Dentistry Uncensored with Howard Farran

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

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Howard Farran:

It is a huge honor for me today to be podcast interviewing Dr. Michael Davis out of Santa Fe, New Mexico. How are you doing this morning?

Michael Davis:

I'm doing pretty well. I hope you're doing well!

Howard Farran:

Say hello to my UMKC Class of '87, classmate Christopher Speak who I went through four years of dental school and who practices up the street from you. I just love Chris. Have you seen him lately?

Michael Davis:

Yes. Chris is a good man. Patients love him, outstanding clinician, very caring, big heart. His daddy was a dentist. He assumed his daddy's practice. I think dentistry's in Chris's blood. But more importantly, he just loves people.

Howard Farran:

He's a great guy. Tell him I'm never going to forget how he almost killed me on A Basin. He took my on my first ski trip in dental school. We drove from Kansas City to Colorado. He takes me right up to the top of the hill and says, "Let's go!" Oh my god. He is an amazing skier.

Michael Davis:

He has no fear. He's still a kid. None of us are kids anymore, Howard.

Howard Farran:

I know! Let me read your bio:

Dr. Michael Davis maintains a private general dentistry practice in Santa Fe, New Mexico. One day per week, he works with disadvantaged populations. He chairs the Santa Fe District and is active with his state dental association. He is engaged with expert witness dental law cases. He is a vocal advocate for ethics in dentistry and the public welfare.

The reason I called you and wanted to podcast interview is you are ... A lot of dentists are in their bubble just practicing, but you get to see a lot of the legal stuff. You get to see a lot of the complicated stuff.

Michael Davis:

The good, the bad, and the ugly. Just like the old Clint Eastwood film.

Howard Farran:

You talk about dental methods and materials and bio-mechanics to the current ethical and legal issues, the DSO industry, Medicaid fraud as a business model, the doctor relationship, lawful contract, legal rulings, the hapless character serving as legal counsel to state dental boards. Where do you want to stop? You're talking to probably about eight-thousand dentists. Most of them are commuting to work. You've been in this field a long time. You graduated from Ohio State University in '81.

What do you think ... How do you think you can keep you listeners out of trouble? What's going on out there? What do you see that a dentist practicing in their little bubble is probably not aware of?

Michael Davis:

That's a dangerous place to be. This whole attitude of, "Hey, I just want to do the dentistry and keep my head down." You've got to have your antennas up. You've got to know what's going around. The environment is always changing around you. You can get bit in the butt. Keep your eyes and ears open, be alert, be active, connect with your colleagues. Howard, your service with Dental Town is phenomenal. You allow other dentists to connect with each other and that isolation gets you in the butt.

Howard Farran:

You've been a member of Dental Town since 2003. Thank you so much. I can't believe you've been a member for thirteen years now. What kind of issues are you seeing that you think a lot of our listeners probably aren't aware of?

Michael Davis:

I think we're finally getting aware of what a tough road our young recent grads have. It's "Well, I paid my dues back in the day." Uh-uh. These young people have it way harder than we can ever imagine. They've got a quarter of a million dollars in student loan debt, not dischargeable in a bankruptcy court. It's a huge burden.

The employment options. Since we had the great recession of 2007, it's hard for these young people. Where are employment options? Where are they going to find work? Where are they going to find medical work? We're graduating more and more of them every day. It's highly competitive for them. We're struggling. They need a big helping hand. Our new dentist committees with the ATP and the ADA are doing something. A lot more's got to be done.

Howard Farran:

What do you think of the current DSO? Sixty percent of the class say they're going to graduate and go work for one of the four-hundred and thirty dental service organizations like Heartland and Pacific and Aspen. What's your general thoughts on the four-hundred and sixty DSO's that are going to employ six out of ten of our graduates?

Michael Davis:

Let's talk corporate dentistry. I'll include all those in corporate dentistry and its a big tent. They're not all the same. There are differences. Sometimes there are big differences, sometimes they're subtle differences. But in general, you've got a corporation in America, we are a free market economy, we have an absolute obligation, a responsibility, to generate a profit for their shareholders. That's number one.

As a doctor, our primary responsibility is to our patients' interests. The patient is at a disadvantage relationship in the doctor-patient relationship, otherwise called, "the doctor-patient contract." They don't have our skills, they don't have our training. They rely upon us. Courts have agreed with that. They know that there's a special contract. There's an automatic conflict of interest there. That's a tough one.

Howard Farran:

What advice would you give these kids working for a DSO? Where are you seeing cases where they legally get in trouble, whether its from the state board? Or do you ever see them getting in trouble from federal lawsuits?

Michael Davis:

Oh, heck yeah. They'll sell them out in a heartbeat. There's a case ... Terry [inaudible 00:06:18]. This is a case in Allen, Texas. I can give you another one in Oklahoma City. These aren't even young dentists. They've been a little more seasoned. And yet, a DSO will cooperate one-hundred percent with the prosecuting authorities. They'll throw that doctor under the bus in a heartbeat. And yet, corporation is monitoring their production metrics for every doctor in their corporation on a daily basis. They know exactly what these doctors are doing. These doctors may get in over their head, they need a little "Come to Jesus Meeting." "Hey doc, all this stuff, you can't keep doing this."

But no, they keep doing it. Everything's honky-dory. They keep dripping in the money. Guess what happens? Prosecutor, they want a pound of flesh. Somebody's been defrauding the Medicaid system. This is a day of reckoning. These young doctors get thrown under the bus, and that's as high as it goes. Prosecutor's happy to get a doctor ... They get a doctor on a felony fraud? They'll love that. Doctor's going to serve a little time? That's fine. Lose their license. Corporation goes on honky-dory, business as usual.

Howard Farran:

Can you give examples? What percent of these DSO's do Medicaid or Medicare? How do you get in trouble with Medicaid or Medicare? How do you end up doing jail time?

Michael Davis:

Medicare isn't an issue, Howard. There's really not much coverage under the Medicare system. It's under the Medicaid system. I've heard, for example, the former CEO, he's now stepped down Rick Workman of Heartland, they're out of Medicaid. There's a lot to focus on the Medicaid model. That's a nasty model, and that's a highly different model than the insurance model or focusing on the direct consumer. It's a very different model of operation.

Howard Farran:

Rick Workman ... For international listeners, Medicare is a federal program for the United States of America, usually seniors over sixty-five. But Medicaid is a state-by-state, so there's fifty different Medicaid programs. It traditionally started as for the poor and underprivileged. You're not seeing any problems with Medicare? Because I know Obamacare added that if you sell medical insurance to a child under ... A pediatric child, it's got to cover dental too.

Michael Davis:

Under the ACA, the Affordable Care Act, we can get into talking about some of these dishonest insurance companies, which for example, they'll sell a healthcare plan for medical and embedded in that plan will be dental. "You've got one-hundred percent coverage for this, that, and the other thing. Exams, X-rays, la-de-da, the whole nine yards." But that's bull. You've first got to make that five-thousand dollar deductible. That's very dishonest. If you've got some other plans, build a dental selling point.

They've got these plans that they put on the exchanges. Every state has an exchange. All of these plans ... That just boils ... I bought ... "We'll cover right now for an exam, and four bite wings." How do you do a complete exam, a new facial with four bite wings? That's ludicrous. But they've got a twelve-month waiting period before you can take that FMX, that full mouth series of X-rays. It's absolutely absurd. Before they can have any restorative dental care. Absolutely absurd. After that twelve months, that plan may not even be in existence anymore. It just boils my blood. I've got no love for the insurance industry.

Howard Farran:

How do people go to jail for Medicaid? What are they doing that can land you in jail?

Michael Davis:

Prosecutors are going for what they call "the low-hanging fruit." They're billing for services you never rendered. You look at the federal Health and Human Services Office Inspector General reports on state-level Medicaid, and so far, they've only done four in the past four years. California, New York, Indiana, Louisiana. What they term, and this is the term they use, "outliers." They're like, "Oh, five-hundred and sixty-seven procedures in a single day." Or you didn't. You talk about red flags. This is so over the top that these people, the outliers, represent nine to eleven percent, depending on the state they audited, of the providers. You've got a sizable chunk of the providers, which are just grossly over the top.

That's easy for them. While the ones who are flying under the radar, its a little more difficult. Their auditors aren't very good. Their attorneys are generally not very good.

Howard Farran:

What other ethics issues do you see from dental methods, materials, bio-mechanics, what have you?

Michael Davis:

Do you want to get under specific scams that are played? We can talk about that. I find this fascinating. You say, "Why is he so interested in this?" It's like CSI. It's got to be in you. It's like those docs ... In the police department, they have the Internal Affairs division. You get to see the good, the bad, the ugly. You see the dark underbelly. At the same time, you appreciate those clinicians who are doing it right, and there are so many more of them. Because of them, you really, in your heart of hearts, you want to weed out those bad apples, because it just makes the whole group look worse. It makes us look terrible. Unfortunately, who we think are the bad apples like, "Oh, I know it's you." Not necessarily. Sometimes its someone so within a state dental association. "This is a big name in dentistry! Big name in dentistry in the state." They're as dirty as a dog.

Howard Farran:

Can you give examples like what they're doing that makes them dirty as a dog?

Michael Davis:

So many. Let's talk about the defunct. It's now defunct: small spinal stentil. That's now, you've been through chapter nine and then back through chapter seven of bankruptcy. That's a company that no longer exists. We can talk about how the same family, at one point, it's been traded among several private equity corporations before it's final demise. But in it's early days, it was owned by a family out of Pueblo, a family of dentists. That same family of dentists was responsible for something called, "B and B Marketing." These are the same people that were putting soda pop and junk food machines down in public schools. You've got a Medicaid provider, supposedly interested in the interests of disadvantaged children, at the same time making profit off the soda pop machines and the candy bar machines in the schools. There's no ethics. In that hometown in Colorado they're heroes.

Howard Farran:

I've always thought it was amazing. I hear it's big, old efficient for enterprise America, and you go into so many places and the Coke is half the price of the bottled water. That's just complete corruption.

Michael Davis:

In fairness, too, you go into these homes ... I know you serve a Hispanic population. English isn't necessarily their first language. As doctors, let's step up a little bit. Let's do some education. Let's do some information on diet. We can do that on a one-on-one basis. It takes a little time. We're going to just make a drop in the profit, I know. But with every drop, we can make a difference.

Howard Farran:

What advice would you give these kids listening to you? Most of my listeners are under thirty. What advice would you give them for peer review from the State Dental Association all the way to expert witness and dental law cases? How could they be safer, better prepared, stay out of trouble?

Michael Davis:

You're going to get an employment contract when you work for a DSO. If you're not sure, you have your attorney review that. There are specific attorneys, there are some on Dental Town ... Jason Patrick's one. There's a number, I don't want to just talk about one. There's a good number. Have them review those contracts. As an ADA member, the ADA will review that contract for brass. Your local attorney and your local community, if they're not familiar with these contracts, you can get in trouble. [inaudible 00:16:03], that attorney's on retainer, out the wazoo, these DSO's. There's no such thing as a boiler plate standard employment contract. That does not exist. They will tell you it does, and they'll tell you things verbally that will never come to pass. Make sure it's in that contract. Make sure everything is ironed out in that contract.

You can be a target for these people. These people are like sharks. You start playing with the private equity boys, and that's what you're doing. It's like, "I work for such-and-such Dental." No. They've got a sham owner in place. That's not the real owner. They can't buy and sell that business. They don't control the bank account of that dental clinic. It's run by a private equity firm or or a DSO, dental service organization. You're playing with some sharp financial cookies. You need some legal advice. Go in there armed with legal advice.

Howard Farran:

Should that lawyer be a state-by-state lawyer? Or is a national expert like, Jason Patrick would be fine for that?

Michael Davis:

Jason is a good resource and he's going to know most of the states because he works through most of the states. Every state's different. In other words, there'll be things in that contract. I've got a whole article on this and I'm trying to think of who's going to publish it. I already forgot. It's in the camp, but it's a good article on contracts to protect the doctors. You've got to get that protection.

Can you use a local attorney? Yes. In some cases, some of that can be good, because he'll have a stipulation in the contract that any disputes must be ironed out in the state or jurisdiction where the DSO is headquartered. Guess what? That puts the doctor at a severe disadvantage in that the headquarters halfway across the country. It's highly unreasonable. As a matter of fact, that may actually contradict state law, statutes. Everything is about going into, finding mediation. You don't want to do that, because they hire the mediation firm. That mediation firm's going to have an automatic bias in favor of the DSO. Don't do it. You don't want that kind of thing. You want to have your own attorney, and if there's a dispute then you can pick the venue for resolution of the dispute. It may be with the state regulatory board, it might be with the court system in the state where you're practicing. A lot of that can be ironed out with legal counsel. Those young docs need legal counsel.

Howard Farran:

Would you say that dentists get more in trouble when they're dealing with government insurance like Medicaid as opposed to private insurance like Delta Dental?

Michael Davis:

Yeah. I would say so. It's almost a set-up, because the Medicaid program is so flawed, and I would call it toxic. Their manner of regulation, historically, is something called, "A and Chase." A payout thousands, hundreds of thousands, millions of dollars to an individual provider. It's insane. They have no auditing, no checks and balances. No pre-authorizations. Then they go in a pull out that money. That's way after the fact. That's not fair to the taxpayer at all. At that time the dentist can for be the provider, and it's not necessarily a dentist, could be long gone or bankrupt. There's nothing to fall back.

That in itself is a flawed mechanism. The oversight is so dismal. The auditors of Medicaid, many of whom are not even doctors. In Texas we had that situation where they weren't even in the dental field. They just were hired by Xerox. They rubber-stamped every orthodontic claim that went through. They had no idea what they were looking at.

Howard Farran:

Does that make you concerned? We're in an election year, and Hillary and Bernie Sanders want a universal payer system. Does that concern you, having the government be the universal payer for insurance as opposed to ... Because you said you get to see government dental insurance, and then you get to see private insurance, and it sounds like you believe the private insurance is far more well managed than the government ...

Michael Davis:

It absolutely is. I'm not going to give the American insurance industry a gold star on the forehead. They're pretty conniving. They're out for number one, themselves. But they're far better than government. Government is just in the toilet. Abysmal. It's going down with a circular swirl. It's that bad. Private insurances, they've got some serious problems too. [inaudible 00:21:27] ... Repealed that McCarran Ferguson Act, which allows the insurance industry sanction from anti-trust laws that every one of us are held by. That infuriates me. That's absolutely infuriating.

Howard Farran:

Explain that to someone who doesn't understand quite what you said about how the insurance are exempt from anti-trust but the individuals aren't.

Michael Davis:

Back in 1945, that's when the McCarran Ferguson Act was passed through Congress and signed by President ... I don't know if it was signed by Truman or Roosevelt. What it did was it gave ... For example, when we go to a dental meeting, we cannot at the podium, you can't discuss your fees. That would be collusion. That would be potentially viewed as you were trying to affect free trade. These insurance companies, they can share whatever data they want with each other. For example, in Canada, when they would have what they would call UCR Usual Customary Rates, every province would submit their UCR. That's for real. That is absolutely for real. Here, it's proprietary business information. You don't have to release that. "Whatever plan you buy, here's our UCR. Let's invent a different one for how much money you want to spend. For how little that you want to spend." That's the UCR. That's one example. That's got to be stopped. The insurance industry's got to be held to the same standards as every other business.

Somebody loves you, Howard! What's going on there with that cat tail?

Howard Farran:

My cat always gets jealous when I'm staring at Skype and not staring at Mimi.

Michael Davis:

It's your beard, Howard. That kitty's attracted to you.

Howard Farran:

She does not like not getting attention.

So, in New Mexico where you're at, what percent of the dentists would you say eighty percent of their practice is patients with insurance? What is the insurance situation like in New Mexico where you're at?

Michael Davis:

Insurance is a big factor. It's everywhere. I don't know a part of the country where insurance isn't a big factor.

Howard Farran:

Compare it to what percent it was when you got out of Ohio State University in '81. Would you say it's a much bigger or the same?

Michael Davis:

It's bigger.

Howard Farran:

It's bigger?

Michael Davis:

It's bigger. Since the recession in 2007, the public, the consumers, they seem to want to use those benefits. They're going to go through a "preferred provider," to use those benefits. It's dangerous for them in many cases, because some of those plans are just so low end. This has happened to you, Howard. It's happened to every seasoned practitioner. A patient wants to leave your practice because you're not on their new plan. They come to you in confidence. They love you. They're not readily astute, their IQ isn't very high, so they show you a list of the providers under this plan. You've already found the list! It's like a mug gallery. These two have got problems with drinking, this one's got problems with drugs. This one is just out of his mind crazy. This one's got hands of stone, can't do crap. Then you find that they've got twelve names and they all work for the same two DSO's. The public doesn't know this.

Howard Farran:

It seems like when I got out of school, a dentist would do the dentistry they wanted to do. They would submit their fees to the insurance, and the insurance would pay a percentage of their fees. Now, twenty-eight years later, it seems like all the dental insurance companies are just setting their fees. You say this kid says, "I want to treat a patient like I want to treat myself, and I want to do it this way," but then when they're done doing it this way, the fees already been set. They might be doing it at a loss. They might be losing money on the procedure. They're not working back from price minus profit equals a budget at how I fix your tooth. They're just fixing your tooth, adding a profit, and the PPO isn't matching that.

Michael Davis:

You can't do that. You'll lose your shirt. You'll be out the doors, you'll be closed, you'll be bankrupt. You cannot do that. You've got to look at what your overhead costs are, and your biggest overhead cost of all is what? Staff salary. I want to say that because too many of these docs say, "I'm afraid to go into business for myself." They talk about the DSO and the economy scale. Guess what? Yeah, there is some economy scale. Yeah, they can buy some supplies cheaper than you can, although you can get into a buyers club. Basically, so many of their overhead costs are fixed the same as you. They're competing in the same job market as you. Let's get back to your question. I digress so darn much, I'm worse than you, Howard!

Howard Farran:

I think it's so funny how so many of these DSO owners, they compare what's going to happen in dentistry to pharmacy and it doesn't make any sense. When I was a little kid, eighty percent of the overhead of a pharmacist was buying the pills from big, billion dollar companies, where it makes total sense that pharmacists all get up on one team to negotiate against American Visern, Johnson and Johnson. But in dentistry, supply is only six percent. I've never seen the competitive advantage of a DSO.

Michael Davis:

What they sell you is, "We've got this economy of scale! And that's how we do it." They do it on a tax dodge, and if you're interested, I can be able to do that. It's going to bore all your listeners, but I'm happy to talk about taxes.

Howard Farran:

Yeah, go on. Because I say that the number one cost in dental offices is twenty-five to twenty-eight percent labor. Next is eight to ten percent lab. Next is six percent supplies. Next is five percent rent, utilities, etc. There's no "scales of economy" in a dental office chain.

Michael Davis:

Maybe a little bit on supplies. They can use a cheap-ass, Filipino-Chinese lab. It shows. You can see the quality of the lab work that comes out of the DSO's. It looks terrible. Actually, it's a nice referral source for me, because all his patients are unhappy. They look at that crown, it looks like a blob. It functions like a blob. Those patients that are ... Those are the patients that can actually floss their teeth, and they don't like that damn overhang. Thank you for the new patient! You're doing all the marketing and within a year and a half you bring them right to me. I appreciate that.

Howard Farran:

The other thing is, almost any dentist you talk to has been practicing ten, twenty, thirty, forty years, still needs new patients, which means they have not kept all their patients for thirty, forty years. In all my observation, the big dental service organizations, they lose their patients faster than anyone.

Michael Davis:

That's by design. The focus on many of them is on that new patient, that hard sell, initial, new patient. I mean, arm-twist hard sell. Get them in there with the financing. It's not an office manager, but you've got a person trained in retail sales to get them in there. "Here's how we can do the financing." It's like going to a used car lot. Is it unseemly? Yes, somewhat. Seems to work with that demographic, that [inaudible 00:29:42] they come in for this, that ... They come out with a rotary toothbrush, they're sold on their hygiene visit. They get the twenty-six dollars for water that they slosh around, and each of them wanted some clorhexadine. They're out selling. You want to really hard sell that new patient.

Versus somebody like you or me, Howard, or most of our listeners here. We want that long-term relationship. We want that word of mouth. We want their co-workers. We want their families. We want their friends. That's a lot of our business. It's a different business model. I really think there is some overlap. We're attracting a very different clientele.

Howard Farran:

It's funny, because the dentists who are the most successful spend all their time building relationships. The ones least successful spend all their time building teeth. We're in the people business. When we do a filling, they don't even know if its from Ivaclaire or 3M or Ultradent. They just know they like you, they trust you, and if they're happy with your work.

Michael Davis:

There's some things that you're doing that are coming through. You mention, "I don't care if it's from Cur, it's from Ivaclaire, whatever company." You're researching that. The way you do, Howard, the way you do. The way most of the listeners do, they haven't been doing necessarily a while. They have more than one ... Felix with the bag of tricks. You put a contact on a posterior molar. The resin. They've got a few tricks up their sleeves. They know how to do this. They've been at it a while. That confidence in success comes through in a certain patient demographic. I don't know that it comes through to all of them. But it certainly does to some. They pick up on that. Some of our patients are incredibly astute. They know us, sometimes, better than we know ourselves.

Howard Farran:

I wanted to ask you about New Mexico, because you're in an interesting state in the fact that there's so many scientists. There's Los Alamos.

Michael Davis:

Sandia Lab in Albuquerque.

Howard Farran:

Yeah. Probably if you pointed to the one-hundred smartest people that live in the United States in math and physics and chemist, they probably all live out there in New Mexico and Los Alamos.

Michael Davis:

The wealthiest county in America is Los Alamos County where they have the nuclear lab. You'd think it'd be the five counties around D.C., which, they come in right after it.

Howard Farran:

What do those kind of people think today about silver fillings, mercury fillings versus tooth-colored fillings?

Michael Davis:

You can't do them in Santa Fe. There's a few people who do them, but by and large that's done. They don't want it. They don't want heavy metals in their body. That has nothing to do with me selling this or promoting this or that or the other thing. That's what they demand. You've got to meet the consumer demand. The consumers say, "We don't want heavy metals. We won't do it." If you're stupid enough to place nickel crowns, they're going to be ticked. A certain percentage of those are going to come back with purple gums by those nickel crowns, and they don't like that. They're mad at you. They don't want that.

Howard Farran:

I was amazed one day. I was at a dental convention. I was sitting next to a dentist from Los Alamos or one of those areas, I forgot his name. He was going through how many of those scientists come in with a list of question about wanting to know all the ingredients, all the materials. They'd answer and then back and forth. Some of these poor dentists had, literally, six hours of homework to answer all their patients. You realize, gosh, maybe you don't really want a bunch of educated patients! Maybe it's a lot nicer to have patients that say, "Well, you're doctor, Michael. You do as you want."

Michael Davis:

Let's say you take the time to answer their questions. These guys are geeks. These guys are science geeks. You answer their questions on bio-mechanics, you answer the questions on materials and methods, you answer those questions, you've won them over. You've won over their family. You've won over their friends. You're going to generate referrals off of them. You really will. I would encourage you, if you know your materials and if you're a materials geek -- and I kind of am, and you are too, Howard -- take a little time with them. Explain that. That's going to come back to you. That's an investment. With investments, you pay up front and hope for future rewards. That's what I think it's going to pay off for. If you take that time initially. They ask other questions.

Howard Farran:

I think mercury is dead. It's never going to be ... Even though the filling lasts thirty-eight years, and it's being replaced by a tooth-colored filling that lasts six years. Even though the silver filling's anti-bacterial ...

Michael Davis:

Six years, Howard. You've got to work with me a little bit. They last better than six years.

Howard Farran:

Not as far as peer reviewed studies that you can find.

Michael Davis:

Yeah, those peer reviewed studies. In the hands of a better clinician, you could take filling wire and horse poop. In the hands of a good clinician, you're going to make it work. You're using good, high-speed evaporation. You've got good isolation. You're not getting six years. I know what the studies say. In the hands of a superior clinician, you throw all that out the window. In the hands of Clyde Skyler, those are two different entities.

Howard Farran:

I think the last kiss of death for amalgam was the fact that now they think six percent of the environmental atmospheric mercury pollution comes from cremating humans with a mouthful of silver fillings. I wanted to ask you about the other controversial thing. There's only really two controversial things in dentistry. One is the silver mercury filling, and the other is fluoridated water. How does fluoridate water go over with those highly elite scientists from Los Alamos? Are they good with that?

Michael Davis:

It's mixed. I'll tell you what my own concerns are ... Let's say that the efficacy is favorable. That's debatable because, you've got a situation in Europe where our [inaudible 00:36:19] rates are diminishing. They're eliminating fluoridated water in western Europe. What's going on? Some of that they're putting the fluoride through other sources like table salt. There's other ways to get the fluoridation. That's an argument. How many people today are drinking tap water? Maybe that was an officious means of efficacy, the liberty of fluoride back in the fifties and sixties and seventies.

Today, I'm wondering how many people actually drink tap water. I'm not sure it's the best way to deliver it. That's my own personal concern. There's areas in Colorado, eastern New Mexico, west Texas where there's too much fluoridation, and you can see the brown. Those teeth are ugly brown.

Howard Farran:

When you see peer review in legal counsel to state boards, what are the issues? Are they mostly implants or root canals or fillings?

Michael Davis:

Howard, it's all over the board. Some of it, you think, "He's just out to get us dentists." No. Let me give you one example. Of course, I can't tell you the name of the doctor. Patient comes in and they have the upper-lower denture. They're unhappy with that lower denture. It doesn't fit. They can't eat with it. It won't stay in. Let's look at the dentures. Good bilateral inclusion. Good extension of the ridges. Retromolar pad areas covered. All extend with a postium and a hanging notch area is well covered. Happy with the aesthetics, able to sing the phonetics, "th" sounds, "f" sounds. Phonetics are really good. "What are you unhappy about?"

"This lower denture won't stay in." "Have you talked to Dr. X potentially about a couple of implants and locators? It looks like a little trailer hitch." "Yeah, he talked with me about that. I thought he was just trying to hustle me. Trying to sell me something." I go, "No. This doctor made you a wonderful set of dentures. This is as good as the technology can deliver. However, I strongly recommend you go back to Dr. X and talk to him about those implants. I think you're going to find a world of difference and you're going to be very excited with the result."

He did just that. He couldn't have been happier with Dr. X and happier with me for getting him back there. It's not, "we're just out to get these doctors." No. It's about serving the public interest, and in serving the public interest, all of dentistry will benefit. I strongly believe that. It's like, "These patients are just too demanding." Serve the patient interest. It's like high tide; all ships rise. Serve the public interest and we're all going to benefit.

Howard Farran:

If a young kid is listening to this podcast or commuting to work right now, they say "I don't ever want to go to the state board. I don't ever want to go there. That seems like a scary process." What advice could you give them to stay out of that process?

Michael Davis:

Number one, if you get a letter from a state dental board, you better answer it. Because not answering it is a violation. That violation may have worse results for you than whatever they may have alleged. I would say fifty percent or more of the complaints that go to the state dental board are dismissed. It depends on the state. My state right now doesn't even an investigator. Don't sweat it too much. If you have to go there, I strongly advice you call your malpractice carrier and get attorney's counsel. You need that.

I'll tell you flat out, administrative law, which is what dental boards operate under, is not the same as our civil court system. Very different rules for admission of evidence. Hearsay can very often be admitted in administrative hearing, which is not admissible whatsoever in a civil court proceeding. Witnesses can be questioned. In some cases in an administrative court hearing, witnesses are grilled, that no judge in a civil court proceeding would ever allow. Never would allow it. You need to lawyer up. That's real important.

There are things out there that are going to bite you in the but, no matter how well you practice. It's good to know who your peer review people are within your district dental society. They can give you some real good heads up. They can give you advice on attorneys as well, because they deal with them all the time. It's tough for a young practitioner to go to an old geezer like you or me, Howard, and trust us. They don't trust us. So many people they've encountered, be it the DSO's or whatever, have tried to screw them over. Some of the dental professors have tried to screw them over. They always try to hustle them. All we want is a better profession. You and I, Howard, we're closer to the end than the beginning, this is absolutely the truth. We'd like to leave this profession a little bit better than when we came into it. I'm no so sure we are, but we're trying. You're making a hell of an effort, Howard.

If a young dentist comes up to you, you'll want to talk to them. I know you do. It's in my heart too. It's in most of us. You want to give them a helping hand.

Howard Farran:

I hear a lot of young kids throwing out many definitions for standard of care. Some will say if you're doing a root canal, you've got to do it like orthodontist. If a young kid walked out of dental school and said, "Magic Mike explained ...

Michael Davis:

[crosstalk 00:42:55] Excellent! You know my history. Magic Mike.

Howard Farran:

Michael Davis was the Magic Mike. You can see him in the movie. So, Magic Mike, if a kid walked out of dental school and said, "Mike, what is the standard of care? How is it measured? Is it my zip code, my state? Is it the specialist in ... "

Michael Davis:

The legal definition is "in a given circumstance, what a reasonable and prudent practitioner would do." So guess what? That's a moving target. Standard of care in 1980 is not the standard of care in 2016. In a given situation, let's say it's Hurricane Katrina and the power's out, we've got some kind of a back up generator and you're just trying to temporize something as best you can and patch it up. That standard of care is very different than in an ideal clinical situation. It is variable. Is dental amalgam still within standard of care? Absolutely. The dental profession itself sets standard of care. What were you taught in dental school?

Now, who judges that? That would be judges and juries who are eventually going to rule on standard of care. Neither profession ourselves set standard of care. I don't know if I'm answering you. It's kind of a roundabout answer.

Howard Farran:

Do you think there will be a day where a 3D X-ray from a CBCT will be standard of care for extracting a tooth or placing an implant or doing a root canal?

Michael Davis:

I think it is for placing an implant. In Santa Fe, we've got ... The cost of CBCT have come way down. You can give your patient a much superior informed consent process, because you know ahead of time with a CT scan. You know the quality of the bone, the location of the bone. "That's an abhorrent variation in your canal." Or "I didn't think the maxillary sinus was that low in that region! The x-ray really didn't show me." The technology's there. In Santa Fe we've got at least CT scans. I strongly advise you use it for standard of care at this point for placing implants.

Going in blind, "I'll just go in blind and maybe I'll hit the mandibular canal." [inaudible 00:45:25] There's not really that many negative structures you can run into. If you hit dense bone, you're probably okay. I have seen some cases, they're just insane with bursting sinuses. Proofing approximal teeth. It's insane.

Howard Farran:

To you young kids out there, I'm fifty-three. I remember back in the day when I got out of school in the eighties, when these 3D X-ray machines came it was because there were some dentists finding used ones, cat scan machines at hospitals. They think they hit bingo, "Oh my god, this hospitals' selling a twenty-year old cat scan machine for a hundred-thousand dollars." It'd literally take up the size of an area of your garage. That was the early CBCT's, twenty-five years ago. Used out of a hospital, the size of a car. I can't believe when I go to dental conventions, you see how little some of these CBCT's are and you're just like, "Unbelievable."

Michael Davis:

They do cost, but you know what? Your local periodontist, your local orthodontist, somebody's got one. You can farm out that aspect of the procedure. It is a wonderful seeing YA technology. You do not want to be proofing mandibular canal and the baristesia ... I guarantee you do that, you're going to have a legal case. I don't know I can win you out of that one.

Howard Farran:

I've been trying to get my homies to do this forever. They fly all the way across the country and drop five grand to listen to a periodontist speak, and they've got a periodontist across the street from them, who's shy and wants a friend. They'll go buy a hundred-thousand dollars for a CBCT machine, and the periodontist or oral surgeon's got one across the street that'd let your patient walk over there and use. It's tough when all your homies never got a dental license unless they got an A in calculus and physics and geometry. They're kind of naturally shy or introvert or kind of scientist. They're techno-geeks. If they would try to get ... They don't need a CBCT machine, they just need access to one, and I don't think they should buy one anymore than would you pay a hundred-thousand dollars for your iPhone, knowing that in five years, the knew iPhones are going to be so much better than the one you've got in your hand. Why would you want to pay a hundred-thousand dollars for an iPhone, and then have to use it for twenty-five years.

If I still had the first cell phone I had, it'd be a Motorola flip phone! Who the heck would want to use a Motorola flip phone? We're just about out of time. Is there any other advice you want to give my homies?

Michael Davis:

I just want to ask, Howard ... I know that in high school, you were a high school wrestler, right?

Howard Farran:

Right.

Michael Davis:

What was that like, getting on the floor with a lot of hot, sweaty boys and rolling around in men's underpants? What was that like?

Howard Farran:

The basketball players always called us "Mad Faggots." I have to admit that. It was so funny. I never parked my car in my garage my whole life. I've always had a professional ... There's a place in Pennsylvania that makes wrestling mats that they use at all the universities. My garage has always been a wrestling mat, and my four boys ... They were all really good by age five. Wrestling has been a very family tradition for us. Now, it's interesting because they used to always joke that there was no money in wrestling, but there was in boxing.

Michael Davis:

They eliminated it as an Olympic sport at one time. That was breaking my heart. That was ridiculous.

Howard Farran:

Now with the UFC fighting, having a good wrestling ground game is apparent. All these guys that were state college wrestlers are now making bank because it's hard to teach a boxer how to wrestle but it's not that hard to teach a wrestler how to box.

Michael Davis:

I think you're absolutely correct. You work in the [inaudible 00:49:30], the kickboxing. Work in the elbows. I like to see headbutts. I know they don't like the kicking on the ground, but, back in the day they allowed a stomp in the very early UFC. A lot of good knee-drops on the chest, on the head, and the fight went real quick.

Howard Farran:

I've got to tell my homies about my relationship with New Mexico, because I went to University of Missouri in Kansas City. I'm from Wichita, Kansas. They didn't have a dental school, but they bought thirty seats a year at the University of Missouri, so thirty kids each year were from Kansas. New Mexico didn't have a dental school, so seven seats each year were from New Mexico, and Hawaii didn't have a dental school. Every class had seven Hawaiians, seven New Mexicans, thirty Kansans and the rest were Missouri. I have so many friends in New Mexico, like Craig Steiken. That was one of my best friends. Chris Spear. There's so many UMKC out there.

Do you think now that Albuquerque has a million people, do you see any new dental schools wanting to come to New Mexico?

Michael Davis:

They're going to push for it. There may eventually be one. A dental school is expensive. I expect there eventually will be one, but we're getting, because of the influx of the DSO's, a lot of young dentists are coming here. I don't think they're necessarily going to stay. They're going to  [inaudible 00:51:00] and all this nonsense. When they work that up in a year or two, squeeze them out.

Even over the past several years, we've had a huge influx of dentists. Because of the influx of the DSO's. According to the state legislature, "What do we need a dental school for when you've got a forty percent increase in dentists over the past four years? That's insane. Can you justify it economically?"

Howard Farran:

Last question today. My two oldest sisters are Catholic nuns. I thought it was kind of silly when they changed my favorite ski resort from Purgatory. They took the name Purgatory away for politically correct reasons. What do you think of that marketing move?

Michael Davis:

I don't like that. Politically correct's gone way run amok. It's gone insane. We can't have that.

Howard Farran:

What do they name it now?

Michael Davis:

I don't know what they call it now. I'm not a skier. I wear snowshoes.

Howard Farran:

[crosstalk 00:51:58] They were so amazing. They had all these runs with all these Catholic names on the runs. It was an amazing deal.

Michael Davis:

The Catholic state. The town Los Crusas. All they needed was an originally Spanish land grant areas. Huge Hispanic population. Hispanic is the ... Latinos are the largest group, larger than Anglos. Everybody's intermarried. All the families are intermarried. Everybody knows a little Spanglish. I'm sure in Arizona you do as well. [foreign language 00:52:34].

Howard Farran:

Twenty-five percent of my practice speak Spanish as a primary language. I'm across the street from the Guadalupe Indian Reservation. Half my staff has to speak Spanish. I was checking into a hotel at Manhattan, several times talking to the person checking me in. In Manhattan you cannot be hired at the Hyatt or the Hilton, or anything if you cannot speak at least seven languages. Is that amazing or what?

Okay, but we're out of time! Michael, "Magic Mike," thank you so much for spending an hour with me. I hope that you gave a lot of advice to a lot of my homies. Keep them out of the state boards.

Michael Davis:

I want to keep them in the green! I want to see these young people pay down their debts and have a good life, and just have a really wonderful, loving relationship with their patients and their families. That's rich. That's wealth. Your relationship with your patients. That's a huge form of wealth ... That doesn't get talked about enough. That's got to be talked about.

Howard Farran:

All right. Thank you so much for spending an hour with me today!

Michael Davis:

You're more than welcome, Howard!

Howard Farran:

All right, have a great day, buddy!