Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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195 What About Amalgam with Michael Wahl : Dentistry Uncensored with Howard Farran

195 What About Amalgam with Michael Wahl : Dentistry Uncensored with Howard Farran

10/16/2015 12:00:00 PM   |   Comments: 0   |   Views: 580

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AUDIO - HSP #195 - Michael Wahl

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VIDEO - HSP #195 - Michael Wahl

Can amalgam be bonded? Can amalgam last longer? Is composite reson nontoxic?


Michael Wahl practices general dentistry in Wilmington, Delaware and received his undergraduate and dental degrees from Case Western Reserve University. He has published over 60 articles in many dental and medical journals and lectured at many major national and international meetings on dental treatment of medically compromised patients, amalgam and composite, and practice management, among other topics. He is a part time assistant attending dentist at Christiana Care Health System.

Howard: It is a huge honor today to be interviewing my buddy Michael Wahl who I think I have known since day one, I think I have known you 25, 30 years. How are you doing this morning?

Michael: I'm doing well Howard, how about you?

Howard: Oh I'm doing very well, and you were my instant hero, it was love at first site. I think the first time I ever heard about you or anything is we were both … We were at the age where we wrote the cosmetic revolution. These guys were coming out and they were saying composites lasted twice as long as amalgam and they were better, and glued the walls together. I mean the composites were just like God's [inaudible 00:00:44] I mean it just have a just perfect stuff.

You were the only guy who wrote the most eloquent article, I think it was published in dentistry today or something like that, where you were just standing there and saying, come on enough with the hype, amalgams last longer than composites. Amalgams are still a quality restoration, they last blah-blah-blah, and you took so much flak from all the cosmetic gurus and everybody was amalgam free and metal free. Do you remember that article?

Michael: I wrote a few actually and there was one article in two parts that I wrote for Quintessense, and I entitled it, ‘Amalgam resurrection, and redemption.’ It was particularly addressed to these anti-amalgamists like the ones you are talking about. I will say that the argument on longevity on amalgam longevity is getting old. Of course amalgam in virtually every study, every big study has shown that amalgam still lasts longer than composite. Now don’t get me wrong, amalgam is bad ugly, and that’s why I usually prefer composite because of the cosmetic appearance of it.

Composites are certainly improving every day, but yes as far as which one lasts longer there's really no context, amalgam generally lasts longer than composite.

Howard: I have to defend everything it's bad ugly because that’s … I'm the champion for bad ugly and I still have four boys, my boys recommend me as their father. The thing that scares me the most about composites is I have lectured in 50 countries. Now can I tell you a composite story, and I'm not going to tell you the country I was in or whatever. I'm in this very-very poor country. I don’t like the term third world because they seem to be a lot more happy and giggle than people in United States and Germany and Korea and Japan. One of the most lovely societies I have ever been in, but extremely poor.

This dentist wanted to show me that he did this high tech dentistry. This little beautiful, 20 year old woman walks in; she’s got a [spun 00:02:57] on her tooth. He draws it and draws it and draws it and draws it, and he numbed it up, then he draws it and he finally gets it out, and I can see the pink. Then he takes his composite kit, and he puts the acid etch on it and she doesn’t like the taste, so she spits up and rinses and spits in a bucket. Then he puts on the [inaudible 00:03:22] and she didn't like that taste so she rinses that off and spits. Then he puts on the resin and then he cures it, and then she rinses it and spits again.

Then he puts on the composite, cures it, then she rinses again and then he spent 25 minutes polishing until it looked just gorgeous, and I'm just sitting there saying, oh my gosh, she came in with a discoloration on a canine, now she has a pulp exposure and a composite that is … It could … I mean it was just unbelievable. Then the next patient came in, different deal, took out an amalgam, put in a composite, and I mean the patient rinsed five times during all the [inaudible 00:04:02]. I mean … We are looking at 2 million dentists serving 7 billion people, I think 3 billion people live in a area where the dentist could not keep it dry, cannot keep it isolated.

There is no rubber dam; there is no dental assistant with a suction. When those dentists are reading international internet forums, trashing amalgam and these people don’t even … There is no chance of isolation. Then there is other people in very rich countries trying to ban amalgam, and it's like if you banned amalgam, about 3 billion people are going to get horrible dentistry, you know what I mean?

Michael: Yes, good point.

Howard: They follow everything American say. When you go to South America, Africa, Asia I mean, well the American said this, the American said … I mean you hear that all the time. What they don't understand is while in America an opertory is about $25,000 with the stuff in it. You can't do that in a lawn chair.

Michael: True.

Howard: I still think amalgam is the champion for the poor.

Michael: It is but even neglecting that part of the argument and that certainly, those are good points. If you just look at it even in this country, you can see that many of the things that the so called anti-amalgamists are starting are simply false. For example amalgam can't be bonded to teeth. I mean there are pit and fissure amalgam sealants that are lasting over 5 years. If that doesn't prove that you can bond amalgam to teeth, I don’t know what will. Not only that, but the bone strength ... Not the bone strength itself is necessarily important, has been shown to be higher than it typically is with composite. You have to extend assertion for prevention. That’s just not true, you don't have to extend for prevention; you can prepare amalgam restorations exactly the same as you could prepare composite restorations as I do.

I use slot preparations for class twos, you don’t need any sharp line angles; you don’t need any holes or hatchets. It's just pretty much almost every single assertion you can show that the opposite is true of these anti-amalgamists, except for the one the ugliness that’s true, amalgam is ugly.

Howard: I don’t even buy the amalgam ugly because I'm a dentist and I stare at teeth all the time. I mean I'm the geek that after a movie someone will say, “Oh what did you think about this actor?” I'm like is that the one with the space between her 2 front teeth? I didn’t know her name and all this kind of stuff, but you know what, I mean you just don’t see molars especially on men. I had this argument with a dear friend of mine. A 6 year old boy has an inclusive stick, and he numbs it up, places rubber dam, and puts on an inclusive composite, and this boys is 6. No one is ever going to see the top of that molar in his entire life. I mean he is a man, he is a boy, he is thick, I mean you don’t … When you are talking to me it looks I have a denture. I mean I don’t even show teeth. I'm sitting there, okay you pick a plastic filling on a 6 year old and his dad's a dentist.

I mean why would you just plug that with a little amalgam. I mean one metal, I mean metal, the other one is plastic, think of a milk carton. I mean why would a dentist with 8 years of college pick an occlusal composite on a 6 year old boy, who has his hair meted up, a burger hanging out of his nose. I mean what is he going to be? A cosmetic molar model, I mean come on. I want to ask you how long do you think that occlusal composite on a 6 year old will last versus an amalgam? Both were done under rubber dam isolated …

Michael: On average the amalgam will last longer, absolutely, yes. I have an amalgam …

Howard: Longer is a vague word, are you thinking of an hour longer, a year longer, twice as long, what do you think?

Michael: Just typically longer, maybe almost twice as long. I admit I have an amalgam still that my dad placed when I was 8.

Howard: Your dad was a dentist?

Michael: My dad was a dentist yeah.

Howard: Your brother is a dentist?

Michael: Yes.

Howard: It's genetic; there is some recessive genes that they are passed along in your family?

Michael: That's it yeah.

Howard: Actually it’s a very interesting deal; I would like to write a book on it, I want to call the nuclear family. When you go to like India and Brazil, continents like that, countries like that, your occupation is more of a family deal. Like it's not common at all in India or Brazil to meet a dentist and there's 15, 20 dentists in their family tree. They are just born in dentistry. Kevin Coachman one of the famous cosmetic dentist one earth, I think he’s got like 25 dentists in his family. It's just like your family does this, you are a dental family and the kids that didn’t want to be a dentists became lab techs or dental assistants, or run the dental office. I mean everybody was in dentistry.

Michael: It's a good profession.

Howard: It’s the nuclear family and it's an amazing thing, it’s a nuclear family where the whole family, they all live together, they are all in one house. I mean you can go … I met a dentist in India and went home and I mean his mom and dad were both dentist, his 3 or 4 brothers and sisters were, grandma and it was like 25 people living in one house and half of them were dentist. It's just really-really cool. They just eat, live, breath right? I knew your brother was, I knew your dad, but you are saying amalgams lasts about twice as long.

Michael: I'm not exactly sure, it depends on the study if can you see, but they could be as much as twice as long on average. Again there is a lot of variation, it depends on a lot of circumstances, on how large it is, how many surfaces, who's placing it, what conditions they are placing it under, but certainly virtually every single large study has shown the same thing. Amalgams last significantly longer than composite.

Howard: What I try users to make questions that probably is about 7,000 individuals knows. Everybody listen to these the community work on podcast are just a huge multi task view. That’s what’s unique about podcasting. It used to be online [inaudible 00:10:21] sat at your desk, you watched a course, you have filled out 10 questions, you got AGD, ADA credit. The podcasts have exploded because they’re multitasking; they’re accumulating the work right now. My job is to ask the question that I'm trying to estimate what they’re and wondering and someone’s probably wondering well why do they last twice as long?

Michael: First too let me say this. The studies that have been done typically have been with amalgam tying its hand behind its back. In other words it was before some of the newer techniques. One of the assertions against amalgam is that it’s been the same. It’s been the same over the last 100 years, there have been no changes. There was a prominent cosmetic dentist who’s made that assertion that because it’s over 100 years old it’s criminal or something like that. Besides the fact that there’s lots of things over 100 years old, I mean aspirin is over 100 years old, it’s still used today. Lots of doctors prescribe aspirin. The flush toilet is, toilet paper, contact lenses, a whole bunch of things are over 100 years old, it doesn’t make them a bad thing.

Many of these studies have been done showing amalgam lasts like many years, but were done before the advent of amalgam bonding where the amalgam was not bonded to the teeth, where the extension for prevention was done for these preparations. Now we have amalgam bonding, restorations are much smaller, they can last even longer. Yet those particular studies were done verses composite which was bonded at the time, and yet amalgam still out lasted the composite. Now as far as why the amalgam lasts longer than composite, just every study of fractured ... People say you put amalgam in a tooth, you just going to wait till it fractures, that’s just not true. The amalgams that have been done, we look at our patient’s teeth, and until recently 9 out of 10 of their teeth that had restorations in them had amalgam in them.

Of course it goes without saying that therefore when teeth fracture, there is a 9 out of 10 chance that the ones with amalgam are going to be the ones with the fracture in them. It’s not going to be the ones with the composite because 9 out of 10 of their posterior restorations have amalgam in them. Yet we with our blinders on will only look at the fact that there’s a broken tooth, and it had amalgam and think this happens all the time. The broken tooth was restored with amalgam therefore the amalgam caused the fracture, it’s simply untrue. Not only that but many of these restorations that are breaking are older because they have amalgam; amalgam has been used longer, whereas the composites are more recent. Still if you look at that you can see it with fractures for example that the fracture rate of amalgam restored teeth is about the same as or maybe a little less than the fracture rate of composite restored teeth.

You look at caries, recurrent caries. The most common cause of failure of an amalgam restoration is caries. The most common cause of failure of a composite restoration is caries. The most common cause of failure of a gold restoration is caries. Its recurrent caries is a very common thing, but if you look at the studies of many-many teeth over many years, the recurrent caries rate of amalgam is very low. It’s lower than that of composite. Exactly why I don’t know. Maybe the amalgam has some type of anti cariogenic properties. We look at as I say the bonding of amalgam, that is something relatively new. It’s only been out for maybe 20 years, it’s in common use maybe for the last 10 or 15 years, but if you look at that this has actually improved amalgam dramatically. Yes composite can be bonded as well, but exactly like I said the reasons why, I don’t know.

I will say that composite restorations are improving, the gap is narrowing in the differences between composite and amalgam, but still if you look at what’s been happening over the years amalgam still is going to be a superior restoration as far as clinical functionality.

Howard: My two older sisters went into the catholic nunnery straight out of high school and then they’re catholic nuns. I spent all my time with, I grew up with going to mass every day and my family has got two catholic nuns, and then I went dentist and …

Michael: Swear to God?

Howard: Say it again?

Michael: Swear to God?

Howard: Yeah my two older sisters I think Mary Kate ... I am 53, Mary Kate is 57, and she’s been a [Krista Conroy Monk 00:15:20]. I’ve been a dentist 20 years, she been a Krista Conroy Monk for 35 years. The other one became an Immaculate Heart of Mary teaching them, but the deal is in religion if you want to believe something, that’s fine if you don’t bother someone else. It still amazes me how many dentists went to 8 years of college and studied math and calculus and physics, and they don’t want to address gravity in math. They want to believe something almost like a religion. Amalgams are bad and evil and they don’t last and composites, and they just ... I mean it’s like dude leave your religious mind at home or on church on Sunday. We’re dentists, we’re supposed to be a science based profession, and it still amazes me how many dentists have non-scientific arguments, I mean ... go ahead?

Michael: This is what frustrates me, because when people are bad mouthing, no pan intended, they’re bad mouthing amalgam, they’re making it look like dentistry is a dangerous profession. That you’re risking your health by going to the dentist and having your teeth filled. When silicate cements were replaced by composites no one tried to assassinate the idea of dentists placing silicate cements, they just gradually fell out of favor and then composite resin replaced them. If you look at pretty much anything like that in dentistry or any other profession, old things go out of favor sometimes and then new things come along and sometimes they’re picked up and sometimes they’re not. With amalgam there’s a special thing where these dentists have to just, they have to call people who are placing amalgams criminal or something like that.

They have to make up these false allegations against amalgam and many patients come in I’m sure you have them too, and they’re asking well is my health at risk from these amalgams. My God this amalgam is toxic isn’t it, well yes, okay amalgam is toxic I’ll give you that. Water is toxic too, do these anti-amalgamists not use water in their practices. 4000 people a year die of drowning from water, many people die of water intoxication where they’re just drinking too much water, a few do. Are we just going to say we should ban water, of course not. It’s the dose not the substance itself, but it goes along with my wider thesis that dentistry is a very safe profession, much safer than many of the professors are teaching us.

The idea that you’re having your teeth cleaned and you’re at risk of a heart infection it’s just, yes there might be a very small risk, but it’s absurd you’re much better off having your teeth cleaned and having healthy gums. It goes along with oh my God you’ve got to stop the anti coagulant because you’re having an extraction. Meanwhile you’re going to have a stroke if you stop the anti coagulant or a heart attack and many people have instead of just going on keeping on the anti coagulant, having the extraction, and it’s an innocuous procedure and you’ll be fine afterwards. There is a whole bunch of areas like this. The idea that a dental visit can make you pregnant. The only way you’re going to get a patient pregnant Howard I am sorry is by participating in the conception. Not because the antibiotic because you prescribed an antibiotic and the birth control failed.

These go along with the same idea that dentistry is a very safe profession regardless of what these people say, whether they’re anti amalgamist or some of the dental school professors. Dentistry is very safe, I mean my dad God bless him. He was a great dentist, but he never took a health history in 50 years, and he never killed anyone either. I am not advocating not taking health histories; I am advocating to take a health history. He didn’t, and he never killed a single person.

Howard: Well health history Joe, health history is 90% of the questions are a joke anyway. I mean people are asking me have you ever had syphilis, gonorrhea or Chlamydia. I mean these are questions you ask in a bar not in a dental office. How can I change my treatment plan if you had Chlamydia in college? I mean I go through these health histories with my dentist friends and say, okay what could this possibly do to your treatment plan? I mean it’s just ... And I quit asking about STDs. It was in 1987 and this man was in the front breaking back, he wanted to speak to me privately in my office.

I am like okay, and he starts going on to this story and he’s about 75 and he almost starts to cry, because I had the STD deal gonorrhea and he was telling me about how in World War 2 he had a 3 day pass, and went to the Philippines, and he’s confessing like I’m Father Howard the priest, and I was like, “You don’t need to tell me this, it's all right, I don’t care about 50 years ago, and I’m not God.” I deleted that question I thought, “Why I’m I asking people if they’ve had gonorrhea?” You know what I mean? It’s just ridiculous.

I have to tell you that there is a lot of dentists with non-critical minds, they want to believe something, whether it's politics, religion, whatever, and then they carry their politics and religion over to dentistry and they just start with what they want to believe and they add backwards. I’ve always thought ... I’ve interviewed 200 people on my podcast. I have always thought you’ve had the most critical mind, I’ve ever met. You see through just everything, and because the antibiotics for movable joints. The research on that is shaky at best, would you say?

Michael: Oh absolutely.

Howard: Even your dad didn’t take a medical history for years, he didn’t wear gloves either. Everything I’ve read on say gloves are huge, the skin on your finger, intact skin if you don’t have an open cut is probably a million times a better barrier than that little final plastic glove you put over it.

Michael: Absolutely.

Howard: We’re putting gloves on just so that we feel safe. It makes everyone feel better. A washed hand, our skin’s been evolving for a billion years to keep us inside and all the bugs, bacteria, viruses and fungus on the outside. Putting some silly glove over, we just do, but it doesn’t do anything.

Michael: Yes, I think that’s a good point. One thing nice about gloves too is that it looks good to patients, and it does keep your hand cleaner which is nice. I used to ... I was practicing before gloves became common, and you get the pressure material on your hands and it’s nice to keep the impressions [crosstalk 00:21:50].

Howard: Talk more about pre-medication for artificial joints, where is your thinking on that now?

Michael: What started that was this rabbit study in the early 1980s. A bunch of rabbits were ... They had their joints replaced with artificial elbow joints or something, real small joints. After they recovered from that surgery, then they were inoculated with large doses of bacteria. Some of them got artificial joint infections. As a result of that rabbit study there were dentist who said therefore we should pre-medicate our artificial joint human patients, because they may be at risk for these artificial joint infections.

What they neglected to say is that these rabbits were injected with so much bacteria that over half of them died from the bacterial injection. They had these massive cases of sepsis; it’s totally a non-clinical situation that we would be facing. In addition other studies have shown you’re much more at risk of dying from the antibiotic even though it’s a very tiny risk. There is a much higher risk, many times higher than you are of getting an artificial joint infection, which if you do get it’s a terrible thing to have. Chances are good you’re not going to die from it. 

Number three is the antibiotics have never been shown to prevent infection in the first place. The best studies of artificial valve endocarditis which is related to dentistry possibly have shown that maybe the antibiotic will prevent the valve infection less than half the time, maybe. That does not translate over to these artificial joint infections. Another thing too is what causes artificial joint infections typically are staphylococci? Staphylococcus is generally never found in the mouth, very rarely found in the mouth at all as opposed to straplococci. There is all kinds of reasons why we should reconsider pre-medicating artificial joint patients.

Not to mention the American Dental Association 2015 statement which basically says there’s not really any scientific evidence that it’s a good idea to pre-medicate these patients. In addition to the American Academy award of surgeons 2012 statement I think, saying we should reconsider this. Bottom line is you’re better off just not pre-medicating people with artificial joints.

Howard: It’s funny how something will culturally solve a bad idea and then it culturally takes roots and then you can’t shake it 10, 20 years later. All apes and monkeys like humans, gorillas, chimpanzees, [inaudible 00:24:48] were all covered with stuff on the outside, strapped on the inside, that’s the basic monkey-ape. I started answering like when you look at the studies of kids dying from Chicken pox which is why we now give them a vaccine.

It’s actually not the Chickenpox that kills them, it’s them scratching it and they cut into those dermis and then the stuff on the outside gets on the inside and whenever stuff on the outside gets in the inside, and whenever stuff on the outside gets in the inside [inaudible 00:25:12] be, that’s a problem.

Michael: Right, and many of the cases in the literature in the past if you go back and look, this person had an artificial joint infection therefore ... And had a demo appointment within 6 months beforehand, therefore it was the demo appointment that caused it. You look at the organism, and it’s a staphylococcus and they never found out what the floor of that person’s mouth was, but if you look at most people floor there is no staphylococci in the mouth generally.

Howard: Another one is [inaudible 00:25:45]. Lots of dentists are always taking their kids in for an ear infection. They’re turning out you can better prevent ear infection by keeping the kids finger nails trimmed. He’s digging in his ear, cutting his ear, bacteria is getting in there, and if you keep the nails short he’s not going to be scratching and cutting the ear skin letting stuff in there. You have thoughts on local anesthetics too, what’s your thinking on locals?

Michael: Well, again people think that ...

Howard: First of all I want you to know that I’m a high class guy, I don’t use any local anesthetics, mine are all foreign imports, mostly from France.

Michael: That’s funny, good. Yes with local anesthetics typically a lot of dentists think whatever the newer one is that’s what I’m going to use. I want to use articaine because it’s newer. It’s kind of like with amalgam, it happens that lidocaine is ... Has been around since 1948 or something. It is probably the safest local anesthetic. I would recommend, even if though they’re all pretty safe, I would recommend lidocaine with 1-100,000 epinephrine.

You can give the most of it before an overdose because that is one thing that’s not in it, you can give too much local anesthetic especially to very young children. There have been many cases in the literature  of overdoses of local anesthetic where people have actually died. You got to give a lot, but still with lidocaine, with 100,000 epinephrine you can give twice as much lidocaine over a short period of time, as you can give articaine.

Howard: Articaine is the ... The popular brand name would be septocaine.

Michael: Yes, that‘s right.

Howard Articaine is the generic chemical name and articaine is the brand name.

Michael: That’s right. Yes ... I’m sorry articaine is the generic name septocaine is the brand name. I’m not saying it’s a bad anesthetic or anything, but why would you want to give one that you don’t ... You can give twice as much with lidocaine. Now articaine has twice as much concentration. That’s one reason why studies have shown that articaine has a higher rate of paresthesia. Again it’s not a very common thing, but there are cases of paresthesia, higher incidence of paresthesia with articaine than with lidocaine.

If you look at the package inserts, they never change those package inserts, and those package inserts are not based on scientific evidence, but they might say, “Oh, there is a risk of malignant hyperthermia if you use lidocaine or something like that. The malignant hyperthermia if you look at it, there were these studies on pigs where these malignant hyperthermia pigs, where they gave them a whole bunch of amid local anesthetics like lidocaine, basically they saw that  there was no malignant hyperthermic response no matter how much they gave massive quantities of these anesthetics like lidocaine.

They did find that after all that the pigs were very numb. The bottom line is you don’t have to worry about malignant hyperthermia. Similarly with interaction with ml inhibitors and epinephrine, you have to give them massive quantities of epinephrine which luckily has a very short half-life. The bottom line is Lidocaine with 1-100000 epinephrine is very safe, it’s ... Other than the overdose possibility, you have to give 14 cartridges to 160 pound a dose, so that’s a lot of lidocaine for an adult.

With a child, a 50 pound child you can give maybe 4 or 5 cartridges. That’s a much higher risk, but other than that there’s really ... Local anesthetic and basic [inaudible 00:29:29] are very safe. People say they’re allergic to local anesthesia, generally it’s just false. There was a local anesthetic that people were allergic to, it was called procaine, that was the generic name. The brand name was novacaine, that’s the word we sometimes use, we shouldn’t but novacaine was a brand name for procaine. That one had a fairly high allergenic potential. No one in the United States that I know uses novacaine or procaine; it's not even manufactured or sold.

It may be sold in the other states I don’t know. All the other anesthetics that are in use are amid local anesthetics. It's highly unlikely anyone's truly allergic to it. If you ask them what happened, then maybe they'll say my heart beat fast or something. That is not a sign of allergy, it might be a sign of an intravascular injection of a basic constrictor, but it's not a sign of allergy. Another myth I would like to address is that somehow mepivacaine or carbocaine is the brand name, is safer than lidocaine. I don’t know why people think that, it's simply not true.

Lidocaine in pregnant women for example, lidocaine is a category B, it's probably safe, but mepivacaine is category C, no one knows for sure. It's probably safe too, but no one knows it's actually in a lesser category. There is a constrictor that is used with carbocaine as [inaudible 00:30:56]. That is the more dangerous basic constrictor than epinephrine. Epinephrine is produced by our bodies. Again there's not a human on the planet who cannot have some lidocaine, there is not a human being on the planet. Again there are certain people who shouldn’t have carbocaine, people with this blood disorder [inaudible 00:31:18] anemia. I don’t even know how to pronounce it. The bottom line is lidocaine with 100,000 epinephrine virtually, anyone can have it.

Howard: If I hear you correctly you just said novacaine and mepivacaine are evil, and the dentists who use it should be killed?

Michael: That’s it; yes along with the people who place amalgam.

Howard: The dentists have amazing minds, they'll tell you that the [inaudible 00:31:42] is too high. I'll go in there and I want to go back to amalgam for a second or septocaine, lidocaine, and they'll say, well how do you get my [inaudible 00:31:50] down? They think the answer is going to be getting online and buying their supplies on a website, having someone sit on a computer for 5 hours and being paid $20 an hour to save 12 cents on gas. It's like well a barrel of bumming agent is about a million and a half dollars. Why don’t you just … I'm just ugly fat bald man, on molars only switch to amalgam, oh no I don’t want to do that.

Okay, you are using a very expensive brand new, brand name anesthetic. We cut that cost in a half using something that's been around since Fred Flintstone. Now I want to use the other one, I mean it's like … I mean every time you put a decision in front of them, low cost, high cost, they pick high cost. Then they complain about their overhead. Warren Buffet said that it's amazing. Warren Buffet said that 95% of CEOs go to work every day and just try to figure out how they can make their overhead go higher, the same thing now with these kids coming at school. 

There are $250,000 students’ loans and they just complain about it all day long, but they think they are not going to be successful without it. $75,000 lazar, $100,000 CBCT, and a $150,000 on a card cam, and I can give them the names of a thousand dentists that do a million dollars a year and take home $400,000 and don’t have any three of those machines.

Michael: That's me.

Howard: Yeah, I mean and a lot of that is because so many … I mean that's because … I don’t even know where to begin.

Michael: I remember when someone said, oh, you can't be successful unless you have an intraoral camera, one of those ones or something for intraoral camera. Because you have to show people, this is what you have and this is what you need, you want to blow it up on a big screen. I never had one, and I was very successful. The point is they'll too, they can't … Don’t patients trust you? Do you have to show them on this big … If anything I think that might make the patient a little hesitant to show him on a big screen or something like that as opposed to here is the mirror, here is my nerve [inaudible 00:33:47] see that, something like that.

Howard: Yeah but admit if you went to a gastro, a proctologist and he said he had to remove a growth, wouldn’t you want him to stick a camera up your butt so you could see it first before he went up there to remove it. Then wouldn’t you want to take it home in a jar after its removed, I mean that’s a ...

Michael: Oh, yeah, I always watch a video of my colonoscopies.

Howard: The funny thing about … They say like I'm allergic to novacaine, that's your energy part of say, okay, that’s fine I will never use novacaine on you. You don’t have to tell him that you don’t have it in your in your office and no one buys it at anymore or whatever. Just keep patting those shoulders and making eye contact. The reason guys like you and me are successful is not because of some toys, it's because we can relate and communicate to the patient, we have empathy, we have listening skills, when they talk we repeat … We nail it on all the soft stuff. What dentists don’t want to hear is they want to hear that they buy a magic bullet for 6 figures, they’ll be successful.

The reason you are successful is because you are a communicator, you are talking, you are likable, you are nice, you are trustworthy, loyal, friendly, obedient and courteously thrifty, everything the boys scout source. I'm going to say I want to tell you about my amalgam deal. They … When patients come in they say, they don’t want a silver filling they want it all natural. I will say, well actually the all natural one is the silver filling because see all the elements were formed in exploding super novice. When the stars collapsed and exploded that's when they made mercury silvers and copper and tan.

It's all natural. These tooth colored fillings are all made by man-made ingredients, are all made in laboratories by men in white coats and everything. The all natural filling comes from an exploding super nova. You don’t want some chemicals made by men in lab coats.

Michael: That is funny, that reminded … Let me read you some of the ingredients of composite resin, so if we could say, oh, they are natural, its non toxic which is false. Here are some of the ingredients, benzyl alcohol, benzyl methacrylate, 2-6 Di-tert-butyl 4 methylphenol, ethoxylated bisphenol A dimethacrylate, [inaudible 00:36:02], base 2 hydroxyl 3, 4 phenoxy propyl methacrylate, and there is a list that goes on and on.

Howard: I know.

Michael: You can find that on the article.

Howard: I know and they say that’s all natural. Yeah, it's all natural never mind it took a man with a PhD and 40 colleagues to figure this shit out and make it in a tube and sell to you. Never mind that it costs one and a half million dollars a barrel, never mind that it lasts half as long as amalgam because you know that 10 year old little boy in your chair Ricardo, you know that that MOD molar that no one  is ever going to see your entire life. You know you could put in for a half the cost and it will last twice as long, and I think amalgam lasts longer because look at the high dentists they like stannous fluoride that's 10, 10 [inaudible 00:36:49], 10 irons are flying out of amalgam.

Silver, I mean silver … One of the pediatric dentists used to put underneath the fillings silver that anti-bacterial stuff silver ... Anyway silver has been ant-bacteria … Every ingredient in amalgam has anti-bacterial bacterial static properties. Because I can tell you this, I know people say, well, where is the study for that? I always say, well, where is the study that if you don’t wear a parachute you die? I mean I want to randomize controlled study where 100 men are thrown out and a half randomly does not have the parachute and half does have a parachute. I want to see the research that proves that you die without a parachute. There is no double blind randomly controlled study on parachuting, you know what I mean?

Michael: There are studies showing that amalgam does have anti … Possibly mercury has anti caries properties. Yes, there are studies, there certainly are comparative studies showing that amalgam has a low instance of caries than a composite resin.

Howard: I would tell you this for me in this 20 years, when an amalgam has recurrent decay underneath it; usually it's just a little bit that the tooth gets hard fast. When I have an MOD composite, and it’s only six and half and seven years old and they come into my office and you take that out, you are taking out oat meal mash with the number four round bar. I mean it just, the tooth just intuitively … What I'm seeing is that I'm just seeing that these bacteria nothing was slowing them down.

Michael: Yeah.

Howard: The white selling companies they get it, I mean I was … I had lunch with Bob Ganley the CEO of Ivoclar. Their holy grail is to put an anti bacterial ingredient in white composite fillings. He said that's like the number one thing they want. They want to come out with a bacterial static filling, I mean they totally they get it, I think Bob Ganley is an amazing man. What else did you want to talk about?

Michael: Well related to what we were talking about a little bit ago was my dad had a really good advice to me I think, which was he didn’t want to be the first to jump on a new technology, but he didn't want to be the last either. I think that's good advice because like you say some of these dentists who are jumping on to every type of new technology, then they’re basically just collecting dust there after a few years, like those intraoral cameras that they want or whatever I think. There a few dentists who use those anymore I think, but that kind of thing and that kind of thinking, you don’t necessarily want to be the first, but don’t want to be the last.

Now don’t get me wrong my dad was ahead of his time. He was the first guy in Delaware to do implants. He used to go up to New York and see Leonard Linkow or something, lecture on the weekends, and because he hated dentistry so much as patients hated dentistry. I remember he used triple trays for crown and bridge and I brought some sample triple trays into dental school with me. The professor’s like you’re not allowed to use them and all this and it’s just so funny and implants. Implants were a crime in dental school, now of course they’re a standard of care. He was ahead of his time, but he wasn’t necessarily the very first to jump on to a lot of new technologies, and I think that’s related to what you’re saying.

Howard: I don’t think these kids ... One of the things I like about doing podcast, I feel guys like us that have made it half a century it’s part of our duty that to keep history alive. I mean I don’t think these kids realize that when I was in dental school the one oral surgeon that was doing implants every instructor was spitting in your ear. They called him the butcher. Yeah he was, the guy is crazy. He’s putting metal, rainmass bars and subperiosteals and he should have his ... They would say he should have his license taken away. He was a butcher, he was ... And some of the earliest implant pioneers would do hundreds of full mouth rehab cases, and then the first one that failed the local board would take the license away.

Michael: Yeah terrible.

Howard: I mean it’s just crazy.

Michael: Terrible.

Howard: I mean, so yeah I mean I’ve lived through this when ... I’ve lived through where in college if you went out and drunk beer at Jack Daniels and wrecked the car and got in a fist fight, everybody was just like well they’re boys, or if they smoke pot, they threw them in jail. If they were gay you could go beat them up and then go to church on Sunday and be fine, now they can get married. I’ve lived through implants being butchery to now state of the art. I mean it’s amazing how things just change and get better if you just give it enough time, you know what I mean?

Michael: Yes absolutely.

Howard: When these young kids are telling me all the problems in the world I am like I had an argument with a kid the other night and he’s talking about our generation ... Our grandparents’ generation they were such anti environmentalist. It’s like dude they were trying to fight Germany and Japan. When you’re trying to build tanks and jeeps to save a world war you’re not worrying about what you’re dumping in the creek at a tadpole. They’re worried about Adolf Hitler not a tadpole or a spotted owl. It’s a luxury for you to not see Germany in your face, instead you’re then worried about the environment, you know what I mean? Just, so don’t judge people when you weren’t there in the right time, but you know what I am, you’ve talked about so many things, artificial joints, local anesthetics, anti coagulants. I want to ask you [inaudible 00:42:24]. 

These guys are listening to us on a podcast; man I wish you would put that lecture online. That way and in Dental Town we’ve put up 350 courses; they’ve been viewed over half a million times. For your literature mind it would just be if you had a PowerPoint to upload those slides so they can see this exact research. I think if you put up a course medical mess of clinical dentistry it would just be phenomenally important and powerful. Any chance you could ever do that someday?

Michael: Sure. I’d be happy to consider something like that. Yeah, and like I say on my lectures I had a professor named doctor I M Pretentious. He came over, I was about to do this occlausal resin or something on a patient, but he comes over oh my God he looks at the health history. Oh my God before you see this patient you have to do a C-B-C, a P-E-T and a D-N-C or something like that, you know what I mean? Get a physician consultation staff. It’s just absurd but doc I am just doing an occlausal resin, what’s the big deal? That brings up another issue too, the physician consultation in dental school, I was taught if you don’t know what to do, just call up the physician and do whatever the physician says, then you’re safe, then you won’t get sued.

Where they come up with these ideas is just beyond me. Now first of all if you’re a lawyer and you’re going to sue someone because of some bad happenstance and let’s say they had a reaction to a drug that the dentist prescribed that the physician said it was okay. Now the lawyer, is the lawyer going to sue the physician, yes check that. Now the dentist has malpractice insurance too. He has a million dollars as malpractice insurance. Is the lawyer going to sue the dentist too or is the lawyer going to say well the dentist asked the physician what to do and the physician said to do this, so we’ll just sue the physician, or would the lawyer lose his law license if he did not sue the dentist. Of course he’s going to sue the dentist, he’s going to sue everyone, he’s going to sue the hospital. He’s going to sure everyone, so of course everyone is going to get sued.

Now physician consultation does not protect you. In fact one of the leading courses of malpractice suits against physicians is guess what, physician consultation. That’s one of the leading courses of it. You’re asking it, I use the blind verses the blind. Whereas you’re asking you don’t know exactly what to do. Well this person had a bypass, a heart bypass. I don’t know if I should pre-medicate or not, I don’t know what the American heart association says, so therefore I am going to call the physician, okay.

Now granted the patient was smart enough to pick you the best dentist in phoenix, Howard. He was smart enough to do that but is he smart enough to pick the best physician in phoenix, or could he pick someone who is a quack, maybe he picked a quack. You’re going to call up the physician, maybe he’s a quack maybe not and you’re going to say well doc I don’t really know what to do. This person has had a heart bypass operation, so what should I do? Okay well, for that you should prescribe a penicillin V, 500 milligrams, four times a day, a week before the procedure and a week after, okay so then go ahead.

You go ahead and prescribe that, meanwhile the patient has an [inaudible 00:45:50] reaction. Whose fault is that? Well take a look at your dental license, does it say on there this is a license to defer dental treatment decisions to non dentists especially if they’re physicians? Does it say that? No, you are responsible for the dental treatment decisions. That is a dental treatment decision whether or not to pre-medicate someone. The American heart association is clear, you should not pre-medicate people with a heart bypass, and if you do then certainly there is a different dosage than the one I prescribed. Who’s going to win that suit, I mean it’s a no brainer, you’re going to lose, maybe the physician will lose too. There is no way you can defend that. I'm not saying don’t consult with physicians if you need some information, but if you already have the information you need consulting with a physician is not going to help you.

The American Heart Association is clear on when to pre-medicate and when not to, and is endorsed by the American Dental Association. Do you want to go with the American Heart Association or do you want to go with an individual physician who may be a quack, you don’t know. Generally if you need information now whether the patient has a particular heart condition, whether the patient had endocarditis in the past, patient may not know that. Okay, well maybe I don’t know I had something wrong with my heart, I don’t know what it was. Okay you can call the physician. Did the patient have endocarditis? The physician says yes, and now I wouldn’t ask the physician should I pre-medicate for that, I would say should I file the American Heart Association’s statement for pre-medication? Then let the physician say yes or no, that’s fine.

I am going to recommend that anyway and let the patient make the ultimate decision. That’s just one example, there’s other examples of physician consultation as well. If you have a patient on an anti coagulant, generally you should leave the patient on the life saving drug, like Coumadin for example. Leave the patient on the life saving drug, because when they go off that drug they have [inaudible 00:47:46] or something, they’re in a much higher risk of stroke or heart attack. There have been many cases where the patients have been taken off these drugs for a short period of time and gotten a stroke or a heart attack. Which would you rather have, a stroke or some bleeding after a dental extraction? Which would you rather have? I say it’s bleed or die.

If you call the physician now does the physician know what an extraction is and how much bleeding is involved with an extraction, and how we control bleeding? Does the physician know that? Of course not. Does the physician think that a root canal is a bloody mess? Yes. Who knows more about dentistry, a physician with 15 years of training after high school or 20 years or whatever? Does the physician know more about dentistry, or does an 18 year old dental assistant know more. Who would you trust more knowing what a root canal is? I would trust the 18 year old dental assistant. Why are we asking physicians opinions for something they know nothing about? No, the answer for that is if the patient is on the proper dose of Coumadin and they have the proper level then you go ahead and do the extraction or multiple extractions or alveoplasty, whatever you’re doing, leave the patient on the life saving drug.

If they have a little bit more bleeding we can control that, we’re lucky at dentistry. We have ways of control. We can have a patient bite on gauze. We can suture the wound if needed. We’re not like general surgery where they got to cut open the patient if there is bleeding, they got to go back in, it’s not like that. In dentistry we’re right there, so we want to leave patients on life saving drugs and be very-very cautious before you consult with a physician.

Howard: Did you know if you’re on Coumadin you can’t eat green vegetables?

Michael: Supposedly yes.

Howard: I want to get on Coumadin. I want to be able to go I’ll pass all the salad, give a double helping of mashed potatoes; I am on Coumadin. Can you call me in some Coumadin so I can just quit all the leafy green vegetables the rest of my life?

Michael: There you go; luckily Coumadin is kind of on the way out. They’ll do these new anti coagulants they are coming in and that they don’t have those restrictions.

Howard: I used to remember, also these young kids don’t remember back in the day, but I got out of school in 87 and that’s when Kimberly Bergalis in Florida said that she contracted AIDS from her dentist, remember that ordeal?

Michael: That’s right.

Howard: Acer had patients coming in and every time but he didn’t sterilize his hand piece and they were saying ... Every time they’d ask me, it was about from 87 to 95 I used to get at least 1 out of 100 little lady grandmas would say, “Dr Farran do you sterilize your drills?” I’d say, “Of course I do but why do you ask?” They say, “Well I’m concerned about AIDS.” I’d say, “AIDS is a sexually transmitted disease, and I have you scheduled for a filling.”

Then I would open my drawer and I said ... I’d do this ... My sister would just die. I’d pull out a condom I said, “But if you feel safer if I have a condom on when I do this filling, my policy is if you put it on me, I’ll wear it.” They couldn’t it even touch it, their hands would go up and they would say, “Is that a real condom?” I’m like yes, “If you feel safer if your dentist is wearing a condom, I’ll wear it, as long as you put it on, I’m not putting it on, you put it on.”

Michael: That is hilarious.

Howard: I loved the way you’ve always stood up to bullshit. By the way how do you keep your mind on top of all this? I’m sure a lot kids are riding to school right now, going to work right now, they’re 25 years old, they’re commuting into their dental office or saying, “How does he know all this? How does he stay up on?” What is your natural behavior to stay on top of all this array of information?

Michael: I do read a lot of medical and dental journals, I don’t necessarily get a journal and read it cover to cover I don’t at all, but I’m interested in certain topics. You can do a Google search or you can do a Medline search, you can ring up a lot of articles, and nowadays you don’t even really have to go to a library. You got everything online, and I’m on the staff of the local hospital, so I’ve got access to pretty much any medical journal or demo journal I want instantly. If in the rare case they don’t have a particular demo or medical journal, then they will get it for me.

Howard: Why are you on staff at a local hospital? What percentage of dentists do you think are on staff at a hospital?

Michael: I don’t know, maybe in downwards maybe 30% or something, but we have a general practice residency there. We have a dental clinic at the hospital, and I just go in like half a day a month or something like that to the clinic, help out the residents and that’s why.

Howard: I bet you’re their favorite dentist? You have to be.

Michael: I do preface everything I say, that’s funny you say that. I preface everything I say. Look I’m going to give you my opinion, but please ask the other dentists too. I’m not saying that I’m with the majority here, but this is what I think about this particular case or that case or something like that, this is what works for me or something. If you’re on your dental school or whatever you can get to the library. You don’t even have to be on a dental school faculty, you can just whatever topic you’re interested in, nowadays it’s so easy just go online and read up on it. I’m very interested in a lot of different topics and that’s what I do.

Howard: We should reminisce; whenever someone emails me or messages me on Dental Town, I love your podcast, because the views have exploded. I always reply back, what’s your demographics? I’m trying to look for their age and their all, it’s basically 30 and under. Every time I hear 29, 27, 24. Nobody has ever replied back, it’s always been ... No one has ever emailed me as old as me that listen to my podcast. I want us to reflect about a story 25 years ago when Readers Digest took study models and x-rays, and they went to about 25 different dentists and they published an article, “Is Your Dentist Reaping You Off?”

The same point is that if you take records to 25 different dentists, you’re going to get 25 different opinions. I still see that on Dental Town, I still see people posting an x-ray or photos and you get all over the board. I get to catch you, you’re the most scientific minded dentist I know, you’re the most critical thinker I know. What percentage of dentist is Art vs. Science? How much of it is my opinion and culture and tradition and religion vs. Math and gravity and physics and Geometry?

Michael: I don’t know if I know how to answer that other than you should try to use as much science in your practice of dentistry as possible ...

Howard: Let me ask you this way. If someone came in, say grandpa came in and he’s 65 years old and he hadn’t been to the dentist in 10 years, and you send him to ten different dentists in Delaware. Would all those treatment plans be the same?

Michael: No.

Howard: How many treatment plans would you get on grandpa if you went to 10 different dentists?

Michael: At least nine probably.

Howard: I know. To these young kids don’t believe everything you here. Dentistry is still probably a thousand years before you just know everything about dentistry. There are so many different opinions falling out there, and it seems like the ones who get on the lecture circuit and have the most boring type personality try to shove these things down your face, and critical minds like you, you never blinked.

Michael: Yeah. Thank you, you’re very kind. It’s fun in the end. Unlike you Howard regardless of what the topic is I don’t just accept whatever I hear. I have to think well, that’s one opinion or that’s one way of looking at something, are there any other ways? Is amalgam really so dangerous? Are people dropping dead? I look at the cemetery, I look at all those tombstones, is dentistry really that dangerous? Are people in that cemetery killed by dentistry? How many people are there, there's thousands tombstones. Chances are not a single one, is dentistry really so dangerous? In dental school we are taught that, say you got to do a physician consultation because this patient could die from this that or the other, they could bleed to death if you leave them on their blood thinner. They could get a terrible heart infection and again there are a few cases where they should be taking antibiotics, but that's even debatable whether the antibiotic does any good.

They could get a heart infection, you clean their teeth, and you didn’t take a health history, oh my God. It's fun to think well, is that really what people die of, are these heart infections from dentistry? The patient had a dental procedure within six months from the heart infection; therefore it was the dental procedure. Wait a minute, lots of people had dental procedures in the last six months, it can't be just because they had a dental procedure in the last six months, no, the symptoms had to have occurred within two weeks so that the … It wasn't the dental procedure, we know that, we can rule that out. It's just interesting to think along the lines of questioning, keep questioning.

Howard: As I get older, so I was heavily involved in getting Phoenix 4 days in 89, and then it expired after 20 years, we had to go through the same thing. I had to go to debates on TV and radio and blah and …

Michael: Fluoride is a poison.

Howard: I know and now that you know, when you try to tell them an argument that fluoride was not made by fertilizer manufacturers, it was made in exploding star. It’s a 13th most common element on earth, it shows up in the ocean naturally at 1.4 per million, we are trying to put it in the water at half that amount. They don’t want to hear it, and the red flags are they are also conspiracy thirst, they are heavily anti government. I think the whole anti fluoride has more to do with they just hate all forms of government. It's like so you don’t like 911, you don’t like street lights, you don’t like roads, bridges, highways, you don’t like order.

You just want mass freaking chaos because everyone else is a liar, and a cheat, and a hack, and a steal, but you, you are sacred holy. It's sad, but at 53 years old, I mean you start to really realize that the earth is inhabited by 7 billion talking monkeys. I mean they just … I think one quarter of Phoenix I mean this is where I have lived since 96. I think one quarter of Phoenix doesn't want to hear anything about science or gravity or anything; they have their religious beliefs, their anti-government beliefs. Fluoride is toxic, I mean it will kill you, it was made by fertilizer manufacturers, and it's so toxic, there's no place to store it so they bribe the government to slowly pour it into the water because it's so toxic.

I'm like, okay, this country has exploded 1,800 nuclear bombs, couldn’t they dump the toxic fluoride there? I mean couldn’t they dump it where they detonated a thermal nuclear bomb. I mean it's so toxic they have to pour it in the water. At some point these people they just don’t want to have anything to do with science for a reason or rationale.

Michael: Right.

Howard: Yeah, so well I want to thank you for getting up this morning and having an hour with me. I'm your biggest fan. I mean how many studies … How many papers have you written, like 60 articles? I’ve been a big fan of your stuff, I would seriously give anything if you condense some of that stuff for a course on medical mess, because I want dentistry to go down the science path not the I believe this path, and I want this path that go down a science path. Amalgams do last longer, they are a fraction the price, lidocaine is less expensive; I just love your critical thinking. I'm your biggest fan, but anything else you want to close, we are …

Michael: I would say it's a pleasure being here, I think thank you so much for everything you do for dentistry, it’s amazing. These podcasts are a great idea. The Dental Town magazine and the Dental Town forums and how do you have time for it, that's why I'm going to interview you, how do you have time …

Howard: I'm going to ask you an overtime question because we are at one hour; I want to ask you a question. Twenty years out of school watching dentist trying to see who is successful who is not, and by success I don’t mean just money, but love what they are doing, long term staff, happy patients that come back, making money for their family. I'm trying to say what do the successful people have that the non-successful … The hugest one I see is that they were committed lifelong learners. They took at least 100 hours of continuing education there, they got their FAG, their AMG, they were life-long learners.

When I saw the podcast I thought, right now after work her society has a study club that’s like the last Thursday of every month and she is tired after work, and she’s got to drive across town and register and eat at Robot chicken dinner, then listen to her speaking. That's her substitute in the market place for about one hour. If I did a podcast and I did a two day, so she is got AM hour of commute and a PM hour of commute. I'm going to get 30 study clubs down a month you know what I mean. I wonder my critical mind says, well which came first did the 100 hours of CE every year for 20, 30, 40 years make this person a great dentist? Or did this great dentist take a lot of CE? I mean did the CE make you great or we just have a great attitude and you would have been great with or without CE, which came first the chicken or the egg?

Michael: That's a good question yeah.

Howard: Because being out here in Phoenix every time I have gone to a CE course, it’s the same group of successful dentists, and they always bring their staff and the ones I never see at CEO is, their practices are coming and going, they fade away. What do you think, do you think the CE makes you great, or great people take CE?

Michael: I think it’s a combination, when you put it that way I think it's probably a combination yeah.

Howard: Okay, well hey we are on overtime. Thank you so much for all that you do and I hope someday you put a course together because this was so much information that so many people would want to see what you are citing or any footnotes or anything from your presentation.

Michael: Thanks a lot Howard.

Howard: All right have a rocking all day.

Michael: See you later.

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