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1302 Silver Fluoride Techniques with Dr. Graham Craig : Dentistry Uncensored with Howard Farran

1302 Silver Fluoride Techniques with Dr. Graham Craig : Dentistry Uncensored with Howard Farran

11/29/2019 6:00:00 AM   |   Comments: 0   |   Views: 338
Dr. Graham Craig AM, MDS, PhD, FRACDS is currently scientific advisor to Dental Outlook. He was formerly Associate Professor in the Faculty of Dentistry, University of Sydney and subsequently, Director of the Dental Health Foundation at the University of Sydney. His clinical interests have involved the use and evaluation of materials and procedures for minimal intervention dentistry as well as the use of metal fluorides in caries prevention. He has a chemistry background with his PhD being a study of iron fluorides as one of the metal fluorides group. He has published 34 papers in refereed scientific journals throughout the world and has presentedover 200 post-graduate courses and lectures.

VIDEO - DUwHF #1302 - Graham Craig

AUDIO - DUwHF #1302 - Graham Craig

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Howard: It is just a huge honor to be podcast interviewing Dr. Graham George Craig AM MDS PhD FRACDS He is currently scientific advisor to dental outlook he was formerly associate professor in the Faculty of Dentistry University of Sydney where my brother Paul runs the IT department for the entire university director of the dental health foundation at the University of Sydney he has published 34 papers and peer-reviewed scientific journals throughout the world and has presented over 200 postgraduate courses and lectures. His clinical interests have involved the use and evaluation of materials and procedures for a minimal intervention dentistry as well as the use of metal fluorides in caries prevention. He has the chemistry brat gown with his PhD being a study of iron fluorides as one of the metal floor I groups. Following completion of his PhD dr. Craig began investigating the potential of silver fluoride in dentistry. In 1978 he and his colleague Keith Powell conducted a groundbreaking minimal intervention programming and they involve the use of silver fluoride in Bork western New South Wales Australia it extended over a six-year period in the first two year results were published in community dentistry and oral epidemiology in 1981. The techniques used became the basis of the handbook by Craig and Powell expanded traumatic techniques for the apprehensive child dental patient published in 2013. It's on his website just go to au is the that's on the periodic table for gold right au is gold and going and that's why my favorite spot on earth is actually the gold coast I know you're from Sydney but the Gold Coast and me we just have some tender kindred spirit up there by Brisbane. He also has a book a handbook of expanded a traumatic techniques for the apprehensive child dental patient that it's also on dental outlook and there's a really nice review of the book on the website because the British dental journal is owned by nature really nice I mean this guy is just amazing it was you're a legend over there I just you think of Australia you can't not think of you or Graham Millasitch or so many of those. Now Graham he's in New Zealand right?

Graham: Graham M

Howard: Yeah

Graham: Yeah he's New Zealand too.

Howard: Are you friends with him too?

Graham: I am now because he lives in Australian ... with glass ionomers, he came from Adelaide.

Howard: So I don't even know where to begin with you all we know is I don't know what's wrong with fluoride but if you put it in the water it brings out all the crazy people and now they're silver diamine fluoride and that's bringing out all the crazy people why how come whenever you say fluoride it just brings out crazy people is that is that is that the nature of the atom?

Graham: I think we think it's a statement of the popular stand basic chemistry basic biology the payments that we strike though they're more like the anti-vaxxers I don't know if you have them in the states the people are against vaccinations it's that small small group.

Howard: We don't call them anti-vaxxers we call them the control group oh okay that way during the next plague we can say yeah that was the control group but yeah I remember when we were fluoridating Phoenix people were driving clear across town to come to my office and show me how a box of rat poison had fluoride in it and they told me these molecules and of course there'd be the fluoride in their name chronic seems like yeah they every one of them had hydrogen in it too and but they just see that one little fluoride right in there so now it's just a box of fluoride.

Graham: Yes I mean any disease going from A to Z was attributed to water fluoridation I mean we had a lot of scare campaigns but we won through and in our six percent of the state is fluoridated which we're very proud of and so we did go through some very rough times however it's a matter of just educating people when parents saw what fluoride was doing for their children, you know that the been you know the the knowledge spread and just accepted there but there are from time to time we do have the odd fringe group come up and say that they're going to save the world by stopping fluoridation.

Howard: Well I always believe that you should know your enemy I mean you should keep your enemies closer than your friend you should study them I mean it's just smart business so I actually during the water fluoridation debates I actually got really involved and I read all their books and I went to their meetings and in America you know some people say America is about truth, liberty and justice after 57 years here I think America's about money's the answer, what's the question and it was just a long long sell to a reverse osmosis machine and these guys would get out all the crazy lunatics and by the end of the meeting they were having them finance installation water treatment deals and I just thought okay now I know I figure out where the money is on this so uh so now fluorides back and it's with silver diamine fluoride and I can assure you on dental town it's the the pediatric dentists do not agree on this at all. There's not many divisions in pediatric dentistry but one of them probably the biggest division is silver diamond fluoride.

Graham: Well that's interesting because I mean we introduced silver fluoride in the 1978 after we can completed the the Burke study and we found the most opposition came from maybe Davis certainly certain certain public health dentists that felt their little empires are being threatened and but the thing that we found that in private practice those that started using it you see what happens over here is that if you get a new patient or a new family they'll try the dentist out of the children first if they win over the children then you'll get mum and then a long time later you'll get dad and they found it a practice builder. Now we've got a practice here in city that's been running for over thirty years using the silver fluoride techniques they have 12 operators there they get patients as far as the Philippines San Francisco New York the extremes that I know of so it does work in private practice for people that are serious about building their practices also for that group of children that have been hired off to general general anesthetics, I honestly believe that a large number of general anesthetics fear for young children can be avoided by the adoption of silver fluoride based techniques so I really do and I think general anesthetics is certainly in certain quarters have been and then a easy out for handling the apprehensive child.

Howard: Well I'm out here in Arizona and twice since I've been on here the 1 office alone the same office has twice lost a child to putting them to sleep and they do this and the people what I understand is that I mean a two-year-old is so high risk to take him into the or even at 3 it's just

Graham: Absolutely

Howard: High risk and and they oftentimes put him under with board-certified anesthesiologists and board-certified pediatric nan as well I don't care if it's a two-year-old and not everyone makes it and it's so sad I mean I mean I couldn't imagine how devastating it would be to lose a child. So a lot of people want silver diamine fluoride to work just because they don't want to take the risk of an OR.-

Graham: It's makes complete and utter sense, I don't mean that the point is you're not cutting off your options I mean you might think we're talking about caries in the state primary teeth okay an application of of sta plus silver fluoride is a traumatic it'll either arrest or slow down the development of the lesion in the meantime the child is getting older and if the arrest and saves the period of time that the primary teeth exfoliate and so a general anesthetic is avoided so and then even if even if one starts off with some diamond fluoride and has to do conventional treatment later it's so much easier because you got the child on the side we found in our book study we were we were taken out to book to handle a group that's Keith Bella myself a group of needle favored kids and the dental team out there said to the principal dental officer in the region unless you do something about this we are all going on strike because they were getting beaten kicked scratched by these children and anyhow we Keith and I went out there it was a bit like going behind enemy lines with only a handgun because we knew yeah we were flying by the seat of our pants but after using the super fluoride approach for three visits so that was baseline six months 12 months probably a NEMA so probably on the fourth visit where he was staying it that the change in attitude of these kids kids that would that were previously so apprehensive actually and ran to greet us when we were sitting these up it was it was a complete and utter change, we had literally turned Tigers into lions and this is the sort of thing that can be yeah it can be achieved.

Howard: and it's kind of we kind of come in as a baby and then we go out as a baby in the United States and the geriatric dentals say that about 4% of Americans will finish out their life in a nursing home and I don't have to worry about it because I'm a man and we pretty much die before we get to the nursing home. If you go to the nursing home it's a woman thing but so if you're a woman out there and they say the average American in a nursing home gets one root surface cavity per month.

Graham: Yes

Howard: and so I'm in the very warm section of Phoenix I would be in this night states would be like Darwin for you in Australia yes and so we have a bunch of tyrese lots of nursing homes so I actually spent I went to about I'd say six or seven or eight different nursing homes and spent a whole shift there and it was always the same it was like one smaller tiny little girl and she would be in charge of a wing for her shift and she's we have to feed them all give them their medication bathe that I mean she had to do everything and then the tooth brushing was a Dixie cup a toothbrush a little bit of toothpaste back and forth on the front teeth spit in a cup yeah that was her oral health regimen and then when you go into the cafeteria every cafeteria cook said well you know we can't they're they're missing half 30 so we just keep it to like macaroni and cheese and cottage cheese and pumpkin pie so so it's just like a carbohydrate fest and there's no broccoli or anything after two so they're getting one root surface cavity a month and I'm thinking Woods silver night on your if I go to your website one of your books is silver fluoride techniques for use in aged care dentistry by Allen Deutsche.

Graham: Well this is some work that Allen has been doing in a nursing home here in Sydney and he's been using the silver fluoride approach and we had published me just published recently in special care dentistry, some of the results is getting it truly amazing because a lot of these patients on polypharmacy they're but poor salivary flow rate of caries development is very high but once again this sort of fluoride approaches brought things under control and I see an enormous useful in age here I really do and I'm I was used to truly treating the younger age group but Allen is very very good intriguingly all the patients and he's recorded the results and has published them.

Howard: Well there I want to talk about some of the differences between Australian silver fluoride and American silver flight I know SDI makes more of a what is it a potassium fluoride.

Graham: I developed that product SDI I gave I made the product in Jeff Knight use in in his thesis work that product was originally designed the the parameters given to me were that they wanted that we wanted something that could be used on a said a symptomatic permanent teeth with large curiously posterior teeth with large carious lesions where the removal of that last way of caries may have exposed expose about and resolving in the mood for some for the pulp therapy. So it was designed firstly to minimize the staining that would occur in the overlying restorations and the surrounding tooth structure so to do that we had I made a silver diamond fluoride with a fair level of ammonia because the level of ammonia what one has in the preparation molecules propensity to stain then the follow up with potassium iodide was to stop up any free silver ions and silver iodide and then when applied more potassium iodide to actually get rid of the white precipitate and that is specifically what it was designed for. There's another silver flow right here in Australia which is water-based it's not available in the u.s. at the present time it's commonly thought that water-based silver fluorides aren't stable well I can assure you the one that is being used now is stable for three years and the additive the stabilizing ingredient is subject to pay them but so if there are two there are they're absolutely two the one that you're using in the states from advantage arrest okay that is basically the US version of the traditional saccharide which has been around for I think over sixty years.

Howard: and so what do you think is going to be the what do you think is gonna make silver diamine fluoride advanced more?

Graham: I think in education I think the word will be spread by parents particularly those who have children that have been told that they needed a GAF to get their dental work done I think give it time quite frankly and I think then it's in the u.s. if I may suggest it needs to be far more concentration on techniques of application see for example by writing a hobby horse here but I think for isolation when you're using STF or whatever silver fluoride you might one must use gardener's Clancy made in the US they've been around for a long time but they keep that area nice and isolate it makes the crazy procedures so much easier and I'd suggest people look at some of the videos done for example by Janet though she's a very practical hands-on pediatric dentist and they do have a look at techniques.

Howard: It's an honor to be in the same profession as Janet isn't it she's the only person I've ever met that was in the New York Times

Graham: Yes she elected like from platform with genitive mantra was I think about two years ago now you've got to know and she's a lovely girl.

Howard: Yeah just amazing do you I feel like you're so smart you should talk about more of the chemistry so it's AGF silver fluoride and SNF that's tin fluoride?

Graham: SNF2

Howard: So its AGF+SNF2

Graham: Yeah SNF2

Howard: Do you think how is the rest of the world looking at this I mean you're over there in Australia you're right next to some major countries like Japan how is Japan looking at this?

Graham: I don't think Japan is a market for so it's a very big market that although they seem to have a traditional they have a bit of a resistance to sort of fluoride there I think it goes back to the days when the beauty reasons women used to blacken their teeth with okay I think this is a name that they used to use iron salts to blacken the their teeth there seems to be I mean also in terms of Japan they were very late to come into fluid tooth but I don't think it's a bit out of touch with that area now but for years they wouldn't touch fluoride toothpaste. So I don't pretend to understand what's going on in Japan but all I can say is that if people are serious in particularly developing country they've got limited manpower that they should look at the SDF silver fluoride based techniques the video but is a it brings a an uncontrolled situation into a controlled situation and they enable them to pick up the high risk patient centric thing first. So I've seen an enormous potential I think they're the barriers that I see that particularly in government areas there's an old saying that maxtor do not pull their monasteries and I think the deficit have built up a big dental team and they get scared that their empires may be getting cut in two.

Howard: What was the saying about the monastery there's an old saying about what the monastery?

Graham: Monks do you know from their monasteries.

Howard: Monks do not pull...

Graham: Pull down monasteries.

Howard: Oh monks do not pull down monasteries okay that makes sense yeah humans are humans are quite interesting little creatures aren't they?

Graham: Yes, I think in people training I don't know anything about dental training in the US but I'd like to see a little bit more emphasis on bit more chemistry and organic chemistry so that then people can understand not only you know silver diamond understand fluoride but the basis the restorative materials like glass ionomer cements which is an acid-base reaction resin converses as you know that developed by Ray Bow and understand polymer chains and things like that I think I think it would help the dental industry as well if they had a highly educated group buying from them.

Howard: Yeah it's really interesting how America they're really not in the university level they're really not into getting their PhDs in math physics chemistry or biology like when I go to ASU where I went to college it's something like 95% of all the PhD grad students are from just Asia so there's just something cultural about like in America people want business and law and marketing and but man if you're just gonna sit down and knock out a PhD in chemistry they're not gonna be born in Nebraska this is a different in Australia or?

Graham: I think what you just said describe destroyed as a local situation very very well.

Howard: Yeah very interesting. I want to switch gears completely to a whole different subject you you also talk about a traumatic extractions you have a handbook of expanded a traumatic techniques for the apprehensive child dental patient extractions.

Graham: Extractions do not feature heavily in the handbook.

Howard: Do not what?

Graham: They do not feature heavily in the handbook.

Howard: Yeah well so you didn't you didn't talk about that in the handbook?

Graham: No we talked about how to preserve primary teeth with minimal intervention.

Howard: Oh that's an interesting title a handbook of expanded A traumatic techniques for the a parental child oh okay okay I'm sorry my brain saw a traumatic and extraction so I want you talk about I want you to put off your I'll take off your Australia hat and and take off my American hat and it's a big planet out there there's eight billion there's seven and a half billion people and I watch them do dentistry in you know 50 countries and in order to do adhesive dentistry you need an assistant high-speed suction a rubber dam and you I go to some of these countries and they're trying to do bonding and you're just like I mean I'll give you one example this little girl she was on she they they removed the decay there's no rubber dam there's no assistant whenever there's something in her mouth she sits up and rinses and spits in a bucket and he painted on the blue etch and then she rinsed and spit out then he painted on the bonding agent and cured it and then she rinse twice then he put in the composite he cured it and then what was the craziest then he spent like 20 minutes polishing it so it just looked beautiful and I'm sitting here thinking I kid that this is this should have been an amalgam and then I go in the United States and I talk to dentists that are just as smart as you know you can be and they they truly believe in their brain that their posterior composites last longer than amalgams and I mean so is amalgam just dead because you know I mean so talk about amalgam do you think amalgams are dead?

Graham: Well I think they are probably in the marketplace but I know if I had to have a posterior restoration and was a choice between resin composite and the amalgam, I'd have amalgam. Look I've seen you know I've seen amalgams in the 50 60 years old you know they last and I when you look at the chemistry of resin compasses I just can't see the longevity especially in the newer the newer ones I mean probably some of the earlier ones they had been a bit better longevity nearly. I think that a lot has been sacrificed him as encompasses for ease of polishing ease of placement now why I talk about resin composites well when I when I did my master's degree it was all the resin composite so before I moved into the other area so and I was fortunate enough to spend time with Dr. ray Bowen at the National Bureau of Standards in Washington and he taught me a lot he taught me how to think and he was a really a great researcher he really was.

Howard: Was your favorite jeffrey night though?

Graham: Sorry

Howard: Was your favorite Jeffrey Night?

Graham: He went to Melbourne I went to Cindy and so Jeff and I met up in the in the mid-1980s when he was talking about tunnel restorations and and I arranged for him to have a lecture here in Sydney which was very well attended then subsequently when he said he wanted to do his PhD I suggested a topic which he did take up and I was only too happy to yeah I can provide the materials to him and act as a you know consult as he as he went through the various stages of writing it up.

Howard: I think he's one of the smartest dentists I ever met in my life.

Graham: He's a good natural thinker, he really is.

Howard: What's the tallest mountain in Australia

Graham: Mt. Kosciuszko

Howard: Yeah I can never say as a poet named of her a Polish explorer.

Graham: Yes correct

Howard: Yeah I claimed that I climbed that with Jeffery night and we had so much fun because it's a beautiful ski resort area and I was lecturing Melbourne one day then two days later Sydney and he said how are you gonna get from Melbourne to Sydney and I said I'll just fly it's about a two-hour drive just no no no I'll pick you up and we'll drive and we'll go this ski resort will climb to tell us the whole way up to that top of the mountain he was just talking about glass ionomer and that's my next question is um why do you see such why do you see so many so big of a variance on glass on him early this seems like the Australians New Zealand and Japan are so much more into glass ionomer than North America?

Graham: Well I think that once again because risen composites were invented in America I think that's historically the reason they're so so popular there but with in terms of glass ionomer cement we had in Australia he passed away a few years ago Graham Mount and he did he showed practitioners how to use glass ionomer cement properly and it's a great material real I'm biased I'll declare my bias it's a very very good material but Graham Mount showed us how to use it I know Jeff uses a lot of it the practices that the practice that I spoke about in the city that uses a silver fluoride approach technique uses glass ionomer cement in our Burke study we won't go to put a resin composite over those treated lesions we're going to put glass ionomer cement and at that time we only had a British product called s before which was pretty crude but it once again it did the job until GC came in with their Fuji2 the bit later and then we switched to that.

Howard: I was not aware that Graham passed away did he?

Graham: Yes

Howard: When did when did that happen?

Graham: That would have been I I'm just thinking as we're talking I think that would have been about four years ago, he was in his 90s and he had some poor health.

Howard: You're in Sydney he was in Adelaide, wasn't he?

Graham: He was in Adelaide that's correct, yes he had a strong connection with the University of Adelaide.

Howard: So back to glass ionomers, we took a filling that was half mercury the other half was silver zinc copper and tin so every ingredient was it was antibacterial anti-biological and we and Americans replaced it with this inert plastic so do you think do you think the next move for these big composite companies like SDI in Melbourne Australia are Ivoclar in Liechtenstein will be to put some antibacterial feature in these inert plastics?

Graham: Well as I see they're trying it all the time but as I understand it I'm not in the area now but as I understand the problem with some of these microbial ingredients is that some well many of them interfere with the polymerization process and you get a product with reduced physical properties so I don't know which two I mean I'd like and I don't know if we come back to glass ionomer cements whether they've reached the ultimate of their development there I don't really know but the resin composite should they could do a lot more they really could but that's up to them it's up to the manufacturers it's how they see the marketplace do they want to make it easy to polish easy to place placing bulk you know all these things are easy to use.

Howard: So you have to websites what are my listeners gonna find on your to websites you have

Graham: We're taking that one off.

Howard: You're taking that one off?

Graham: Yeah

Howard: Okay so then you're just gonna go to dentaloutlook.


Howard: Dentaloutlook that's the one?

Graham: Yeah what happened is that I think you have you but in you know the states they took over the the web section the red dental education shop and they made to in moving it over to a new provider they mention it managed to destroy 70 percent of its functionality and so what we are in the process of doing is picking the bits and try and making the dental education website a stronger one.

Howard: Oh so you're gonna so you're gonna think down dental outlook and move it to dental education?

Graham: No I'm taking down dental education shop

Howard: and move it to dentaloutlook?

Graham: and move it over to dentaloutlook.

Howard: Okay interesting and what happened with dentaleducation the people that run it it's not running it is right?

Graham: Well it was a it was a very it was a it's there are certain programs you can use to to run websites WordPress Kentico but this is a forerunner of those and it was done by an American lass who was living in Sydney and it was extremely good but the problem was in moving it no one understood how to use the you know the back end of the program and it was just ruined.

Howard: So when you go to your website so if you go to dentaloutlook I mean you have so many things out leaflets and booklets posters and wall parents handy cards recall cards children's products what is what is the core of what you're trying to accomplish on your

Graham: Okay historically they listed Sydney they got rid of our department they did a rationalization and got rid of our department at that stage I thought I was too young to maybe go back to pro to older to go back to private practice and so I thought well what else I thought there was a need for dental education material and I thought well I might be able to help educate patients by bringing out the right dental education material so that was over 20 years ago so those items that you see now a remnant I suppose of early activities we still which we still provide them but it's by no means the situation that it was say ten years ago because a lot of new dentist simply do not read hardcopy they do not regard copy and so the whole dental marketplace in that area has changed.

Howard: So you've written a lot with our Keith Powell who's an orthodontist now he's an orthodontist and you have a PhD were you any dental specialty too?

Graham: No no III deliberately stayed out of a speciality because I wanted to treat I wanted to be a general dentist now what happened is that when our department was on the process of being obliterated or taken out of action Keith moved over to do orthodontics I moved over there was no demand in Australia for people with expertise in metal fluorides so actually I was retrained as a graphic artist and started producing those publications that you just mentioned.

Howrad: So I wouldn't switch gears just something else I'm the business of dentistry, you remember George Port?

Graham: I do

Howard: I love that man he brought me down him and his wife Ruth brought me down probably every five years and I'd always do this to her I'd fly into Auckland New Zealand then do Melbourne Sydney Perth Adelaide Adelaide Perth Gold Coast anyway it was a fighter six-city tour every five years and I just thought he was just I thought him in Ruth were just the most amazing people in the world but I got to see you know when I first started going down I say about 1990 there weren't really even hygienist down there in 1990 would you agree dental hygienist?

Graham: No no no they're a recent addition but now we have dental hygienists we have different therapies therapists and we have health service and they are doing a fantastic job they really are, they're going out to tough areas and they're they're performing a great service I've got a great deal of time for them.

Howard: Well it's kind of it's kind of interesting because that's what I see down there the dental therapists they like it but in America that is a very controversial thing and it's so bizarre because it started about in this case in Alaska where Alaska if you cut Alaska in half each half would be bigger than Texas, which is the second largest so they had areas in Texas I mean in Alaska larger than most states that didn't have any dentist and they needed some rough-and-tumble person to get on a sled dog a snowmobile or an airplane without wheels but rudders to go in these areas and I mean the dentist in America thought it as if they were flying in there to sell drugs to children I mean again why do you think a dental therapist dental hygienist expanded duty functions why do you think all of those things are fought so hard?

Graham: Protection of empire.

Howard: So you would say money is the answer, what's the question?

Graham: Yeah

Howard: Yeah and what's amazing is when they approved dental therapists you know I actually buy I get a go-around I lecture in those states that have those and those dentists tell me oh I love it I I have two hygienist they do the cleanings I don't want to do the cleanings and now I got a dental therapist they're doing the fillings I don't want to do the fillings and now I'm just sitting there doing molar endos and difficult extractions and placing implants and you're like yeah that's what all the people would do but I'm gonna ask you another question I'm in Australia they kind of granted asylum to a bunch of foreign trained dentist since I've been going there I noticed.

Graham: Absolutely

Howard: Yeah talk about that, tell him what happened, you were down there.

Graham: Yeah well the bureaucrats have been on government bureaucrats felt that the way to control a surety a perceived shortage of dentists was to bring in foreign trained dentists and they brought them in and they kept bringing them in and we kept bringing them in. I heard recently from a person involved with our Australian Dental Association we now have enough dentists to 2035 I feel very strongly about it because it's increasing the pressure to over prescribe and I don't like it, I don't like it, I'd rather see dentists a bit too overwhelmed my patients then have been looking for work.

Howard: So you're saying you're saying that when dentistry gets too overcrowded too saturated that with student loan debt and office overhead debt and all the leverage that it incentivizes them to over treat and become more aggressive.

Graham: Absolutely absolutely i stop the case after case.

Howard: and I mean they people should know I mean if an animal in the zoo gets too hungry it's probably gonna kill something and eat it these kids in America they walk out of school with two hundred eighty five thousand dollars of student loans and then they go buy a practice for 750 so they're under 30 years old they have a million dollars in debt they graduate 6,000 of these kids a year and so to sit there and say no I think I'll just watch that we don't need to treat it or I could paint some silver diamond fluoride but insurance will pay for a pulpotomy, a chrome steel crown.

Graham: Yes yeah

Howard: So how does someone balance balance that I mean how do you balance supply and demand it doesn't matter if you're selling Kleenex but man when you're selling liver transplants and root canals it starts to get your attention?

Graham: It's very difficult and once again I can't comment on the United States situation but here in Australia the decisions to bring in overseas dents remain by bureaucrats sitting behind a computer away from their the rock faces that were down in Canberra they it was and I don't know what other politics was involved I had my suspicions but the end result is that we got far too many overseas dentists into the into the country.

Howard: Same question Australia is a I always wondered if this is related you're the leader in the world of publicly traded dental office chains America doesn't have one. There's not one dental chain traded on the New York Stock Exchange the Nasdaq over-the-counter yours truly Australia. You have all three three four three or my gosh you have you have one three hundred smiles with Daryl Holmes you have Pacific smile groups with Alex Abrams you have G& with Raymond Hung you have all three.

Graham: We have more actually.

Howard: Okay do you think that was related to the bringing in a lot of foreign trained dentists do you think that tipped the scales?

Graham: I don't know if I understand the economic model was worked out by a dentist and they had some help from others and a number of others saw the so-called viability of the model and decided to decided to follow it now but be careful what I say but

Howard: No you're on Dentistry Uncensored you can say whatever you want.

Graham: I don't know whether it long-term it's a good thing or bad thing for dentistry and probably you need to talk to someone more closely involved in the area than me.

Howard: Well I do know that publicly-traded dental offices the biggest restriction they have is dentist and their average dentist only stays with them for a year or two and when you look I mean years ago you just go to their LinkedIn page I mean if you if you go to their LinkedIn page of the biggest DSOs in America it seems like every fifth person is a dental recruiter I mean they're they have scores of people just trying to find a dentist and yeah and so I always thought hmm you have three publicly traded dental dsos and America has none and I always thought it probably got a big boost from letting in a lot of foreign trained because it's a supply and demand equation I mean what percent of the dentist right now in Australia do you think for a foreign trained?

Graham: That I can't answer yes that's a very good question.

Howard: When I'm down there now remember when I'm down there I'm winning dentist that drink too much and stay in bars till three the markets they were telling me it was an easy ten percent of the dentist

Graham: Oh they'd be more now I'd say 20 yeah I said maybe but the and also the workforce has changed a lot because of the female in the workforce often they don't work full-time they you know have you know sort of part-time jobs so the whole and I suppose the corporates would be an ideal place for them to to work some of them I know very well near us there the one of the corporates is at open seven days a week they're in there in a shopping center near here and to keep the Elise in the shopping center they must they open seven days and so they open seven days a week it's yeah as I say I just I just get a slightly uneasy feeling about how did dentistry has become commercialized rather than care of the patient is we were brought up to do once again be shown by a teacher.

Howard: Well you know it's kind of weird because then you have stuff like this and was present published in the age this year according to the Australian Dental Association's Victorian branch the wait times for general dental services have almost doubled in four years a de VB chief executive associate professor Matthew hope crafts says the state and federal government need to boost funding to public dental I mean he was actually a saint thinking they you know the way the wait time is too long, what do you think of that?

Graham: They just don't they just don't prevent cavities if you want to serious about dental public health you look at the areas that aren't fluoridated you might use dental hygienist more in a preventive role I mean I just can't relate to this business of dentists and magically make the public deadly fit I think it's nonsense I mean the only thing that makes sense in dentistry is prevention the only thing that's why I thought so hard for fluoridation and that's in topical fluorides and things so get SC own there's no such thing as a permanent restoration and as you know every time the restorations place that kept me gets bigger and so the the destructive cycle continues so I have no sympathy whatsoever the four segments moving.

Howard: and I also I don't know why I feel more comfortable asking political questions to a dentist in a different country I would never like this next question I would never ask an American dentist for my own tribe I would you know they always say never talk about religion sex politics or violence but since I you're from a different tribe there's a proposal again that Australia should introduce a Medicare style universal insurance scheme for primary dental care for five point six billion dollars a year paid for in a rise in the Medicare levy which so do you think do you think dentistry should be part of universal health care paid for by the Australian Government?

Graham: I can only talk about Medicare and I feel once again very strongly about this the previous attempts by the federal government to subsidize dentistry and they did it some years ago for patients ostensibly with medical conditions and so they subsidize dentistry but it was the whole scheme was wrong and that they had to stop it cost too much and that concerns me about the expanding Medicare. I think it's an once again I an invitation to over prescribing, when you've got government money that the patient's not paying for it or not paying very much it's I don't think it's a good seen people do not appreciate what they do not pay for I'm sorry that sounds a bit controversial but I am so against this this this overprescribing it's something that is completely unnecessary.

Howard: Yes humans have to have skin in the game and the difference between a dent who's an employee and a dentist that owns their own practice I mean that is entirely two different beasts you know that they own their own office they're marrying they have stay-at-home children they try to do the molar root canal pull the wisdom tooth takes ee try to grow their practice take online te for cheaper if they're an employee they're like don't want to take a course less somebody pays for it if anything looks even like they're gonna have to work hard they just refer to an endodontist or oral surgeon humans it's a very it's kind of amazing. I was really surprised that I don't know why I was surprised with this I mean Australia is a very old country but that Adelaide celebrated its hundred year anniversary this year I don't know why I found that so shocking I mean.

Graham: We're very young country.

Howard: Well I mean it's really not that young of a country but I just was I would have expected that in Melbourne or Sydney I just didn't think Adelaide had a hundred year old dental school why do you think I found that so bizarre.

Graham: That's a very good question Howard, I don't know.

Howard: Yeah I'm just like are you kidding me Adelaide has a hundred year old dental school I mean I just I, you know what my favorite city in Australia is you're not gonna believe this it's Perth.

Graham: Oh Perth is a beautiful city.

Howard: Oh my god, so if you're in America so you know you go to Australia and almost half over half the country lives in Two Cities Melbourne and Sydney so let's say that Melbourne and Sydney are like say Seattle and or San Fran and San Diego, Perth would be clear on the other side like Florida and so it's it's a five hour plane flight to the other side it's only about three hours from Antarctica correct by air like a three hour flight?

Graham: To Antarctica?

Howard: Yeah

Graham: Well they do run pleasure flights down there but I think it might take a bit longer than three hours.

Howard: Okay but it is so unique because there's no mass transportation there's no mass cultural transformation it's just everything in that cities like they thought of it themselves it's the most unique place that I've ever seen.

Graham: It's a beautiful city it really is I'm very I'm very fond of Perth and it's a wonderful feeling when you get there I can't describe it they've got a different the oceans a slightly different color it's, you feel like you're going on going on a holiday when you go to Perth they've done everything so well there, they really have.

Howard: There's only one holiday you don't want to spend in Australia.

Graham: Where

Howard: and that's Christmas because it's summer down there and they're playing in their bathing suits with Santa Claus hats on the beach and in America it's cold that time here so you want this big heavy snow coat and snow and boots and Christmas is about snow and if you ever go down to Sydney Australia during Christmas it's swimming suit time and they got her Santa Claus hat it's so funny to see him playing beach volleyball with set with dressed up with Santa Claus hats on Christmas Eve you're just that's a slightly different. So are you you know I think a bias that Americans might have is how they might always lump Australia New Zealand together butI found those to be very separate countries I'm talking about dentistry ideology I found them Australia and New Zealand I saw New Zealand to be a very unique dental company culture do you agree that Auckland is...


Howard: Auckland was not another city from Australia I mean it is completely different culture customs.

Graham: Yeah it's a lovely place news is a beautiful round that Queenstown the area in the southern island.

Howard: Lord of the Rings

Graham: Sorry

Howard: Lord of the Rings

Graham: Yes yes exactly,there are differences but there are some similarities there's a great rival really between New Zealand Australia and the sporting field whether whether it's cricket rugby union its it's a very unique place and we're very happy to have them as neighbors.

Howard: So what year did you graduate from dental school?

Graham: I didn't tell you, 1960.

Hopward: Okay so right now today there's thirteen thousand two hundred sixty-six dentists in Australia sixty-three percent male thirty seven percent female how many females were in your class?

Graham: Their would have been 4 in a class of 42 .

Howard: Okay so ten percent.

Graham: Yeah and all those were European extraction none of them were the appearance it all come from Europe so that's what happened there.

Howard: So would you say when you got out of dental school it was a male profession and now it is 37 percent it's almost half female?

Graham: Absolutely

Howard: and what are your thoughts on that how do you think that's changed dentistry or do you think it hasn't changed dentistry?

Graham: Well I think it's good because female females are traditionally have good empathy with their patients no I don't think it's a bad thing at all not at all and I mean if you look at Europe but I mean you'd have the statistics for Europe I think there's a heart very hard proportion of female did this in many European countries.

Howard: Well especially Eastern European when it was essentially a planned economy if he had muscle used to be hammering nails or join an army and fight so when you go into a lot of those Eastern block's dentistry didn't you know what was the female deal but yeah it seems to me that the market perceives them correctly as having more empathy more sympathy. With my four boys It was so cool until they fell down and started crying and then they'd run all the way around me to get to mom I mean they you know the minute the minute they had a or crying they had what had nothing to do with me I also see studies saying that um moms are more likely to ask women dentists questions and follow-up questions then mail I just my gosh. So where are you are you in Sydney?

Graham: Yes

Howard: Well next time I come visit my brother can we go out...

Graham: You are more than welcome I'll show you I will show you the north. Your brother is on the harbor side on the southern side we are on my wife and I are on the northern side near Manley you probably saw the manly ferry when you were here so we are we close to that.

Howard: Now do you have a car?

Graham: Yeah yeah

Howard: My brother's been there five years and he says he just doesn't even want a car he said they that public transportation and takes him right to the University he thinks it would really slow him down to park it and parking and he still hasn't got a car and when I'm down there with him we just go anywhere in town just all day long so.

Graham: Yeah he's in a very good situation with very very good public transport and I could understand and also be difficult to find places to park cars where he works and around his place it makes complete another sense yes.

Howard: Well I can't believe we went over one hour but I have to tell you this every time I go visit my brother the only reason I get an airplane and fly back to America is because I got four sons and five grandchildren living here but if I never would have had a child and never had any grandchildren there's not a chance I'd fly back and I say I mean where my brother lives I mean I mean you could just walk out of his house walking at every block is a restaurant a bar a book shop you know they just I mean and then in my house I could go out and lay down in the middle of the street for three days and no one would probably find me I mean you know it's and yeah I mean it' but yeah I just love Sydney I love everything about it I think you're the luckiest man in the world living there and next time I go see my brother we'll have to go do something fun.

Graham: I would love to see you love to see you.

Howard: Alright we'll have it we'll have a drink here we'll have a shot of silver diamine fluoride.

Graham: Something like that

Howard: Aright well your 18 hours ahead I assume it's a 5 p.m. here it must be what noon...

Graham: It is just after 11 oclock in the morning here.

Howard: Aright well thank you so much for coming on the show today and talking all things silver diamine fluoride it was just an honor to podcast you.

Graham: Thank you very much Howard.

Howard: Have a great day 


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