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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Joel H. Berg is Professor and Lloyd and Kay Chapman Chair for Oral Health at the University of Washington School of Dentistry in Seattle.  Dr. Berg is a board-certified pediatric dentist and was President of the American Academy of Pediatric Dentistry for 2012-13. Dr. Berg previously held positions as Chair of Pediatric Dentistry at the University of Washington from 2003-12, as Vice President of Clinical Affairs at Philips Oral Healthcare (Sonicare) from 2000-2003, and as Head of the Scientific Department for ESPE Dental AG (Seefeld, Germany) from 1998-2000.  He is the author of the book Early Childhood Oral Health, and of over one hundred manuscripts and book chapters on subjects including dental restorative materials for children and other work related to biomaterials. His current research interests include the development of dental caries prevention programs using risk assessment models and early childhood oral health.

Howard: It's just a huge honor for me today to be podcast interviewing Joel Howard Berg. Thank you so much for coming by.

Joel: Good to see you, Howard.

Howard: We've been friends for thirty years. He's a Professor and Lloyd and Kay Chapman Chair for Oral Health at the University of Washington School of Dentistry in Seattle. Dr. Berg is a board-certified pediatric dentist and was President of the American Academy of Pediatric Dentistry in 2012. Dr. Berg previously held positions as Chair of Pediatric Dentistry at the University of Washington from 2003 to 2012, nearly a decade; as Vice-President of Clinical Affairs at Philips Oral Healthcare (Sonicare) from 2000 to 2003; and as Head of the Scientific Department for ESPE Dental, Seefeld, Germany, from '98 to 2000. He is the author of the book, 'Early Childhood Oral Health', and of over one hundred manuscripts and book chapters on subjects including dental restorative materials for children and other work related to biomaterials. His current research interests include the development of dental caries prevention programs using risk assessment models and early childhood oral health.  You know, I've been a huge fan of yours forever. You've been to my office. I got lucky one time. I was coming back from a seminar and I go to sit down in my seat and I sat right next to you. Do you remember that?

Joel: Sure I do.

Howard: And poor Joel, he thought he was going to get [unclear]. He had his laptop out, all ready to work, and I yakked at him for the whole three hours.

Joel: No, I enjoyed it. I remember that conversation. You talked to me a long time ago about doing this. So, I'm glad I'm here.

Howard: You know, it seems like when you look at spending money, children... I mean, the meaning of life is to survive long enough to reproduce, and moms would rather... I mean, I would give my kidney to any of my children or grandchildren, and pediatric dentistry is everything, and so many grandparents... I mean, Grandma doesn't want veneers. She wants braces for her granddaughter. So, you're sitting at the junction of meaning of life and dentistry, pediatric dentistry. But gosh darn it, if at least men my age, if you said, "What's the one thing you never want to do?" It's pediatric dentistry. Dentists would rather do a root canal, a filling, a crown. Has that changed over the years?

Joel: Well, we're seeing a lot more interest in pediatric dentistry. If you look at the ratio of applicants to people accepted into specialty programs, I think we're either the highest or the second - we're up there.

Howard: The most competitive.

Joel: The most competitive to get into.

Howard: And what is the ratio now?

Joel: I think if you look at the total of the number of unique applicants - because people apply to multiple programs - and the number of positions, it's around three applicants per position.

Howard: Three to one to go to ped grad school?

Joel: Yes, and I think it's probably in the same range, even a little higher ratio than orthodontics or oral surgery, for example...

Howard: Really?

Joel: … or endo which has a low number of positions, it kind of excludes people who realize they have no chance because there's a low number of slots, so we do have a fairly...  we have a larger number of positions each year nationally.

Howard: Now, I heard the United States has three hundred and twenty five million people and they don't even have three hundred slots for a pediatric dentist, so it's less than one out of a million.

Joel: I think it's a little more than three hundred now. It's been corrected. It might be around three twenty - I don't have the exact figure right now for you.

Howard: Yes, three twenty.

Joel: But it's almost doubled, but it's still low, you're right. It's still very low.

Howard: Well, in a country of three hundred and twenty five million million people, that three hundred and twenty slots means we train one new pediatric dentist each year for every one million people.

Joel: That's a good way of putting it.

Howard: That doesn't seem...

Joel: And if you make a comparison to medicine, where most parents take their kids to a pediatrician as opposed to a family physician, it's the opposite in dentistry. About 65, 70% of children are seen by general dentists, which is a good thing because it's family practice, and only 30% or 35% are seen by pediatric dentists.  So, it's not the same scenario as in medicine.

Howard: The really sharp pediatric dentists... the slow ones to marketing, they're always marketing to general dentists to refer pediatric patients; and the smart ones say, "Forget that! I'm going right to the pediatricians, the Ob-Gyns." They're picking up these new patients right when they're made, as soon as they come out. I tell pediatric dentists, "Don't focus on the general dentist, because he's going to send you the one they've already scared, that's crying, bad behavior." It'd be like an orthodontist only getting Class III malocclusions.

Joel: Right.

Howard: To get that 80% Class I malocclusion sweet spot, Invisalign case, go after the pediatricians.

Joel: I think you're right. Most of our referrals come from pediatricians, but I would say to those general dentists, and as I said, the majority of kids are seen by GPs, appropriately,  I think - it's part of a comprehensive practice and there's an advantage a general dentist has, because they can see the mother, they can see the father, they can see the caregiver, they can see the siblings, they can see the whole family, and oral health is a family issue. When you talk about behaviors, it's important to have the whole family, and so, to a certain extent, there is that advantage. As you just said, pediatric dentists often get referred from GPs patients who didn't survive in the practice and maybe it becomes even more difficult to treat them afterwards, but I think the connectivity is always going to be important. Pediatric dentistry is unique as a specialty. The other eight specialties of dentistry - there are nine in total - the other eight have a specific discipline that's carved out. You mentioned endodontics or periodontics.

Howard: Right, yours is just small humans.

Joel: Exactly. Ours is about a population, and the beauty of pediatric dentistry...

Howard: About a population?

Joel: A population, children being the population.

Howard: Yeah, I mean endodontists do root canals, oral surgeons do surgery.

Joel: Right.

Howard: Pediadontists just do the small humans.

Joel: Small humans and people with special needs. And we like that, and we like the fact that it's beyond the dentistry. We can shape the behavior. I argue with people all the time, and my best buddies - in my industry days, I got to know a lot of prosthodontists and people who use impression materials and I learned all about scanning. I'm going to be, I'm the incoming President of the American Academy of Aesthetic Dentistry, which is anomalous for a pediatric dentist. They look at me like, "What are you doing here!?", somewhat, but it's a wonderful group of people who perform some of the highest end dentistry, but that group and others realized that dentistry as a profession is about excellence and doing the right thing for populations - and I argue with all my buddies, whether they're prosthodontists or general dentists, that the most important visit in the dental office of one's lifetime is the age one dental visit, and I can argue until the n on with anybody on that one because where do you get a better chance to shape the behavior and prevent disease than at an early age? And I would tell a general dentist, "If you want to measure the health of your population, lower the median age of your practice, because the earlier you get them in, the younger you get people in, the more chance you have to shape preventive behavior, because caries - the most common disease in humans - is a behavioral disease. It is. It's preventable. Unlike all childhood diseases, diabetes, asthma, you can't prevent those. You can manage them. But in the case of dental caries, we can actually prevent it if we provide the information and the experiences that are going to be important to keep this child cavity-free for their life. So, that age one dental visit, nothing more important in one's life.

Howard: One of my favorite quotes: "It is easier to build strong children than to repair broken men", by Frederick Douglas.

Joel: True. Great quote.

Howard: Yeah. It's everything. You've said so many things. It is a family disease. The thing that bothers me the most about pediatric dentistry is, it seems like about every quarter a general dentist can't work on this child - behavior, whatever - sends it to a pediatric dentist. Pediatric dentist says, "We can't manage it either. We've got to drag this patient to the OR. It's only two and needs eight pulpotomies", and a board-certified pediatric dentist and a board-certified anesthesiologist put the child down and they lose the child; and then it's all over social media. And I find it so grueling because in the media, the dentist is always the bad guy. I've never heard one media person say, "Hey, Mom..." - and the mom gets a million, several million Dollar bonus reward for having a two-year-old that needs eight root canals!

Joel: Yes.

Howard: So, she wins the lottery of money, although losing her child, and nobody ever... There's no journalism in America. I mean, we just had the driverless cars. So, Uber in Tempe, they had their first accident.

Joel: That's right, they had the accident here.

Howard: Yeah, their first accident.

Joel: But that's nothing compared to the number of accidents that occur by us.

Howard: But that's not in the article that, that very day one hundred people were killed by humans driving cars. There's no in-depth journalism.

Joel: I agree with you.

Howard: And they never ever go in and say, "Mom, how did you manage to have child that needed eight root canals at age two?"

Joel: Right, that's why I go back to the prevention.

Howard: And if this woman gets $2,000,000 or $3,000,000, it should be given to a dental school to do oral healthcare deals. And then the other thing that bothers me the most about pediatric dentistry is, a two-year-old needing eight pulpotomies, Kromasil crowns, isn't because it ate some Cheez-Its and cookies. This is because Dad has a bombed-out mouth and he's kissing the baby, and Grandma's got gum disease and she's... People know the waist down. All those STDs are transmitted, and AIDS clarified that for the Planet, that you can pass germs downstairs, and they haven't even started the discussion. The other end of the body, you have a newborn baby and you hand it to Grandma who's wearing the upper and lower partial and has gum disease, Grandpa's got a bombed-out molar, and they're kissing the baby right on the mouth.

Joel: Well, you're hitting all the right points, Howard. I think it's a behavioral disease, and regarding what you said before, it's unfortunate that any child would die with anesthesia for any reason, but the fact is, in looking at the American Academy of Pediatric Dentistry Guidelines for Sedation, which are in common with the American Academy of Pediatrics, they went together on those, when the guidelines are followed there's never been a death. So, I think it's important to know that there are guidelines, there are ways of practice to prevent those things from happening.

Howard: So, you think these deaths aren't from board-certified pediatric dentists?

Joel: Well, I don't know about each instance, but I think that...

Howard: [overtalk] had two in the last three years.

Joel: Yeah. I don't know. I've heard about those.

Howard: Yuma, Arizona.

Joel: I don't know the specifics. It's unfortunate that it ever happens. It should never happen. That's why we go to great lengths to develop training programs and guidelines.

Howard: But I'll call [sounds like: uncle] on this. There's only three publicly traded dental offices in the world. There's none in America. There's two in Australia, 1300SMILES, Pacific Smiles, and Q & M out of Singapore. When they did their IPO, the lawyers looking at claims, these companies are not allowed to do... almost all the deaths are between birth and sixteen years of age and sixty-five and over; so, there are oral surgeons...

Joel: Higher risk patients.

Howard: ... can only do patients seventeen to sixty-five, because obviously anesthesia on a two-year-old is a hundred times more risky than on a twenty-five-year-old. Agree or disagree?

Joel: I don't know about a hundred times, but it's definitely riskier. That's why we have careful guidelines and we have certain age limits, or age requirements, so we would rarely, if ever, do anesthesia on an eighteen-month-old or a twelve-month-old, but two-year-old to three-year-old who has ten or fifteen large cavities with facial cellulitis, evidence of a real health risk that could kill the child, it would be very dangerous for the child. That's seen every day in every city in the country. We have to do something about that, and from a behavioral standpoint, I call children under three, not uncooperative, but pre-cooperative. They're not supposed to be cooperative. In medicine, if you had to have tubes put in your ears, you wouldn't even think about not doing general anesthesia. Although, having observed hundreds of those procedures myself, that's a heck of a lot easier than what we do. You could hold the kid for a few seconds and do that, but it will never be considered. So, it really boils down to a question of medical necessity. If it's medically necessary, these procedures, and they are in these instances, then we have to do what is necessary to provide the medically necessary care. So, to me, it's a question of is oral health part of total health, and if the mouth is part of the body, then you don't ask the question, "Well, that was only dentistry. Why did we do it?" "Is it medically necessary?" is the question; and then you deal with the same issues of safety that everybody deals with regardless of the procedure, whether it's the ears or the feet or whatever it may be. So, the question shouldn't be about dentistry, it should be about is it medically necessary? And sadly, as you said earlier, because the behaviors weren't there to prevent this disease, which is almost entirely preventable, it becomes medically necessary to preserve the health of the child. That becomes the issue. That's what our age one visit is about, providing that information to parents. Unfortunately, the ones who come in, sometimes they're the ones who maybe don't need to come in. The ones that don't come in at age one are the ones that we want to get to. And by the way, general dentists, we've trained thousands of general dentists across the country. In Washington State we have a program called ABCD, Access to Baby and Child Dentistry, a very successful program. This improved access to health for babies. It's an amazing program. And other States have programs like that.

Howard: What does ABCD stand for?

Joel: Access to Baby and Child Dentistry.

Howard: Access...

Joel: ... to Baby and Child Dentistry.

Howard: Okay.

Joel: And it's a very successful program that has resulted in, for example, Washington State used to be one of the lowest Access to Care States for kids in the country; now, in Washington State, as a result of ABCD, it's one of the most likely States for a child to have access to dental care. And it's all education and promotion and consumer awareness. Health literacy is what this is about. You know medicine, they talk a lot about health literacy. I think that's one of the most important subjects in dentistry for health, because - you talked earlier about the parents, you're right - it's all that. If the mom's got dentures at age fifty, if they have a lot of cavities in their mouth, there's the transmission part, you refer to that, and by the way, that's a whole new subject, which is fascinating. We're just learning about the oral microbiome. I just was emailing some of my buddies who are the top microbiome people, many of them not dentists, some are, but I think that's where all the discoveries are going to get made that are going to change our profession. They're going to just change everything we do when we learn about that microbiome in the mouth. But it's about access to the families.

Howard: But it's not even... well, first of all, it blows my mind that there's dentists on Dentaltown that don't believe it's transformational.

Joel: It's scientifically proven.

Howard: So, if you just walk out in the backyard and there's a giraffe there, it just appeared?! What? Did the tooth fairy bring it? Don't you think that giraffe came from a mom and dad, and they came from Grandma and Grandpa? But when you said, 'microbiome in the mouth', I've already read a ton of literature that maybe the biggest factor of the microbiome in the mouth is the microbiome in the sigmoid colon. The thirty feet from your mouth to your rectum has 100 million bacteria, fungi, viruses, microorganisms, that you didn't get from Mom and Dad. Whereas when Joel (we'll just call you Howard because your middle name is just perfect!), when you look in the mirror, what you see is 10 million cells that you got from Mom and Dad, but from your mouth to rectum is 30 million. So, that whole cord is connected. So, if you have a lot of pathology going on in the mouth, it is amazing. I think, the number one transplant in the world right now is a fecal matter transplant.

Joel: Yes, it's a big transplant. It's important and saves people's lives all the time.

Howard: And then the other thing about the oral microbiome, when you started talking to me about this bacteria, that bacteria, when you say that, are you aware that every ninety days they discover a new bacteria in the mouth that they didn't even know of before? And when people say that cavities are caused by streptococcus mutans, did you know that four millimeters down in the decay, there's not even any streptococcus mutans?

Joel: Well, yeah, there are so many facts that are really interesting and I think the amazing thing about the microbiome science is people have theorized for years, you know Miller, who was the first dental microbiologist who worked in Robert Koch's lab in Germany,  he talked about the bacterial transmission of disease in 1882; Miller, who was this dental microbiologist if you will, proposed the oral systemic connection that we talk about today, and he made all these theories, most of which are true today, but he couldn't prove it. So, what's interesting is the laboratory science, the actual ability to perform the experiments in the lab, the genome science, the sequencing techniques; twenty years ago you couldn't have done 23andMe because it was too expensive. You couldn't do it at all. Ten years ago it was too expensive. Now you can do it for $75. We adopted a dog who was injured here in the next county on Christmas, and we don't know what breed she is. So, on Amazon we bought a kit for seventy-five, fifty bucks and I can find out what breed this dog is, what hybrid breed the dog is? That would have cost $10,000 five or six years ago. So, the techniques and the cost effectiveness of the laboratory techniques that allow the scientists to make the discoveries are improving every week. So, I stay in touch with these lab guys because they've had all these theories for years, but they can't prove them until the lab science catches up to allow them to do the experiments. So, to your point earlier, they say there are five hundred plus species of bacteria in the mouth, whatever number you want to propose. Some people say a thousand. But let's say it's over five hundred. But what is known, what has been known for some time, only about a third of those can you grow in a petri dish, whatever you call it, in the [sounds like: culturer].

Howard: Right.

Joel: The other two thirds we've never known they were there until we could see the RNA and DNA. Now we know their presence and now with modern techniques, some of which have only been developed in the lab in the last year, you can actually see the sequence of events that occurs when you feed sugar to this biofilm. You can see how it really acts like a community, in the same way that the pituitary gland sends a signal when you're scared to the adrenal gland to make adrenaline. Adrenaline doesn't come by itself. It has a signal, a hormone signal. The biofilm acts in the same way. So, strep mutans, we know it makes acid, but now we know that it needs a signal from something else to turn on that acid production. These guys are communicating. They're talking to each other. I always say in my lectures, Howard, that I'm not actually speaking to you right now. It's a biofilm that's occupied my body because it needs vocal cords. I should make a movie about that. I think it'd be a best seller, because the reality is we have ten times as many bacterial cells in or on us as we have human cells.

Howard: Right.

Joel: We are mostly bacteria. So, we interact with one another, to your point earlier about the fecal transplant, if you don't have it, it'll kill you. We need each other to live.  We coexist. We understand very little about that coexistence. So, all of these discoveries about the oral microbiome are going to shape the way we think about caries, because now we know there are these new bugs, for example, Veillonella is one genus, that seems to turn off the acid production. So, maybe we don't focus on killing the acid production by killing mutans. Maybe we figure out how to uptick the ones that are good, that say, "Hey, we don't want that acid production." Let me just shift gears if I could for a second, a related subject, it's a little superficial, but I think it tells the story. You mentioned the GI tract from the mouth to the rectum. The gastrointestinal business, the whole gastrointestinal disorders business is about $100 billion a year in the U.S. Caries by itself is about $125 billion.  The business of dentistry is about a hundred and sixty, if you include all the medical costs, a hundred and seventy billion. Caries is most of it. Most of dentistry is dental caries. That's the disease that we treat and then you have periodontal and you have other things that we deal with, but most of what we do, we're cariologists, we're cariology clinicians, because everything we do is treat the effects of caries. We don't actually treat the disease, we treat the effects - and that's most restorative, most prosths, everything but perio is pretty much the effects of restorative. In medicine you have, for example, medicine that deals with most of gastrointestinal disease, not surgery. The whole field of medicine is mainly medical management, not surgical management, but dentistry is mainly surgical management, waiting for the results of the disease, that is the broken-down teeth, etcetera, rather than treating the disease itself that causes that problem, and there's a drug called Nexium - you've heard of it, I'm sure. It's for esophageal reflux. It's over-the-counter now. But last year it was by prescription. I think about two years ago, something like that, maybe three at the most, they sold in the U.S. over $6 billion of Nexium. One pill, $6 billion. Second biggest Dollar selling pill in the United States.

Howard: What's first?

Joel: It's a mood-altering drug and I can't remember the name of it. It'll come to me in a second. Abilify.

Howard: Abilify is the highest.

Joel: Yes, Abilify was the number one that year. I don't know what it is today, but it's probably near the top, and I believe it was number one. But Nexium was number two.

Howard: Do you know what number three was?

Joel: I don't remember, but I can get you the list.

Howard: Ryan, Google the list.

Joel: I'll send it to you.

Howard: Google it by Dollar amount.

Joel: It was by Dollar sales, obviously not by volume.

Howard: The top 10 prescriptions by Dollar.

Joel: By Dollar, yeah, because if it's by volume, it's going to be antibiotics and things that are cheap.

Howard: Actually, the number one by units has been Hydrocodone for twenty years.

Joel: That could be, yeah, because they're cheap to purchase, not on the street but to purchase by prescription.

Howard: I mean the most prescribed.

Joel: Yeah, I believe it is, by volume. That makes sense. But by Dollars, 6% of the total gastrointestinal disorders expenditure in that year was one pill. Now, if you compare that to dentistry, Dentsply just merged with Sirona. There's a $5.7 billion company. So, everything that Dentsply Sirona does is less sales than one pill in medicine, Nexium.

Howard: Nexium. Wow!

Joel: And that says a lot about the profession, because most of what Dentsply Sirona does - good things for us in the profession - is to deal with restorative treatments.  So, if you think about it, they're preparing us for surgical repair of teeth. But medicine, you have a big drug that manages it medically. And I'm not saying drugs are the answer, but it's about to the perspective. So, what does Nexium do? Nexium stops acid production in the stomach. It's a proton pump inhibitor, so it goes through some biochemical pathway and interrupts it to prevent acid production. But caries is acid production. So, in the former case, you take this pill, Nexium, it somehow makes its way to a process which occurs in the stomach and maybe distal esophagus and stops this acid production. So, why can't we do the same in dentistry for caries? So, I think these discoveries that are going on in the lab, that the scientists who I try to stay in close contact with are looking at the microbiome, they're looking at how to interfere acid production and that's ultimately how drug development occurs and how the idea that we could actually interfere with the disease itself before it manifests itself as a cavity could be interrupted. We think in dentistry of restorative treatment - which is important, it's essential, that's why we do it - but what if we could change the focus of the profession entirely so we're managing the disease, which is what most of medicine does, and that would bring us into the medical profession. Sorry, I said a lot, I'm just talking.

Howard: No, no. What you're saying is true. Dentists are molar mechanics. They mechanically remove these infections and all they talk about is how to fill in the hole with cement. And when you talked about ABCD, Access Baby Child Dentist, it's got to go all the way to when she finds out she's pregnant.

Joel: Yeah.

Howard: Because when I talked to - who used to be the Executive Director of the American Dental Association, now he's the head dentist at... [sounds like: Bremmer]?

Joel: Yeah, I can't remember his name right now. Jim, yeah. Branson?

Howard: Jim Branson.

Joel: Yeah.

Howard: I listened to his lecture in Florida and basically a premature baby is their most expensive thing. It's $1 million. And the number one thing they link it to is gingivitis, periodontal disease. And so, that baby's in there, when the body senses an infection, somehow it's saying, "You need to get out of here."

Joel: Prostaglandins.

Howard: Yeah, and that's the time that, not only should you be getting rid of the gingivitis and gum disease and treating all of that, but that's when the family needs to be counseled, saying, "Everybody in this family has got to get their oral health under control before this baby comes out, and when this baby comes out, we're not going to kiss it on the mouth. We're not going to sit there and take the bottle and say, 'Mmm, that tastes good', and then put it in there. We're not going to take food and blow on it and stick it in their mouth. We're going to get out everybody's rotten teeth and gum disease and gum infection."

Joel: Well, I think the thing about kissing and all that, Paige Caufield is the scientist who initiated that idea. I think he's now at Ohio State, but he did that when he was at Alabama. He's a pediatric dentist and microbiologist and he showed...

Howard: What's his name?

Joel: Page Caufield. C-A-U-F-I-E-L-D.

Howard: Can you find him?

Ryan: What's his name?

Joel: Page Caufield.  C-A-U-F-I-E-L-D. He's a brilliant guy. You ought to interview him sometime.

Howard: Yeah, pediatrician, microbiologist.

Joel: Pediatric dentist...

Howard: Pediatric dentist.

Joel: ... and microbiologist.

Howard: In Alabama?

Joel: I think he's in Ohio State now. He was at NYU after Alabama, and I think he's at Ohio State now, I believe, but I can find him. He's a fascinating guy and he's the guy that proposed this idea that a mother transmits her microbiome. He calls it the 'fidelity of transmission'. In fact, he went all over the world and looked at the oral microbiome of babies and parents and he found out that it was such high fidelity, the likelihood that you would get the mother's microbiome in your mouth, that he could tell you where your ancestors came from by looking at the bacteria in your mouth. He can take a sample of your bacteria today and say your ancestors came from this part of Africa four hundred years ago, because that's how well it's transmitted from parent to child. So, interesting stuff, but the thing about the mouth and the feeding, I think he doesn't particularly like the people who say don't kiss your baby and all that, because it's almost impossible to avoid. But what he says is, because you're aware that if the mom's got a bunch of cavities and her mouth's rotten, the kid's going to have that problem too. We need to educate about, you're going to cause the problem that you had to your baby just because you have that mouth. It might not be preventable. It might not be preventable. So, just making them aware of that. As you said earlier, Howard, everybody cares about their kid more than themselves sometimes.  And so, it's making them aware that, okay, you had this problem, but your kid doesn't have to have the problem.

Howard: Is that him?

Joel: That's Page.

Howard: That's Page.

Joel: That's Page. Good man.

Howard: Unbelievable.

Joel: Brilliant.

Howard: Well, I need to get him on the show.

Joel: Yeah, he would do it. He would definitely do it. He's brilliant.

Howard: Can you email me that link and we'll get Page on the show? Yeah, because the parent would actually be more motivated; say, she was afraid of the dentist...

Joel: Yeah.

Howard: ... she'd be more motivated to 'suck it up, Buttercup' for her baby than she would be for herself.

Joel: Yes.

Howard: When I think of what parents do, I mean how many parents did I know thirty years ago that at Christmas time they wouldn't exchange between the parents, because the kid wanted a bicycle and a big wheel and… you know what I mean?

Joel: Right.

Howard: I mean the only reason we are here is to make babies, who make babies, who make babies.

Joel: Be fruitful and multiply.

Howard: Yeah. And then another thing, the orthodontists are just as bad. The dentists are just mechanically removing infection and all they talk about is the bonding agent of their stupid cement, instead of trying to go to this unborn baby and saying, "Let's try to make it not premature. Let's bring in the whole family." They could be doing seminars in their office, like the first Thursday of every month where, if you're pregnant, come to my office, bring the whole family. We're going to talk about how to prevent dentistry instead of drill, fill and bill. And there's dentists doing it - they're packing the house. Same thing with orthodontics. The anthropologists are telling us that homo sapiens is a two-million-year-old species, a hundred billion have come and died before we were born.  We're coming up on eight billion now and they're just finding malocclusions in the last century or two, and it's because you were nursing and when they fed them, here's a mastodon bone that the baby chewed on and all these forces are spreading. Now the first time baby has any difficulty, they switched to a sippy cup and a bottle that looks like it was made for a blue whale, and then the food is all processed, pureed stuff. So, this kid has...

Joel: It's all about the parents' convenience instead of what's right.

Howard: Yeah. There's no mammary gland force, spreading the maxillaries, he's not chewing on anything. So now, this kid is fourteen years old and he needs four wisdom teeth pulled, 25% need another four bicuspids pulled, rapid palatal expanders. So, we take all of our babies and put them through this 10,800 board-certified orthodontist program, because nobody has asked the question, why did no-one need ortho the first two million years? And the orthodontist, they could be having a program and saying, "Hey, last Friday of every month, if you're pregnant, come to my office and I'm going to teach you how to save, and you won't need ortho a decade from now. You'll save yourself $6,500. Come into my office." And then the 'law of abundancy': the more you give out, the more you'll care. Everybody will be talking about, "Oh, yeah, we went to Dr. Joel Howard Berg's office, and I'm going to try to nurse her for a whole year and we're not going to feed her apple sauce and we're gonna go out and get roadkill and have the baby chew off bones."

Joel: Yeah, a lot of the things you're saying, the evolution has occurred in part because of the behaviors we do.  So, evolution is adapting to behaviors. So, who knows how much is there? A lot of orthodontic problems are caused by early loss of baby teeth from caries, again going back to that age one visit. One of the main stories we tell people, which is based on good evidence, that if you don't take care of this kid's teeth, they're more likely to need orthodontic care because of space loss. Even a millimeter of space between the permanent first molars' loss can be problematic, and you have a cavity in one baby tooth and, approximately, you could have enough space loss to make the difference. So, those baby teeth are the best space maintainers. There's a lot of connectivity to that preventive thing you're talking about.

Howard: The most, I would say controversial thing in pediatric dentistry... there's not much controversy among pediatric dentists on Dentaltown. I'd say of the nine specialties, pediatric dentistry is the most robust. There's more pediatric [unclear]. The orthodontists, of course, they can't talk to the little people, so they had to make me make them their own Orthotown, which you can only go on if you're an orthodontist. I can't even go on Orthotown and I own the damn site.

Joel: Really?!

Howard: Yeah, they're a special club. Oral surgeons are great, endodontists are great, but pediatric is the most robust.

Joel: Do we have a Pedotown?

Howard: No, we don't have a Pedotown.

Joel: We'll open it to anybody!

Howard: We could. I don't know if you guys know this...

Joel: Dentaltown could be Pedotown.

Howard: I don't know if people know this, but we made the ability... Dentaltown is a twenty year old website, it had five programmers for twenty years. It's half a million lines of code, and we made it so you can cut and paste it and have your own, all the features of that thing plus the app, and we host that for you. We started doing that. That's how we had to make Orthotown, Hygienetown, and now I did one for my city called to Tukeetown. But if someone out there listening wanted to do Pedotown, we could do it. Say your wife was a quilter and wanted Quiltingtown, and it wouldn't even have to have the name 'town' in it; but I think if they all had the word 'town' in it, it would brand it better.

Joel: There's a pedo Facebook page called iPedo that has around four thousand pediatric dentists on it.

Howard: The problem - I mean, I like Facebook, I'm on Facebook - the only thing I don't like about all the Facebook groups is...  we are the computerized bulletin board service, a forum, so I can go right to pediatric, the searchability.  Facebook is just like, it hasn't changed since the beginning, which was email groups. You'd sign up for Dentists at CompuServe, you'd open up your email and there would be a thousand emails. Then there was Internet Dental Forum and Root ZX, and it was just pure "I've got to get this out of my email". So, all Myspace and Friendster did, they just took it out of your email and it's still that endless newsfeed, which hasn't changed on Facebook, Twitter, Instagram, LinkedIn. There's still just no organization. But the first social media...

Joel: Yeah, it is kind of random, isn't it?

Howard: ... was the computerized bulletin board system, which all the scientists - that came out in the '70s - so, all the scientists who invented the Internet, that's all they were doing. When you go to NASA, you go to Jet Propulsion Laboratory, you go to anybody who wants to get something done, they're all on a bulletin board system.

Joel: Interesting.

Howard: They're all on a forum, and as far as the endless newsfeed, where you open up Twitter and there's just tweet after tweet after tweet, that's fun and entertaining and I like it. You see news headlines, you see things you might click into. It's kind of like, you remember when cable television came out and you thought, "Wow, I have five hundred channels!", but all you did was just scrolled through all five hundred channels?

Joel: You can't find one you want to watch though.

Howard: Yeah, you can't. That's what I think of when I see Twitter and Facebook and LinkedIn, but back to the deal, the only thing they're arguing about is silver diamine fluoride. But see, I can go to Dentaltown and I can go right to pediatric dentistry, or I can go do a search.

Joel: For silver diamine.

Howard: For silver diamine fluoride, and pull up every thread, organized by last active one to least active; and then what's neat is, say three years later some dental student wants to learn about something you guys are all talking about today, it's all right there.

Joel: Yeah, that's great.

Howard: And the other thing about Facebook is, you make a post on those groups or you make a post on your page, all your people don't see it. If you make a tweet on Twitter, Instagram or LinkedIn, all of your followers will see it. But on Facebook, it's all algorithms about what posts you make.

Joel: I'm starting to hear about that on the news.

Howard: And the only people that don't...  all these people on Facebook are legends in their own mind because they think, "I've got five thousand followers. I made a post and five thousand people saw it!" Are you out of your mind? What's the stat, Ryan, of what posts actually get seen? What percent? Facebook says 6% of your posts are seen by your followers. 6%! So, you're basically in the bathroom talking to your mirror.  Whereas on Dentaltown or Twitter or LinkedIn or Instagram... like I've got fifteen thousand followers on Instagram, I make a post there about we had a podcast - they'll all see it. I've got twenty-five thousand on Twitter - they'll all see it. I've got thirty-six thousand on LinkedIn - they'll all see it. I put it on Dentaltown - they'll all see it. You put it on Facebook...

Joel: Yeah, it's random.

Howard: No-one's going to see it unless you give them money and you boost the posts. It was a bait-and-switch. It was, "Hey, join Facebook, spend all this time building your following", and then as soon as you build your following, "Oh, when you make a post, you have to pay money for your following to see it." So, if you're making a post on Facebook and you're not giving Facebook money, about 6% are seeing it. That's why...

Joel: Do these limited sites have business interests that can purchase posts or is it only limited to those?

Howard: What are you talking about?

Joel: This iPedo site, for example, could a company come in and buy an ad or push a message?

Howard: You could push an ad. Well, there's all kinds of tools you can do, by zip code, by this, but I couldn't post this podcast and say everybody in the pedo group will see that. You could post it...

Joel: But only 6% would see it.

Howard: Unless you write on that post that says 'Boost the Post'. Do you see that?

Joel: I haven't seen it, I'll look for that.

Howard: If you boosted the post...

Joel: But I have to pay for that.

Howard: Yeah. If you boosted the post for money, oh, yeah, they'll show it all.

Joel: Interesting.

Howard: So, here's the twist. If you're in social media and you're not giving them any money, don't own the stock.  If you're on social media and you're getting money. That's the stock you own. Facebook, the stock is amazing. The sales are amazing. The income is amazing, because you have to give them money for anybody to see it. Any podcast I do, I could easily buy my way to a hundred to two hundred thousand views. I've had ten that have had over a hundred and ninety thousand views, but I had to get out my credit card for that. It's not organic. The only secret to lower price is lower cost, so you always want to lower your costs. But we're down so many roads right now. Oh, back to the pediatric dentist.

Joel: It's great, I love this!

Howard: The other reason I made it cut-and-paste and hosts on Dentaltown is because there's 2 million dentists in the world - we've only got a quarter million of them on Dentaltown and they're all English. When I lecture in Cambodia and India and China, a lot of these people want different languages, so if you think you're the social media king of Russia and you want a Russian town, a Russian Dentaltown, or anything like that, just email me: howard@dentaltown.com; we can do that. But again, it's silver diamine fluoride, and here's where it lies: there's a lot of research that says it doesn't kill the bugs, it just kills some of the bugs. It just delays bugs, all those things; and there's no insurance code for it and if they do charge, they're only getting $20.

Joel: There is a code, but it's...  anyway.

Howard: But the other side of it is, back to Facebook, the postings of children dying in the OR. So, anytime a child dies, there's a pediatric dentist that says, "Well, why did you drag her to an OR? Why don't you just paint it with silver diamine fluoride? Why didn't you delay it?" And then here's the other side of the controversy. There's only one company that sells it, Elevate Dental Care.

Joel: Another one just launched a product. There'll be three or four by the end of this year.

Howard: Because the United States is a racket with the FDA. There's another one that's like silver diamine fluoride, out of Australia.

Joel: That's correct. Just got launched.

Howard: But they've decided they're not going to pay money to go through the FDA to get it FDA-approved to sell it in America.

Joel: No, they are. They are now. I just got contacted two days ago.

Howard: They are? Okay, well, that's how much I know. I'm behind on my news.

Joel: I'm lecturing at the CDA next week on Friday. They contacted me because they heard I was lecturing about medical management of caries and I always talk about, amongst other things, silver diamine fluoride. So, now that they have this product, they said, "Hey, we want to talk to you." So, that's how I found out, just the other day. I don't know when they launched it, but they've been trying for years.

Howard: Because of the FDA.

Joel: Yeah. They have this second compound they put in there called potassium iodide.

Howard: Right.

Joel: It supposedly turns it white after it's black. There's some debate. I don't know enough about it. There's some debate about whether it reduces the efficacy, and does it really make it white in perpetuity or does it turn dark later? But to your point earlier, Howard, I think...

Howard: Have you talked to Geoffrey Knight about that?

Joel: He's one of the developers of this new product.

Howard: Right, but are you in contact with him?

Joel: I have not. I've talked to Geoffrey a long time ago. I haven't talked to him in years.

Howard: Do you still have his contact? Because if you do... 

Joel: I probably do.

Howard: Okay, yeah, so talk to Geoffrey Knight.

Joel: He's one of the inventors of that...

Howard: He's a scientist who happened to be a dentist.

Joel: He's an interesting guy.

Howard: He's in Melbourne, where SDI is.

Joel: Yeah, exactly. I remember he used to put Saran Wrap on top of glass ionomer restorations to cure them, which was interesting, to shape them, and he'd have the patients bite into occlusion with the Saran wrap while it was setting. It was an interesting idea, conceptually. I don't know how practical, clinically, but I remember him doing that.

Howard: The only thing I don't like about him is he almost killed me.

Joel: Because you were in the car with him or something?

Howard: No, when I lectured down in Melbourne last time, I had climbed the tallest mountain in Africa, so he's like, "Well, you're in Australia and we're in Melbourne and the tallest mountain in Australia is only three hours away. I'm driving you there. That way you can say you did Africa and Australia." So, I thought, "Okay." And got there and the area was closed because it had snowed like whatever, and we're sitting there - I swear, you can't make this sh*t up! The snow was to our waist, and by the time we got to the top, I just fell down; and he's in the best shape in the world, and he's sitting there yelling at me. I'm laying in the snow. I'm done.

Joel: You've got a picture of this?

Howard: And he's like, "What? Are you going to lay here and die? You'll freeze to death, you idiot! Get up!" He's yelling at me, "Get up! Get up!" So, I finally got up, but I've got bragging rights. I did the tallest mountain in Africa and Australia.

Joel: Congratulations on both of them.

Howard: If I would have done it by myself, I would have been up there dead to this day.

Joel: Well, he didn't try to kill you. But let me just comment on what you said before. I think you raised a good point about the silver diamine, and I'll just try to be succinct, the two sides of the story you say. I think that silver diamine fluoride is great. It's a wonderful innovation into the armamentarium of a practice. I have this slide I show that's called 'The Medical Management of Dental Caries'. I'll send it to you. It shows the continuum of management, with the far right being operative dentistry, which is most of how we manage caries, the very late stage; but there's all this stuff that you could do, because every one of those caries lesions that resulted in a crown or an MOD or whatever it is, started down here where you can't even see it, at the microbiome level. You have all these different places where you could intervene before it becomes a hole in a tooth. That's the concept that I lay out. So, if you think about silver diamine fluoride, it does kill bacteria. Silver is a powerful antibacterial. There's no question about that. They used to put it in kids' eyes to prevent transmission of sexually transmitted diseases at birth. Now we use antibiotics, but it's been used for war wounds, to prevent burn injuries from getting infected, but, in any case, silver kills, but the problem is, it's got to get to the lesion. It's got to get to the depth of the lesion. So, there's a lot of debate and a lot of people who say, "Well, it's like holy water. It'll take care of anything." Well, nothing is perfect. It adds to our armamentarium, it's an important agent. I'm thrilled that we have it. But if I have a two-year-old who's got eight cavities that I can see, maybe I can't even see them clinically, but you know that they're much larger radiographically. There is no way I can get that fluid to the depth of those lesions. It's impossible. That kid needs restorative dentistry. So, I think it's important to have a balanced view, to prevent a medically necessary treatment, to avoid a severe medical problem for that child. Some kids can't be benefited only with silver diamine fluoride. For some kids, you can delay what otherwise would be a general anesthetic episode until they're old enough to be cooperative. They're not pre-cooperative. They're not cooperative. They're four years old, they'll get in the chair, maybe we'll use nitrous, maybe we just give local anesthesia, and we can treat them. We look at every situation uniquely, but it certainly doesn't eliminate the need for general anesthesia. That's a false statement. It gives us something else in our armamentarium to think about. So, when I have a conversation with parents about, I have this two-year-old... on an average day in practice, with the residents in our program and students, we might see eighty kids. So, on a given day, I might refer as many as ten kids for general anesthesia. We have a very high-risk population in Seattle.

Howard: I just wouldn't think of that as Seattle.

Joel: Poverty is related to it, although not all people who are Medicaid are poor.

Howard: But you think of Amazon, Microsoft, Boeing.

Joel: Well, we have those too. We have a mixture of everybody.

Howard: You'd think it would rich... shipping, cruise ships...

Joel: We have Amazon patients. Our clinic is designed so that we treat everybody. We have five, six chairs in this bay, this kid's parents might work at Boeing or Amazon or Microsoft, and then I have three kids who are covered by Medicaid. We don't know. We don't care. I don't even care when I treat them, they're all the same, and I like the fact that we can treat them all the same; and yes, it's more likely that the kid who is on Medicaid is going to have that, but we have kids of all walks of life who end up in the OR at age two, and it's all behavioral, it's all about sugar in the diet. It's all about sugar. At the end of the day, it's all about sugar. Let's finish SDF real quick. It's very important, I'm thrilled that we have it. It's going to expand medical management of caries and it will allow us to avoid other treatments or delay them, but usually you still have to restore the tooth. In many cases you still have to do it early and it may require general anesthesia. So, it gives me something else to put into the conversation with parents on many cases, but we decide based on what's best for that child. 

Howard: Okay, so, let's try to put them quantitatively in order. Variables. A two-year-old comes into the OR. You've got variables. You got transmission from the parents, you have diet, you have home care, you have water fluoridation. Put them in most to least. 

Joel: I'm glad you asked that. That's my one of my favorite things to say. The transmission one is in a category by itself because that is what it is. You can't control that. But of the things you can control, the next three are the order. You wrote them down in order, the ones that you can control, they're in order. Diet, hygiene, fluoride. You can pump all the fluoride you want, but if the kid's eating sugar all day long, fluoride is not going to touch it. Nothing beats a bad diet. Diet is the worst.

Howard: I was a big part of getting Phoenix fluoridated in 1989. In fact, the Arizona Dental Association gave me the Arizona Award for Outstanding Contribution to the Profession of Dentistry.

Joel: Congratulations.  

Howard: And then twenty years, we got it later. Then I lost all my heart and soul about that when I was lecturing in Singapore and Tokyo and the dentists there were saying, Singapore is water fluoridation, Tokyo is not. So, there's a great control, very similar, Asian people.

Joel: We see that across the US.

Howard: And their DMFT rates both drifted down evenly the same, and the people who showed me those charts and read me those papers were saying, their thought was the increase in home care from mother to child, and that the child wasn't really doing the home care that the dad was doing, that the variable was with the mom; and as you educated the dental IQ of the mother, the pediatric dental decay went down.

Joel: You're right, but what they're doing though is they're changing the diet, they're changing the hygiene, the way they brush the teeth. And the thing about this, diet is all about frequency of sugar. Parents don't know that. Adults don't know it. Educated people don't know it. It has very little to do with how much sugar you eat, the risk of caries. It has everything to do with the frequency. If you sip on a cup of coffee that has one teaspoon of sugar and you sip all day long, you have a very high caries risk. But if you have one Coca-Cola at mealtime, you may have other problems. If you're having that three times a day and you otherwise take care of your teeth, your risk is low. It's only about frequency. And that's what we need to talk about, is frequency. On the hygiene, it's very clear. I wrote an article for one of the dental hygiene journals a couple of years ago about making everybody in the dental practice a personal trainer. Everybody, the front desk, everybody should be assigned to a patient because there's no gene that encodes for your ability to brush your teeth. Nobody knows how to brush their teeth, so how the heck are they going to brush their kids' teeth? So, we make them brush their kids' teeth. I want to watch them do it and then take corrective action and then show them how to do it. It's like going to a personal trainer. If I want to lose weight and get in shape, I hire a trainer. A bad trainer is going to say, "Here's a list. Go lift these weights and come back and see me in a couple months." You're going to hurt yourself. You're not going to get anywhere. The good trainer is going to go through each exercise. Watch you do it. Say, "You're too slow, too fast, move this way." They're going to watch everything you do. That's what we need to do with toothbrushing. We have to be their personal trainer and show them how to do it, because people don't know how to do it. I used to work for a toothbrush company.

Howard: Sonicare.

Joel: Yep. I know this. Nobody knows how to brush their teeth. Except for dental hygienists, they can clean their teeth perfectly.

Howard: I got my MBA from Arizona State University, where your two daughters went, right?

Joel: Great school.

Howard: They got their Masters. That's my favorite gym, right on Mill Avenue. It's a bar called Gym.

Joel: Really?!

Howard: So, you can't lie. You say, "I'm going to the gym", and you go there.

Joel: How is it spelled?

Howard: G-Y-M.

Joel: And it's a bar?

Howard: It's a bar!

Joel: That's funny!

Howard: So, you might find out that your daughters were misleading you for all these years, saying, "Yeah, Dad, I go to the gym three nights a week."

Joel: I drove by that campus the other day. There are all these buildings going up. It's like a different world there now.

Howard: Yeah. Let's talk about home care and toothpaste, because let me show you what's confusing to the dental students. There's a lot of research out there that says when you brush your teeth, that the toothpaste isn't a variable; that if you dry brush, you can brush for two minutes and remove all the plaque, so toothpaste is unnecessary. A lot of other people say, no, the toothpaste is everything. It's the fluoride, the calcium.

Joel: The fluoride is necessary.

Howard: Yeah. So, we solved that. You have to have toothpaste because fluoride is necessary, not just for pediatric, but all ages.

Joel: Well, you need fluoride for all ages, and it's not a matter of how much.

Howard: So, you need a dentifrice with fluoride.

Joel: Absolutely.

Howard: So, all the dry-brushers are correct in that dry brushing for two minutes will remove the plaque.

Joel: Well, there's two issues. There's the fluoride effect, which you need; the drug effect, if you will, of fluoride. You need that, tiny amounts, I call it the 'legume family': for a six-month-old or a one-year-old, a lentil size, and then a pea when they're age three, and then an edamame at age six.

Howard: Oh, that's cool.

Joel: Nothing bigger than a lima bean.

Howard: Have you got a chart on that?

Joel: I think I do somewhere. I can send it to you.

Howard: [inaudible]

Joel: Yeah.

Howard: Ryan, make this. What do you call it?

Joel: The legume way of deciding how much toothpaste.

Howard: The legume way of deciding how much toothpaste.

Joel: So, a lentil...

Howard: Wait. The legume way of deciding how much toothpaste. You got that Ryan?

Joel: Up to age three, you need a lentil. People say a smear or a pea size - pea is too much for a one year old.

Howard: Okay, so, one to three is a lentil.

Joel: A lentil is tiny. I used to tell people, "Go to Costco, buy a bag of lentils. It'll last your entire practice life. Give one to every parent to show how big it is." I used to give lentils away.

Howard: Let's do that, Ryan. Let's go give all these legumes. So, one to three is a lentil.

Joel: Right. And then three to six you can go to a pea.

Howard: A pea.

Joel: And then from six to twelve you can do edamame, which I love.

Howard: You have to spell that. It's the green bean at the sushi bar. How do you spell it?

Joel: E-D-A-M-A-M-E. Edamame. And then you can go maybe to a lima bean or a fava bean. How's that?

Howard: For thirteen to adulthood.

Joel: That's the most, you don't even need that much. You could stick with edamame if you want to. That's plenty.

Howard: Thirteen plus is a lima bean?

Joel: Yeah, let's say lima bean, a little bit bigger than an edamame, but that's it. That's how much toothpaste you should use.

Howard: And what bean is too big?

Joel: Oh, I don't know. What are those big beans? I don't know what they're called. Is it a fava bean? I don't know.

Howard: So, I'm confused, because my favorite bean is refried beans.

Joel: They're smashed up.

Howard: With a margarita.

Joel: When you brush it on your teeth, it's a refried bean, okay.

Howard: That is really cool. You know what I'm going to do? I'm going make those with my grandchildren.

Joel: Yeah, it's something to think about, and it also teaches people that when it comes to fluoride on your teeth, it's about dose, not if. It's how much. We talked earlier, Howard, about people not understanding statistics, and one death here, which is unfortunate, or this and that, but the accident that occurred in Tempe with the self-driving car, not considering a hundred deaths in a day for humans driving. The example I give is, when we had the anthrax scare back in 2001, I think there were seven or eight deaths in the United States from that anthrax that was sent in the mail. Do you remember that? And the treatment for that is Cipro, the drug, Cipro. So, within three days, the entire world supply of Cipro was depleted. People in Kansas were buying Cipro, even though this happened in Washington, D.C. Seven people died. The chances of that person in Kansas getting anthrax was infinitesimally small, but every year thirty thousand people die from the 'flu, but nobody gets a 'flu shot. Thirty thousand, it's actually a more than forty thousand last year, died from the 'flu in the U.S., most of which was preventable with a 'flu shot. But it's not exciting, it's not in the news. So, people hear something, and they say, "Well, that's going to happen to me." You know what I mean? So, statistics is one of the most poorly understood subjects.

Howard: It's because they're always emotionally anchored.

Joel: It's emotionally anchored and not factually based.

Howard: It all emotional.

Joel: Fluoride is the same category. We have a lot of anti-fluoridationists. I talk about, "Look, it's a tiny amount. It's a naturally occurring agent. We're not talking about giving too much. You wouldn't give your kid two adult Tylenol's. You'd give them a baby dose of Tylenol. The same thing with fluoride. It's all about dose." And to your point about needing a dentifrice to brush versus dry brush, brushing your teeth, as I've learned, is a fluid dynamic and mechanical effect and you have these fluid dynamics that help push the plaque away in addition to the physical force. So, I think the dentifrice does stimulate the fluid dynamic effect a little more in addition to having a mild abrasive. I think there is some evidence that it's an additional plaque removal effect by adding a dentifrice.

Howard: But let's go back to Sonicare. People don't brush correctly, two minutes in the morning, two minutes at night. Do you think the Sonicare and Ultrasonic toothbrush, some electric toothbrush, is more effective than a manual?

Joel: I always say that the best toothbrush is the one that you use. It gets down to what you said: are you going to use it twice a day for the recommended time? And most people don't and they don't do it properly. Most people can't brush properly. So, if a manual brush makes it easier for you to do it properly, then that's a better brush for you. Sonicare, or power brushes, have the advantage of... you still have to place the bristles in the right way, positioning. There's positioning and movement. Two parts to brushing, positioning and movement. If you position the bristles with a manual correctly and you move it correctly, you can get the same result, but most people don't position them correctly and they don't move it correctly, more importantly. The Sonicare or other power toothbrushes, we'll do the movement for you, but you still have to position. Teeth are curved. I always tell people, "When you want to wash the windows of a skyscraper, you could take a fire hose and just spray it with high pressure, but they're not going to get clean, so they pay people a hundred grand a year to hang from the building and risk their lives with a squeegee, because that's the only way you can get that window clean." Teeth are even harder because they're curved. They're like that window. The only way to do it is to have some contact with that surface. So, what's the likelihood that an average person who isn't trained in dentistry - we know how to hold instruments and we know the contours of every tooth - is going to be able to get that there. So, whatever makes it easier for you to do a good job is the right product. We have to teach people that. Brushing is a lot less effective because people don't know how to do it.

Howard: This is Dentistry Uncensored, so I don't want to talk about anything that anybody agrees on. So, let's go to the next massively controversial issue. People are all for sealants, but I mean if you go to PubMed, you could literally find hundreds of articles that say that 40% of sealants have failed the first year and then 90% after year two. So, rant on sealants, rant to me on sealants when I'm already jaded because most of the research says they fail in a year or two. Agree or disagree?

Joel: I disagree. It depends what research you're looking at. You can always find studies that support one side or the other. If sealants are done correctly, that's the key.

Howard: But that's what dentists always say. When you say the average amalgam lasts twice as long as the average composite, then the dentist is always going to come back and say, "Well, if you did it the way I did it..." Well, I'm not talking about the way a board-certified pediatric dentist [overtalk]. 

Joel: So, the answer to your question is you're right. If you just look at reality. I haven't seen those studies that look at what actually happens in practice. Probably the biggest factor is not doing sealants when they should be done, because of not believing it's going to be successful or whatever. But the literature, the fact is clear - and you were talking about reality and more and more I appreciate that than I used to. 

Howard: Even Gordon Christensen, when he evaluates a product. These people always brag, "I'm a CRA evaluator." They're so dumb, because Gordon has a reality.  Only 10% would be an A dentist and then 20% B, then 60% C. So, he has the full distribution. So, some of - I'll just say some people I know that always bragged to everybody that they are a CRA evaluator - they're on the F list. Because Gordon wants to know what does the sh*tty dentist think of this, what does the D dentist, what does the C? So, when some guy is bragging and wants you to buy him drinks in the bar because he's a CRA evaluator, first, find out if he's an A, B, C, D, F, because that's the back...

Joel: Well, I can tell you that the science is clear that - and I understand your average dentist's point for a lot of things - if you place a rubber dam, which most people don't use...

Howard: Okay, so, let's go through a protocol. Give me your protocol.

Joel: I'm not saying you're have to use a rubber dam every time, but if you are unsure about your ability to control the moisture...

Howard: You know I made every one of my dentists and hygienists practice under a rubber dam 100% all the time?

Joel: I'm a big rubber dam fan.

Howard: But you know how I did it?

Joel: How?

Howard: I just went to each operatory and I tacked a rubber dam up on the ceiling, so, they're always working under a rubber dam.

Joel: That's good. I think the biggest reason that dentists don't use rubber dam is because, in dental school everybody uses rubber dam, then they get out and only 20% do, and I think it's because we don't do a good enough job training them to train their auxiliaries to place it. I think in Arizona the law allows them to do it as well, to place the rubber dam. If I give the anesthetic - I think dental hygienists can give anesthetic...

Howard: All those laws, I don't even like talking about them.

Joel: I don't even know what State.

Howard: They're never enforced. Like you say, hygienists can't read an x-ray. Show me one hygienist in prison today from reading x-rays. Your Attorney-General wakes up in the morning, they found some dead chick in a dumpster, somebody murdered, somebody torched a house, and the dentist is worried about, "Well, can my dental assistant place a rubber dam?" And while he's thinking that, a car drove by his office with three pounds of cocaine in the trunk.

Joel: Well, you're a realist.

Howard: My staff does whatever they feel that... treat other people like you want to be treated. If my dental assistant thirty years ago, said, "I want to place a rubber dam", I let her place a rubber dam. I didn't run to the legal center and start asking.

Joel: Well, they can, but if...

Howard: I think all laws are just suggestions written by stupid people. 

Joel: Okay, but I think the rubber dam, if a rubber dam is used, the best protocol would be to use a rubber dam; but you can't always do it.

Howard: What about Isolite?

Joel: Isolite works, and if you can visually look at the area and see that there's no contamination of the surface, physical contamination by saliva or water, then you have a pretty good shot at getting a good result with Isolite. Remember that when you have Isolite as opposed to a rubber dam, you still have humidity. When you put the mirror in the patient's mouth, if it condenses on the mirror, there's humidity. It's 100% relative humidity, maybe except in Arizona where it's dry. I didn't think about that. Maybe it's not true here. I'll have to the test that. I hear you sweat a liter an hour. I told my wife, you've got to drink a lot of water when you're sitting by the pool.

Howard: I've got to warn you about one thing. This mountain you just came to.

Joel: Yeah.

Howard: It's forty-two miles around, and then the next city over is Maricopa, it's twenty-two miles back. Those are my two three-and-a-half-hour bike rides, and if I leave in the dark, I can bike all the way around the mountain with no water. I can bike twenty-two miles to Maricopa and back if I leave the house at four. The minute the sun cracks, you drank an entire deal of water every thirty minutes.

Joel: I agree with you.

Howard: And this is amazing, I've always wanted to do this. This would be too sadistic, psychotic, neurotic, but everyone says you cannot walk from Phoenix to Tucson, which is only ninety miles away, or run it or jog it or anything without water. Wouldn't that be the coolest race in the world, Phoenix to Tucson?

Joel: With no water?

Howard: No water.

Joel: Why would you want to do that?

Howard: Well, it would be a reality TV... can you imagine everybody dies except one guy makes it to the finish line?!

Joel: I'd rather eat ten wings with no water. Go to the hot wing contest.

Howard: So, in the desert, the minute the sun's up, your evaporation is out of control. 

Joel: It's like a liter an hour. It's crazy. Anyway, so, the rubber dam, there's some work done by Bob Feigal, who passed away a few years ago, but a good scientist, a pediatric dentist. He showed by adding the dentin bonding agent prior to placing the resin sealant, that if there is some minor contamination from saliva contamination or even a tiny amount of water, that you could penetrate that dentin bonding agent with the sealant and have the same results and outcomes as you would by having a rubber dam. So, I think what is taught now in most pediatric dental programs is, if you're not using a rubber dam, to place that dentin bonding agent first and then place the sealant. You'll have the same effect. I think the studies you looked at that showed the poor results - and again, I understand reality - I think if those same dentists, if they're using Isolite instead of a rubber dam, which I understand, they ought to try the dentin bonding technique. It just takes a few extra seconds. You etch it, you rinse it, you dry it, you place dentin bonding agent - a fourth generation adhesive would be the dentin bonding component, it has the HEMA - and you would then place the sealant. You'll get a good result. Feigal showed that very clearly in studies and people follow that now.

Howard: How long have you been teaching pediatric dental residents?

Joel: Oh, it's been thirty-three years.

Howard: I wish you would make some online CE courses for it.

Joel: I would love to.

Howard: It's my biggest passion for a couple of reasons. The Millennials, they've got $350,000 of student loans. It's very expensive to fly across the country and go to a course.

Joel: I know.

Howard: We put up these courses and they're like eighteen bucks. We put up four hundred courses. They're coming up on a million views. But why I'm so passionate about it is, we only charge people in the rich countries. When I lecture in Ethiopia, Somalia, Tanzania...

Joel: They get free access?

Howard: Yeah.

Joel: That's great.

Howard: I walked in in Katmandu and when the Dean realized I was that guy, she started crying. She said all of her textbooks are twenty years old and those four hundred Dentaltown courses are her everything.

Joel: That's a beautiful place. I want to go there and visit that, actually.

Howard: And then I was just in South Africa and Cambodia and Indonesia. I was in South Africa. Most people, when they're in a place, they want to shop, whatever. I just want to see dental offices and I've seen dental offices in fifty countries, and I was in South Africa, three different dental offices - and I'm not talking about in the rich Johannesburg or whatever, I'm talking about out in the countryside. And I walked in and this guy took a look at me, he goes, "Are you Howard?" And I said, "Yeah." He goes, "Those courses. I thought I was a great dentist and I thought I went to one of the best schools in South Africa, but that was twenty years ago." He says, "I watched every single one of those four hundred courses." He hugged me for like five minutes. We are transferring so much knowledge...

Joel: To stay up to date, you have to do that.

Howard: ... from the first world to the underprivileged worlds, who live under dictators and crazy people and all this stuff. So, you would be doing this course, and this would be... India has four dental schools for every one in America.

Joel: They have eighteen in Bangalore. I've been there many times, and they have eighteen dental schools in one city.

Howard: So, every one of them would be watching that course.

Joel: There's a lot of need all over the world. It's great that you do that.

Howard: I think Steve Jobs... I mean, when you and I got out of high school, this was an IBM mainframe that only a rich corporation or government could have, and now three and a half billion people have got it in their pocket, and I think 2007, invention of the smartphone, to the next century, 2107, will be humanity's finest century, because knowledge is going to zero cost, where a hundred years ago, only the richest people got to go to college.

Joel: Right.

Howard: Now the poorest person in Bangalore...

Joel: Has a cell phone.

Howard: ... has more access to unlimited free information.

Joel: There are more cellphones in the world than there are toothbrushes.

Howard: Yeah. Fred Margolis. Friend? Thoughts?

Joel: I don't know him well, but he's been instrumental in education in pediatric dentistry.

Howard: He passed away.

Joel: Yes.

Howard: I always credit him with bringing lasers to pediatric dentistry.

Joel: I don't know who brought lasers to pediatric dentistry. There are quite a few people that talk about it.

Howard: Well, he brought it to the forefront.

Joel: Yeah, and there's a lot of people who use lasers and that's another subject.

Howard: Do you have to go or are you...?

Joel: I have to go in a little bit. I have to go get my wife in a little bit to take her somewhere.

Howard: He can stay all day! He'll just be in the doghouse. But you've got to talk about lasers because that's a big decision. You come out of dental school, $300, $400,000 in debt. Now you go to pediatric dental school, another three years of debt, and then you come out and they're wondering, "Should I buy this $100,000 laser? No shot, no drill pediatric dentistry."

Joel: There are a lot of people who swear by it and every year at our meeting we'll have one lecture on lasers and they'll say you can use it for everything and it could eliminate my burs and handpieces and only use lasers now for all my preps. But it hasn't hit the mainstream yet, for a reason, I think.

Howard: What do you think the tipping point is in dentistry? 5% of dentists will buying anything. In Wall Street, the tipping point is 20%. What do you think the tipping point is in pediatric dentistry before something takes off? What percent of pediatric dentists today use silver diamine fluoride, would you say?

Joel: The vast majority.

Howard: What percent of dentists have a laser?

Joel: I don't know the answer, but it's low. It's definitely below 20%, I would say. 20% probably is about the tipping point for us too, I would think. When I was in industry, I saw that phenomenon.

Howard: It's so bizarre how the 80/20 rule always shows up.

Joel: I believe that. It's just human behavior.

Howard: How much more time do you have?

Joel: Just a few minutes.

Howard: Okay, let's wrap it up. You said you'd give me an hour. I've only taken an hour ten.

Joel: I'd love to come back.

Howard: Okay, final question. The business of dentistry. How are market forces changing the way that we practice from when you and I were little?

Joel: This is fascinating. This is one of my favorite subjects. When I lecture, I talk about the biggest changes in our profession, and one them is medical management of caries, and we talked a lot about that. One is big data. We talked a little bit about that, but we could talk two hours about clinical decision-making based on outcomes of everybody. If I have a patient in my chair who is eight years old and they're going to exfoliate this tooth in three years, I want to know should I do a composite on this or should it be glass ionomer, or should I do a stainless-steel crown. What if I had access to six thousand cases, exactly the same demographics, same situation as this one, and instantaneously I could look at what were the outcomes of having chosen A, B or C. Instantaneously.

Howard: You're talking about machine learning, artificial intelligence.

Joel: Or just talk about decision-making, clinical decision-making based on informatics, and the data's there. Everybody has their software, if we could de-identify it, pool it. Facebook's doing it. Everybody else has data, so data mining. That's the second big area, but the third biggest area is the payer system. Dentistry is a fee-for-service business, but who's driving the cost of healthcare? Do you remember about a month ago, there was an announcement made by Jeff Bezos and Warren Buffet and Jamie Diamond? They said, "We have a million employees, we're spending too much money on healthcare." Buried in there is dentistry, by the way, in their papers. Nobody has disclosed, they haven't disclosed what they're going to do, but they're spending a fortune. They're the biggest purchaser of dental care in Washington State, Amazon is.  Amazon's got four hundred thousand employees and growing fifty thousand a year. Their HR department has twelve hundred people in it. HR department has twelve hundred people in it!

Howard: And the first company that'll... Amazon and Apple will hit a $1 trillion market cap. 

Joel: And they're self-insured, all these companies. So, when they go and they purchase from Delta or wherever, they hire somebody to manage their plan, they're paying the cost. It comes from the dental insurance company, but they're actually paying that money for that filling. They're self-insured. So, if suddenly everybody got cavities the next year, everybody starts eating sugar at Amazon, they'd pay a lot more money to fill those teeth. So, they're noticing the costs, medical and dental, and they're saying, "We need an innovative model, because we're paying these bills." And the same thing with Boeing, and the same thing with T-Mobile and all these big companies. So, that's the market forces that are going to drive costs. They're first going to look at children and how we can prevent, so, going back to the first thing we talked about. They're going to say, "Okay, we have priorities. Kids got to be first. We got to prevent this disease so that when they become adults, they'll be more productive citizens." They don't want them not showing up to work when they're adults because they have a toothache. That costs them a lot of money. They want to improve oral health, so they're going to start paying more attention to how can we improve oral health by prevention, by early intervention, instead of just waiting for the manifestation of the disease. And I think the market is positioned to do that, and I think this announcement by those three guys, dental has got to be included in that conversation, and it will be, because it's not cheap.

Howard: Do you think when Obama was rolling out the Affordable Healthcare Act, do you think he should have mandated water fluoridation? It's a federal law that salt has to be iodized to get rid of goiter. It's a federal law that breads have to have B6 and riboflavin to get rid of beriberi. So much of this is all federal law. The only one that they decided to let each single city, State decide about water fluoridation. Because of the politics of it, it was a communist plot.

Joel: Well, I think there is that.

Howard: Or do you think it's not therapeutic?

Joel: Water fluoridation would be great, although, going back to our list, you have the diet as the biggest factor. Fluoride, as you saw in the two communities example, it definitely makes a difference in a population. You can see a community which is fluoridated. I always say that if you blindfolded me and put me on an airplane and dragged me into a dental office and selected a hundred kids randomly from that office and I didn't know where I was, by the time I got to the tenth kid, I could tell you if the community was fluoridated or not. That's how powerful it is for a community, but for an individual person, not for a population, the diet is the most important thing. So, I think early intervention and education, health literacy, are the most important things, and the Affordable Care Act did do some good things for kids, but for adults, they're left hanging. Medicare, dentistry is not part of it. Whether that's good or bad, we can debate that.

Howard: And when you do these Kromasil crowns, the mother's so upset because they're so ugly. They're metal and they say L4 on the side of it. There's some new, white tooth-colored ones.

Joel: Yeah, the zirconia.

Howard: Yeah, zirconia. Is that [sounds like: Nucor]?

Joel: There's three or four different companies.

Howard: Can you name them?

Joel: NuSmile.

Howard: NuSmile.

Joel: That's the biggest one.

Howard: Out of Houston? 

Joel: Exactly. And there are many others that are very good. They're prefabricated. There are six sizes. The challenge there is, because there are six prefabricated sizes, you've got to cut the tooth smaller than you would like to fit the sides, rather than custom-making, but there's new technologies that I'm following that are very interesting - people out of the orthopedic business - and I can't disclose too much because they told me not to talk about it, but I can just tell you that they're looking at ways for permanent teeth (and I said, "Do it with baby teeth") to have a patient come in and scan them before you cut the prep. Scan the teeth. They make a crown to fit the tooth after it's prepped and they have a jig that will ultimately cut it for you with robots, but for the foreseeable future, we'll actually have, like with implants you have a surgical guide, kind of a surgical guide with a special bur that's designed for that tooth, for that patient. So, when you cut the prep, this crown they just made will fit.

Howard: Can you disclose the company?

Joel: I can tell you, within a month I think they're going to be...

Howard: You've got to be one of the most connected people in dentistry.

Joel: Well, when I was in industry for ten years, the asset I gained that I value the most - and I think you would understand this - is the people I met. Interesting people like you, and I never would have met you if it weren't for my industry days; and I think that the more people you meet... I always say we have a problem in dentistry, this caries problem. The solution is not going to come from within our profession, it's going to come from outside. So, the more people and areas you can discover, the more scientists you can discover who are in this field, the better.  If I can have just a minute...

Howard: You can have all day!

Joel: I'll conclude with this one. I went to a lunch about...

Howard: Just don't think about your wife. She's not going to leave you over this. She might bitch and moan, but she isn't going to leave you over this.

Joel: Okay. So, about seven years ago, the President of the University of Washington at the time, he's now the president of the NCAA, Mark Emmert, he was into seeding ideas, interdisciplinary, cross campus. That was a great idea. So, he set up these lunches where he invited people from different parts of the campus. I was sitting at a table with five people, one guy was a geologist, one person was an astronomer, somebody was a sociologist and this other guy was a mechanical engineer. We were supposed to spend one minute saying what we were interested in. So, I talked about early childhood caries, this big growing crisis, and this guy, Eric Seibel, said to me, "Well, I thought cavities were done in kids. My kids don't have any." I said, "I would have guessed that, that they don't", but he goes, "Actually, they're worse now." So, he talked about what he does, he's a mechanical engineer. He's designed this device called the scanning fiber endoscope, and it's a tiny fiber, they can make it less than one millimeter in diameter, a fiber optic thing at the end of which is an HD camera, and he can take this camera, insert it - and he's been using it for endoscopy of the stomach without sedation. I saw it in a video. A patient can talk, no sedation, and you get high resolution imaging of the stomach. You're looking at the fact that some ovarian cancers start in the fallopian tubes and then seed to the ovaries, the first non-invasive, possibly, way of screening for that with a tiny HD camera. So, we talked about teeth, interproximal lesions. He can put fluorescents in there and look at the early caries lesions. Maybe we can look interproximally without separating the teeth even. So now, fast forward, he got a group together and we got a grant. He's now got a national science foundation, a $1 million grant. He's had several grants, a Ph.D. student completed his Ph.D. in this, and he is designing (once he gets some more funding) a device that could detect caries lesions and then maybe treat them and then follow up the effect of your treatments with certain agents that are yet to be developed before they have formed cavities, early lesions, seeing them formed at the early stages in enamel, and on his team is a guy - this is fascinating - this guy was an expert in florescence. He was involved in designing the cockpit display on the 777 airplane for Boeing. He's retired from Boeing - actually he was a subcontractor, he didn't work for Boeing - but he designed that display. You know it's all black until you turn the power on, then it's florescence that lights up the screen. So, he's an expert. He's read all the caries literature. This guy knows more about caries than me, and most dentists who I've met. He is passionate, and he's got an entire team around this, to develop this device to see those lesions early. So, this is a guy who thought we didn't even have a problem. Now, seventeen years later, he's got this team of people, none of whom are dentists; engineers, students getting Ph.Ds. around this caries subject, and it's growing. So, the more people like that get involved - that's why I love meeting people who have expertise, hopefully even outside our profession, that can help us.  We help each other. So, I think there's a great future by meeting interesting people.

Howard: Well, send me names and links of any of these contacts that you think should come on the show.

Joel: You could interview Eric. You should talk to him, the guy that developed that device.

Howard: Did you find it, Ryan?

Ryan: No.

Joel: It's called the Human Photonics Lab.

Howard: In Seattle?

Joel: In the University of Washington. The Human Photonics Lab.

Howard: The Human Photonics Lab. And the guy's name?

Joel: Eric Seibel. S-E-I-B-E-L. He's the chief guy in the lab.

Howard: So, you mentioned Boeing and that, did you think it was bizarre that Boeing Seattle, that they moved their headquarters to Washington, D.C., I mean Chicago?

Joel: Yeah, they have a small footprint there, but it's the official headquarters. I don't know, people said it was because of the unions and this and that. At the time it was a big deal, but now it seems like not a big deal because there's not that many employees. Most employees are still in Seattle. There are some in South Carolina for the 787 manufacturing.

Howard: I thought that it was very bizarre. If I was the CEO of the company, I'd want to be right where all my workers were.

Joel: They said it was because of easier access to the airport in Chicago, to various parts of the world, more direct flights, things like that, I don't know, who knows why.

Howard: And where do you think Amazon's second headquarter will be?

Joel: Your guess is as good as mine!

Howard: Oh, you know!

Joel: Yeah, yeah. I call Jeff Bezos every day and we talk about it. I don't have any idea.

Howard: Where would you guess?

Joel: I think Washington, D.C.

Howard: Yeah, he bought a home there, dude. You've got to watch the monkey.

Joel: And he owns The Washington Post.

Howard: You've got to watch the monkey!

Joel: Yeah, I think Washington, D.C. or that area is probably going to be it.

Howard: People get it all caught up in all this weird stuff. He's a human. He's bought a house in Washington, D.C., he bought The Washington Post, so it's going to be within a thirty-minute commute from his house to work.

Joel: I agree, maybe in Virginia, but it'll be somewhere in that area, yeah.

Howard: You are so fascinating, but I think we can both agree, a lot of people might think you're the greatest pediatric dentist that ever lived.

Joel: No, no! I know a lot of them.

Howard: I think it's Jeanette MacLean.

Joel: Jeanette's great. I just had lunch with her.

Howard: She made the cover of the New York Times.

Joel: Yeah.

Howard: She is my favorite, so I don't want to hurt your feelings.

Joel: I had lunch with her last week, with other people.

Howard: She is just so passionate.

Joel: She's very passionate about silver diamine fluoride and things like that, and she's young and I think she'll shape this kind of...

Howard: Well, everyone's young to us!

Joel: Yeah, that's true. She'll be one of those shapes the future we're talking about.

Howard: Yeah, well, I just love her passion.

Joel: She's terrific.

Howard: I mean, the woman eats, lives, breathes, dies pediatric dentistry around the clock.

Joel: She does. I think Jeanette is great. I'm going to our annual meeting next week. Our annual meeting is the week after next in Honolulu, the AAPD meeting. We'll have a great attendance there.

Howard: When is it going to be?

Joel: Starts on the 23rd of May. 23rd of May till the 28th of May.

Howard: Now, will the blue whales be coming through there?

Joel: I have no idea.

Howard: Okay. In the winter when everybody visits Hawaii, you have the sperm whales, which are huge, but in the summer, June, is the largest creature that ever lived on the planet.

Joel: I'd love to see a blue whale.

Howard: Larger than any dinosaur that ever lived.

Joel: I would love to see a blue whale.

Howard: When I saw the first one, I couldn't breathe, and my heart stopped.

Joel: It's unbelievable.

Howard: They're the size of a semi truck. His pupil is bigger than your head.

Joel: They eat plankton though.

Howard: I think they come in June, but Google that.

Joel: I'll Google it.

Howard: Because if you are there the 25th to the 28th and it turns out that those whales were coming three days later, and you miss that.... it's like the Serengeti. I'm telling you, you all liked 'The Lion King', you all like Disney. When you go to the zoo and you see a hippo, you go... when you go to the Serengeti and you see a million birds take off at once, when you look over at a pond and there's fifty hippos, when the guide stops and says, "To the right", and you're looking and you're like, "Where? What?" "The tree!", and you're looking at the tree, "What, what?" He says, "Just shut up and stare at the tree", and you're looking at the tree and then you see a giraffe in it! I mean it is so... but those blue whales are bigger than any Tyrannosaurus Rex.

Joel: I want to see one. You've got me motivated.

Howard: It was my first, besides with the dog or a cat, because I can talk to both; I had my first interspecies contact, non-dog, non-cat, with a blue whale.

Joel: I can see that happening.

Howard: Can I tell you the story? So, you're going out there and then you stop, because they can't get too close, and if you're lucky, the boat's legal, it stops, the whales start coming your way.  This little baby - and by baby, I'm talking about, I don't know, twenty feet long, this huge thing, and he started swimming. The guy says, "Be quiet, be quiet, a baby's coming." And it comes, and it swam around and then it got right on the side and turned on its side. That's when I saw his eye, and then he turned around again, and I saw his eye, and he has looked at us. I mean, he's looking right at us. Does it again. Then all of a sudden, a hundred yards away, this big old Mama lifts her butt out and smacks that water and that baby just shot over to her, and you just knew that that little baby, his mom had just yelled, "Get your butt back home right now, or I'm going to smack you!" You could tell that baby is like, "Oh, my g*d, I'm in trouble!" And we just all sat there, and it was... I mean, raising four kids, I saw that behavior.

Joel: Same thing.

Howard: It's just the same thing.

Joel: Same thing. You see it with dogs, you see it will all species.

Howard: I mean, that is a human, total human, and his brain is what? Bigger than both of our cars combined.

Joel: Yeah, they're big.

Howard: If you're going to be there, find the dates.

Joel: I'll check on it. Thank you, Howard, for this opportunity.

Howard: And your Rolodex, I'd love your Rolodex. Anybody you think that my homies would love to listen to, send me an email with their links and [sounds like: vitums]. We can do it over Skype, long distance. If they're in Phoenix, call by the house.

Joel: Okay.

Howard: But seriously, you've been a big mentor of mine for three decades. Thank you for all that you've done for me personally and for the sovereign profession of dentistry.

Joel: Thank you. Appreciate it. Thank you so much.

Howard: Alright, buddy.