Dentistry Uncensored with Howard Farran

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

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Howard:

Hey, it's a huge honor to be out here with an idol of mine. No, really. You were one of the first guys that were doing CBCT, 3Ds, posting cases on your endo blog from www.TheEndoBlog.com, and you're an endodontist at SuperEndo.com, but I remember the first time that I ever put together that a CBCT and a root canal was you, the Endo Blog. Then I have always leaned on you, "Post these on Dentaltown," and I got you to post another one of your cases.

Jason:

I always appreciate the reminder.

Howard:

You're just an amazing man. Your endodontist practice has three endodontists.

Jason:

Three full time endodontists.

Howard:

You're the caboose. We're out here for the third time.

Jason:

That's right.

Howard:

It really is an honor that you found an hour.

Jason:

I'm glad you came and we enjoyed having you come speak at our seminar.

Howard:

Oh my god, that was so fun. Let me read your bio. You grew up in Indiana, which means you're a Hoosier. Moved to Salt Lake City as a senior in high school. What made your family move to Salt Lake?

Jason:

Just a transfer of my dad's job. We packed it up and headed West.

Howard:

You went to BYU, served a mission in California speaking Spanish. Spanish was the only D I ever made in my entire life and I can still remember [San Martine 00:01:38] telling my mother that I was linguistically retarded. I thought it was true because the happiest day of my life was the day my mom said I no longer had to take piano lessons because the piano teacher was screaming at my mom about how he couldn't carry a tune in a lunch pail. I'm like, okay, I can't hear these foreign words and I can't hear music. Went to dental school at West Virginia University, graduated in '99.

Jason:

Did you know that they beat ASU this last week?

Howard:

Oh did, they? In football?

Jason:

In the football game. Go Mountaineers.

Howard:

Go Mountaineers. That's the main difference between us is you like college football and I like the NFL. Go Cardinals. They're going to go all the way this year. Then you did an AEGD at West Virginia in 2002 fourteen years ago, an endo residency at W of EU. Moved to Arizona where your wife grew up because you wanted to be closer to your mother-in-law. How did that work out?

Jason:

It's worked out great.

Howard:

You're only saying that because it's being recorded and your mother-in-law can find this on YouTube.

Jason:

She might listen.

Howard:

Then you joined Ed Carlson, who is just one of the most amazing endodontists I've ever met. I mean he really is. You guys have tried to be leaders in the endodontic education for those in the East Valley. You put on the Inner Space seminars. What is the Inner Space? What's that name come from?

Jason:

We always try to come up with a fun name. I think Ed came up with that one. Root canals, referring to the inner space of the tooth, so we thought that'd be a fun name. About thirteen years ago we thought that would be a great way for us to share our clinical experience. It's really turned into a great group of people to come. We have anywhere from sixty to eighty dentists.

Howard:

There was a hundred when you had me I think. There was standing room only.

Jason:

You're a big draw.

Howard:

I'm a big draw? No, I'm just a big guy. I want to ask you one politically incorrect question. It's funny, why is it that an endodontist will have a seminar and share everything you know, an oral surgeon will help you ... hell you can break off the top half of the tooth, send it to an oral surgeon, he'll pull the bottom half and then try to give you some tips. I remember back in '87 the oral surgeon called me and said, "Howie with the flap you had, I couldn't pull it out." Dude, if you can't see it, you're not going to pull it and make a bigger flap. Periodontists, same way. You can call any periodontist in town and say, "You know that implant I referred you? Can I come watch you do it?" Hell yeah.

All the nine specialties are that way, but there's not an orthodontist in this town that will have a steady club to show you how they do ortho. Have you ever noticed that? Why do all the other professions say, here's they're thinking. The oral surgeon's like, "Well yeah, you should pull all the teeth you can, because I know you're not going to be able to pull all the wisdom teeth in the back and whatever." Endodontists, well you assume the general dentist is going to do the K9 or the number eight, and you'll show them how to do that because you figure he's probably not going to retreat a distal second molar. Why do you share and why do you think orthodontists don't?

Jason:

I don't know. I can't speak for the orthodontists, but our philosophy has always been we know that the majority of root canals are still done by general dentists. We're trying to develop a partnership with people, with the dentists that we work with. We want them to do the root canals that they're comfortable doing, and ones that are profitable for them. Frankly, if you start a molar and if you take two hours and then you break an instrument off and then you have to bring them back for another two hours, and then you end up having to refer them out, you've lost a lot of time, you've lost a lot of money. We've tried to teach people do the best endodontics possible and we'll help you to do that, but we want you to be comfortable with doing it and we want you to know that we're here to help for the ones that you don't like to do.

It's really about partnership. The best referring relationships that we have are offices where we truly feel like we have a partnership. We don't feel like we're getting dumped on, like they're throwing all the mess-ups over our way, but actually they learn how to make good referrals, and we in return, we learn how to T up those patients so that when they go back they're ready for restorative.

Howard:

It sounds like you're a golfer.

Jason:

Not really.

Howard:

You just knew all your listeners were.

Jason:

The dentists appreciate when they come back the patient says, "Hey, I need a crown. Dr. Hales said I've got to get back in and get this crown done." We really try to build partnerships. Those are the most rewarding relationships as well when we have partnerships with the general dentists. Providing information and helping them to do the best endodontics has always been our goal.

Howard:

The most important thing you do also I always thought with specialists is whenever I sent a wisdom teeth to the oral surgeon, I always sent the treatment plan and told the oral surgeon, it's very important to me to get a third person endorsement for the oral surgeon to say, "By the way dude, I notice you have eight other cavities. You need to get back in there and get those filled, or those eight cavities might turn into eight root canals, I'm going to be pulling eight more teeth on you." It's so great when an endodontist, it's so smart when you get your specialist office manager and your office manager to be faxing and emailing the treatment plans.

I know a dentist is going to sit here and say, "Well is that HIPAA compliant?" If you're going to spend your whole life worrying about an invisible OSHA man and HIPAA man that no one's ever seen, go burn your office down tonight, but it is very important. I wanted to ask you about that comment you made on specialists. I know pediatric dentists tell me that they don't even like referrals from dentists because they always send them this kid who they tried to do something, they already scared him, they already hurt him, they already made him cry, he's already unmanageable. They like to go after pediatricians and get that kid six months, a year old where their first visit is a fun pediatric dental office and they concentrate everything on pediatricians.

When you're an endodontist, does that one guy who does almost all the Zendos and only sends you a broken file, a retreat or things like that? In your heart, is that account more a pain of the ass or do you look at it as just a five alarm fire and firemen like fighting fires?

Jason:

Of course it is.

Howard:

Of course it's a pain in the ass?

Jason:

Yeah. When there's not working relationship it's hard, and if you're busy enough that you don't have time to spend, what people don't realize is that if a file's broken in a tooth, it can take anywhere from ten minutes to an hour to get that out. Like most of us, the overhead of the procedure, if we have to double the time of the procedure then the profit goes almost to nothing.

Howard:

Do you double the fee on that?

Jason:

No.

Howard:

You can't do that?

Jason:

There's a file removal fee and we don't typically, the doctors that we work with routinely, we don't nickel and dime on those type of fees. If there's a perforation repair, if there's a file removal, on doctors that we have a good working relationship no. Because what does that do? That inflames the patient when they walk out the door. Now they're really upset because they had to pay extra for a file removal. The dentist stared it, couldn't finish it, and now it costs more to go have it taken out. We try to make sure that the patients, when they come to us, they have a great experience, and then they go back feeling confident in the dentist that they've seen. Frankly, it's easier for us to help patients that way when we have that working relationship.

We're glad to help anybody at any time. There are times when we've had to sit down with certain doctors and say, "We notice you're getting a lot of file separation," and try to help their technique. We've done that before and give them some tips.

Howard:

Thanks for not mentioning my name on the broadcast.

Jason:

Like I said, we're all about helping and building teamwork between generalists and our specialty.

Howard:

Well follow-up that. Socrates said we only have two emotions, fear and greed. I think in molar endo, the number one fear is the file's going to break. Can you talk about that a little bit? Which file is most to break and would it be the small little fifteen or twenty or is it the big thirty-five or forty?

Jason:

I think that's all depending on your technique and the file that you use. You can break any file, depending on the anatomy and the force that you put on it. One of the things that I really enjoyed with the cone beam is that when you have that type of a complicated treatment, the cone beam gives you so much more information to be able to manage that complication.

Howard:

The broken file?

Jason:

Exactly. A broken file separates, let's say it's halfway down the distal root on a lower second molar. Now you're trying to decide am I going to remove more tooth structure getting this file out, or can I get around it and seal it off with the second distal canal? We take a cone beam, and we can then look at the root anatomy and see that the two canals come down and join. We can tell that by sealing the other canal off we will essentially seal the file in. That's different than if that root has a separate apex.

Howard:

I never even thought of that.

Jason:

It's fabulous. Then you explain to patients, "Look, we were unable to get the file out. If it's down around the curve we can't get to it without destroying the root. Then you feel confident in telling the patient, "Don't worry, because we've actually sealed it in and made it part of the filling. We got around it and we sealed it in." On a case like that, a patient walks out the door perhaps with a file sealed into the tooth, but we still feel real confident in the treatment that we provided because we know the anatomy and we've addressed it. That's just one of the little ways that the cone beam has affected the day to day practice in endodontics. I can't imagine practicing without the cone beam now.

Howard:

Some of those cases on TheEndBlog.com, some of those cases, I mean when did you start that? How many years ago was that?

Jason:

I think it was in 2007.

Howard:

2007, this is 2016, so it's coming up on ten years ago. I seriously think the first time I ever saw a CBCT and an endo and put the two together, I'm kind of like chocolate on my peanut butter and you got peanut butter in my chocolate was you a decade ago. How many cases do you have on that?

Jason:

I think I have about two hundred and fifty posts maybe. I was looking at it the other day, I think I've had over a million visitors over the course of that time.

Howard:

You are a legend. A lot of my friends, Tom Giacobbe, Tom [Madern 00:13:07], Tim Taylor, Bob [Savet 00:13:09], a lot of my friends talk about those cases on there. By the way, all five of those people are all alcoholics by the way, just if you're curious.

Jason:

The original thought was if I'm going to take the time to share a case, why not put it somewhere where I can get to it again some day when I need it. That's why I did it in a blog format rather than a newsletter that goes out and then people throw it away.

Howard:

You mean digital instead of print?

Jason:

Yeah. Now I'll routinely be talking to a patient, and I'll say, "Hey, we're talking about this type of a case." I'll just whip over and pull up the blog and say, "Here's a few examples of this type of treatment."

Howard:

Oh to patients?

Jason:

Yeah, I'll use patient education.

Howard:

Speaking of patients, you and your brother started a patient thing, GradeYourDentist.com.

Jason:

We did.

Howard:

Tell them about that. How the heck did you go from root canal to GradeYourDentist.com?

Jason:

I am kind of an idea guy. I love to come up with new ideas. About a year ago I started working on how do I get patients to give us reviews? I think it started because we had three reviews on Yelp and one of them was a negative review. It wasn't that negative. The patient was complaining that the doctor was switched on [crosstalk 00:14:21].

Howard:

I don't mean to interrupt you. Last month this lady walked in without an appointment. We spent two hours with her explaining everything, talking to her, explaining everything and all this kind of stuff, and then verified her insurance and all this stuff. Then she was made that she'd have a co-payment and this and that, and that she'd have to give us money. After two hours she finally just said, "If you're not going to do this for insurance, I'm going to leave." I said "Well we can't do that. Then she goes out and writes this ...

Jason:

She blasted you on Yelp.

Howard:

Then she just ripped me a new one on Yelp. The whole team agreed that with these online reviews, the planet is filled with batshit crazy people and they got a smart phone. You know what another friend told me? A very SCO guy said that, if someone goes to your reviews and it's like five reviews and they all say, "This is the best guy since sliced bread," that's less believable than if ten percent of them because if they start seeing bad, because most consumers know that you only have to look at your family reunion to realize there's other crazy people living on the planet.

Jason:

That's true. You can take a bad review and turn it into a positive experience based on the way that you respond.

Howard:

Explain that.

Jason:

For example, if a patient goes on Yelp and blasts you, you as a business owner can respond to their complaint.

Howard:

I did not know that.

Jason:

You can go and you can respond. You can invite them to come in. While you can't share patient information online, you can certainly show other people who are reading the views that as a business owner you're responsive, you're listening and you're willing to work out any issues. That can then take a negative review and turn it online. The people who are reading reviews, they can tell when there's somebody that's crazy. They can read the review and see the sincerity.

Howard:

Is that because the last name is Irish?

Jason:

Well perhaps. We basically tried to start driving some reviews to Yelp, and realized that all of the reviews that went to Yelp, they get buried in their system. Over the course of the last year, I've been trying different things to get patients to write reviews for us, and then finally my brother and I found a product that we developed.

Howard:

Joel.

Jason:

Joel. It's called GradeYourDentist.com, and what it does is it gives you a single URL website that you can give to your patient. You can text it to them. You can email it to them. They click on that and it will guide them through the process of leaving an online review. As the dentist, it allows you to choose the sites that you want them to go to. You can give them choices of Yelp, Facebook, Google and Health Grades, and then when you get enough Facebook reviews and you want to drive more, you could take Facebook off and you could add Vitals or Dr. Oogle or whatever third party review site. What I found for us ...

Howard:

I got it right here.

Jason:

I think we pull it up here.

Howard:

Brian, can you zoom in on this a little bit.

Jason:

Here's an example.

Howard:

Oh no, go back. I want one with the blood and guts. That was awesome.

Jason:

Here's an example of our practice. A patient, we give them this link and I sometimes will just text it to them right from my phone. They go in and they pick out which doctor they saw that day.

Howard:

Was that short fat bald guy Ed, was he a Calvin Klein model before?

Jason:

He was a hand model. Then the patient then has a chance to tell the kind of experience they had. This is a filter where if they had a good experience, they select. If they had a bad experience, it invites them to email you directly. It's not encouraging them to go online and complain.

Howard:

A good experience would go to Yelp and a bad experience would be emailed to you.

Jason:

When you go to a good experience, it goes to any one of these websites.

Howard:

Google, Yelp, Health Grades, Vitals.

Jason:

You as the doctor get to pick which ones are up here.

Howard:

First just talk about Google Plus, what percent are using Google Plus? Is it like 80/20? Is it eighty percent?

Jason:

Google's the big dog. They're the most important. Looking at the statistics, most people who do reviews are going to Google, either using it on their laptop, their PC or their handheld device now. Yelp is probably the second most used.

Howard:

What's Health Grade's and Vitals?

Jason:

Those are just other review business sites. There's hundreds of them actually. Yellow Pages have one, Dr. Oogle, there's just tons of them. You pick ones that you want to focus on, but look at this. When you click on Yelp it's going to give the patient a few instructions, and then it's going to take them directly to that Yelp page. They don't have to go search you out on Yelp, it drops right in the place where you can leave the review. What I found since we started doing this, you see we've got eighteen reviews on Yelp that have stuck.

Howard:

Since you've been doing this, you've got eighteen reviews?

Jason:

Well I had about three or four good ones, and then since we started this process, what I found is that Yelp does not like people, Yelp doesn't want you as a business owner to ask for a review on Yelp. They want their Yelpers to spontaneously go to Yelp and review. When you do it this way it gives the patients who are more likely to use Yelp that choice. What I found is that it's really successful at getting those reviews to stick. It's just been a neat product, and I just pulled a report. Our practice I think generated about twenty reviews in the last two months that have been on Yelp, Google, Health Grades and Yellow Pages.

Howard:

I just texted the link to my whole team and you.

Jason:

Right on.

Howard:

How much does something like this cost? What's your business model?

Jason:

We're just getting it rolling. It's $299 for a year per doctor, or you can do $30 a month if you want to go month by month.

Howard:

Nice.

Jason:

If you look at the value of an online review, it's pretty significant. I think Inscriptions, our Arizona magazine, there was an article that said, and I'm not sure if I believe this, it said an online review can be worth up to $500. I don't know how they would calculate that, but the reality of it is when somebody goes online and says something good about your practice it stays there forever, and it affects the search engine. When people are Googling and searching, it's going to affect the search engine. It's a very inexpensive way to do search engine optimization. I hear some guys are out there they're paying $1,200 a month to a company to do search engine optimization and bring them up on the Google searches, but this is something that will last forever. Once it's written down there, it's there for a long time.

Howard:

Nice buddy. This was your idea, and then what's your brother's background?

Jason:

My brother's a developer. He does web design.

Howard:

Is he a programmer?

Jason:

He's done some programming. He worked with a hospital company that had a software program.

Howard:

Good luck. Has this been fun for you?

Jason:

I know I'm never going to make any money doing this kind of stuff. I enjoy root canals, and that's where I want to spend my time, but it's been a lot of fun working with my brother. We have a project to do together, and [crosstalk 00:22:25] full time.

Howard:

My best friend is my brother. Now next time he comes down here have him come by Dentaltown.

Jason:

Okay.

Howard:

I've been trying to get my brother to work with me forever, but he moved from Kansas City to Sydney, Australia.

Jason:

I tried to get my brothers to move down to Arizona too. I was able to get one brother to move to Arizona, and I have two other brothers that stayed in Utah. This is the next best thing. Work on a project with them if I can.

Howard:

You said you like to do endo. I'm just curious, what percent of dentists do you think like endo and the follow-up question is what percent of the dentists out here don't do endo or molars? Have you ever seen what percent of America's hundred and twenty-five thousand ...

Jason:

No, off the top of my head, the statistic that comes to my mind is that seventy-five to eighty percent of endo is still done by general dentists nationwide. I couldn't give you ...

Howard:

Every dentist I meet I always ask them what percent of your root canals fail? You've been practicing ten years. They always say the same thing, "Knock on wood, I haven't had one yet."

Jason:

Oh yeah, that's bull.

Howard:

I'm like, "Okay." What is there four thousand endodontists in the United States? Four thousand in all, so every time they do a retreat it has to be an immigrant from another country.

Jason:

Geographical success. Those are the ones that move all the time.

Howard:

Tell these guys what percent of the four thousand endodontists work is retreating a failed root canal and how many of these things fail.

Jason:

In my practice, I'll bet I do twenty-five percent of retreats. Twenty-five to thirty-five percent.

Howard:

What do you think the success rate is of endo done in America today?

Jason:

I still think it's very high. The reality is most of the statistical numbers that we have about success of endodontics or implants for that matter, they're all affected by the quality of the study. The reality is the research in dentistry, the quality of the studies has been fairly poor for a long time.

Howard:

The podcast we released this morning was Carl Misch. Carl Misch has published as much as anybody, and he said that on all these peer review journals, he says no one's ever asked for the data. He has three examples of implantology where someone submitted the data and has never even done the surgery. One guy went on a sabbatical and at the end of a year of not practicing dentistry, he came out as an implant expert and starts lecturing on implants. It reminds me of the joke that 93.8 percent of all statistics are made up.

Jason:

That might be right.

Howard:

Hey, you just gave a lecture on cracked teeth. Can you talk about that?

Jason:

We had a nice big group of dentists and we talked about cracked teeth. Our goal in that presentation was to help make sure that the specialists and the generalists were using the same terminology. When you talk about a crack or a fracture, we kind of use those terms interchangeably, and sometimes they're confusing. They can be confusing to each other. They can be confusing to the patient. There's five types of cracks.

Howard:

There's five types of cracks?

Jason:

There's five types of cracks.

Howard:

How do I get to fifty-three and not know there were five.

Jason:

That's why we talk about the five types.

Howard:

Did you name one crack after each one of your daughters? You have five children?

Jason:

I do have five?

Howard:

Are they all daughters?

Jason:

No, one boy. The first would be a craze line. Everybody has craze lines. That's a crack. It's a crack in the surface of the enamel.

Howard:

How do you spell crazed?

Jason:

C-R-A-Z, craze.

Howard:

Crazed line?

Jason:

A craze line.

Howard:

That's an official type of ...

Jason:

A craze line.

Howard:

This is the five types of what?

Jason:

The types of cracks. This comes from, this is an AAAE publication. You've got a craze line, and we all know that that's not a big deal. All adults if you look closely enough, certainly if you look under a microscope you'll see little craze lines, little cracks in the surface of the enamel. No problem. There's no treatment needed at this point. The next type is when the crack goes a little bit deeper through the enamel into the dent, and that's when we begin to call it a crack. Those types of cracks, again, are the early signs of stress. They don't necessarily mean that the tooth has to have a root canal or to come out, but you need to recognize that those are early signs of fractures or early signs of change in the tooth caused by cyclic flexing of the tooth.

If we can recognize those and treat those earlier, then we'll prevent them from going bigger and deeper and jeopardizing a tooth. We talked about cracked tooth syndrome and how to diagnose those cracks. Then you have, let's see, the cracked tooth.

Howard:

Number three.

Jason:

Number three is a fractured cusp. That's when the patient comes in and says, "Doc, I broke my tooth. It doesn't hurt but a whole half of it broke off." Those fracture are usually down at the bone line. Those are treatable, but they oftentimes need a root canal for restorative reasons. You have a fractured cusp. Then you have a split tooth, and that's a crack on steroids. That's a small crack.

Howard:

By the way, I am not on steroids. Everybody accuses me.

Jason:

I know. I've seen you in the gym.

Howard:

I'm taking steroids. This is all natural.

Jason:

I know you're an Iron Man. I've seen it.

Howard:

Split tooth?

Jason:

A split tooth.

Howard:

That's a fractured?

Jason:

That is a crack that started coronally in the surface of the crown, and went apically. When it gets down below the CEJ and down into the root, then we call it a split tooth. Essentially the tooth is breaking apart. At that point it's no longer treatable. It's too late.

Howard:

The split tooth is something that goes below the bone?

Jason:

Below the bone.

Howard:

It's a fractured cusp that goes below the bone.

Jason:

No. A fractured cusp, usually the fractured cusp they're going to come in with it flexing or it's going to be broken off all the way, and we simply restore the tooth. The crack is an incomplete fracture, so it's a crack line that runs down the tooth. We see those around the old amalgams and around the [inaudible 00:29:01] have those little cracks on the mesial marginal ridge and the distal marginal ridge. You see them. All the time. If those are left untreated long enough, those cracks go deeper and deeper down into the root, and then they turn into a split root or a split tooth. I described to patients it's a crack that's just been there too long and it went crazy. Now at that point it's no longer savable, a split tooth.

Then the fifth kind is a vertical root fracture. Those are cracks mostly found in endodontically treated teeth that start at the end of the root and work up. They typically start at the apex of the root and work their way up. Those five cracks, too often we just call it a crack and we don't communicate really well about what we're talking about. We used the term a cracked root, fractured root, kind of interchangeably, and it's important that we understand if we're talking about a split tooth or a crack that's savable or a craze line that doesn't really require any treatment, but we need to be aware of it and watch it because if that craze line turns into a crack we need to be more aggressive about treatment and protecting the tooth.

Howard:

You mentioned the word cyclic fatigue, which draws me all the way back to Creighton in undergrad where a, I forgot if it was a chemistry class or physics class where one of the lab deals he took a plate of marbles and he put them in the oven for three fifty for ten minutes, he took them out and he dunked them in ice water and they all shattered. Then he said, "See, you still have all these marbles and they're all shattered because the molecules all shifted but none of them are broke. They're still all functional marbles." Then he drew the parallel to Creighton Dental School who he said, and I don't know if this is true or false and I'm asking an endodontist, he said that Americans have the most craze lines that turn into cracks and fractures because our society uses the most ice.

We use hot food, thermal cycle to cold, hot food thermal cycle. He said that when you went to Asia and Africa and Latin America that you didn't see all these craze lines. He's told me, I think that was in 1980, he told me, he said, "If I found a jaw in the middle of the ocean and it had craze lines," he said, "I'd bee ninety-nine percent sure it was from the U.S. or Canada, and if it was from Africa or Asia it wouldn't have all these craze lines." I remember the first time I lectured in Portugal, lives in Portugal. I'm eating at this restaurant and I order a Coke and she just brings me a glass of hot Coke. I said, "Oh can I have some ice in it." She came back and she had this little platter and she put like three chips of ice in it. I'm like, "No, no, no." I said, "Take the glass. I want the whole glass packed with ice and then I'm going to pour the Coke over it." She goes, "Are you from the United States of America?"

I said, "Yes, I am." Is that true or false?

Jason:

I've never heard that directly. I would assume more that the fact that in developed countries are keeping our teeth longer and we have better dental care, and so over time if we keep a tooth long enough, just the wear and tear of life and stress. Maybe it's the stress levels of Americans. We probably have a lot more stress.

Howard:

Yeah, and we are living longer. I read this study that going back fifty thousand years, the average age of a human was seventeen and a half years. Four thousand to two thousand years ago it jumped up to thirty-six, and then 2000 to now it's up to seventy-four, so these teeth basically were only meant to go seventeen and a half years.

Jason:

We're asking them to do a lot, and fortunately they do. They're amazing. I'm always amazed at the healing ability of the tooth. I've been working with an ENT a little bit, and we've been doing some cross over sinus cases.

Howard:

I want to podcast that guy or try and get him on [inaudible 00:33:14]. Can you hook me up with him?

Jason:

Sure. I was fascinated because we were talking when they go in to do their sinus surgery, essentially they just go in there and blow through the walls of the sinuses and just tear out the bone and open up the cavity, and when they do that, that bone never comes back.

Howard:

Say that, what do you mean it never comes back?

Jason:

We're so used to when, we work in the mouth, when we work in the alveolar bone, we cut that bone away and do an apico and it comes back. I'm so used to seeing bone heal around endodontically treated teeth that you forget that it might be the only place in the body where you can injure the bone so much and it will just grow right back. When they do sinus surgery, those sinus walls, they don't grow back. Once you've had a sinus surgery once, the holes they put in the wall to open those pathways, that's like that for the rest of your life.

Howard:

Who's your sinus buddy? He's an ENT?

Jason:

Yeah, he's an ENT. His name's Tim [Hagen 00:34:20]. He's with Arizona Science Center, and his partner is Ryan [Reel 00:34:25] and these two guys are amazing. They're rhinologists, so that means they're ENTs who have done additional specialty training just in sinus. There's only three rhinologists in the Phoenix area and these two practice together.

Howard:

Ryan Reel and Tim?

Jason:

Hagen.

Howard:

What's their website?

Jason:

It's Arizona Sinus Center. I'll have to Google that.

Howard:

Why are you working with rhinologists? Are they rhinologists or ENTs?

Jason:

They're ENTs but they're specialists.

Howard:

Their website, Arizona Rhinologists?

Jason:

No, Arizona Sinus Center. They go through their ENT residency and then they do additional fellowship just in sinus. One of the things that they'll use is endoscopes, and most ENTs, if you go in for an exam, they don't typically use an endoscope. Much like an endodontist would use a microscope to do a root canal, a rhinologist like Dr. Hagen and Dr. Reel, they'll use endoscopes, and they'll go in and they'll visualize your sinuses and then recommended treatment based on that. The way we got hooked up is I just had a patient that was getting ready to have sinus surgery with Dr. Reel the next week and I'm doing my exam and I'm taking some CTs and I'm looking at it going, "This is an androgenic sinusitis." This is the tooth causing this sinus abscess.

I put together some information and just started to communicate with them. I laugh about this, but they're the first physicians to ever respond to any communication that I've sent. We began to work together.

Howard:

Do you know why that is? Same reason, you could sell your practice because it's a business that has value. You can sell a vet office, a dental office, a chiropractor. You can't sell a medical practice. They don't sell them because with Medicaid and Medicare, having a gazillion patients, everyone has a gazillion. Anybody can set up and have a gazillion patients. There's no value to medical offices. That should be your first red flag there's something wrong with the medical insurance industry when you can't even sell the damn business. They're so flooded with patients and their margins are so low that they can't spend the time talking to referrals, doing everything that we do in dentistry. A veterinary office treats their dogs better than a Medicaid practice.

America should tiptoe slowly into Obamacare because everybody will have access, but everybody will have access to Ikea. There's trade-offs to everything. Since then, have you ever done any other cases with these rhinologists?

Jason:

Oh yeah.

Howard:

Because you had them this week.

Jason:

Dr. Hagen actually came and spoke at the Arizona Endodontic Association recently. With the cone beam, that's one of the things that we're seeing. It used to be patients would ask, "Could this be causing my sinus problem," and I'd say "Well maybe." With the cone beam we can take a scan and you can literally see changes in the floor of the sinus and you can see perforations in the floor of the sinus. We're now able to diagnose an endogenic sinusitis and tell patients, "Absolutely, this tooth is causing your chronic sinus issues." We have patients that come in here that say, "Well I've had sinus surgery. I've been to doctor after doctor and this problem keeps coming back." We take a scan and it's a dental abscess.

Howard:

Could a dental abscess on a tooth on the right, would it just make the sinus on the right be blocked or would it make them all?

Jason:

What happens is it can affect one sinus, and then as that sinus backs up that can then move and affect the other sinuses. Typically it's going to affect the side that the sinus is on. I've worked with these two doctors. That's what fascinated me, because I've been into their office and observed what they do.

Howard:

Where are they at?

Jason:

They're in Phoenix?

Howard:

Downtown?

Jason:

Right off of 7th Street I think.

Howard:

By St. Joe?

Jason:

I don't know. I'm not as familiar with that. It's right off the freeway. I know it's right when if you're going to the Suns game, you turn right instead of left to get to the stadium. Right down there. We've worked on a lot of cases together. It's been fun. They've sent patients over here that have been bouncing around from doctor to doctor, sometimes even ENT to ENT until they finally find somebody who reads it as a dental abscess.

Howard:

What's the difference between a rhinologist and an ENT?

Jason:

A rhinologist is an ENT who has done a fellowship in sinus treatment.

Howard:

Interesting. You're talking to thousands of dentists; what do these people need to know about those five different cracks? How does this go from knowledge to clinical, a craze line to a crack to a fractured cusp, a split tooth and vertical root fracture?

Jason:

This information I think ...

Howard:

More about terminology.

Jason:

It's terminology, but it's also really important for treatment planning. As you talk to your patients and you get out your intraoral camera, you want to show them the things that you're seeing in there mouth. When they see what you're seeing, they're going to accept treatment. They're going to want to have treatment. When you show them a craze line you can tell them, "Look, if this gets worse, it can turn into a crack and then we're going to need to do something." Then you can take your camera over to the other side of their mouth and say, "Look, this is already a crack. You've got a crack on the mesial marginal ridge. We're going to test it. It's still alive. If we put a crown on it now, you may not need a root canal."

I like to tell patients, there's a study that says that if you have a vital healthy pulp and the tooth has a crack in it, if you cover the tooth with a crown, eighty percent of the time they won't need a root canal. That means twenty percent of the time they still will, but if you have patients in your practices now and they have cracks in their teeth but those teeth are vital, if you cover them now there's an eighty percent chance you'll save them from having to have a root canal. Right there is a little gem to help your treatment plan, your crowns.

Howard:

I want to go through some diagnosing and treatment plans, common questions I see on Dentaltown. Again, all the data I have from feedback on these podcasts is that everyone that ever sends back, they're usually thirty and under, been out of school five. I think I've had like two emails that were over thirty. That's all I'm getting. A very common question they ask ...

Jason:

You asked me about the blog. I've been doing the blog since 2007. Guess how many posts I've gotten Ed to do.

Howard:

How many? Zero?

Jason:

Yeah. There's definitely a demographic of dentists who are going to put it online.

Howard:

I feel so sorry for Ed because he's another short, fat, bald guy. One time he was at a dental convention and some guy came up and hugged him and kissed him on the back of the head, because he thought it was me. Poor Ed, he has to wear a sign, "I'm not Howard."

Jason:

The younger dentists are the ones that are going to be on there.

Howard:

One of the common questions they have, and I see this a lot, they know the tooth ache is on the lower right but they just can't tell which one. Do you have any helpful ideas? Obviously when they come in they're like, "Oh my god," and then they're sitting there and they're looking at the x-rays, they don't see periapical release and everything they touch explodes. What do you do when you just don't know which one it is?

Jason:

Most of the time, when I see patients that come in, I'll take them through just my regular diagnostics of percussion. Well palpation of the gingival tissues or the buccal vestibule, percussion, probing, thermal testing. If thermal testing isn't giving us enough information or is not working, we'll go to EPT testing, electric pulp testing, radiographic exam, and then sometimes we'll use the cone beam. We use all of those, and with all of those I can't put my finger on the cause of the pain and we've ruled out the non-tooth sources like TMJ, muscle referral patterns, neuralgia, sinus issues, if we don't think it's any of those and I truly think it's a tooth and one of these teeth is going south, I tell the patient, "Let's give it just a little time. I know it's going to suck for a couple of days, but it's better to give it a little time and let those symptoms localize a little bit more."

I might just give them some medication, say, "Come back in two day and we're going to retest." Then two days later we're going to go through the same battery of tests and we're going to see one start to stand out. Okay, now number nineteen's a little more sensitive today.

Howard:

You give her pain meds or pain meds and antibiotics?

Jason:

If there's a necrotic tooth then they're going to get antibiotics. If there's no sign of necrosis, then I don't necessarily always give. If the patient's symptoms are, "I've got terrible temperature pain," and we think it's an irreversible pulpitis, then we may just manage it with pain medication. I don't throw antibiotics at everything. Sometimes I want to give it just a little time and say, "Let's let this tooth show us which one it is."

Howard:

Next question is, I know there's no way to answer, I know it's a case by case still, but sometimes they're sitting there and the tooth's broken down. It would need a root canal, a buildup a crown, sometimes you're looking at this and then they're thinking, "Should I do a root canal, buildup and crown or just extract this thing and just put in a clean implant?" How do you get hands around it? Are teeth just interchangeable with titanium implants?

Jason:

First of all, our treatment here in our practice has always been what would you do on yourself and your family?

Howard:

You'd shoot the patient?

Jason:

If you can get a margin on the tooth and can get a fair rule, then I'd try to save the tooth. I think a natural tooth is better than an implant, first of all because you can always take the implant option down the road if you have to. What I see, sometimes people say, "Well let's take the tooth out and let's put in an implant in there. They're interchangeable, they're the same and an implant lasts forever and it can't get a cavity." When you think about that argument, an implant certainly doesn't get a cavity, but the bacteria that causes the cavities and the periodontal disease are still there, so you can get peri-implantitis and the thing that I try to explain to patients is implants don't feel the same way as a tooth feels. An implant feels different because there's no periodontal ligament.

An implant doesn't always look like a natural tooth doesn't unless it's adjacent to a natural tooth. When you do these front central implants, the ideal situation is in between two natural teeth. That's because the two natural teeth next door are going to make that implant look like a real tooth. If you put two implants next to each other, the gingival architecture changes. One of the interesting things to think about, and if you go back to your embryology back in the day, if you remember all tissues form from the ectoderm, the endoderm and the mesoderm.

Howard:

Oh man we're going way back.

Jason:

I had to go back and pull this out to look at this.

Howard:

Say it again. You're talking about an embryo? An embryo or a fetus?

Jason:

The embryo forms three layers, the mesoderm, the ectoderm and the endoderm, and from those three layers all tissues of our body are formed. The ectoderm is where the enamel and the tooth comes from the ectoderm. The alveolar bone of our jaw comes from the mesoderm.

Howard:

The alveolar bone?

Jason:

The alveolar bone comes from the mesoderm. They come from two different embryonic tissues. Sometimes people say, "Well I'm going to pull out the tooth," and the tooth, the ligament, the bundle bone are all ectodermal origin.

Howard:

Tooth, ligament and what?

Jason:

The tooth, the ligament, the bundle bone, the periodontium itself.

Howard:

Bundle bone? You'll have to review that?

Jason:

The periodontium. The periodontium all comes from that same embryonic tissue. You take that out with a tissue and then you stick an implant back into the alveolar bone and you want it to look like a natural tooth, but it doesn't. The bone doesn't grow up the same way. You don't get the same gingival architecture and you [crosstalk 00:47:48].

Howard:

There's really something called bundle bone?

Jason:

There is. That's what the PDL attaches into.

Howard:

The PDL attaches into into bundle bone, which then turns into alveolar bone?

Jason:

The bundle bone is the PDL attaches to the root and to the bundle bone. That's what the ligament attaches to. When you take out the tooth ...

Howard:

You're saying I went to dental school before they had discovered bundle bone?

Jason:

I guess my point is when you take the tooth out that tissue is gone and it's gone forever. That ectodermal derived tissue, the periodontium is gone. It's gone forever. You put in an implant in there, it's going into the mesodermally derived bone. That's why teeth and implants aren't the same, and it drives me nuts when I hear people say, "They're interchangeable. It's a tooth, it's an implant, they're the same, or the implant's better." I'm an endodontist, so I'm biased, but I think the natural tooth should be saved as much as possible.

Howard:

Do you think it's bizarre that the tooth, the ligament of the bundle bone came from ectoderm, the alveolar bone came from mesoderm, and you're an endodontist and the endoderm ...

Jason:

Yeah, you'd think.

Howard:

You'd think the whole damn thing came out of the endoderm if you're an endodontist. Do you feel bad that the only thing that starts with endo [inaudible 00:49:09]?

Jason:

Yeah, I feel short about that.

Howard:

All those studies are biased because they're always doing studies on teeth that were lost from decay, structure [inaudible 00:49:17], and alveolar and mandible anterior bone. They never do implant studies on people who lost their teeth from gum disease in the back of the maxilla and then they come out with their cherry picked data and say, "Implants have a ninety-five percent success rate." Yeah, if it was a meth patient in Apache Junction that lost all of her teeth from meth and you put four implants down here, but let's talk about the millions of people ...

Jason:

Real people.

Howard:

... real people that have periodontal disease and that's interesting.

Jason:

That's across the board though. Not to pick on the implant research because the endodontic research can be just as bad. The reality is real teeth, I think there's nothing that can replace a real tooth as good as the tooth itself.

Howard:

It is kind of funny when some of these dentists talk about evidence [inaudible 00:50:05] and they're always talking about research and yesterday Carl Misch was talking about that all the stuff he's done no one's ever asked for the data. Then another good friend of mine who's a dentist who owns a company, just gives me the list of all these people where if he'd just give them $5,000 grand they'll take his product and do a study that will show how great it is. With everything you have to be moderate. You got to balance clinical experience, what are your peers saying. You're also into pulpal regeneration? Is your nickname the Dical man?

Jason:

No, Dical's a thing of the past. Pulpal regeneration is a new procedure in endodontics where we take an immature tooth that has become necrotic. These are young patients, nine, ten years old. They had an accident, knocked a tooth and the tooth became necrotic.

Howard:

Knocked the tooth out, avulsed?

Jason:

It can be avulsed or just a traumatized tooth that was traumatized prior to the final formation of the root. It's an immature open apex. In dental school we used to learn apexification and apexogenesis, used calcium hydroxide. Now what we're doing is we're actually trying to get the tooth to come back to life and regenerate the pulpal tissue and start the development of the root again. It's fascinating.

Howard:

You can do that even if the tooth was knocked out?

Jason:

Yes. It's fascinating.

Howard:

I figured it was like Superman breaking his neck. If the tooth came out, you broke the never and it won't heal.

Jason:

No. The more I've done this in vital pulpal therapy, the more I've realized how the healing ability of the pulp is better than we give it credit for. We'll see a tooth that has become necrotic, it's draining, and we'll go in and we'll clean it out. The way the pulp regeneration works is you access the tool, you debride it with minimal instrumentation. You don't want to remove any more tooth structure than you have to.

Howard:

Even if it's necrotic?

Jason:

Even if it's necrotic, yes. Irrigating with sodium hypochlorite, then you do an EDTA rinse, and then you initiate a blood clot. You've got this open apex, you take a file, you go down and you pierce the periapex apex and you it to start to bleed back into the canal again. Then we close it off with a special filling coronally. We used to use MTA; now we're using more bioceramics. Then you restore the tooth from above. Then what happens is that that blood clot that comes in either brings in stem cells or stem cells that are left inside, what we'll see happen a good percentage of the time is that that tooth will come back to life, the abscess will disappear and the root will literally start to grow again. We'll see dentinform forming back in the root again.

Howard:

Is there an age limit to this? Could you do it on me, a fifty-three year old if I had a necrotic tooth?

Jason:

That's not ever been done. Normally the apex is supposed to be at least a millimeter open is what the current guidelines are?

Howard:

That's called apex?

Jason:

No, it's called pulpal regeneration.

Howard:

What were the other two things you said?

Jason:

Apexification is what we used to when you'd put calcium hydroxide in the immature root over and over and over until a little calcific barrier would form at the end of the room, and then you could then fill it with gutta-percha. The problem with the apexification is the root is still as weak as it ever was. You get a little barrier against what you can pack your gutta-percha, but the root walls never get any thicker. With pulpal regeneration, the root literally comes back to life and starts growing again. The root gets thicker and gets longer.

Howard:

The human body's amazing. I always think it's weird where someone comes in with a pain core, they're all swollen, you take out this wisdom tooth. When they're done there's like a ping pong ball hole back there, and they come in ten days later and it's just all pink, all pretty and you're just like, "We didn't do anything, we just popped the tooth and the human body just takes over." It's really amazing.

Jason:

It is. It's an exciting part of endodontic practice.

Howard:

You said something, MTA. Explain what MTA is.

Jason:

Mineral trioxide aggregate.

Howard:

That was an endodontist who basically was?

Jason:

His name was [Mammoet Torabinejad 00:54:49] that developed it out of Loma Linda.

Howard:

It was pool repair stuff, porter cement.

Jason:

The story I heard, it's like Portland cement. It's like a medical grade Portland cement essentially.

Howard:

Are you friends with him?

Jason:

No, I just know him.

Howard:

I've been trying to podcast that guy because he was the inventor of that. You said you used to use that and the complaint about that was that it worked really good but it was very expensive.

Jason:

That wasn't the biggest complaint. The biggest complaint was sometimes you could get some discoloration of the tooth with the MTA. If you put that in an anterior tooth, you get some discoloration.

Howard:

Is it like an apicolectomy or is it more for perfs?

Jason:

We use it for any type of root repair. Apicolectomy, root perforation, and we began using it for pulpal regeneration as well, but in the anterior areas sometimes you get a little discoloration.

Howard:

Discoloration was the main thing. You said now you switched from Portland cement to bioceramics?

Jason:

Yes. We're using some of those now for this type of treatment.

Howard:

What are brand names?

Jason:

Like EndoSequence. Gosh, I can't remember all the brands. That's the one that I use I think most of the time.

Howard:

EndoSequence?

Jason:

Yeah, I think that's made by Ultradent perhaps.

Howard:

Dan Fisher, my buddy, have you ever met Dan?

Jason:

I haven't ever.

Howard:

He's probably one of the most amazing men that ever walked into dentistry. I've been trying to get you to get a cracked tooth course on Dentaltown.

Jason:

It's coming.

Howard:

It's coming?

Jason:

Yes, it's coming. Now it's official. It's online, it's coming.

Howard:

It's official, it's online? What does that mean?

Jason:

Well I just told everybody online that it's coming.

Howard:

Yeah, I would love to do that. You're an amazing guy. Also my god, you could write so many papers just out of your endo blog.

Jason:

I don't know about that.

Howard:

How many cases did you say you have on there?

Jason:

I think there's a couple hundred posts.

Howard:

Each post is a case?

Jason:

Some of them are cases. Most of them are cases. The busier I get, the harder it is for me to [crosstalk 00:57:08].

Howard:

I've only got your for three more minutes. I want to ask you two important questions. We talk about the standard of care. We've got to do endo as good as the endodontists. We can't be in there flipping [inaudible 00:57:20] or things that are unacceptable. Is a CBCT before doing a root canal and/or a microscope to see better as opposed to just loops, is that kind of getting to be the standard of care? Let me ask you more specifically, what percent of your root canals are used in a CBCT? What percent are used in a microscope, and what would you think if some guy says, "Oh yeah, I do all my molar endo," but he never uses a CBCT and he never uses a microscope?

Jason:

That's a great question.

Howard:

Thank you. You're the first podcast person that ever said that. Took three hundred podcasts.

Jason:

Microscopes we use on a hundred percent of our cases.

Howard:

What magnification is that about?

Jason:

Our scopes go from five up to I think twenty power. Most of the time at about six to eight power. We have a scope in every operatory. Every root canal's done with a scope.

Howard:

Is it mounted on the ceiling?

Jason:

Mm-hmm (affirmative).

Howard:

You prefer that? Which scope are you going with?

Jason:

I use the Global.

Howard:

St. Louis, you like that one?

Jason:

It's what trained with, but I like Zeiss scope too. Every case is under a microscope. Cases that we use cone beams on are retreatments, surgeries, not every case. The cone beam takes a lot of time. Takes time to take, takes time to read. I don't take it just to generate fees. That's now why you get a cone beam. You get a cone beam for the information it gives you. If I have a severely calcified tooth, it might take a cone beam. If I'm going into retreat, I take a cone beam to see what can I improve as I go in to do this or where's the canal that they missed. If I'm in the tooth, if I've started a root canal and I can't find the canal, this is what's really amazing, is I'll stop and I'll say, "Okay, look, we're done for today. We're going to take a cone beam on the way out the door."

I'll use that cone beam to map the canal system. When that patient comes back in, within minutes, having the map, I'm able to get in and find that canal. That's how I use it most of the time.

Howard:

Did you just say that you mostly only use a CBCT on retreats?

Jason:

Retreats, surgeries and difficult initial treatments. I don't take it routinely.

Howard:

What do you mean by surgery? Apicolectomies?

Jason:

Yeah.

Howard:

I want to ask you because in your lifetime as an endodontist, Delta covers thirty three million people, so basically one in ten Americans have Delta. It seems like the insurance billing information is showing that apicolectomies have been trending down your entire career. Why do you think that is?

Jason:

Well because of the advent of the implant. That is becoming a good way to replace the tooth, and frankly I think there are too many teeth that are given up on too soon. I like to be the one to tell the patient, "Look, you really got to take this tooth out." I tell the patients that all the time. I refer a lot of patients to have implants when I see that the tooth is no longer savable.

Howard:

What is usually that tooth looking at?

Jason:

It's a tooth that's got severe periodontal disease or it's got a crack or a fracture that makes the endodontic prognosis poor. When the endodontic prognosis is poor, that's when it's time to invest your money into something with a better prognosis. If you take a single tooth and a single implant side by side, the prognosis is almost identical. When you start adding now this tooth has a crack in it, it's been retreated, there's perforation in the tooth, all of those things then decrease that prognosis. I like to just give patients the choice and say, "Look, you can do this treatment but I think your money might be better spent taking that tooth out." I had one this morning. It was a patient that had had a root canal, and I opened it up and I found a crack.

With the microscope I could see it going right down the distal wall of this number eighteen molar, and it went at least three millimeters below the CEJ. I told the patient, "We can do this, but it's going to fail again. You're better off taking this out, getting another implant."

Howard:

I was going to think that maybe CBCTs would be more important because, and by the way we're in overtime, wouldn't it be safe to say that the number one cause of the failed root canal is missed canals? Is that a fair statement? True or false?

Jason:

Probably. It's a high percentage. On most upper molars that we do retreatments on, we find missed canals.

Howard:

Just real quick go through, you gave me one to five on cracks, give me one to five on the missed canals. Most likely missed canal. Is it an MB2 on a [crosstalk 01:02:30]?

Jason:

Absolutely.

Howard:

Is that the 80/20 rule?

Jason:

Yeah, probably.

Howard:

Then what would be the second? I'm guessing the second canal distal canal molar?

Jason:

Yeah. The lower molars have that fourth canal about thirty percent of the time. That's going to be probably the next most likely, and then the bicuspids. The bicuspids have the varying anatomy. They can have one canal or two canals. It's important that you make sure that you hit all those. The mandibular anterior teeth, I think they can have a second canal about ten percent of the time. That's usually you're going to miss the lingual canal if you miss it. If there's two, it's going to be the lingual canal that you miss because of the access that's coming from the lingual, you always will find the buccal first.

Howard:

Well that was a fast hour. We're in hour three. I just want to tell you seriously dude, I think you're a legend. Congratulations on getting a million views on TheEndoBlog.com.

Jason:

Thank you.

Howard:

Good luck. Go to GradeYourDentist.com.

Jason:

You got to be patient there because we're in the very early stages. If anybody's interested, go sign up and we'll get you some information to it.

Howard:

If you sign up today and tell them you heard it on this podcast, he'll give you a free root canal. You just come in here, point to a tooth, free endo. Seriously dude, thank you so much for an hour of your time today.

Jason:

Appreciate everything that you've done for our dental community and what your media organization has brought dentists together from all over the world and you're doing a great work. I have to say I really admire the efforts that you make to educate the rest of the world that doesn't have the benefit of the educations that we have here in the Western world. I think that's a great mission, and I look up to you for that.

Howard:

It is the coolest thing in the world when you walk into a dental school in Asia and the dean starts crying because her entire curriculum is those online T courses, which we make for free, which you are going to add a cracked tooth course on.

Jason:

That's right. It's coming.

Howard:

When they go to dental school in Katmandu and Ethiopia and Tanzania and all over, [inaudible 01:04:45], I swear to god that this is their whole dental school curriculum and all their books are twenty years old, and more times than not in a different language, like Mandarin, Chinese or French and they're all like, "Well we're all from Tanzania," but they're on Dentaltown. Then Google Chrome translates to sixty-eight or eighty different languages, so when you put that cracked tooth course in, there will be little kids in Ethiopia who are twenty-two years old whose entire family is paying for this little girl to go to dental school, and she'll be listening to Jason in sunny Mesa, Arizona. All right buddy, thanks for your time.

Jason:

Thanks Howard.

Howard:

Take care.