Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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212 Hygiene Today with Deborah Levin-Goldstein : Dentistry Uncensored with Howard Farran

212 Hygiene Today with Deborah Levin-Goldstein : Dentistry Uncensored with Howard Farran

10/30/2015 2:00:00 AM   |   Comments: 0   |   Views: 553

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A veteran of dental hygiene education, Deborah Levin-Goldstein shares how to master your craft as a hygienist.



Deborah Levin-Goldstein is a graduate of the University of Pennsylvania and Columbia University.

She has been a dental hygiene educator at Northampton Community College in Bethlehem, PA for thirty-three years.

Deborah has presented numerous continuing education courses on a variety of topics to dental and dental hygiene societies as well as Dentaltown in 2013.

She has published in the Journal of Dental Hygiene and is a contributing author for six chapters in the textbook, Head, Neck and Dental Anatomy, fourth edition.

Howard: It is a huge honor today to be interviewing Deborah Levin-Goldstein who is an extremely accomplished dental hygienist. It’s just an honor that you spend the morning with me. How are you doing today?

Deborah: I’m fine, thank you. Thank you for that nice complement.

Howard: You live in Bethlehem, Pennsylvania right?

Deborah: I do. That’s where I teach. Yes.

Howard: That’s … How far is that from Philadelphia?

Deborah: About an hour and a half north of Philadelphia.

Howard: You teach at the hygiene school there?

Deborah: Yes. There’s a local community college and I teach there, yes.

Howard: How long have you been …

Deborah: 34 years. 34 years.

Howard: 34 years, wow. That is amazing.

Deborah: I got a job at a graduate school. I graduated in May and I started teaching in August.

Howard: Of what year?

Deborah: 1982.

Howard: 1982. I would have been a sophomore at Creighton University.

Deborah: Well, I’m just a little bit older than you Howard.

Howard: No, really, we’re about the same. I know when we can’t tell, I’m 53. What do you think of the dental hygiene as a profession today? You always see … After the 2008 depression and it really was a depression, the [1970 00:01:21] depression, they try to save the dollar and they lost quarter of the banks and we had one third unemployment from 1932 to ’36. In 2008, we had the same depression, but they realized from their mistake in 1970, they gave up the dollar and they printed six trillion pieces of paper and recapitalized the banks and it was crazy, but since then …

Since Ronald Raegan’s free trade, we lost 50 million manufacturing jobs, men have been pouring into healthcare because it’s 17% of the economy. We lost most of our manufacturing and jobs in construction. It’s amazing to me. Right now, I have four dental assistants, two are men. I just go into … My office manager’s a man. I go into … When I go to the doctor and get a physical, are you seeing men entering hygiene school?

Deborah: Yes, we’ve had one or two per class over the past several years. I can’t say it’s been any record numbers. We do see a spike in the amount of students we admit. That stays constant at 40, but the number of applicants goes up. We can be anywhere from 200 to 300 applicants for 40 spots. That’s been consistent ever since I’ve been a teacher at the college,

Howard: They have two years of undergrad requirements then they go to your program for two years or do you just do a A to Z four year program?

Deborah: No, it is not a four year program, it’s a two year program. It’s an associate in applied science. They can actually do everything in two years. It’s a very busy two years, but they can … Most students take a year of general elective science courses, bio, micro, chem, and then they come into the hygiene program. It’s essentially a three year program for most students.

Howard: What is the cost these days?

Deborah: Oh, the tuition, it depends upon where you live. If you live within Pennsylvania, it’s a little bit cheaper, but because we’re very close to the border with New Jersey, we get a lot of individuals from New Jersey coming into Pennsylvania. I would say it’s probably anywhere from $2,000 to $3,000, $4,000 a semester. It’s much cheaper at a community college.

Howard: To give away our age, are most of the ones from New Jersey, they’re young … Are they Bon Jovi fans, or Bruce Springsteen fans?

Deborah: Well, that depends. There are some older women who come back as a second career after their children are older and have gone to school and there are a lot of younger students who just feel hygiene is a good stepping stone. They want to combine hygiene with maybe office management. I have a student who wants to do that. She wants to run an office, but do hygiene a couple days a week, which is a great …

Howard: How much money does it actually cost?

Deborah: To go to school?

Howard: Yeah.

Deborah: I would say probably for the two years, it’s probably between $8,000 to $10,000.

Howard: That’s it for two years? $10,000 for two years?

Deborah: Yes. Many …

Howard: Holy moley.

Deborah: Most of our students get jobs. They’re getting recruited by big corporations now. Heartland, Aspen. They’re recruiting our students. In fact, I just talked to my director yesterday and said we got to get those companies in here to tell our students what they’re looking for in professional hygienists?

Howard: I’m friends with … They have Heartland out there. Do they have Pacific Dental Services out there?

Deborah: No.

Howard: That’s a west coast …

Deborah: Aspen, Smile Builders.

Howard: I’m not very familiar with Aspen. I’m really familiar with Heartland, because I’m really good friends with Rick Workman. You send me an email, I’ll reply to you and CC Rick. You tell me what you need them to do. I’ll reply it back to rick and it will be done today.

Deborah: Thank you, because they’re opening some offices not far from us and students are looking for full time jobs. That’s what they want. They want to recoup their losses after hygiene school and go from there and take off. When you mentioned the 2008 depression, we saw real spike in students trying to get into the program, because they’re looking for a quick fix. The community college is like a quick fix. They say, “Oh, two years, I can do it in two years. It’s not that hard.” There’s only 32 teeth and they realize sometimes what they’re getting into. Most students are very successful, graduate and do well.

Howard: What do they get in an hour, when they get straight out of school?

Deborah: I would say $29 to $35.

Howard: Wow. $29 to $35. Do you think that’s held steady over your, for real wages in your 30 years at it, real wages or do you think the wages are drifting downwards, staying flat or drifting upwards?

Deborah: I think they’re drifting slightly upwards. The closer you get to either New York or about two hours west of New York city, the closer you get to New York city, the more money you’re going to make. The closer you’ll get to Philadelphia, the more money you’re going to make. In the Lehigh Valley, where we are, Allentown, Bethlehem and Easton, we flooded the market with hygiene students. The job …

There’s not a lot of fulltime jobs, a lot of students get multiple part time jobs, but students are looking for full time jobs with benefits. That’s what they’re looking for. They’ll go to companies like Heartland, Aspen, Smile Builders, work a couple of years, get some experience and then maybe move into a private dental office.

Howard: Are those two guys in the class or they’re just there looking for a hot woman with a great job?

Deborah: No. one unfortunately is engaged to a lovely girl and one dropped out. One it was not quite what he expected and I think it was just a little … Sometimes, it could be too challenging, but we had many male students, young and old, come in the program. I’m thinking of one graduate about three years ago. He’s doing fantastic. He’s doing very well.

Howard: The reason I said that is my dad’s brother mike, he’s still alive, the only reason he went to nursing school is because when they got out of high school in Parsons, Kansas, my Aunt Shirley went to nursing school and he still hadn’t scored a date with her. He always signed up for nursing school so he could sit by Aunt Shirley and it took another three years. She wouldn’t go out with him until the third year of nursing school and then they graduated together, he became the first male nurse. He still tells everybody this day, “I never wanted to be a nurse, I just want to marry your Aunt Shirley.”

Deborah: We did have a student who followed another student into our hygiene program. He later became a hygienist, but I think it was because of that other female student, but he did very well among the female students for a while.

Howard: These podcasts are being devoured by dental students. I hope that if these dental students have younger siblings that are thinking about going to dental school, I thought the dumbest move I made in dentistry is when I got to dental school, there was a hygienist in the class. They learned about everything all the way up to perio, they just had fillings, crowns and root canals, they had learned it all, they didn’t have to study nearly as much, but what was unbelievable is that when …

We had a part time job, I was parking cars or working at Walgreens for $3.50 an hour. Back in the day in ’84 and ’87, they’re making $20 an hour and get eight hours in on Saturday and then they had connections to all the dentists and they knew all the specialists. They had jobs lined up. One of my physician friends, he knew that path too. He became a phlebotomist, then a registered nurse, then a medical doctor. He already … We’re doing the hospital rotations, he’d already lived in there for four years.

I just can’t believe that I went to Creighton University and was doing some undergraduate, biology, chemistry, psychology, all these things that you’re never going to use ever in your life. My friend up the street, he’s a math major, I ask Tom all the time, I said, “You ever used math one time in dentistry?” he just rolls his eyes like, “I don’t know what we were thinking.”

I think being a hygienist is the ultimate undergraduate degree if you really want to be a dentist or whatever. How is … What are your thoughts on the future, how is dental … Let me say this, how has hygiene changed from when you walked into it to today?

Deborah: Oh, it’s changed tremendously. Just the theories on the immune system, perio, dental materials are radically different than from when I went to school. Completely different. We used to do what we call, what was ‘a gross scaling’ we don’t do anything like that anymore, but I give anesthesia now. In fact, we’re teaching students to do anesthesia. There are a lot of new products. I think it’s, to me, it’s completely different.

Howard: I think it’s a great step forward that we can give, the hygienist can give anesthesia, give anesthetic in [inaudible 00:10:47], but I still think the next step to go, with one person in America dying every hour of oral cancer and a huge portion of this is related to HPV, it’s still irks me that I can go get an HPV, I can go get a flu shot at Walgreens, but not by from an hygienist. Your hygienist are seeing all these elderly people and they could be saying, “Hey grandpa, have you had your flu shot this year?” They’re not allowed to. With oral cancer, it just blows my mind that we are not asking about the HPV vaccine and giving it to them.

Deborah: You know, I agree with you. That’s something I had to teach. I teach pathology, so I had to teach oral squamous cancer and divide it up now between oral cancer and oropharyngeal squamous cell carcinoma with HPV. That’s a whole new break off of oral cancer, but what bothers me about most hygienists that I see are that they cut out, when they get out of school, they cut out the extra oral and intraoral exams and they spend more time on scaling.

When you read the obituaries, no one ever died of calculus in their mouth. They die of oral cancer. That’s something that hygienists are cutting out, trying to save five minutes in a day, they’re cutting out the oral cancer exam. They’re missing that and they’re spending more time getting the calculus from the distal 18 and no one dies from that.

Howard: I want to be famous by being the first dentist to ever die of galvanic shock.

Deborah: You’re too much.

Howard: That’s the shock from two dissimilar metals like when you’re having an amalgam touching a full [crosstalk 00:12:26], just in case anybody listening didn’t catch that joke. Anyway, it’s amazing. Why would anyone think that gum disease is more important than oral cancer when 10% of Americans of age 65 don’t have one tooth in their head including half of my pedigree and by 70, it’s 20%. You got all these fine people living without a tooth in the head, but they’re dying one in per hour of oral cancer. What is the issue?

Deborah: I understand. I think it comes to time and quality. I think hygienists think oh got to get all the calculus off the lingual number 25 and don’t spend 30 seconds sticking the tongue out and looking in the back of the mouth. Yes, sure, the throat area. Also, what’s changed too, that’s one thing that’s changed. There are so many remineralizing products now. We didn’t have any of these products when I came out of school. We had fluoride. That’s what we had, fluoride. When you think about the course I just did for Dentaltown …

Howard: Which has been very well received. Everybody’s loved your course.

Deborah: Thank you very much. That’s …

Howard: I really loved it too.

Deborah: Thank you. These are just new products that are on the market, despite the fact that we have all these increase in scientific knowledge. We have the increased commercial preparation. We still have carries. You’re talking about tooth loss and carries. That’s one thing that hasn’t changed since I’ve gotten out of hygiene school. We’re not putting a dent in carries as well. These products … Go ahead.

Howard: No, I always tell dentists. I say why are you high on yourself and the dental profession? Because imagine if you’re retiring from  the fire department and they say, “Deborah is retiring and after 30 years on the force, I just like to say that almost all the houses are burned down.” The retiring sheriff and we say, “Since Deborah was a sheriff, every year, there are more murders than the year before. When she started out, there were 5000 people in this town and now there’s only eight left.”

Dentistry, we have 25% of the town still don’t have water fluoridation and during that whole Obamacare, the dental community was silent by just saying, “Hey Obama, dentistry is 5% of healthcare, why don’t you just get rid of all the stupid rinky-dink city council?” imagine if the city councils were all arguing over the flu shot or are any of these vaccines where all these people think they cause autism and all …

Why don’t we put all the CDC measures up for a city council vote every two years and basically DMFT, diseased, missing and filled teeth 3 is rising over the entire planet. These dentists go into a community and 40 years later, there are more cavities than when they started and they think they did a good job. It’s also … Sorry to interrupt. On the nine sovereign specialties recognized by the ADA, everybody’s talking about endo and perio and pedo, they never talked about public health. We’re all public health dentists.

Deborah: Sure. Caries is a public health problem. I think it’s the number one reals on while young four young children to miss school.

Howard: 52 million school days are missed a year from caries. It’s eight percent of the emergency room visits.

Deborah: Right. If you don’t want to … If a parent doesn’t want fluoride gives a lot of remineralizing products. They have calcium and phosphate, we have over the counter toothpaste, we have Rx toothpaste that contains remineralizing products. We have prophy paste, we have varnish. We have gum. We have gum contains remineralizing agents. Professional fluoride gels, whitening products. You can buy MI Paste and Clinpro tooth cream on Amazon. There’s a wide variety of products. All the fluoride in the world, it’s availability to get to the enamel is limited by how much calcium and phosphate is in our saliva.

Unless you know and get your saliva tested, you’re not going to know how much calcium and phosphate you have, so why not put some products in? Put some products like MI Paste, you can take it on your index finger, smear it in your mouth and add some calcium and phosphate, so when you drink fluoridated water, then you have calcium and phosphate ions immediately available for uptake for the fluoride. There are a lot of different products.

I just don’t understand why we’re in this static state with caries. I understand dentistry relies on fillings, restorations, fine, but caries is preventable and we can do a lot more. I agree with you, to prevent decay.

Howard: Okay Deborah, I want  … These kids are commuting to work, we got about 7,000 listeners per show. They’re mostly under 30. Every time someone emails me, I reply back tell me your demographics. They’re all 25 to 30. They need to hear specifically you talking to a patient. I’m the dad and I’m at the appointment and my seven year old or ten year old or teenage kid is sitting there and he’s got a six inner proximal cavities. Talk to me as the dad on what products specifics, which names, of how I can be trying to reduce caries more and remineralization.

Deborah: Okay, just tell me again how old is the child?

Howard: Make one up.

Deborah: Okay, I’ll put a little bit older child, because a lot of products for remineralizing the enamel cannot be used in children under age six except for varnishes. Particularly if they have a high fluoride content, because we want to decrease the … Not decrease the amount of fluoride, but be careful about the amount of fluoride up to around age eight until all the permanent teeth have calcified, because otherwise, if you put too much around, you get fluorosis. Let’s just take a 12 year old.

I would just say to you Mr. Farran, your child has a lot of inner proximal or between the tooth decay. We can give a prescription toothpaste that contains more fluoride than a normal over the counter toothpaste that you buy at Walgreens or Giant, at a supermarket. We can give you with a prescription that you can get filled today. We can give you a prescription toothpaste that your child can use at night before bed that has 5,000 parts per million fluoride. Five times the amount of fluoride in a regular toothpaste.

You brush with this in place of the regular toothpaste once a day at night. Then the child, after brushing for two minutes and buy it … I would recommend a power brush. I don’t know why people are still using manual brushes. The power brushes work so much better. Even a battery powered brush is an advantage over a manual toothbrush in reducing the amount of bacteria in the mouth. Brush with this.

We can also use a varnish, which is a sticky, resin like product that contains fluoride or some of the varnishes now have chlorhexidine in them, which is an antimicrobial that would reduce the bacteria that causes cavities in your mouth, in your child’s mouth and we can apply this varnish every three months. There’s … there’s a lot of other products that we can do. We can look at the way your child’s eating, the frequency of ingesting carbohydrates, a lot of snacking is not good.

There’s a lot of other options. If you don’t want your child to have fluoride, products that contain fluoride … Some parents Howard, I will say, are very vocal. I had a parent in last week, very vocal about not allowing her children to have any fluoride, that’s fine, but there’s a lot of other products that we can use. It would depend upon whether they want their child to have fluoride or not to have fluoride, but there’s a lot of products.

Howard: These specifically named brands. You mentioned the 5,000 part per million fluoride, was that a Crest Pro?

Deborah: Yes. Clinpro has a product that, by 3M, as well as PreviDent products. They’re all 5,000 parts per million fluoride. There’s a lot of ….

Howard: Do you like one of those more than the other? Do you like 3M? Who makes PreviDent?

Deborah: Colgate.

Howard: Colgate?

Deborah: No, I don’t have any preference, one over the other, no.

Howard: You know, what’s so funny for me, for Colgate? You know how in America when a product is so ubiquitous that it becomes the name, that the Supreme Court takes away the patent. You can’t patent the name Kleenex anymore, because everybody started using it. “Hand me a Kleenex.” Most of the world, there’s no word for toothpaste. They just say Colgate. It doesn’t matter what brand they’re saying. Colgate for Africa, Asia and Latin America is just like Kleenex for America. Even here people saying Coke, “I’m going to go get a Coke.” “Oh, you want a Coke?” “I mean I want Dr. Pepper, but sometimes I say that …

Deborah: Yeah, also … Okay.

Howard: Back to the varnishes.

Deborah: Yes. There’s …

Howard: Name brand.

Deborah: There are a lot of different ones. MI Paste has a varnish. Obviously Colgate has its own varnish. Some of these varnishes contain fluoride, some contain fluoride and/or chlorhexidine . You can apply …

Howard: Deborah, when I read about varnishes, they’re so overwhelming, massively effective, but when you’re going to offices, they’re just … You probably … I probably get more likely to be ran over by a unicorn than see someone use a varnish. How widespread you think varnishes are or not?

Deborah: I think … First of all, they’re an advantage over the fluoride trays that some offices are still using. You put those awkward trays in the child’s mouth and they gag and they don’t like fluoride. One of the things that I recommend would be to … Varnishes are not popular, because they make your teeth feel dirty again. We clean your teeth, at least in the clinic that I’m teaching, we clean your teeth and I say to patients, now we’re going to make your teeth feel like they’re not clean.

We’re going to put this varnish on. You have restrictions. You can’t eat anything hot. You can’t anything hard or crunchy for about six hours. Don’t floss in those spots. There are a lot of restrictions. I think the varnishes are not … How should I say, as smooth as they could be. They make your teeth almost feel dirty again. I went into the ladies room yesterday and the patient who had been in clinic was picking the varnish off her teeth. I said in about six hours, it’s going to just flake off of your teeth. She goes, “I don’t like that feeling. I don’t like that feeling.” It’s not as smooth as it could be.

Howard: Some people say … They get hung up on this evidence based dentistry, which is a good thing and a bad thing, but a lot of people are saying that if you really look closely at the research, you do not see a reduction in periodontal disease or caries or anything on six month recalls. You only see it take effect at three month recalls. What would you say to that?

Deborah: I haven’t looked at all that research as well as probably you have, but I would say the further you get away from the actual cleaning, deplaquing, debridement and the less compliant the client is, sure, you’re going to have the build up with a biofilm and everything is going to go downhill from there. You’re going to have increase, leading upon probing all those clinical parameters that we’re going to see.

Howard: Practicing in phoenix, all my patients have one thing in common, they’re all compliant on their non-compliance.

Deborah: Yes. It is a problem. That’s another thing I teach. It’s very difficult. I think too, dentistry is making a move. Now, we have CAMBRA, Caries assessment … Caries Management by Risk Assessment. That risk assessment model that now we’re using that you hear so much in medicine. You have so much risk of getting this disease or that disease. We have CAMBRA now.

CAMBRA was developed by the California Dental Association about ten years ago. The American Dental Association has its own CMBRA form. Philips Sonicare  has a CAMBRA form, CarieFree, that whole system that uses Xylitol has a CAMBRA form to assess risk for caries.

Howard: Is CarieFree, is that Kim Kutsch?

Deborah: I believe so.

Howard: Who would be the best person to have a CMBRA online e-course?

Deborah: I would say someone from 3M. I know they had been in Dentaltown and giving courses. 3M has an excellent CMBRA program.

Howard: You know someone there? You know someone there that you could email?

Deborah: Ellen. Is it … Neuenfeldt. That’s right, Ellen Neuenfeldt.

Howard: How do you spell her name?

Deborah: N-E-U-F-E-L-D-E-N-T. No … F-E-L-D, I believe it is. I have it … I can email it to you Howard.

Howard: That is a huge massive advancement. Again, these things start on the coast and they’ll end up in Parsons, Kansas about 10 years from now. That starts rolling in faster.

Deborah: I know. We encourage students now to do a caries risk assessment and a periodontal risk assessment as well. I know some of these programs are computerized. If your office is paperless, you can do it on a computer. Ours is in a paper form where we ask the clients do you brush with fluoridated toothpaste. Is your water fluoridated? This is your plaque score. We’re trying to combine it with risk, you’re at a low risk for decay.

Continue to use a fluoridated toothpaste. Don’t change anything. You’re at moderate risk for decay, use a mouth rinse. You’re at high risk for decay, now perhaps we need an Rx product, just as you would your high risk for heart disease, so we’re going to have a medical intervention. Now, we’re going to have a dental intervention.

Howard: Do you think that the … Another thing, it’s fun when doing something for three decades and living half a century, you see what’s old and expires [crosstalk 00:27:52] … You got to see the pediatric dentist on Dentaltown talking about silver nitrate’s making a comeback. I think for the first time in my 30 years, dentists are becoming less mechanical engineers, building bridges and houses and barns and crowns and they’re becoming more biological in nature.

They’re realizing that we’re really … At the end of the day, we’re biologists. We fight these gram negative [pack 00:28:15] of anaerobes, P. gingivalis, streptococcus mutans, even that’s a joke. Just to say that is a joke because when they’re dissecting on a cavity, by the time they’re four millimeters deep into the cavity, there is an even streptococcus mutans and they’re inventing, discovering a new species every three months.

You were talking about remineralization and you’re talking about 5000 part per million fluoride, made by PreviDent or Clinpro, but you’re also talking about calcium phosphate. What toothpaste products use that? Would switching from orange juice to orange juice that’s fortified with calcium or more milk? Any other things [crosstalk 00:28:57] …

Deborah: I think too, if you’re going to have a product that has calcium, you’re going to swallow it. Mouth effectiveness would be somewhat negative. There are products … For example, ACT is a remineralizing agent. Amorphous calcium phosphate. That’s in toothpaste as liquid calcium. That’s what it is called, liquid calcium. That’s an in Arm and Hammer toothpaste. You can provide that to someone. One other thing that these products do is in addition to putting calcium and phosphate into the saliva for uptake by fluoride, they also decrease sensitivity, because they put a smear layer of calcium and phosphate over the dentinal tubules.

If you’re like me, my teeth are sensitive and I use Sensodyne toothpaste and I have to build my smear layer off every day. There are a lot of other products. MI Paste is minimal … Minimum, excuse me, intervention paste. CPP-ACP, that’s Recaldent. Recaldent is found in chewing gum, Trident chewing gum. You can chew if you have a demineralized phase. I don’t think clients always understand remin and demin either. We can do a better job with that.

There are other products. Novomin is CSP. That increases the pH of the mouth, increases calcium and phosphate levels over days. These are all products that have been developed by dentists. TCP is in a lot of the Clinpro products. That’s functionalized calcium phosphate that is what they call SMART meaning that the calcium is prevented from interacting prematurely with the fluoride until you’re in a certain level of demin. I’m just fascinated, these are all created by dentists. ACP was created through funding from the American Dental Association.

Howard: ACP. What does that stand for? What’s the name of the company, ACP?

Deborah: ACP is amorphous calcium phosphate. It’s in a lot of products, Arm and Hammer for example has that.

Howard: I still crack up, every time I see arm and hammer, I still crack at … He immigrated from Russia and he was a pharmacist in Manhattan close two hours from you. Until the day he died, everybody thought he was the arm and hammer. They thought he was the baking soda man. He was founder of Occidental Petroleum. He said, “You know, I just can’t get away from this Arm and Hammer baking soda.” They see this rich guy in a jet. They just assume he sells baking soda. I still …

Deborah: I still got Asians that tell me they dip their toothbrush into baking soda and brush their teeth.

Howard: I want to go to the other end. There’s a very famous hygienist named Trisha O'Hehir who wrote a book about dry brushing who still swears, she’s been in this profession for 40 years, she still swears that two minutes of brushing is what you need and that there’s no evidence … As far as removing the plaque, she says you don’t need any toothpaste.

Deborah: I definitely have to agree with her. I don’t think you need toothpaste. I think toothpaste does have some active ingredients such as fluoride, such as some other products, for example, potassium nitrate, that will decrease, have an effectiveness, but yes. I agree. I think you could just wet your toothbrush and brush your teeth. Your breath may not smell great.

Howard: I don’t care about my breath, because I’m single, but every time I’m in the shower and that toothpaste is gone or it’s out, because one of my three boys living with me stole it, I just go through that Trisha O'Hehir lecture saying, “Howard, you don’t need the toothpaste, you don’t need the toothpaste.” I just do the whole brushing, but it is … Your mouth doesn’t … It does feel clean and all that stuff, but it just don’t feel as zesty. I also want to talk about … There seems to be a lot of changing and thinking about caries being a communicable disease.

We know that babies aren’t born with it. We know that when a mother kisses baby and doesn’t have any teeth, those bugs die because there’s no oxygen anaerobic environment, but as soon as that first baby tooth pops out and there’s a flap of tissue laying up there, that’s the first place these gram negative anaerobes that can live in oxygen take place and then the baby’s infected and you still don’t see anybody in the media …

When they talk about body to body disease, they talk about sneezing colds or you’re sick, wash your hands, but nobody in the media’s talking about your husband has ten untreated cavities and bombed out wisdom teeth and you kiss him every night and he kisses the children good night and the mom’s coming out with the cleanings. You don’t see any in the media talking about it.

You don’t see anybody in the movies. What are you teaching your kids in hygiene school that talking to, that you can’t kiss a trash mouth any more than you would have intercourse with someone who is infected with an STD.

Deborah: Right. We teach them that the biofilms are communicable and the bacteria communicate. Another thing that you could recommend, for someone whose mouth has a lot of untreated decay is how about … One who kisses a baby, how about an xylitol wipe that you can wipe the baby’s teeth with. You don’t need to brush the baby’s teeth, but just wipe with a xylitol wipe. They make these products.

Xylitol unfortunately has to be effective with a certain percentage or dose. I don’t know the dose right off the top of my head. One of the side effects of too much xylitol is diarrhea. We can’t have that. there are wipes that you can use. Many of these remin products, I’m thinking about one product called Remin Pro, contains xylitol. It has extra calcium and phosphate plus xylitol. A lot of these products combined preventive strategies.

Howard: Who’s correct? You have three dogs, I have two cats. I don’t know if you don’t have … They have found out through genetic sequencing that the streptococcus mutans that humans picked up that causes all this decay actually came from cats about 15,000 years ago in the fertile crescent. Do you have three dogs and not cats because you’re mad at those cats for giving us disease? Do I have two cats, because without cats, I wouldn’t have a job and I end up be working at Taco Bell or should I …

Deborah: I brush my dog’s teeth every night. I don’t use toothpaste. I wet a toothbrush and I just brush their canines and their back teeth. I do it religiously every night. Everybody laughs at me, but my dogs never have to have their teeth cleaned and I got six or seven dogs in my life. None of them have had decay.

Howard: I was raised catholic, so whenever I hear someone say they do it religiously, that means they do it on Christmas and Easter.

Deborah: No. Actually, my mom was catholic. I think we have a share of background there.

Howard: You have a good healthy amount of guilt then? Your mother was catholic. That is … Putting on your hygiene education hat, the private practice hat, a lot of private practice hygienists, you mentioned heartland. When you go into some of these corporations, they have more protocols. Some of them that work at various corporations do not like protocols when it comes to placing chips, like Arestin chips or different types of chips. Some people think …

Some people forget [inaudible 00:37:16]. They work for a dentist, a dentist says they have a six millimeter pocket, you put in this chip and here’s the deal. Some hygienists don’t believe in it and think is my dentist doing that because they’re buying these chips for a few bucks and putting them in for a lot … is it a finance thing or is it a research, this will help thing? Go over there, the [crosstalk 00:37:37], there’s … What is, there’s Arestin, there’s PerioChip …

Deborah: There’s PerioChip Yes, sure. Atridox.

Howard: Will you go through? I want you to go through the chips, those three chips. Then there’s some dentists still when someone comes in and gets [inaudible 00:37:52] curettage is given a script for a tetracycline 250 milligrams a day BID, twice a day, for ten days because we were trained back in the day that tetracycline shows up in the gum tissue seven times more concentrated than all the other bacteria’s.

Then some dentists, they’re so frugal in Dentaltown, some of them buy their own canister of tetracycline and they just open the pills into a dish and then they wet it and when they’re done, they actually paint the tetracycline into the socket. Talk about all those things.

Deborah: I think … First of all, when you talk about systemic tetracycline versus localized, local drug delivery of some of these products, the localized drug delivery, right into the pocket, tends to work a little bit better because it stays there. Now, it bio-resorpt, so it biodegrades on its own. The patient doesn’t have to come back for a second visit, have whatever it is taken out. I think there are some advantages. We use Arestin at my college. It’s easy to place, but so is PerioChip. PerioChip is just very easy to place.

Atridox is easy to place, it’s a little bit awkward, because you have to mix the liquid and the powder together with your thumbs for about a minute or two. It times consuming. It goes in as a gel and hardens up. Arestin goes … It’s minocycline. It goes in, these little microspheres extend outward into the pocket and they kill bacteria. We’re seeing … I just saw a patient last week who had Arestin placed four or five months ago, tremendous, two millimeter decrease in pocket depth and no bleeding upon probing.

Howard: Would you recommend Arestin or PerioChip? Is PerioChip minocycline too? What is PerioChip?

Deborah: No, PerioChip is chlorhexidine.

Howard: Chlorhexidine? Which one of these two would you recommend?

Deborah: I recommend both of them. I recommend anything that you can place into, directly into a deep pocket.

Howard: You recommend these. These are huge hygiene builders, because what most dentists don’t understand is I just bill hundred an hour, they paid 35 or 40. You do the math on hygiene departments. Most of them lose money. If you added a few things like this, they would be in the profit zone.

Deborah: Exactly. The fees for these products are tremendous … They charge now. For us, we’re very lucky that the company gives us the product free to use, we’re a clinic, to use. The problem is when we run out, we don’t replace them. We do it for a free service at my college. Dentists are charging much more than that. I’m hearing $40 a quad, $50 a quad. It really depends, but sure, anything that the hygienist can do to individualize treatment would be fantastic.

I think sometimes hygienists get into this mindset … Okay, I have eight patients today, one an hour. Okay, eight, seven, six … They’re just starting to count down and not thinking about all the things they possibly could be recommending to the client.

Howard: You mentioned that these local antibiotics were microspheres. What did you think about that microsphere controversy where the toothpaste company was putting these colorful food additives in there? I disagreed with the controversy, because I raised four kids. I know you have a boy. I raised four boys. I saw a bit, the spheres, like giving them a bath. If I put them all four in the bathtub and there are no toys, they be out in one minute.

They'd be fighting [you 00:41:48], but if I threw a bunch of boats and balls and whatever the hell that floated in there, they'd stay in there for an hour and I'd have to keep bringing more water. Toothpaste, I think if it doesn’t taste good, look prettier or whatever, a kid doesn’t want to do it. I didn’t really see the tradeoff. This thing was approved as a food additive and if it makes a two, three, four, six, eight or ten year old kid brush their teeth … I didn’t agree with the controversy. Did you agree with the controversy? Did you think this should be removed?

Deborah: No. to me, I agree with you. Whatever gets someone motivated to brush teeth. Some people just intrinsically are motivated to brush teeth. I like a clean mouth. That’s the concept of using xylitol wipes when the teeth come in to give the baby an idea of what the teeth should be cleaned. A clean feeling. No, I agree with you. I think anything that you can get a kid to do to brush a teeth.

Howard: Another thing I never liked about the hygiene department that I changed in mind that I thought it was very effective is this hygienist would see this six year old kid, who’s never flossed his teeth once in his life and she does the whole cleaning, floss his teeth and all that. I would go in there say there’s really no evidence that you can do something twice a year and change his kid’s diseased, missing and filled teeth. You got to be as Vince Lombardi, coach. You got to be his motivator. You got to be his inspiration.

Why don’t you set him up and hold a meter and then have him floss his teeth and then when he starts in the middle, you can train him, no, we start on the upper right so we don’t miss anything, we go to the upper left. We drop down and then we … I cringe whenever I see a hygienist floss someone’s teeth, even if it’s a 50 year old man. Look at his pano, he’s got 15 fillings in his mouth, everyone was an inner proximal filling and MOD from not flossing. He’s got recurring decay under these MOD amalgams. The other thing about …

Probing, I made them probe differently. I said they have to probe the buckles, lingual first. First I’m going to probe the gums where there’s air, where there’s 20.9% oxygen where the bugs have a hard time growing. It would be like three, three, three, and all the way. Now, I’m going to probe in between the teeth where there’s no oxygen, which by the way of your 28 teeth, you already have 12 flossing fillings in between teeth. Now we’re going to floss, it would be like four, five …

Then they would just … I’d say, “Let me see you floss.” You could tell, they wouldn’t even roll it on their finger. You could just tell these people who never floss. I just think the whole hygienist mode of that, I got to get in there and remove all this plaque. I got to get in there and floss. I have to do all this stuff. They’re believing too much of their own, that they can go in there like Obi-Wan Kenobi twice a year and knock out this disease with a lightsaber. That ain’t it. You got to be a motivational coach.

When I would have moms come back and just rant and rave, they say oh my god, ever since I started coming here, I tell my two boys or four … Okay, time to go to bed. They go, “Oh, I got to go. I got to go floss, Missy …” They’re saying … I assume they’re talking about their hygienist Missy and she goes, “Oh my god, now I got to put them to bed a half hour earlier because of coach Missy, they’re going to run in that room, standing on their stools and doing this whole routine.

They weren’t doing it for their mom, their dad or their dentist. They were doing it for Missy. I just thought … I just think the whole hygiene mentality has to change that. I’m not going to do anything twice a year to change anything. Same thing with bypass. Have you see those studies on bypasses of twins where one person gets the hundred thousand dollar bypass and the other one, do to health insurance, couldn’t afford it, but he change his behavior, quit smoking, lost 40 lbs.

The one who didn’t get the bypass, but quit smoking and lost weight and all that lived three and a half years longer than the one who get the hundred thousand dollar bypass? When I read that … How many times have you seen that with four quads of gum surgery? We do four quads of gum surgery, four quads of plain curettage, they walk out the door, nothing changes their behavior and one or two years later, they’re right back at square one.

Deborah: I think part of the problem is floss isn’t always the answer. Flossing is hard. We have a lot of different floss products. What about a water pick? They’re called water flossers now. That’s what they’re being marketed as now. They’re a great alternative. There are air flossers that use that little puff of air between your teeth. Look, whatever you’re do inter proximally … It doesn’t always have to be floss. That’s what I’m trying to emphasize with my students. We could use [inaudible 00:46:34], little interdental brushes.

It doesn’t always have to be floss or flossing, which is a difficult skill. In addition to a manual toothbrush, now we’re going to use the modified Bass method of toothbrushing. That’s difficult. Why don’t you just buy a power toothbrush and brush your teeth with a power toothbrush. It’s much more effective. It removes more biofilm. It’s rotating 30,000 cycles a second. Why not just use that? It’s so much easier. It shuts itself down after two minutes.

You don’t even have to think. You just sit there and move the brush. You don’t even really … The brush is working. You’re just moving it from tooth to tooth. I agree. I don’t think you always have to use floss in a … There’s other devices that we can use to clean inter proximally.

Howard: By the way, from my fans back in Kansas, when she says the modified bass technique, that’s the modified catfish technique if you can catch that. what toothbrushes do you … Let me say this succinctly, when these companies start claiming that they were a substitute for floss, a lot of dentists and hygienists went literally batshit crazy. They were jumping off buildings.

Is there any product, specific names that really is a substitute for floss, because we all have a ton of patients say I hate the floss? Someone says I hate the floss, can a dentist or hygienist say use this, it’s basically the same effectiveness?

Deborah: Look, once again …

Howard: That may … That’s the only question that make you stutter, you’re like, “Ah …” Even you didn’t want to go there.

Deborah: No. I think you could use a water pick. I’m just … I don’t want to commit, because I don’t know the research as well. I would say to a patient try a water pick, try a water flosser. There are certain regimens you have to follow with that. You can put an antimicrobial into the reservoir and shoot the Listerine between your teeth as well at the same time. I think that’s very effective at removing biofilm.

Howard: I think the biggest problem with the water pick or water floss or whatever is all their marketing and advertising is setting it on some pretty woman’s kitchen or bathroom sink and women hate it, because they go nuts when you leave the toilet seat up, let alone leave a bunch of water splash all over her …

Deborah: They have to [crosstalk 00:49:14] into showers.

Howard: I know, that’s the one I love. They have to be in the shower. No one cares where’s water in the shower. If everybody marketed it and say, “Oh, put it in your shower,” because they don’t think about that. They just think on the water spots on the mirror, their pig husband left the toilet seat up.

Deborah: It is messy, yes.

Howard: Just move the whole thing into the shower. In fact my favorite is the shower floss. You unscrew your shower head, you put it on there, it hangs down. There’s four pillars on there and me and my boys, no one knows which colors who. We’re all using everyone’s. It’s fantastic. The boys love it.

Deborah: I think that’s a viable alternative. I really do. The air flosser, the little bit of research I read, it’s very effective. We even have those little tiny, they look like very small interdental brushes that go between the teeth. Once again, we don’t have to always use floss.

Howard: Let’s go on to toothbrushes. You still going to every grocery store and they have soft, medium, firm. You still seem … Do you still believe that you have to use soft? Is there still … There’s 330 million Americans and still a huge portion on one … If it’s a Brillo pad, if it’s wire bristles, what do you see in toothbrushing [crosstalk 00:50:41] …

Deborah: Certainly. Sure, you can find hard bristle brushes and you had people that use them and have recession. A lot of times, individuals say to me the soft ones, it just don’t work. It doesn’t feel like it’s doing anything. Once again, I will say to them then if you don’t feel it’s effective, try a battery operated brush or a power brush. It’s going to be much more effective at removing the bacteria in your mouth.

Howard: Which brand you recommend?

Deborah: I think I like Sonicare. I have both. I have Sonicare and Oral B. I switch off all the time. Some days, I use a Sonicare, some days I use my Oral B. it depends upon where I am at the house to use them. I have them at school. I tried it, I take them into the bathroom at school and brush my teeth with them there. I don’t use manual brushes.

Howard: I know you’re my idol because you’re a hygienist talking about power toothbrushes like most women we talk about their handbag. You’re talking about these whether these are Gucci or Prada or Louis Vuitton.

Deborah: I think a battery brush is a very good alternative.

Howard: Go mouthwashes, wasn’t there a mouthwash. Wasn’t it Listerine saying about five years ago that a minute of Listerine, swish a minute of Listerine would …

Deborah: They got trouble for saying that, yes.

Howard: Who they get in trouble from, do you think … They obviously had research.

Deborah: I believe it was the food and drug administration said it has to be labeled as an adjunct to or in addition to brushing and flossing. It can’t claim to be a substitute for brushing and flossing.

Howard: Oh, it was brushing and flossing? I thought it was just flossing. Was it brushing and flossing?

Deborah: It might have been just flossing.

Howard: What do you think about the 27% alcohol in the mouthwash for cancer? Some people say you got to be alcohol free. You got to be alcohol free if the person’s used to be an alcoholic and they refer for that and it’s got to be alcohol free, some were saying, for oral cancer. Then you got other people here saying that no, alcohol causes cancer when you’re swallowing it and you’re running it to the liver and it’s the changes in the liver that causes oral systemic cancer. It’s not the … If you soak your finger in Jack Daniels every night, you’re not going to get finger cancer. You have to drink that …

Deborah: This is something I had read the research on, because I do teach this. As far as I know, there’s been no research to prove that using alcohol in a mouth rinse causes oral cancer.

Howard: I never bought the cancer model the first time I took pathology in undergrad, because they talk about these talks, like alcohol in Listerine or are they … Talking about all these things. Every time you talk about that stuff, if I just applied it to a room full of rabbits, the rabbits would all die or the mice or the gerbil. That’s … You see a cancer, you see this rabbit who’s multiplying every 20 minutes and growing so, if this is a carcinogen, we should all be eating this stuff, because it just makes everything grow.

I always knew something is hijacking the nucleus, getting into the DNA and turning it on to just start going into hyper drive. Putting a toxin on your alcohol doesn’t make any sense, but running it through the liver and then tearing up a big part of your immune system and your health and functions and your body’s weak and then goes immunocompromised and gets taken advantage of, that made sense, but not soaking your finger in alcohol, then the cells just go cancer. They would die. They would turn to white. They fall off.

Deborah: There’s a lot of … Look, if you don’t want … if the alcohol bothers you, it might bother a mother with young child. Look, use Crest Pro Health, it’s alcohol-free.

Howard: I’m old school …

Deborah: [Crosstalk 00:54:33] Essential oils … Yeah, sure.

Howard: I’ve been at Listerine since, I think, I was 10. My mom and dad when I was … I still use the same cologne as my dad, the same mouthwash as my … Here I am, he’s been dead 16 years, I still use all the same, all those brands. I just don’t feel clean unless I swish for a minute at Listerine. I do my minute by … When I’m done, I put that in and then I’ll go put on my underwear, suit, socks … I know that it’s been in there for one minute. By the time I turned the coffee pot on, I put it in the sink. Do you use mouthwash? Do you use Listerine? What do you think about mouthwashes?

Deborah: No, I don’t. I don’t … I use mouthwash. I don’t particularly care for Listerine only because it stings when I use it. However, I do … I have some recession, so I do brush with PreviDent 5000 plus, booster plus, every night, because I do not want to get root decay. I do brush with extra fluoride.

Howard: Isn’t that funny how the psychological … When I use the non-fluoride or the ACT with fluoride and I use that and I don’t get that zing burn. My walnut brain thinks nothing happen, but when I’m sitting there and my eyes are watering and I spit it out and gasp for air, my walnut brain thinks oh, you killed everything.

Deborah: A lot of offices use Listerine as a swish for a client to reduce the bacteria in the mouth during aerosol procedures, they’re using the ultrasonic or the polishing. They’re reducing … It does reduce bacteria in the mouth very effectively.

Howard: I wish hygienists would think of another thing that I notice day in and day out for 28 years. Back in the day, it was ‘87 and this little Arkansas company called Omni came out with this, the bleaching. It wasn’t even a month or a year before I started realizing that Americans or humans, they’re all or none. You either haven’t gone bowling in five years or you own your own bowling ball. You either haven’t gone to the lake in ten years or you own your own boat.

It’s the same thing with oral care. What I notice is that when people started getting braces or bleaching their teeth or taking out amalgams, putting composites, they got into their teeth. As soon as they like what they saw in the mirror, they start taking care of it, but when they didn’t like what they saw in the mirror, they didn’t want to think about it or deal with it or brush and floss.

I still think bleaching and bonding in cosmetic dentistry and orthodontics and short term ortho and anything that makes them motivated to say, “Oh, I like my teeth,” then everything you’re talking about gets implemented.

Deborah: Sure. There’s even in whitening products, there are remineralizing agents. Part of that is to decrease the sensitivity after post whitening. Some clients … I know when I whiten my teeth, I had extreme sensitivity and had to really step up and use additional fluorides, but now some of these white, day white, night white, have ACP in them.

Howard: Do you think any of those whitening toothpaste … I like Bob Ibson’s Rembrant. Do you think it actually does slightly whiten the teeth overtime or you think that’s marketing?

Deborah: Slightly. I think it’s a shade or two. It’s not going to be extreme, but for some people, that’s all they need. Most people that I see need a gel.

Howard: A gel? When your son, if he ever grows up, gets married and has a grandchild, when he comes over your house, are you still going to have the candy bowl that all grandmas have?

Deborah: Unfortunately, I noted for having … I did have a candy drawer, but …

Howard: You do? Is it all just xylitol candy?

Deborah: I do. No, it’s not. It’s the regular. I try not to eat candy, but it’s the regular thing, but I made every kid who slept over and there were a lot of kids who slept over at my house, brush their teeth before bed. They would come to my house for the weekend with no toothbrush. I’d say, “Hey, I got a toothbrush upstairs. We’re going to use it upstairs.” I made them brush after dinner before bed. They would say to me, “Do I have to brush my teeth again?” I’m like, “Yeah, you got to brush again.”

Howard: I only got you for a minute left and I’m embarrassed to ask this question. It’s a grotesque question. It’s a foul question, but nevertheless, it’s all over social media that if your toothbrush has to be 20 feet from the toilet, because the researchers showing that when you flush a bowel movement, fecal matter is flying through the air and they’ve isolated it on toothbrush and your toothbrush can’t be in the same room.

Now people are wondering should I cover it? Some people are saying that will make an atmosphere to breed bacteria better. Some are now throwing it in the drawer, some are moving it to the kitchen sink and some say it’s crazy. What are your thoughts on toothbrushes and toilets?

Deborah: I’ve heard the same …

Howard: That’s what we’ll name this pod cast. We’ll say Deborah Levin-Goldstein discusses toothbrushes and toilets.

Deborah: That’s a good one. I know they teach that the micro. Our teacher teaches that and all my students tell me that. Look, I would tell you some of the power brushes have little sanitizers. You could buy sanitizers for your toothbrush. They use UV light that will sanitize them somewhat, but yeah, I’ve heard that too. Mine is not the same room. I don’t know how much it matters, but yes, I heard that many times.

Howard: Now, we’re in an hour, so I’ll have to wrap this up in overtime, but I still want to tell you. I still have to say something that I’ve been doing my whole life. When I … The gold standard of kill is always going to be bleach. Every time they come out with any other ingredient, all the research compares it to bleach. Bleach is it. Over the years, they come out with all kinds of compounds and nothing kills as much as bleach.

I had an old periodontist who when I opened up in ’87, I was 24, he was about 80. He told me that he still recommends his patients take an eight ounce glass of warm water, put one cap full of Clorox bleach, over the counter, end of that cap and then swish that for a minute and he still said nothing you guys will ever talk about will ever be as effective as a cap load of bleach and a warm glass of water. What are your thoughts on that?

Deborah: I think bleach is a very good disinfectant, a very good surface disinfectant. I think it might be a little too harsh for the oral environment. We do have tissues. We do have the enamel. Enamel is not replaceable, so once we lose it … I have never swished with bleach. I like to use bleach as a disinfectant in my toilets, but I never used it in the mouth or I’ve not recommended it in the mouth.

Howard: Hey, you said enamel’s not replaceable and I just want to say either are you. You’re an amazing, amazing person. You’re a student of the literature. You’re a registered dental hygienist, you have your master’s degree. You’re just an amazing, amazing person. Your two courses on Dentaltown, ‘Non-cancerous oral diseases that every dental professional should know’ is a must watch. Actually, you got to watch that in the office. That is a lunch and learn, because your hygienist is going to sit there with you and you all need to talk about it.

‘Repair and protect enamel with remineralizing agents’, that’s the whole office is got to be on there, because you never know in the dental office who those patients are going to ask [inaudible 01:02:15] questions. It may be the assistant, it may be the hygienist. Sometimes it’s to the receptionist. The whole office … You’ve done so much for dentistry, you’ve done so much for Dentaltown. Deborah, thank you so much for spending an hour with me today.

Deborah: Thank you very, very much for having me. It’s an honor.

Howard: All right, have a good day. Bye.

Deborah: Thank you.

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