Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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196 The Circle Of Treatment with Louis Malcmacher : Dentistry Uncensored with Howard Farran

196 The Circle Of Treatment with Louis Malcmacher : Dentistry Uncensored with Howard Farran

10/19/2015 2:00:00 AM   |   Comments: 0   |   Views: 483





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AUDIO - HSP #196 - Louis Malcmacher



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VIDEO - HSP #196 - Louis Malcmacher


Louis Malcmacher, DDS discusses the circle of treatment o facial pain, facial esthetics, sleep medicine.

 

Dr. Malcmacher is dedicated to applying simple, commonsense clinical and practice management solutions to help dental practices improve production, add new services to be provided to patients, raise collections impressively, significantly reduce overhead, eliminate stress in the office - and have fun in the process!

 

 

www.facialesthetics.org

 

drlouis@facialesthetics.org

 

800 952-0521




Howard: It is a huge honor today to be interviewing Louis Malcmacher, my friend for probably close to 25 years. I've seen your lecture several times. All I can say about Louis is him and his wife are two of the greatest quality people I've ever met in my life, and you're always on the cutting edge. Whatever the cutting edge of my career was, 20 years, looking back, you were always five years [inaudible 00:00:34], and everyone loves your lecture. You're just a hell of a neat guy. How are you doing today?

Louis: Good, I'm doing great. Mutual admiration society. I was on of the first subscribers of the Farran Report, okay. I've been following Howard Farran, whose just a genius in the practice management side, and he's a darn good dentist too, which nobody knows about. They know about your practice, but you know your stuff all the way around.

I just wanted to say I'm glad. I was afraid I would be under-dressed here, because every time we lecture together, you're in the Hawaiian shirt, and I'm always in the formal suit and tie, but I gotta go to see patients soon, so I already put on a smock here. I'm glad I'm not under-dressed or overdressed. We're about the same today. 

Howard: I can't tell you how many times I walked in to do my mic-check or whatever before a lecture, and the president of the society that invited me in saying, "so are you gonna go back to your room and change?", and I'm like, "no, are you?" I've lecture in sweats. 

I want to say about your background, we both have the background. I'll pan to mine for a second. The neatest thing about my profession is that all my friends are dentists, and dentists are all readers. I have spent the night in 100 dentists' homes in 50 countries, and they always have at least 100 nonfiction books. All dentists are readers. When you spend the night in someone who's not a dentist, a physician, or lawyer, they have three books, and they're all fiction. I think the thing that I love the most about choosing dentistry is that all my friends are readers. It carries over to their thoughts on politics, religion, society, economics. Its one of the most fun professions to be into, just 'cause all your colleagues are readers. 

Louis: Right. Listen, we all love to be educated. That's why we went into dentistry. How many groups do you talk to, that I talk to? We just love education. We love to read, we love to know things. We're people with toys. We love our toys, and we love to learn. That's really what makes dentistry exciting.

The dentists that I see, and I'm sure the dentists that you see all the time, they come up to you and they say, "oh my God, I hate dentistry, I'm so bored, I hate it", and you ask them what they're doing. "Well do you do fillings?", "Yeah", "do you do dentures?", "no, I hate dentures." "Do you place implants?", "no, that scares me that surgery." They don't do anything in their offices. The dentists that are really successful are the ones that love to learn, because that makes life successful, and that makes life fun. It certainly makes dentistry fun there too. 

That's why I'd like to be out of the curve. I love it when people tell me I'm crazy. You know what, its fun to learn. Lets bring some of these things into dentistry. It can't be the same old thing all the time. That's how you get bored, and that's  how you get burnt out. You talk about that all the time.

Howard: That was the first of many scoldings I got from our common friend, Gordon Christian. He's a DDS, he's got a MS, he's a prosto, but he has a PhD in psychology. I wrote this article on lasers, back when the Farran report, when you subscribed. By the way, the Dental Town Magazine was the Farran report five years first.

Louis: Right.

Howard: It was a print-medium back then before the internet when I was sending you one thing. Its from Farran, it's the Farran report, but then when the internet came out and it became two-way, it was no longer about me, it was about a community, and I called it Dental Town. I wrote an article about lasers. It stands for light amplification stimulation emission and radiation, or losing all savings equals reality. In my MBA walnut brain was saying that, "you want me to buy a $50-thousand laser to do what a $1 disposable scapulae blade could do?", and Gordon read that and chewed me out.

He said, "Look Howard. These guys get burned out. If they buy a toy and it makes them happy, and it makes them want to go to their office and play, you can't even measure the return on investment of that. Our problem is doing a repetitive task over and over, eight hours a day, five days a week for forty years, it's gonna lead to burnout. Olympic swimmers have height burnouts because they said, "okay Louis, you're a butterfly, so I want you to swim the butterfly an hour before school, an hour after school, seven days a week, from age five to twenty-five. These guys get to the point where they can't even look at water anymore. 

Gordon was telling me, to buy a toy, to be happy, to love what you do is priceless, so don't be knocking their toys. Then I watched my four boys in the sandbox and the bathtub, just sand or just water, they'd be in and out in five minutes, but you throw a bunch of trucks and toys and pales ... The more shit you could throw in the bathtub, the longer they'd all stay in there till their fingernails got clean. That was the key. Go find five toys and throw it in the bathtub.

What has got you excited? Why are you always happy and smiling? What's got you excited in dentistry today?

Louis: Well first of all let me just go to the toys for one second 'cause then it'll fold right into the answer there. What Gordon says is true, but your MBA background has served you very well because it was okay when the toys only cost you a few thousand dollars, but when they're starting to cost $50, $100, $150-thousand, you better be making the right choices, 'cause that can mean bankruptcy for a dentist, so yes, we love our toys, but there's not an unlimited. 

When you and I first started dentistry, I could open almost two offices for $100-thousand, and now its a single piece of equipment, right? Now, you better be making the right choices. They're all great for the right practice, and for the right dentist. Here's what gets me excited, and I love the big toys there, too.

First of all, I love helping dentists understand what are the big toys appropriate for that. We've got three practices in Cleveland, Ohio, and we've maintained a very low overhead 'cause we really work hard at the whole thing. For me, and its the thing that we teach all the time, what gets me excited is teaching dentists new skills. Skills with their hands that they can actually go out and produce dentistry for the rest of their careers. 

I'm all for technology, but you buy a piece of technology and you and I both know, every computer you buy is outdated by the time you bring it home and set it up, and technology gets outdated and there's a huge cost to technology. If a guy can teach you skills-based dentistry, and that's all the stuff that we teach, and botox, and fillers, and TMJ, and sleep, and all those different things and a million other things to come, that's what gets me excited. What gets me excited is making dentists really, really successful by 'teach a man to fish' kind of thing, because you can feed them all you want, but if you teach them to fish, we can really feed.

There are so many problems that we've got to face in dentistry and a lot of challenges, and I say this all the time, and actually I've heard you say it, and it was one of your articles in the last few months in Dental Town there as well. If you're not gonna expand your services, and you're just gonna be a teeth mechanic then that's great, but you're gonna be extinct as a teeth mechanic at some point. 

You've got mid-level providers coming out, you've got technology that can replace a lot of different things that dentists do. There are a lot of political and technology courses that can ... My God, its time for us to be doctors. That's what it is. We've got to stop being teeth mechanics, 'cause that really lowers our own self esteem.

Actually there's a thread on Dental Town where I wrote, and I posted an article about why dentists have low self esteem, and this is one of the reasons. We think we're only teeth mechanics. We're not. We're real doctors. That's something you've talked about forever, as well.

Howard: What's amazing is you're so upbeat even though you live in Cleveland and the Browns are only 2 in 3, so Louis is happy no matter what. Even though the Cleveland Browns can't deliver, he's still happy. 

Louis: Right. When you're a Browns fan you live with that. Hey man, there were times the Cardinals weren't doing so well. I remember those days very well. 

Howard: The Cardinals always do great until their quarterback gets tackled and is out for the season and they don't win a game after, so we're at the early stage with the healthy quarterback, so we'll be good for a while.

Lets start talking about some things. What are your thoughts on TMJ and oral facial pain?

Louis: TMJ and oral facial pain is one of the things that scares dentists the most. Actually I did a little video chat that I sent out a few weeks ago saying, "these are the patients that give you diarrhea." These are literally the patients that dentists are scared to death of, because they're not trained to treat it with simple, minimally invasive ways to go ahead and do that.

This is such a typical scenario. We all have been in our practice for a long time. Patient comes in with TMJ, pain, bruxism, even something like that, we give them a bruxism appliance, and they're having some pain. We say, "here, wear this for a few months and let's see what happens." Now I don't know about you, but if I'm in pain and I go to a doctor, when do you want your pain gone, Howard?

Howard: Right now. 

Louis: Right now. No, here's something, wear this for a month, two months, and we'll re-evaluate and see what's going on. Then the patient comes back, by the way, what bruxism appliance do we choose? Whatever our favorite is. We don't give any thought to it. They come back, and you're adjusting it, and the patient's getting worse, or not better, staying the same. They're frustrated, you're frustrated. They spent a few hundred dollars, and you can't wait for this patient to either move or die, because you don't know what else to do with them. 

Or, better yet, you put them in ortho, do a full mouth reconstruction, and their pain is still no better. We've been doing things wrong like that, and that's why dentists are scared to death of these patients. 

When you have 85% of all TMJ head and neck pain coming from the patient's muscles in the head and neck, and in the face, its time to take a step back. These are evidence-based studies that go back years, I go back years for this. How about we take a step back, learn how to identify these muscles, treat these muscles. These are muscles that we work with all the time in dentistry. They teach them in every general dentist oral facial pain residency around the country and around the world. 

Let's teach some skills-based ways to treat this with trigger point therapy, which has only been around for 50 years, and I was lucky enough to learn it in dental school. Botox is great for relaxing muscles. That combination, we get rid of facial pain patients that are coming in with a bag of bruxism appliances from ten different dentists, it's really just amazing. Its not hard, it only takes a few minutes but you gotta get trained, you gotta know what you're doing.

Howard: What percent of dentists do you think do what you just said, use botox, or dermatology, or use botox for TMJ and oral facial pain? What percent?

Louis: I know in our American Academy Facial [states 00:11:50] the AFT, we have over 9-thousand members, dental members. We have some physicians and nurses there as well. A lot of them have gone through our TMJ and oral facial pain training, and they do it all the time so it's thousands of dentists. From a political point of view, there are only in the United States, 300 oral facial pain patients. No wait, say that again. 300 oral facial pain specialists, and I use "specialists" in quotes because its not an official specialty by the ADA recognized or anything like that.

Howard: The ADA's not official either, its a membership club. Remember when the ADA was telling these dentists in Texas they couldn't say this 'cause they weren't a specialty, and it was the Texas board that said, "who even are you? You're not a government agency, you're a club. Shut up, go away." 

Louis: You're right. I know.

Howard: When people say, "well that's not a legal specialty", the ADA's not the government. They're not ...

Louis: Right.

Howard: Yeah.

Louis: No, I'm not saying these guys are not specialists. These people are specialists, but there are only 300 of them.

Howard: Wow.

Louis: Okay?

Howard: What's the website of that?

Louis: Of what? The oral facial pain?

Howard: Yeah.

Louis: American Association I think of oral facial pain, or something like that. The American Academy of Oral Facial Pain. 

Howard: American ... Okay.

Louis: There are only 300 of them, and you take a look of the journal of the ADA that just came out, and it's sitting in your offices, where one out of six patients has oral facial pain. You tell me how 300 people can go ahead and take care of one out of six patients in oral and facial pain. In a lot of places, there's not even an oral facial pain specialist to send them to. 

Dentists need to learn these skills, and they're amazed at how after a few trigger point injections, and there's a real skill and technique to giving them. After you identify these muscles and you give some of these, pain goes away that the patients have had for years. I could show you some frightening stories where patients have had both TMJ's cut off, and put in these titanium TMJ's that they came to an AFE  remember that gave them a few trigger point injections, and their pain went away for the first time in 25 years. 

Its really something that we have got to do. Physicians know nothing about it. We train a lot of physicians. They know nothing, but as soon as the patient says, "TMJ", they say, "go see your dentist." Then the dentist gets stuck and is a little bit afraid of what's gonna happen next 'cause they don't know what to do with them.

People can bounce around. Its about time general dentists can learn to do these things and really do them successfully, and its productive for the practice. It's something that really affects the bottom line there, as well.

Howard: Louis, you put up three of the amazing courses on Dental Town. Advance practice management for dental practice, and the second one, "beyond drill, fill and bill. Treating caries like the medical professionals we dentists really are." The third one, "maximizing office efficiency and time saving through offer dentistry." Everybody just loved them. You really raised the level of our brand of online sea. 

You should do a course on this. I think a dentist from hearing you to joining the American Academy oral facial pain, that might be a big leap, but maybe if you deconstruct it, and put a middle step in the middle, and had a course on that, maybe an hour online sea would make them jump.

Louis: Right, absolutely. We know, the AFT gives full-day trigger point injection courses and botox courses and that kind of thing, but certainly it'd be a great introduction, sure. I'm happy to do it. 

Howard: You're a saint. You really are. Is botox more about TMJ and oral facial pain, or is it more about cosmetics? How should a dentist look at this? Is it a cosmetic thing, or a TMJ oral facial pain?

Louis: It's really about whatever the dentists wants, because you hit on the two aspects of botox and what's been going on. There's nothing special about botox. People get all jumbled up and get all excited, "oh dentists should be doing, they shouldn't be doing botox". All botox is is a tool. That's all it is. It's just a pharmaceutical agent that will relax muscles depending on how much you put into it. 

It affects TMJ and oral facial pain. We get a lot of dentist that come to AFT courses 'cause that's all they want to learn. The problem is that once you're starting to treat facial muscles that also go ahead and affect the patient's aesthetics , you need to know the aesthetic aspects. If you put too much botox into somebody's face, their whole face will fall down and they'll have no control. They'll literally look like they're a martian 'cause they can't move a muscle. You need that balance.

Then some dentists come in 'cause they want the aesthetic part of it. Pretty soon, though, dentists go right between. Botox is always used. There's always this blend of aesthetic and therapeutic uses that you need to know both, before you go ahead and give it. It's a great tool for oral facial pain.

I've been treating TMJ patients, as you have, as everybody has, for years and the frustration has really gone out of it. Now there are defined protocols. Here's how we're gonna go ahead and treat it. If it works, we know it's muscle-based, patient is happy. If it doesn't work, then we know it's not muscle-based. Then we send them to the physician, and to the neurologist, and to other healthcare professionals who know take us seriously because we know what we're doing, and what we're talking about.

There's always a blend. There's never botox only for aesthetics  or only for therapeutics. You need to understand and be trained on the blend of the two. Hey, whatever dentists like. Botox for aesthetics  has boomed in dentistry. I don't know how people do aesthetic dentistry really without it. Botox for muscles, and to relax them and get rid of wrinkles. Fillers to go ahead and fill things in, and everything around the lips and the cheeks and that kind of stuff, it's all part of dentistry.

Instead of talking about as we have for dentistry in a long time, live lines, smile lines, and that kind of stuff. Now we can actually do something about it. We can really control the whole thing, so it's great all the way around. It's important to remember, it's not magic. It's about knowing the muscles, it's about knowing the anatomy. Botox and fillers are just a tool. There's no reason to get all hyped up and say, "oh, dentists shouldn't be doing botox", why not? We use a lot of other pharmaceuticals in our offices and in our practices, because we're real doctors. We've got to get past this, and understand we are real doctors, and it's about time to become that.

Howard: I think the easiest cosmetic procedure that I do is I just turn down the lights, and it enhances my cosmetic ... It's funny because humans are a social pack animal, they're very tribal, and they get very, very mad when someone comes into their tribe and they have a different language, accent, religion, blah, blah, blah. What's so hardwired, frustrating about dentistry is that when you ask about a flu shot, these patients ... Grandma's going to the dentist; she may be going to the dentist more often than any of her specialists she goes to. You try to go to the state board and say, "can dentists give a flu shot?", no. Who stops this? The dentists. 

Louis: Right.

Howard: The pharmacy tech at Walgreen's can give a flu shot? They're not even a pharmacist, they're a pharmacy tech. No education. Give them ten bucks, give you a flu shot.

Louis: Just hired an hour ago.

Howard: Yeah, but my local dentist at the state board are making sure it's banned for a doctor of dental surgery, eight years of college, to give a flu shot. The other one is oral cancer. We're not allowed to give an HPV vaccine. I can't talk to a parent and say, "well your kid's under twelve, let's talk about HPV. It's oral care ..." I already know three dead people from oral cancer, and who's stopping me to give an HPV vaccine? Dentists at the local board, but if you go the physician and they say, "HPV vaccine", the doctor isn't going to give the injection. They leave the room, and a nurse or an LPN or a certified nurse assistant comes in.

Dentists are always the first ones. They get in a circle, everybody has an issue, they get one bullet, and everybody shoots one other dentist for one other issue, and at the end of the day they're all dead. They need to relax. We need to all work together, like botox. 

Who would have guess that the number one people against botox would be our own colleagues at the board? Are you kidding me? Really? I'm humored about that. 

Louis: Let me just tell you one thing about that, because we work really hard with state boards, myself, the AFT. We have trained more state dental board members, and it really just comes down to education and making them really understand. Then you've got to tell dentists that it's okay. Your state board says it's okay. I say this all the time, dentists have a very hard time taking yes for an answer. 

Their minds are just wired to say, "everyone told me I'm bad. You're bad to your assistant, you're bad to front office, you're bad to your patients. You're bad, you're bad, you're bad." Take yes for an answer, my God. Now you have the opportunity to do this. We fought like this for eight, nine years. You can now do this in nearly every state around the country without a problem for aesthetics , for therapeutics all within the scope of dental practice. It all just came down to educating. 

Again, we've had more state dental board members take our course than I think have taken any course in dentistry along the line. It's just about education, but you're right. It's frustrating. We're our own worst enemy, and for no good reason. We really, for no good reason.

Howard: Only one state, Tennessee, are you allowed to give a flu shot.

Louis: It's amazing.

Howard: 49 other states block a flu shot, but you're right. You've always had the right attitude, you've always been a perfect leader. You're the full package. You always see the positive. The glass is half full, where so many dentists I see, the bottom quarter of the glass is half empty. That's amazing.

Louis, I want you to walk us through a patient. A lot of people listening, podcasts are huge because it's a multi-tasking thing, almost everybody listening to these things are commuting to work. Believe it or not, the average commute of my follower is an hour, which is why we do an hour. Before I have you walk through a patient that comes into your office with TMJ, I want to back up a little bit. Why do most TMJ people claim that 85% of TMJ is women?

Louis: 85 to 90%, because that's what the statistics show. That's just what the statistics show. 

Howard: Why do you think that is?

Louis: They have must more stressful lives, they're multitasking. God only knows what it is. 

Howard: That's why I asked you. You are my God.

Louis: I wish I had that power, wow. I wish I had that power to understand it.

Howard: Do you think it's as subtle as they have estrogen and we have testosterone, or do you think it's more environmental behavior of career, kids, husband, stuff? Do you think it's more environment, or do you think it's something as fundamental as over-creasing making of estrogen?

Louis: I think it's all those things. Literally, I think it is all those things. It's just amazing for that. I'll speak in front of a big dental group, and I'll ask them, "who here has had any kind of oral facial pain, TMJ and that kind of stuff?"

First of all it's amazing. Just dental professionals, and this is just my anecdotal by looking at all these crowds over the years. It's probably 70, 80%, and most of them are women. Most of who we employ are women. It's all those things, the reason they happen. You're right, the statistics are so way out there. 

I think a lot of it also is, and I know a lot of people think that men are babies, but I think that men can be a little more tolerant of head and neck pain in terms of they'll just work their way through it. Not so much in terms of other pains around their body, but they'll kind of work their way through it. You do see a preponderance of women, there is no question about it, but it can affect anybody. It really can affect anybody.

Howard: You think men don't have it because after their wife has hit them upside the head with a frying pan so many times that all their muscles are loose and relaxed?

They're probably thinking how does this work, 'cause you made a scenario up. Someone comes in with TMJ, and you're taking an impression, and they they should have the pain out now, but you're taking an impression, you're sending it to a lab, you're not gonna get it back for a week. I want you to walk a [inaudible 00:24:31].

I'm a woman, I come into your office and I want to see you because I have oral facial pain. Describe the average women patient. What are her symptoms, and what are you exactly doing on that first appointment?

Louis: First of all, you are the ugliest woman I ever saw in my life. Lets get that out of the way right now.

Howard: My name's Howeenie.

Louis: Lets get that out of the way right now. The initial entry is no other than any other patient, except you need to take a look at their medical history like you mean it, instead of just looking at it. How many patients come into every patient and they check off headaches, and the dentist says, "okay well let's take a look at your teeth, and just go right by the headaches or migraines or TMJ", 'cause again, they're afraid.

You really need to do a good history. This is done by all of my team members, because I like to be doing dentistry. Anything that's delegate-able  , should be delegate-able . That's one of my big things, and in Dental Town of course you talked about practice management. Use your team, they're intelligent. Train them how to go ahead and do that so they get a really good history. How long have you had it? Where'd it come from? What do you think causes it? What do you do for it, all those different things. A little bit more. They see headache or TMJ checked off, they're gonna have a discussion with them so I have it all by the time you come in.

Then you come in, identify it, point to it, and then we do, in addition to all your dental exams, and everything else, radiographs, everything you're supposed to do. We go ahead and do a muscle examination, but not the little muscle examination where doctors go over to the patient and just poke and feel, as if to say, "okay, you really do have these muscles." We've got to identify the pain, and not only that, we want to try to recreate the pain in the office.

The way we're gonna do that is really push on muscles. Everything from the shoulders on up. This is a really good muscle exam. How hard are we gonna push on these muscles? Again, a lot of patients will go, a lot of dentists will go, a lot of dental professionals go, "yeah, it's right here on my shoulder. It's right here." They're pointing you to where the trigger point is. What we're gonna do is we're gonna go ahead and do a really good trigger point examination on these muscles by ... And you can do this yourself, Howard. Anybody doing this, again, if they're listening to this and they're driving, don't do this while you're driving 'cause you need two hands.

Take the palm of one hand, your thumb of the other hand, push against that palm until you actually blanch the skin, and then let off. That's about four to eight pounds of pressure for about six to ten seconds. I'm gonna really push on that. Patients are gonna say, when I'm pushing on their Trapezius , if it's a recognized trigger point, they'll say, "yeah, yeah. I feel that in my jaw." Trigger point pathways, literally are these pathways that were identified by Janet Travell MD, and a thick book years ago. We just follow a classic trigger point pattern exam, and if we can recreate that pain, then we know exactly what muscle is causing it, and then we'll go ahead and do a trigger point injection.

Typically with botox you can do it with litocane, but the trigger point injection is to go ahead and get rid of that. Literally sitting in the chair, if you've identified it and it's real, the patient's pain will start to go away. You can recreate the pain, and you can make it go away. I'll do this all in one appointment because this will show the patient that we can really do something.

Then you get into the bruxism appliances, but one important aspect of this is again, we're into total treatment, and what we teach a lot of is dental sleep. Dental sleep causes bruxism, a lot of bruxism is tied into TMJ and oral facial pain. Before they leave that day, they're coming in for treatment and we get ready to send them their pain, they will go home with their bruxism and home-sleep monitor, and this is distributed in dentistry by Stat DDS. The Stat DDS bruxism and sleep monitor, and they're gonna take an overnight sleep study, but it's the only one that also measures bruxism.

Bruxism affects one out of three patients. We know that for years. The studies go back years on that, and it's the most common dental disease and the only thing we don't measure. You wouldn't treat perio without a pro, you wouldn't treat endo with an x-ray. It's the only thing we don't measure. Now we have, with technology, the capacity to treat it. You don't really check for sleep. Sleep is amazing. The whole dental sleep medicine thing, which we're all for, which we teach in the AFT all the time, but it's amazing. 

It's a medical disease that requires a medical diagnosis. No dentist can go ahead and treat sleep without that medical diagnosis, and yet we're testing for it. Well I'm gonna suggest you test for bruxism in sleep, because I can treat bruxism, and I can diagnose it. Now I can talk to any sleep provider. We find a lot of patients with TMJ oral and facial pain have bruxism, a lot of that bruxism comes from airway issues that are sleep issues. It's really the whole package together.

By the time you're done with that ... If I'm injecting them in the face because they got some trigger points, and I'm using botox, I gotta make sure they look good. Really the mantra in the AFT is "make your patients look great, feel great, and sleep great", and not necessarily in that order. I'm gonna evaluate their TMJ oral facial pain. It's related to sleep, it's related to their looks, it's related to bruxism, so I'm gonna do all of that, but now it's a systematic protocol that I'm gonna put the patient through, instead of just guessing here and just guessing there. That's gotta go out the window. You can't just be making bruxism appliances for patients without knowing what you're doing, without a plan here. 

Howard: If you just treat the bruxism and you're not getting a sleep diagnosis, the sleep apnea can be dangerous for you.

Louis: Right.

Howard: You can die from sleep apnea.

Louis: Absolutely. Most bruxism comes from sleep. That's the amazing thing here.

Howard: You said there's only one monitor that can measure bruxism and sleep, and that's you said Stat DDS. Is that www.STATDDS.com?

Louis: That's it. It's the only one that ...

Howard: One T, S-T-A-T, just one T? Stat? DDS.com?

Louis: Yes. Just the way it sounds. S-T-A-T D-D-S.com

Howard: How much is that machine?

Louis: That machine's $5-thousand.

Howard: Wow.

Louis: It's about the cost of any home sleep monitor, is what it is.

Howard: Dennis won't buy anything unless it's $50-thousand to $150-thousand. 

Louis: I'll tell him to go raise the price.

Howard: If they raise the price of that to $150-thousand, they'd sell 10-thousand tomorrow. If this thing had any value, it'd be worth $100-thousand.

Louis: 'Aint '  that the truth.

Howard: How long is Stat DDS ... tell us about that. What city is that at? How long has that been around? Who's their key opinion leader, Dennis? Tell us the Stat DDS story.

Louis: Right. I'm probably their key opinion leader, because ...

Howard: Well then how come we don't have an online course on it from you?

Louis: Yeah, we can. 

Howard: Would that be part of your botox, TMJ, oral facial, Stat DDS?

Louis: It's what we call, in the AFT, we call it the circle of treatment 'cause they're all related. Facial aesthetics , facial pain, and the sleep are all related into one circle. So many patients come in at different parts of that circle. If they want to look great, I'm a dentist, I can help them because I've got botox and fillers. If they come in for pain, I can help them because I've got trigger points in botox. If they come in and sleep because they snore a lot and they heard that there's an oral appliance, I can help them but they're gonna come into that circle and they're gonna be part of everything. It's all about looking great, feeling great, and sleeping great. They're all related. If you don't sleep great, you don't look great, you don't feel great. If you don't feel great, you don't look great. You're usually not sleeping great. It's all those different things together.

Stat DDS is a dental company that pretty much grew ...

Howard: What city are they out of?

Louis: They're also in Cleveland.

Howard: Oh, they're in Cleveland?

Louis: Yeah, they're in Cleveland, and they pretty much grew on the ankles of the AFT. The AFT started growing and the AFT needed botox syringes and this and that. A group of young entrepreneurs ... The AFT has gotten so big, knock on wood, that they're servicing a lot of the AFT members. There was a need for bruxism and sleep monitor, so there is a distribution company for that. There is a need for PPO management, and there's service companies, medicare enrollment, they do that. We could spend literally an hour on ten different topics over the next year if you want for that. 

Now, the AFT is getting into implants, teaching general dentists once and for all how to go ahead and do implants. Stat DDS will be the distributor of products for implants and that kind of thing. That's how the growth of that company has come along. Pretty much on the ankles of the AFT and everything that we do as an education company. 

Howard: You know what's so funny? You know how many times I've had this conversation where dentists go, when you talk about sleep apnea or whatever, and they roll their eyes and say, "there's no market for that. You'll spend all your time. There's no market for it.", then I'll say, "oh well do you know so-and-so who's five miles from your office?" He's like, "no." I said, "well now that's all he does. He's full-time with that. He doesn't do root canals or anything else anymore. He's a full-time sleep only ..."

There are so many dentists who now only do this while there's dentists across the street that don't even want to learn it 'cause they said there's no market for it. I'm like, "dude, in your state, there are people that now just specialize in this and that's all they do", and you just said your association has 9-thousand members.

Louis: Right. I'll tell you, my opinion on this whole thing is dentists can do whatever they want to do. They can do whatever they're successful with. For me, the way I like to practice is I like to do a lot of things in the office. Me personally, I don't want to be sleep-only practice 'cause I like doing crowns, bridges, implants. I like doing that. I like doing some botox. It's like the dentists that tell me, "I don't know. I learned to do botox, I can't find a patient." Man! It's the number one aesthetic procedure in the world and you can't find a patient? How about telling some women in your practice that you do it. 95% of women do all the aesthetics  in the world. I bet you you can find some bait. What can I tell you?

Howard: It's also how the dentists doing the most Invisalign , usually are the ones doing them first for free on their hygienists and receptionist and assistant, and then when the person says, "can you wear the tray at work?", and they're like, "I'm wearing my tray right now." 

Louis: Right.

Howard: The dentist should be able to get ... He's got a couple assistants, hygienists, receptionists, spouses, wives, sisters, in-laws. People who don't have one positive Yelp review, I'm like, "dude don't you have a mom or a sister? Really? Nobody loves you on earth? You can't find one buddy from college? Nobody will write you one good Yelp review?" What went wrong in your life when your own mother won't write you a Yelp review? Wow.

Louis: Some dentists think it's unethical to actually ask the patient to write a nice Yelp review. That's not unethical. That's good business. People ask me and you for Yelp reviews and all those kinds of stuff. It's so funny the way dentists are. You're right, there are lots of sleep patients. There are 40-million people there, and 90% of them are undiagnosed. You're right. The challenge is sleep is a medical diagnosis. The AFT model, and the model that really I teach so much is go through it through bruxism. 

Fact, by the way, dentists are much more comfortable wit bruxism. Most bruxism is related to sleep because of airway issues, nocturnal bruxism. Lets do something we're comfortable with. Lets test for bruxism at the same time we're testing for sleep. That keeps you within the scope of practice so that the state dental board can never call you and say, "hey I hear you're only treating sleep. You're diagnosing sleep? You're in trouble, you're practicing medicine." No. I'm practicing dentistry because I'm also measuring bruxism. We have a huge different take.

A lot of dentists have been trained on sleep and they've done nothing with it. They've made investments of 20, 50, 100, $150-thousand, just like you said. They love to make those big investments. You've got to do something with it. Not that a big investment is bad. Don't ever hear me wrong. Just like you said, but you gotta know that you're the right practice, you're the right dentist for it, you're gonna go ahead and use it. To get started, you don't need anything more than a $5-thousand investment, and then just getting trained on it. Then you can see it's for you. Then you can see.

For us, we see a lot of interplay between TMJ, bruxism, sleep, and facial aesthetics  and dental aesthetics . We see this all the time. If you're not looking, you're right. You're never gonna find a sleep patient. Once you learn how to look and understand it, it's all about education. This is exactly my point about us really being doctors. The truth of the matter is physicians know nothing about TMJ. They know very little about sleep, so we can really be leaders in this healthcare field.

Howard: I hate it when you learn a lot of time learning something and don't do anything with it. I read an entire book on vegan-ism. I didn't do anything with that information. I want you to start with how does this machine measure sleep and bruxism, and then I want you to talk about what is the connection between sleep and bruxism? How does Stat DDS measure that, and how is sleep apnea related to bruxism?

Louis: It's pretty simple. All of us deal with their rate. Here's where I'll get to a bruxism issue in just a minute that I hope will scare the pants out of every dentist that's going ahead and listening to this. 

Sleep issues, obstructive sleep apnea, that's the big one that everybody talks about, OSA. All that means is when people fall asleep, their tongue falls back, it blocks their airway, they don't sleep, oxygen's not getting to the brain. They'll wake up twenty times a night, they won't get good sleep because they're not getting oxygen. That's pretty much it. They wake up in the morning, they're very tired, they're very sluggish, they're irritable. All the things like any human being almost wakes up in the morning with. A lot of people have this problem of obstructive sleep apnea.

Lets get to how it's related and then I'll tell you a little bit about how this monitor works. Why is bruxism related to sleep apnea? It's pretty simple. What's the brain's mechanism for getting people to open their airway when they're asleep? You fall asleep, your airway's blocked, oxygen's not getting to the brain. The brain sends all of it's signals to the Masseter  and Temporalis muscles. You remember those muscles? That's all dentistry, right?

Howard: Yeah.

Louis: To say move the jaw forward, you've got to open that airway. One way to move the jaw forward, and everybody's been trained in CPR is the jaw-thrust. Neck extension jaw-thrust opens the airway, and the patient literally, if they have obstructive sleep apnea, will take this rescue breath all of the sudden. They'll fall back asleep, they'll stop breathing. Jaws will start moving. 

You and I know that when the Temporalis and masseter start moving the jaw forward, that technically is called bruxism, and people can do it 100 times a night, and they can really do it very aggressively as you know. These are two of the biggest muscles in the head and neck, and the produce a lot of force.

The patient wakes up the next morning, wakes up and their jaw hurts. They come into the dentist office. The dentist says, "what's the problem?", "oh, my jaw hurts, here." "oh, you must be bruxing, here's  a bruxism appliance." Never asks about sleep. If it's coming from sleep, then you need to know that information. You also need to know how many times a night they're bruxing to really see if it's destructive here. 

Let me just give you the nightmare scenario that we found a lot, then I'll tell you how this test works. The nightmare scenario that we find all the time is patient comes in, "my jaw hurts". "Well, you must be bruxing at night.", "Why do I brux at night, doctor?" "I don't know 'cause at night your brain's asleep and your jaws just go crazy. You may have an occlusal interference that's causing your jaws to go crazy at night for that", and then makes them a bruxism appliance.

Their bruxism is clearly coming from sleep, many patients. If you make them a bruxism appliance that shoves their jaw backward like an anterior plane appliance, you have now just done what do their airway, Howard?

Howard: Closed it.

Louis: Closed it more, right? Now they go back home, they're wearing this appliance. Now they're really uncomfortable 'cause they're getting less oxygen at night. You've closed their airway, not opened their airway. I'm the dentist, I didn't know. What do I know about the airway, right? We can't claim ignorance anymore. Before you ever make a bruxism appliance, is the way we teach it because at this point you're getting the point where this could be called malpractice already, you go ahead and you test them for bruxism, and for sleep, and you see what the issue is. All this is is a monitor that sits across their chest. A couple of belts, very similar to other sleep monitors, but it's a medical-grade. 

They use this monitor at the [Mayo 00:42:02] clinic, at the Cleveland clinic, at really big sleep laboratories and medical centers around the country and around the world. There's also an EMG patch that goes to their masseter muscle. A patient presses a button before they go to sleep on the unit, and it measures their sleep but it also measures how many times they brux a night, and how hard they are bruxing. It measures both the duration, the intensity, and how many times they're doing it. 

Now I have some objective data. Everybody goes crazy with evidence-based. Now I have some evidence-based data on this patient. I've measured their bruxism. Now whatever treatment I do ... By the way, go straight by the numbers. I could certainly do a course for Dental Town on this. You go straight by the numbers. If their numbers are this much bruxism, this is the kind of appliance you make for them, and this is what you should be doing. Should you be doing botox or TMJ? There's a whole list.

Stats DDS has a report that they give to doctors based on the readings of this monitor that they do this, 'cause that's part of the service they provide for the people that have this monitor, that will tell them, "this is how much the patient is bruxing. This is the kind of appliance you should go ahead and use for them. These are the appliances that are not good for them. These are the kinds of restorative materials that can withstand their bruxism, and you should consider this treatment option, this treatment option, this treatment option. Now a dentist sits down with a patient, they have got an objective, evidence-based report on that patient, that the patient looks at and is much more likely to go ahead with treatment. That's pretty much how that works.

A patient can take home this monitor, wears it at night, brings it back the next morning, and in our office and I know many AFT member offices, they bring it back the next morning, it's got to be by 9:00, 10:00 o'clock, 'cause I have the next patient that this is going out with. We have many AFT member offices that have four or five of these monitors. Like you said, I guess they wanted to spend at least $125-thousand right before they got serious about it.

They're really cooking with this, but they're doing better dentistry 'cause they measured the bruxism. It's pretty much it. Do you like it when an implant fails, or crown fails, and we say, "well the patient's bruxing". Well, great. How do you know they're bruxing? How much are they bruxing? How do you know if you did something for that bruxing that it's working? Now you can measure it, just like you can measure a perio-pocket.

Howard: For the bruxism part, is that pad attached by a wire? Does it go to one side of the face or two?

Louis: Yeah. It's an EMJ patch. One masseter, and it leads right into the monitor, and the monitor is pretty much a hard drive, and the software just measures all the bruxism at night. It's amazing when you see these reports, 'cause you can literally see when they brux at night, many times it's directly related to when they have an apnea, when they stop breathing. Then the brain says to the Masseter , "start grinding", then you see this huge spike of bruxism. Then they start breathing again, and it repeats itself, 20, 30, 100 times a night.

Now this takes out the mystery of a patient that comes in and says, "my neck. My jaws are hurting." Why are they hurting? You must be bruxing. Oh you must have an occlusal interference. I'm not knocking occlusion. I'm all about occlusion. We do that all the time, but some of this nonsense that we've had that's got no evidence behind it, for years that people have bruxism or TMJ 'cause they have a few occlusal interference. 

I like occlusion 'cause it saves my dentistry. I need it for good dentistry, but it's not the cause of oral facial pain, that's  for sure. You've got sleep, you've got muscles that are much more the cause of TMJ and oral facial pain before that. Our big, for us in the AFT is, measure the darn thing. Why are you even making a bruxism appliance when you have no clue what you're doing? We don't guess at anything else. We don't guess. A patient will say, "it hurts somewhere down here", and we'll be measuring and knocking on teeth, and doing ice cold tests on teeth to find the right tooth. We don't go ahead and do five endos, unless you want to build your practice you can do five endos. We don't do this in any other aspect. It's about time we've become real doctors when it comes to bruxism, TMJ, sleep, and you'll do better dentistry. If that patient is bruxing, whatever you put in their mouth has no chance of survival, and that really frustrates dentists too, right?

Howard: I think the occlusal people are funny, because if you listen to their religion, doesn't an orthodontist blow out the Curvis B, the Curver Wilson taken from K9 dines, to group function. We have 10-thousand dentists called orthodontists doing everything the TMJ people say won't work. Yeah, there's something more to it then how the teeth touch down.

Louis, do you charge the patient to take that monitor home? Is that a cash deal? Does insurance cover that? If you buy a $5-thousand machine, you come into my office, I send you home with it ... Is there a fee for that?

Louis: That's a great, great question. AFT members have used different models. The model I always use in my practice is I don't charge a thing for this, because first of all the consumables to go ahead and do the test, once I own the machine ... And you can rent the machine. Stats DDS will rent the machine so you don't have to have a big cash outlay. You can buy the machine with whatever you'd like to do for that.

For one of my offices I think we rented, one of my offices we actually bought the machine. It doesn't matter. For me, I'll tell you my model. You can charge for it, you can try to charge medical insurance. To me it's just not worth it. I like to open the doors. I'm gonna test everybody that I think needs testing for less than $20 in consumables, that's what it costs me to do the test. 

Listen, I'm an experienced dentist, as are people listening to this. You know if the patient's bruxing. You can see the evidence a patient is bruxing. How many times do you tell a patient, "hey you're bruxing. You need an appliance.", and the patient says, "no, I'm not bruxing. I'm just fine." He's got these tiny little teeth, and he can eat chewed steak with all of his front teeth with no problem, and he'll tell you he's not bruxing. 

You know what, let's measure it. I'll just give him that to take it overnight, because it's gonna give me data to do more dentistry. I know I'm gonna get at least a bruxism appliance which is $5 to $600 in our offices, and that's pretty much a national fee. I make it an oral appliance which is $2-thousand, $3-thousand, $4-thousand, depending on the appliance I'm making for him. It has boosted our production like crazy.

I'll tell you something really interesting. It's something that we could do because we're a member-based organization, the AFT, and because we teach these skills, we've been able to measure. Dentists that have gone ahead and taken the AFT bruxism and sleep course, TMJ, and botox and fillers, we did a member survey of people that have been doing these services for over a year and a half; only those members that were doing these, and they boosted their practices by $26-thousand on average per month. Some more, some less. 

Then we did oral appliances, we did just botox, we really put some of this out. Oral appliances, in my own office, we've quadrupled the number of bruxism appliances, just bruxism appliances, just by testing people. Now we're doing anywhere between five and ten oral appliances a month. Depending on the practice and the associate, we have AFT members that are doing 25 appliances a month, 'cause they got four or five units and they're really chugging this out.

I like to not charge patients. I don't want to give them a reason to say no. I know this is gonna end up in the bruxism appliance at least, if not more dentistry oral appliances. I'll tell you this, I don't do an implant case without checking the patient's bruxism. Who in the right mind would put in ten implants, five implants, three implants, without knowing how much the patient bruxes, if and how much they brux. I don't do a unit of three units or more without checking bruxism, because I don't like failures. Neither do you. I hate failures on a ten-unit case. That's really frustrating. 

Let me take bruxism out of the equation by measuring it, treating it before I go ahead and do it, with occlusal, or full abrasion, with all the other stuff. It's a simple, overnight test. It doesn't take any time in your office. You teach the patient how to do it by a YouTube video or by auxiliaries. They give them to you the next morning. Now I've got real data on this patient. It's changed the way we practice dentistry certainly in the AFT and certainly  in my own practice. 

Howard: I think a big thing that Stat DDS should do is find out how many units they've sold to how many dentists, and how many of them went back and bought a second machine. I know several dentists that do now have like five of them. If that's not proof that this can work in somebody's office I don't know what is. 

I want to ask you a couple questions. You still see debates by dentists and hygienists. You have a lot of hygienists listening today, that when they see abfractions, they think it's from the toothbrush. 

Louis: Right.

Howard: Talk about the difference between abfraction on a toothbrush versus bruxism grinding?

Louis: Right. And/Or gird, and/or any kind of acid reflux and that kind of thing. It's funny, and only with you will I say stuff that's politically incorrect, 'cause you and I freaking talk to each other like the brothers that we are, right?

Howard: Right.

Louis: Well, evidence-based ... Listen, abfractions is a great example of this. When you and I were in dentistry, and growing up, and in dental school, abfractions with toothbrush abrasion, that's what's causing it. It was evidence-based science. Everybody accepted it, right? There were studies up the wazoo. How in the world did we ever believe that abfractions come from tooth-brushing when nobody brushes their teeth? You would think that patients are such great brushers, they've actually wiped away a tooth structure. It's pretty much ridiculous. I used to believe it a lot, but when you start to see ...

Howard: You know who corrected the dentist on abfractions?

Louis: Who?

Howard: It was the veterinary dentist. They were like, "dude, we see these on all the animals and they don't have toothbrushes." It was actually veterinary dentists that they learned this.

I want to ask you another question. Sometimes dentists get a little anal, but they get mad when you say TMJ 'cause they want TMD. How does the American Academy of facial aesthetics  solve this issue that the B to C consumer market, they branded TMJ? Then the anally-retentive dentists are saying, "no, it's TMD." Is it TMD or TMJ on your website or social media?

Louis: We call it TMJ. You know why? That's what patients call it.

Howard: Right.

Louis: I'm gonna talk to patients' language, it's ridiculous. It is a funny thing, I've got to say. TMJ is a part of the anatomy, but now we treat it ... It's the word for the disease. If you go to a doctor and you say, "I have a knee problem", you don't go to the doctor and say, "you know I have knee", right? Of course I've got knees, right? TMJ has become the disease, but it's the way patients talk. Of course talk that way to patients. You're right. 

Howard: The American ...

Louis: Say what you mean. It's ridiculous. It's called TMJ in the consumer. It's amazing. The AAFE, the American Academy of Facial Aesthetics website, facialaesthetics.org is really built for physicians, nurses, dentists. There's components for everybody. Certainly it's big with dentists because everything we do in dentistry. I can't tell you how many consumers come to that site. It's incredible, looking for information. Of course we call it TMJ. Why? I've heard that from dentists sometimes. I've heard it derogatorily, "well of course, the AFE calls it TMJ when it's really TMD", what, are you kidding me?

I'm trying to build practice. The only way to do that is talk to patients' language. You've said that many times. A dentist will be with their radiographs up against the screen talking to the radiograph, telling the patient, "you've got this and this and this", using all kind of technical language. It's ridiculous. That's just a ridiculous way to think about it, but dentists will be dentists, right Howard?

Howard: What percent of dentists do you think are so anal you could sharpen a number two pencil in their rear-end.

Louis: Automatic, automatic.

Howard: Right? Automatic. You're right, you've got to speak the language. By the way, what are your thoughts on gird, since you opened that can?

Louis: Oh yeah, certainly something you need as part of your medical history. It's something that if you see, it's gonna dissolve teeth. Again, why would you put in a bunch of restorations, a bunch of crowns where gird gets to the margins and eats away at it? Certainly it's something that the patient needs to ...

Howard: You know what I heard from the holistic alternative people, and I tried it, and it absolutely worked on a patient? It's so counter-intuitive, but a shot of vinegar before you go to bed in your stomach. In the morning they wake up, and instead of regurgitating and gagging and brushing their teeth, brushing and gagging, and I swear patients swear by it. Just apple vinegar, a shot of this. You would think that acidic nasty-tasting vinegar would actually make you want to just throw up, and I swear patients swear by it.

Louis: I'm good for whatever works. 

Howard: Yeah, yeah.

Louis: Scotch or bourbon for me, but I'm good for whatever works.

Howard: They need to come out with a vinegar made by Jack Daniels. I'm telling you, that is the main thing. Louis, you are so amazing, and you're alwayss so upbeat, and you're always so full on fire. I really hope you make this online course 'cause to explain the Stat DDS, how that works, the bruxism, the botox, the facial aesthetics, are you gonna be able to do that in a one-hour online course, or do you think that's gonna be two hours, what do you think?

Louis: It could be whatever we want. It could be a series of courses. I'm all for it.

Howard: Are you up for that?

Louis: Yeah, absolutely. I do it all the time. I'm happy to do it for you.

Howard: You are an amazing man. You're just an amazing man. Anything else you want to close with? They've got the Cleveland clinic, they've got you, what is it with Cleveland and research based science?

Louis: We've got Lebron. Don't forget about Lebron, we got basketball season coming there again. Cleveland, we've got a  very, very strong, strong medial community here. It's something that I've been proud to be a part of for a long time. It really does. There's a ton of research. We keep building new hospitals and research centers. I actually am on the board of medical foundation that just gave a $10-million grant. Case Western Reserve Medical School is building a brand new school. Medical, dental, nursing all together, so we're really into integrated medicine, medical-sciences and that kind of stuff. It's just my upbringing.

Certainly we've really patterned the AFE along those lines. Really bringing everybody together under the same umbrella, 'cause it's amazing how much we, as dentists can learn from physicians, but even more amazing is how much physicians learn at dentists, at our courses. They are just blown away. At a TMJ and oral facial pain trigger point course, we will have a general dentist sitting and standing next to a neurosurgeon who's coming to learn how to do trigger point therapy, and they talk like they've been buddies.

Its funny. Physicians can look at dentists and say, "hey, these guys really know what they're talking about.", but like you said other dentists will look at them, "oh you got to stop doing that, we're just teeth mechanics." That kind of thing. We're all into that in Cleveland. Certainly  it's the philosophy of the AFE as well. 

Howard: These podcasts are always listened by someone downloading from all 206 countries. Tell the international viewers, you're on one of the five great lakes. Cleveland, Ohio, what lake are you on?

Louis: We're on Lake Erie. 

Howard: Lake Erie. Does that freeze over to where a car can drive on it in the winter, or not really?

Louis: Oh, no. We're not quite that cold. We're in something called the snow-belt, so that lake acts as a snow machine sometimes. You could wake up in the morning and have two feet of snow because of the lake action on there. That's why I travel so much in the winter giving courses, because I hate being here in the winter. I'm getting too old to fight that snow.

Howard: I remember one of the greatest dinners I ever had. I was lecturing in Cleveland and some dentist came up to me and goes, "you fly out tonight?", and I go "no, first thing tomorrow morning." He goes, "what are you doing for dinner?", I said, "no plans." He said, "you want to come to my house? My wife makes the best spaghetti in the world." I said okay. He lived on the lake.

Louis: Yeah, right.

Howard: That was the most beautiful view. We sat there on the porch eating spaghetti, killed a bottle of wine. It was just ... My God that was gorgeous.

Louis: Cleveland is a great place to live and it's a great place for sports, even though we never quite do as well, but we also have ...

Howard: What's the bigger town?

Louis: The Ohio State Buckeyes, so our Buckeyes keep us interesting.

Howard: What's the bigger city, Cleveland or Cincinnati?

Louis: Oh, Cleveland. Well, at least in Cleveland's eyes, Cleveland's a bigger city.

Howard: It's a bigger city? Okay. Well hey, we're out of time. It's been an hour, Louis. Thanks for being, you've been an idol of mine. We've lectured at the same convention so many times in the last 25 years, and I just think you're just a hell of a guy from A to Z. I do. I just think you're a role model from A to Z. I love your amazing mind. The books behind you explain all. Thank you so much for spending an hour with me today.

Louis: All right, right back at you, Howard. We really appreciate it. We'll see you again.

Howard: Tell your lovely wife I said hello.

Louis: Okay, I sure will.

Howard: All right. Bye-bye.

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