice be?

Anne Koch:

That's a feeling among certain specialists. There's no doubt about that. I've always had it just the opposite way and I'm probably not in the majority. I don't think I'm in the super large minority. I think it's getting closer and closer to maybe a 60-40 type of thing. Here's my feeling; If you're a specialist, and let's talk about endodontics. If you're and endodontist you're an education source for that entire area. You're an education source for all your referral dentists. My attitude is understand that they're going to do some of these easier cases just because the financial aspect. If you reach out and you create a relationship where you're educating your general dental referral base, because it's a referral business, how to do some other cases easily, how to do these basic cases easily and well I think by creating that relationship you can let them know why they need to send the more difficult cases to you. What it does, it's a referral business. There's room for everybody.

What I have seen, because I've spent so much time in medicine, and in the last few years, let me just do a quick sidebar. The only thing that physicians do better than we do as dentists, there's one thing that they do better, and they do a lot better than dentists. You know what that is? They don't criticize each other. You can leave behind a hemostat or a sponge and the other physicians not going to say anything negative. In dentistry, you go to a dental office, "I think I can get my root canal closer to the end of the root. I think I can make that crown better. That looks like a C3 to me. I think you're more of an A2 and a half." We should be a little bit more considerate of criticizing each other in dentistry. Physicians are very good at that. Other than that [crosstalk 01:29:17].

Howard Farran:

Physicians never brag about some equipment they bought.

Anne Koch:

No, no.

Howard Farran:

You'll never see an add sign, we bought the new deluxe MRI, and Ultra ... Dentists are like I have the same day dentistry, I have a laser.

Anne Koch:

Right. In dentistry, we have a continuity care. We have a follow up, but one thing that physicians, I've seen in the surgical specialties, I've seen young surgeons reach out to older more experienced people if they could watch them. The senior surgeons, the only concern they have is, "I don't want you saying that you did training with me specifically." Some of them will limit it to a week. Some of them may limit it to two weeks. What they're doing, they're reaching out, and even just observing. I think that is something in dentistry that you just almost never hear of anymore.

Howard Farran:

What specialties are more open to sharing their knowledge with their referrals versus, "No way. Close my door."

Anne Koch:

To me I thought for years the best specialty out there in terms of sharing their knowledge and information was endodontics.

Howard Farran:

I agree.

Anne Koch:

Endodontists were the guys out there. One of the things I did when I was running my program at Harvard I had my endodontic residents teach the rest of the school, meaning undergraduate dental students and other post-doc residents, how to get patients profoundly numb. Not numb. Profoundly numb. There's a trick and it shouldn't just be the [inaudible 01:30:46] of endodontists and oral surgeons. I have always felt, and held to the belief that endodontists were the best about sharing their specialty. I can also tell you when I spoke at the AAE this year, and when I spoke at the ADEA meeting, I think this was the keynote where they had this on tape, I have never been more proud in my life to be a dentist then I was at that lecture.

That's come a long way when all of a sudden I'm a keynote speaker being a very visible transsexual women. I see myself as a women. If you want to make it officially I was a guy, so I'm officially a transsexual, but everything works. Everything looks totally natal. Still, that's a bit of a stretch to have me as a keynote at a dental meeting, that I think they deserve a lot of credit for that. For the AAE this year to have me as a speaker twice, I think that says a lot. What it says is stuff that's positive.

Howard Farran:

Last question.

Anne Koch:

Absolutely.

Howard Farran:

There's a lot of old guys, I'm 54, that every molar root canal they do they give a Pen VK 500 milligram and 16 tabs of Vicodin. Talk to that. Do you agree or disagree?

Anne Koch:

I disagree with that. I'm [crosstalk 01:32:08].

Howard Farran:

No, no I said do you agree that there's a lot of dentists out there that do that?

Anne Koch:

Yes, absolutely. Actually some specialists. I'm 67, so I've been around. I was practicing dentistry before we had gloves. We had gloves we only used [crosstalk 01:32:20] okay. I also around, I just mentioned it the other day, years ago when we used to do pin retained amalgams. When I was in the service I used to call them Brunswick amalgams. They'd say, "Brunswick?" Yeah, I'd say, "10 pins, right." We'd put pins all kinds of different directions. We used to actually mix amalgam and we would add a little bit extra mercury because on those big amalgam build ups it made it easier to condense. I've seen a lot of changes come across the table here in 40 plus years. I'm not a person like dental schools. Dental schools treat antibiotics sometimes like it's the plague. On the other hand you have people who use it as a total crutch. There's an indication for antibiotics. Just like there's an indication for implants, there's an indication for root canal therapy. The big thing with antibiotics in addition to some of these prophylactic indications is when there's systemic involvement.

When somebody comes in and they have a tooth that they feel like their head's going to blow off that's all inflammatory cells. Antibiotic has no effect. There's no need to give antibiotics on that. If the patient is not swollen and they don't have any type of systemic symptoms there's no need to give an antibiotic. Now, if somebody comes in swollen I'm going to give them antibiotics. I've had people argue with me saying, "Well, wait a second. That's immunologically driven." "Wait a second you've never worked as an endodontist. You're an immunologist. You're a Ph.D guy." I've had some times where people, and this is a clinical sense you know what I'm talking about, some times if people have a big area and that tooth is symptomatic I'll give them prophylactic antibiotics after instrumenting, after case.

People say, "Well, that's really not necessarily." Yeah, but then patient blows up and they come back to my office and the first question they ask is, "How come you didn't give me an antibiotic?" That's the gray area. That's my clinical experience in these cases, but really the big thing is there are too many dentists giving antibiotics in areas that it's not systemic, it's inflammatory driven. If you have a vital tooth there's no reason for antibiotics in endodontics.

Howard Farran:

What antibiotic do you give?

Anne Koch:

Well, for me there's a couple of things. For me the antibiotic I like, when I'm using things, ConA prophylactically is Pen VK. That's Pen VK, 500 milligrams, one time QAD, seven to ten days generally seven days is enough and I'll stop that. If you go to use antibiotics use them properly. I'm not a big fan of Amoxacillin in endodontic infections. I think it's a little bit too broad. If somebody comes in, and I will tell you right now, between 1991 and 1998 there was probably no endodontist on this planet, I can't speak for Mars and Venus, but there was probably no endodontist on this planet who treated more HIV patients than me. I treated it down in Philadelphia with Michael Glick and then when I went up to Harvard I treated all the Fenway, and especially the Deaconess.

The Deaconess is a very famous hospital in Boston and the Longwood Avenue area that is immuno compromised patients. These guys would come in on a Friday afternoon swollen up in a canine fossa. Those years this was just at the beginning of a cyclic. They would dump all this medicine on your bracket table. I couldn't IND a hard cellulitis up in the canine fossa. I would put them on Clindamycin and I would put them on Clindamycin and they would come back Monday morning. I would do a nonsurgical root canal. I love Clindamycin. I like Clindamycin better than Metronidazol, which is flagyl combined with Augmentin or combine it was Amoxacillin. I like Clindamycin because it's really great. It gets anaerobes.

Howard Farran:

Last question of this.

Anne Koch:

Okay.

Howard Farran:

Opioids it's-

Anne Koch:

Out of control.

Howard Farran:

-all over the news.

Anne Koch:

All over the news.

Howard Farran:

A lot of people they're in pain. A lot of doctors, every single moral gets 18 down. Some are afraid to. What's your thoughts on opioids?

Anne Koch:

I've used Vicodin, Vicodin ES, in my career very, very little. NSAIDs combined with acetaminophen works really well.

Howard Farran:

Why do you say NSAIDs and acetaminophen. Is asprin still a bad guy?

Anne Koch:

No, but what is happened is Elliot Hersh has some of this stuff where in Pennsylvania, you can google Elliott Hersh H-E-R-S-H, has some interesting study on pain medication where they've used ibuprofen combined with acetaminophen. For me as an endodontist even in terms of apicoectomies things like that apical surgery, we basically push NSAID's. Would we occasionally write a script for Vicodin or T3? Yeah, we would do that, but that would not be the principal thing.

Howard Farran:

How do you prescribe the NSAID's and on your [inaudible 01:37:22]?

Anne Koch:

Well, one of the things that they're doing is they're doing irregular NSAID's, which is what? 400 milligrams to 600 milligrams. You could do 600 milligrams, 325 of acetaminophen.

Howard Farran:

At the same time?

Anne Koch:

Yeah.

Howard Farran:

Every four hours? Six hours?

Anne Koch:

Yeah, and you can go back and check that. I would double check on that, because to me-

Howard Farran:

Some people wonder that if you should ... you give them that dose before you even start?

Anne Koch:

I used to start NSAID's before. I'm going to say an asterisk here. Right now when I was actively practicing I wasn't doing the NSAID's and acetaminophen. This is something that people are starting to use now. I would double check exactly on the dose. It's NSAID's and acetaminophen. I think it's basically 400 to 600 milligrams of ibuprofen combined with 325 acetaminophen, but check that.

Howard Farran:

You think dentists have created a lot of addicts over the years?

Anne Koch:

I think physicians have created a lot more than dentists. One of the things that would change in this game for me when I was really actively practicing was Massachusetts is really a great state. Massachusetts cares about three things. Politics, sports, and revenge. That's Boston politics, sports, and revenge. Massachusetts cares about education and healthcare. We would have pharmacist call us and they would say, "Dr. Koch you just wrote a script for T3. We want to let you know this is the fourth codeine prescription this week for this patient. Cancel the script." That's I think pretty much all around the nation now. I believe probably. One way or the other you've got to check or you can basically check how much the patient has in terms of these scripts. In Massachusetts the pharmacist will call you.

Howard Farran:

Do they have to call you or is it just culture?

Anne Koch:

I believe maybe at the point now it's probably mandatory. I'm not quite certain on that, but Massachusetts is very proactive on that. The T3's and the Vicodin ES is not being prescribed as much as it was. For me the amount that dentists prescribed generally has been very, very minimal. I think you see physicians keep people on some of this atypical pain that they have, back pain. I think physicians have a little bit more culpability in this than the dental market.

Howard Farran:

I just want to say last thing on a marketing tip I've been a dentist now 30 years. I've taken all my pharmacists in my zip code to dinner. I've had them out to the house at dinner. Do you know how many people go up to the pharmacist and say, "Should I buy this anbesol? What's the advice for a toothache?" They go, "Go see Howard Farran." I remember wining and dining Brad within three weeks when I got here. 8% of all emergency room visits are tooth in nature. I've driven to each one shook their hand, given them my referral cards, send them cookies with [inaudible 01:40:24] because the emergency room doesn't want to treat a toothache.

Anne Koch:

Let me ask you about have you had anybody else in Dental Town talking about this combination of NSAID's and acetaminophen?

Howard Farran:

On a course?

Anne Koch:

Yeah, even anything.

Howard Farran:

I don't think so.

Anne Koch:

This is getting a lot of publicity out in the schools because the studies. Again, what everybody should google is Dr. Elliott Hersh University of Pennsylvania. It's basically the studies that they've done. It's really interesting. Elliot has also developed a nasal and a dental anesthetic.

Howard Farran:

Oh yes.

Anne Koch:

Okay, the same guy. What he's had a lot of studies on is this combination of-

Howard Farran:

What's his nasal anesthetic called?

Anne Koch:

I don't know what the name of it is, but I know he's had a nasal anesthetic.

Howard Farran:

Is he a friend of yours?

Anne Koch:

No, but he's on the faculty down there.

Howard Farran:

Okay, well introduce us if you remember, or I'll try to find him.

Anne Koch:

I'd like to do that, because please check out, and I'll go back and check out the exact number. What he has with the ibuprofen plus acetaminophen. In the past it was always kind of one or the other. You gave NSAID's or you gave acetaminophen and it was a combination that they had really profound good results in terms of pain medication, so check it out.

Howard Farran:

I have mixed feelings about opioids. Everybody says how bad Vicodin and Percodan, and Oxycontin, and heroin is, but then when I look at my music collection it's half heroin.

Anne Koch:

Let me tell you what day is the worst day of the year for endodontists in terms of people trying to scam drugs. It's the Wednesday night before Thanksgiving. It's notorious. You get all these calls of people calling up because you're an endodontist and it's like, "My tooth hurts." "I don't want you to come in. Okay, I can give you a script. I'll call in some ibuprofen 600 milligrams." "No, no that doesn't work for me." Then of course they proceed to give you the pharmacology for Vicodin ES. Wednesday night before Thanksgiving.

Howard Farran:

Why Thanksgiving?

Anne Koch:

Why what?

Howard Farran:

Why the night before Thanksgiving?

Anne Koch:

They realize they don't want to bother you. It's a great excuse. They're like, "Oh, I don't want you to come in. It's the night before Thanksgiving. Just call it in."

Howard Farran:

[crosstalk 01:42:30] time on Thanksgiving it's so funny because everybody thinks Thanksgiving is turkey and stuffing, and apple pie. Thanksgiving started up in your part of the country and for the first 100 years it was a seafood fest.

Anne Koch:

Stripe bass, cod fish, oysters.

Howard Farran:

Yeah.

Anne Koch:

Absolutely.

Howard Farran:

There was no turkey for Thanksgiving.

Anne Koch:

I would prefer a stripe bass, cod fish, oysters, scallops.

Howard Farran:

Yeah, that's the original Thanksgiving.

Anne Koch:

Oh my God there is nothing better in the sea then [crosstalk 01:42:55] scallops.

Howard Farran:

I want to tell you, you put up six online CD courses on Dental Town. You were the first one who ever hit 10,000 views on an online CD course. You're a legend. I've seen you lecture so many times when I was getting my FAG, my MAG. I just think the world of you. Thank you so much for all that you've done for us.

Anne Koch:

The feeling's likewise and I'm so thrilled to be back in [inaudible 01:43:20] with the Dental Town community. I'm thrilled.