Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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982 Lessons from Dermatology with Dr. Dustin Mullens : Dentistry Uncensored with Howard Farran

982 Lessons from Dermatology with Dr. Dustin Mullens : Dentistry Uncensored with Howard Farran

4/4/2018 6:10:53 PM   |   Comments: 0   |   Views: 150
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982 Lessons from Dermatology with Dr. Dustin Mullens : Dentistry Uncensored with Howard Farran

Dr. Dustin Mullens began his residency training at Affiliated Dermatology in July of 2016. He received his undergraduate degree in Biology from Coastal Carolina University in Conway, SC. Dr. Mullens received his doctorate degree from Edward Via College of Osteopathic Medicine-Carolinas Campus. Following graduation, Dr. Mullens completed his internship training at OhioHealth O’Bleness Hospital in Athens, OH. His professional memberships include the American Osteopathic College of Dermatology and Sigma Sigma Phi Honor Society. Dr. Mullens will be training with Affiliated Dermatology for the next two years.

https://www.affderm.com

 


VIDEO - DUwHF #982 - Dustin Mullens




AUDIO - DUwHF #982 - Dustin Mullens


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982 Lessons from Dermatology with Dr. Dustin Mullens : Dentistry Uncensored with Howard Farran


Howard: It is just a huge honour for me today to be podcasting interviewing Dr. Dustin Mullens, a dermatologist. He's with affiliated dermatology. He began his residency training at affiliated Dermatology in July of 2016. He received his undergraduate degree in biology from Coastal Carolina University in Conway, South Carolina. Dr Mullens received his doctorate degree from Edward via college of Osteopathic Medicine, Carolina campus. Following graduation, he completed his internship training at Ohiohealth O'Bleness hospital at Athens, Ohio. His professional membership included American Osteopathic College of dermatology and Sigma Sigma Phi Honor Society. Dr Mullins will be training with affiliated dermatology for the next two years and I thought, my gosh, of all the diseases, I just would imagine since we're in the desert, don't we have more skin cancer here than in, say North Dakota? 

Dustin: Absolutely, we do. Actually, skin cancer is most common here in Arizona, comparative to the other states in the United States, mostly because of the snowbirds coming here to the United States down to Arizona during the winter months in the north, so we are average population age is kind of the ripe age for skin cancer that fifty to eighty years old, We're starting to see a lot of these skin cancers crop up the sun related skin cancers. So it is much more common here in Arizona. Second highest incidents, we're second only to Australia for melanoma, so we tend to actually follow a lot of the Australian skin cancer guidelines for some of the practice that we and recommendations that we have for patients. 

Howard: Okay, so this is Ahwatukee Uncensored, o I don't want to ask any easy questions, I want to get straight to the controversial stuff that I hear chair side for thirty years. I hear that you see this chart of skin cancer going up while you see the chart of using sun protection factor is current going up? Like when I was a kid, I was born in sixty-two. You are probably thinking, I was born in thirty-two, but I am not sure it was sixty-two. There was no such thing as sunscreen. In fact it was the opposite. You would put baby oil...

Dustin: Baby oil and iodine

Howard: ...but here's the other part of what confuses the normal person who is not a dermatologists. They say, well, you know, if I put on a bunch of Sunscreen, I can go float the river for four hours. I can go golf for four hours, but if I didn't use sunscreen and I'm Irish, I couldn't do it between eleven and four. I'd have to do my hike on South mountain at six in the morning. And I had a really smart engineer. He's like 80 years old telling me this big lecture on it. He goes, I think they got it all wrong. The more sunscreen they put on, then they go out in the wrong time without sunscreen. They wouldn't go out in the wrong time. And if sunscreen prevented sun cancer, then why is it going up? So I hate to unload all that on you, as your initial question. You are probably going to cancel and walk out right now. 

Dustin: You captured a lot of like the history that we have moved from and to over the past few decades, but getting to just sunscreen in general, it's got sunscreen use. I agree. Back in the day, when I say the day, seventies or even the early eighties, a lot of the sunscreen that we even had wasn't really worth a dork back then.

Howard: Worth a what?

Dustin: a Dork.

Howard: a Dork. I've never heard that one.

Dustin: It was not that great. Don't kick yourself in the butt. I tell this a lot to the patients, to the people that are saying, you know, I kind of grew up on the coast of California and I have them now saying they are seventy years old and they are saying I had a ton of Sun history and you know, I am kind of embarrassed about it. Well, the people that were applying sunscreen at that time, it wasn't that fantastic either, so they didn't really have too much of a leg up on them at that time. Now it has really improved. We have had a lot of improvements since then and it's still improving. But the risk with sunscreen, we do know that yes, you do see a trend of skin cancer incidence is increasing across the board in the United States for your non-melanoma skin cancers and melanoma, which is scary. It's very scary when you are looking at them by the numbers. 

Dustin: We are talking skin cancer alone is more common than any other cancer combined. All the cancers you combine them, it does not equal the total number of skin cancers. 

Howard: That is crazy! 

Dustin: It is crazy. And what is the actual number of skin cancers that occurs in the United States? We don't know the exact number. We have an estimate. We believe a million basal cells will occur over the year. You know, that is an estimate because there is no mandated reporting on these non-melanoma skin cancers. Now, melanoma skin cancers, we have a little bit more of a specific idea of the number of melanomas diagnosed. We are talking two thousand and fifty melanomas will be diagnosed in the state of Arizona this year. We know that those were reported. That is your melanoma. That is the one that kind of makes the pupils dilate when we see those in the office when it comes through on her pathology, because that can carry a much more higher mortality, so it is usually a little bit more complex and it is a little bit more scary for the patient and the provider to go through, but the non-melanoma the one that is related to...

Howard: That's what you call basal cell?

Dustin: Basal Cell and squamous cell, that is the number one and two skin cancer respectively.

Howard: Basal cells number one?

Dustin: Basal cells number one.

Howard: Squamous number two?

Dustin: Squamous number two.

Howard: And you call those two combined?

Dustin: Non-melanoma skin cancers, we call them NSMC, non-melanoma skin cancers. And what those comprise of is a cumulative sun exposure, is what makes you at for those skin cancers. When I mean that, I mean decades, I mean twenty, thirty years of being outside. Say a guy that works outside outdoors. Say he is a construction worker over a thirty year period, so he starts at eighteen. I am seeing him at fifty. He is starting to get just the actinic or the pre-skin cancers. That would proceed these skin cancers. It takes decades typically to accumulate the skin damage from the sun aging and skin cancer causing rays to start building these skin cancers. So where do we see them? Sun exposed areas. We'll see them on the arms, face, neck, ears, nose, lips, eyelids, areas like that. Backs of the hands, you know, much, much less common to see these, although it can happen on the trunk thighs, but usually it is only sun exposed areas. Now, we can see on the shoulders, you know, underneath on the v of the neck and the chest. 

Dustin: Those do get some sun as well. But that's typically where you see those, those sun exposed areas. And those are the ones that are most common here in Arizona because of the sun. 

Howard: And those are all the non-melanoma...

Dustin: Yeah, the non-melanoma skin cancers. So when we talk about our population in Arizona, our took in the greater area. We are really looking at people that are seeing a lot of those types of skin cancer. So when we have people walk in through the door and we are doing our skin cancer screenings where we are checking every area on their body, looking for any atypical or abnormal appearing spots or lesions, those are the ones that we're really typically seeing are the most common, much more common than melanoma.

Howard: But those are not as lethal?

Dustin: Not as lethal. When we say lethal, we are meaning that it obviously can kill you, but also we kind of use that term generally speaking, for something that can metastasize, meaning spread from say the arm to a different location either to the skin elsewhere or internally to an organ. So metastasizing. Melanoma is much more likely to do that. It can be very common to go to the brain, is a common place for it to metastasize for melanoma. That is scary. 

Howard: So I'm safe?

Dustin: Well, President Carter, right? So Jimmy Carter, he had the metastasis to the brain, but they have got some fantastic new medications that are actually able to treat and sometimes melt away some of those metastasis and that worked for him. But for the non-melanoma skin cancers, we don't generally see metastasis or spread elsewhere. It just grows locally. And that can make it easier to treat, but it sometimes can be very difficult depending on the location. So when I said that these are the non-melanomas are going to be on sun exposed areas, we are talking nose, we are talking ear, we are talking lips, eyelids and boy, that can be disfiguring. If somebody gets a skin cancer on their eyelid or their ear or their nose and you are talking about treating that surgically, removing that, that can really leave the individual disfigured depending on how big and aggressive that local tumour was. 

Dustin: Well now these non-melanomas may not metastasize, but they will grow locally and over time left untreated or neglected, I am talking years. It can continue to grow and maybe get a little bit deeper in the local tissue. So your final defect after you cut it out and remove all the cancer cells, could be larger if you leave it untreated. And then to close that up is a difficult task for any surgeon. And there is actually been a special field called Mohs or Mohs Micrographic skin cancer surgery. Mohs surgery is the term that we use. It's actually an eponym named after a guy named Frederick Mohs and he is an individual that created this type of surgery for skin cancers, specifically speaking for cosmetic areas, face, hands, genitalia. Areas like that where you do not want to leave the individual disfigured that can be life changing and so what you have are these individuals that are kind of not a step above, but they have extra training above a dermatologist, usually fellowship trainers, society trained. Meaning where they have acquired the total accumulate number of procedures to be able to attain that kind of a specialization or expert level of skills, and what they do is they cut out real time. 10.13 You come in with the skin cancer, say on the nose, and they'll go out and they'll chase the margin of just the abnormal skin cancer cells, just chase around it. Traditionally, we'd take a wide excision out and we know with 99% probability we'd capture all of the abnormal cells with taking that nice lips outside of it with a margin. We know by just odds that we’ll capture all the abnormal cells. Now with this Mohs Micrographic skin cancer surgery, what they do is they just dance right around the outside margin of the abnormal cells. They cut that out. They put it on a slide. They have a specialist called a Histopath tech. While that patient is there on the table, they take that tissue, they go plate it on a slide which takes a special technique that they do, and then the Mohs surgeon at that time will take the slide back and look at it under a microscope and when they look at it under a microscope, they'll have their coordinates of north, south, east, west, basically looking, they sometimes think of it like a clock, twelve, six, three, and nine. And they'll know, based off of those margins, if they have all clear margins, meaning there's no skin cancer cells on the outside and at the base, and when they get to that point, then they can close the patient up. Not until then do they stop, so say at three o'clock position they see just a little tumour cell right at the periphery. So what they'll do is they'll go to the three o'clock position on the patient and then they'll just chase right around the three o'clock position, and they'll just try to capture just that area because everything else is clear. So it wouldn't make sense to take another big cut. They'll just chase the three o'clock and then they'll go and do the same process again. They'll put it on a slide, they would go back and look at under a scope and then they'll see if they got it all cleared at the three o'clock. 

Dustin: If they have it all cleared then, then they can close it up. Now that's one part of their specialization where they can cut it out and they can look at it under a scope and make the diagnosis of clear or not clear and then go back and take more. That's one part. The other part is the kind of the art of being a Mohs surgeon and that's where they actually have to close it up and when you have to close it up on one of these locations like the face, boy you have to be really good at what you're doing because you want it to look like you were never there or ideally as close as possible to like you were never there. So a lot of times what they'll do is they'll use different types of flaps and grafts and closures and rotations to actually mimic the normal skin folds that we have and just normal skin. So it looks like it's in the normal creases, maybe along the eyes or along the, you know, the paranasal folds, you know, just look like it was our natural creases. So when I look at somebody, my eye doesn't get drawn to something that looks kind of geometric, like some other closures you might get on another locations, it may look more natural. 

You know, that's a professional or specialization within dermatology that was created, which I think is kind of fascinating. That field was created out of the need. You know, it's a relatively speaking, it's a newer field in dermatology because of the need for it. You know, skin cancer is becoming so much more common, like you're talking about, we're living longer than we ever have before. So these things are cumulative related to sun exposure, they're going to become more and more common as we live longer. And you know, it becomes a question of what's the most cost effective, what's the most cosmetically pleasing? What's the most curative? Most surgery, generally speaking for these non-melanoma skin cancers is superior in terms of cure rate. We're talking ninety-eight to ninety-nine and a half percent cure rate with basal cell and squamous cell, you know. There's no 100% in medicine as you know. But boy...

Howard: You're saying basal and squamous?

Dustin: Yeah, it gets close. Not melanoma. 

Howard: So everything you've been talking about so far has been about non-melanoma skin cancers.

Dustin: Non-melanoma. 

Howard: And that's basal cell and squamous cell? and you’re saying the five year survival rate is what?

Dustin: Cure rate is ninety-eight to ninety-nine and a half depending on the surgeon. 

Howard: So then its twin sister is melanoma? 

Dustin: Yeah, so melanoma we don't draw, there's only a melanoma in site two and a certain kind of stage in, or at least severity of the melanoma. What we’ll consider doing what's called a slow Mohs, which is a hybrid of most surgery. Whenever we're taking the tissue and putting it on a slide to look at it under a microscope, the type of processing that that tissue undergoes, is only good or ideal for these non-pigmented lesions. Whenever you try to do that to melanocytes, which a melanoma arises from, it doesn't plate correctly and it doesn't allow you to appropriately visualize the cells and that's why it's not an ideal treatment option for melanoma in general, but there's what's called a slow Mohs procedure where we do the normal processing, which takes up to a few days to process and put it on a slide and have dermatopathologists review it. 

Dustin: And then at that time we cut it out. We'll do that process and the patient will have a bandage over that wound site that's not closed yet, but they'll go through the same processes before where they check the margins, the deep end peripheral margins, and then once we know that it's all cleared, will bring the patient back and then we'll close it up. That's because of the way that the tissue has to be processed for it.

Howard: But what's the five year survival rate on a melanoma?

Dustin: So the melanoma generally speaking, so if it's a, your first stage melanoma, your melanoma inside two's, it can be 99%.

Howard: For stage one?

Dustin: Yes absolutely. And that's typically treated with what we call wide local excision. And that's a five centimetre margin. So it's a pretty good size margin. You're talking on both sides of the actual defect. So…

Howard: Five centimetres?

Dustin: Centimetre.

Howard: Five centimetre margin?

Dustin: They're going to get a five... 

Howard: So the inch is two point five four. 

Dustin: Two point five four centimetres per inch, Yes. So it's going to be, you're going to have a large cut. 

Howard: Do they cut?

Dustin: Absolutely.

Howard: So what are they doing? Stage one, two, three, and four? 

Dustin: Stage one, two, three, and four. 

Howard: So, stage one, you said it's ninety-nine?

Dustin: You can get to 99%, if you have a wide local excision is done with a five centimetre margin, it can be up to 99% cure rate.

Howard: So what is stage two?

Dustin: boy, it drops down to like 87% and then even drops down much further than that.

Howard: What is stage three?

Dustin: Stage three is down to like the fifties. And then down below that it's even lower. I think it's like twenty-five to thirty. 

Howard: So the point is, skin cancer, you got to get checked regularly. I mean you don't want to sit there and say, well, I haven't gotten checked in five years. And they say, why? And you say because my tanning salon insurance didn't pay for it. How often should you get checked and should you get checked more regularly when you're fifty-five like me versus twenty-five, like Ryan? 

Dustin: Good question. So skin checks, we base those off of the patient, meaning risk factors for the patient. So age is one of them, where we kind of look at that and you know, throughout the United States we kind of agree that anybody over fifty, you should be getting a skin check at least once a year. Now, in the geographic regions where there's a high UV index such as, you know, Arizona, Ahwatukee. We recommend the younger individuals come in and get a baseline. It's a very good idea to get a baseline because you could have kids that are getting sun exposure. You know, we have three hundred plus days of Sun a year here. You compare that to somebody in Pennsylvania say or Kansas. 

Howard: You were born in Pennsylvania?

Dustin: Yeah, absolutely. We're talking about many days of Sun. 

Howard: So do you think Arizona from where you were born in Pennsylvania, which is pretty North. 

Dustin: Yeah...

Howard: So do you think we have like twice as much as Philadelphia or is it just like maybe...

Dustin: Oh yeah, absolutely. So we were talking in terms of days of sun exposure, three hundred plus here in Ahwatukee versus, I mean, you could, you're stretching it. Yeah, you're stretching ninety to hundred and fifty, and then you're talking most of those months, you know, from October to March, in, say Philadelphia P A, they're going to be wearing long sleeves.

Howard: And so if we lived in Philly. Not only will we have less skin cancer, we would've won the Super Bowl.

Dustin: We would have won it, we would have been Super Bowl champions.

Howard: Oh my god I've picked the wrong state. 

Dustin: I don't know about that. But yes, that puts us at a risk just by birth, if you're from Arizona, you know. You're kind of behind the eight ball, so to speak with that in regards. But there's other factors that we look at. Risk factors, redheads. Redheads in Ahwatukee areas, there's going to be thirteen times greater risk of melanoma, than the average person in the population. So redhead. Just...

Howard: And those would be pretty much all Irish and Scottish?

Dustin: Yeah, in a mix of the above.

Howard: You know what's funny about here. I've lectured to dentists in fifty countries. 

Dustin: Yeah.

Howard: You go to Vietnam, they're all Vietnamese. You go to Korea, they're all Korean. You go to Japan, they're all Japanese. Even like Poland, they're all Polish. You come to America and no one even knows what they are is the most mutt nation and everybody is a mutt. 

Dustin: And that's what makes it difficult for a lot of our studies, the United States exhibit or at least, and then comparing them to say a Denmark study because it might not reflect what we're seeing day to day in our offices. But we do know individual risk factors, redheads, freckles, blond hair, blue eyes, those are all going to be higher risk. 

Howard: So me, personally? 

Dustin: For you, so blue eyes right there off the bat. I'm looking at you, you know, blue eyes. You're going to be high risk factor for skin cancer. 

Howard: How many times higher?

Dustin: We'd have to go through the risks of family history of skin cancer, personal sun exposure, have you used a tanning bed before? How many burns have you had, you know, there's all these things, you know. Occupation, you're a dentist, you've been indoors. 

Howard: But then on the other end of that deal, so many people, I've had so many African American friends and patients say, yeah, I don't have to worry about that. I'm like, dude, Bob Marley died of skin cancer. And they were like, no he didn't. 

Dustin: Yeah he did.

Howard: And I'd say Google it. Yeah. I shocked some kids in Ahwatukee. 

Dustin: Bob Marley had a melanoma on his big toe... 

Howard: Yeah.

Dustin: ...and he used to play soccer without shoes and he thought it was an old soccer injury. So he had this black spot underneath his toenail and the thing kind of just never went away. And there he thought it was an injury from soccer and that's what killed him. You're absolutely right.

Howard: Yeah, I've done a little African American boys in my practice this tall and they're like, no...

Dustin: So, melanoma can happen in the eye. We have pigmented cells in the back of the retina. So we have pigmented epithelium in the retina. It can happen underneath the fingernails. So in an African Americans, most common.

Howard: I want to go back to one thing. So, when you were talking about Basal Cell and squamous cell.

Dustin: Yeah.

Howard: You tell me it was all the sun exposed area. 

Dustin: Typically.

Howard: So you actually believe in sunscreen?

Dustin: So, to get to the point of sunscreen...

Howard: And what's the better sunscreen? A shirt on, or putting cream on?

Dustin: So yeah, I guess that you know, I did leave that out. The sunscreens, I am a huge believer in. Huge believer in sunscreens. Absolutely. 

Howard: And sunscreen protect not just basal and squamous but also melanoma?

Dustin: Yes, absolutely. 

Howard: So then you're saying that the melanomas would be more likely to occur in the same area? 

Dustin: Interestingly, that's the confusing conundrum with melanoma. There are some melanomas depending on the type. We have different subtypes of melanoma, like a Subungual on the hands or an Acral melanoma. We have Lentigo Maligna melanoma usually slow growing on the sun exposed areas like the face. Superficial spreading melanomas. You can see those on the trucks in the back and the button, the thighs and those locations where sometimes we see them most commonly aren't sun exposed areas, but now that we have genetic profiling and mapping, we can see that what call UV signature, mutations in the melanomas that are related to UV exposure, but they're not the sole driver of the melanoma. It's an accumulation of mutations and sunlight can contribute to acquiring more mutations, being more likely to go at a barren and become a melanoma, but there's genetics that play a role in this as well. We know there are certain genes that can be related to higher risk of melanoma and skin cancer in general, but that's a fantastic point that you made. So yeah, sometimes we'll get young individuals coming in and anybody really. If we're pulling an abnormal moll, we call Dysplastic Nevus, it might be on their back and they might say, well, you know, I really haven't had a whole lot of sun exposure there. Can you explain that? It's a combination. Genetics, if you have over one hundred moles, over a hundred moles will put you at a higher risk. If it's greater than two centimetres or twenty millimetres, that could put you at a higher risk. There's different things that could be inherent within that. They could place you at a higher risk. Now sunscreens, Oh, you bet you. There's some better sunscreens and not out there. And it can really vary on the SPF level. The minimum level of SPF that you need to prevent skin cancer and the kind of the sun aging rays is SPF of thirty. 

Dustin: Now, there's also a too much of a good thing and we know that and we're actually learning that right now. What we're learning is, you know, some patients will me, why would I get an SPF hundred if thirty is all I need to prevent skin cancer? Well the way that it's recommended per square cubic inch or centimetre squared of area to apply, it's actually a pretty thick layer. Not a lot of people like putting a thick layer sunscreen on and when you're applying an SPF thirty and like we generally do 99% of the population. Actually only one out of ten people wear sunscreen. So we're saying...

Howard: How many?

Dustin: One out of ten. 

Howard: Only10% wear sunscreen?

Dustin: Yeah, in a lot of those studies that they pull that from, is actually a lot of females that wear it in their makeup. And so not a lot of people wear sunscreen.

Howard: So you're a big believer in sunscreen? 

Dustin: And now SPF thirty to fifty is generally what I recommend, I like SPF fifty. Now for people that are higher risk for people that like applying it very thin, which a lot of us do. That's where the benefit comes from by buying or purchasing an SPF seventy-five or an eighty, because it's going to allow you to apply it thinner, or behave more like an SPF thirty.

Howard: Do brands matter? 

Dustin: Good question. Actually, Some brands are better than others, but sunscreens can really vary on price and it's more expensive, does not always mean better. Neutrogena in general makes some really good products that are also affordable. So when you're talking to...

Howard: And what is Neutrogena? That's a brand? 

Dustin: Yeah, Neutrogena is a brand there. And they have a sheer zinc. Is an SPF fifty and there's a ranking system that we kind of know of that where they look at the chemicals that are in the sunscreen, because you can have a chemical based sunscreen which basically takes the UV rays and absorb that and refracts and deflect and the energy so it doesn't reach the skin and the cells and cause genetic mutations and damage in aging, and risk of skin cancer.

Dustin: So that's a chemical blocker and you also have a physical blocker. Your physical blockers are what we really favour, but a lot of the patients tend not to like historically because that's what we associate with the white paste on the nose, on the, the guy that the lifeguard at the beach, because it's a zinc oxide or titanium dioxide. I like zinc oxide based sunscreen's is better. That's going to provide what we call broad spectrum. There's two types of UV rays that we try to protect from the UVA and UVB. And broad spectrum means that it blocks both of those. Your zinc oxide based sunscreens are called a base of their natural. So it's going to be a natural blocker and it's a physical blocker. So Neutrogena makes a zinc, a sheer zinc. It goes on dry and you can put your makeup on over top if you're a female and wanting to put makeup on and you are your moisturizer, it's very easy. It's a little bit more elegant, so to speak. And they kind of make these nanoparticles with them now. That's one of the technologies that we have where it makes it a little bit more pulverize, where they're able to apply it and it's not just white paste. It's a lot smaller, that's a lot more tolerable for people to use day to day. They can use that. So I favour the zinc based over titanium dioxide. But I'll take the physical blockers over chemical blockers any day of the week.

Howard: So, what do you think is better, a blocker or avoiding certain hours of the day? 

Dustin: So the most important thing is to always be wearing sunscreen. No matter the time of the day. It's important to have sunscreen on, especially if we know we're going to be outside. Sun exposure starts when you walk outside to your car to go to work, while you're driving to work. We get a tremendous amount of sun through the left side of our driver's side window. That's why we see some skin cancer on the face is more common in the left side. So it's certainly, we're getting that exposure from getting out of her car, going to work, going to lunch. Those times we're getting it throughout the day. The worst parts, you're absolutely right. Typically between ten and two, or even out here, ten and three, ten and four, is our peak hours. And usually we if you can't see your shadow, run! That means the sun is right above you. And it's at its peak.

Howard: I've never heard that. That's a great one.

Dustin: That's just kind of, you know, you always seek shade, but I kind of, I like where you're going with this, you know, in terms of is there a better option than sunscreen. I think sometimes there is a, a really great alternative to sunscreen depending on the function or the activity that you're doing. A lot of hikers, we're not going hiking for just two to three hours. You're recommended the reapply sunscreen every two to three hours. Now what if I'm hiking and it's our three don't want to sit down and just lather up again. Do I want to get that out and go through that whole process? Well, ideally, if you didn't have anything else nor other option, yeah, I'd recommend that. But what we have now is we're talking about sun protective clothing. And sun protective clothing actually is just clothing. It's any clothing in general is going to be sun protective. Now there's certain colors that are going to be better, like your reds, your black, your dark colors are going to be a little bit more protective. The ones that are going to have a less, they're going to be more of a thread count, higher thread count, tighter weave of the actual threads, that's going to be more protective. And now we actually rank clothing on how well it protects you from the sun. It's called the UPF. Ultra violet protective factor. And basically that's just a fraction of the amount of UV light that's able to penetrate the clothing and reached the skin. So, UPV of fifty means one fiftieth of the UV rays can reach the skin through that clothing. So, you wear long sleeve clothes, which you can get some really nice light breathable clothing. It's long sleeve. I wear it myself golfing. I golf out here and it can get hot out here. You can get long sleeve, you can wear pants. And that's sun protective. You know, you don't have to have sunscreen on if you were in that sun protective clothing. Why brand hat? We typically recommend a three inch hat all the way around. Protects the ears, protects the face. 

Howard: But is that only between ten and three?

Dustin: No anytime of the day. Anytime of the day the Sun protective clothing's fantastic. 

Howard: Okay, so again, Ahwatukee Uncensored. 

Dustin: Yeah.

Dustin: By the way, you are an amazing man. I mean you’re just like, he has no notes, no Powerpoint, he's like Beethoven on a piano. Well, but then, my patients are hearing exactly the opposite information saying, well you need to go out and get ten minutes. You should be eating your lunch outside only because you need Melatonin. You need Vitamin D. 

Dustin: Absolutely.

Howard: And they're saying that the typical person who wears their clothes to work, if they sit outside their whole lunch hour, they won't get enough. But if they were in their backyard and they get stripped down...

Dustin: Get naked and go outside for ten minutes yeah.

Howard: That is five minutes on each side. So, that's very opposite information. 

Dustin: It is. And you know, some of the most intelligent people I've ever met in my life believing that. Not dermatologists, but historically some dermatologists did believe that sun was good and to a degree a little bit of sun is good. Five to ten minutes over say just the arms is quite enough to get your daily vitamin D. Actually, most of our vitamin D comes from our diet.

Howard: Really? 

Dustin: Absolutely. A lot of our greens. A lot of our Greens, we get a lot or vitamin D through that or foliage. So a lot of vitamin D is dietary. But, the sun exposure can help with a little bit of an additional type of vitamin D that we can make. 

Howard: When you say Greens are good, what type of green candy are you talking about? 

Dustin: Just any, any Greens Yeah. 

Howard: Talking about when you're on an Easter egg hunt and get the green eggs and not the yellow, pink and purple. 

Dustin: No. No. 

Howard: So vitamin D's in greens? 

Dustin: Yeah, so like a lot of your diet, yeah, you get most of your vitamin D. 

Howard: So then the other one would be, the only one you have to get from the sun then would be just Melatonin?

Dustin: Melanin.

Howard: Melanin.

Dustin: So the sunlight, yeah, Melatonin, he actually does play a role in the Melatonin, like with sleep. Our sleep cycle, a lot of it is based off of seeing natural light. And that means how are going to feel if we're seeing a little bit, if we're seeing less sunlight, we're not going to feel as good overall or general sense of well-being might be lower. This is what a lot of us in the north seasonal affective disorder.

Howard: Seattle, Philly.

Dustin: So you go where you don't see the sun for four or five months, you're going to start feeling down. You’re not going to feel that great.

Howard: You know what my dentist friends in Alaska say? If you live above that, what does it, the thirty-fifth...

Dustin: Or whatever latitude. 

Howard: Yeah, And like North of Fairbanks Windberg range where in the winter it'll go completely dark for like three or four months. 

Dustin: That has an effect on them. 

Howard: And they said that the, the alcoholism rate doubles or triples. It goes from like 15% to thirty. 

Dustin: What you’re going to do when it's dark all the time?

Howard: Some people, when the summer comes out they say, what did you do? And they go, I bought 20 cases of vodka and went and slept my trailer for three months. 

Dustin: Yeah, it's zero degrees out, and there's no light. So it does have a role and sunlight from the time that we get up, within that timeline of us seeing natural light outside that has an effect on arousals, you know, activity. Just being wakefulness. So it has, sunlight and light in general, it has a lot of positives. I don't want people to turn into a vampire and never go outside. But I want that to...

Howard: That was my next question. Do vampires ever die of skin cancer? 

Dustin: Yeah they do. I don't know, maybe. 

Howard: You know who my favourite character is in every vampire movie? The sunlight. 

Dustin: The sunlight? Cloves of onion, I don't know, or garlic or whatever it is. 

Howard: So then what's your final professional recommendation about everything I need ten, fifteen minutes sunlight every day for?

Dustin: I'd say... 

Howard: Vitamin D and Melatonin. 

Dustin: So five to ten in the sun exposed areas outside of direct sunlight is plenty enough. You're somebody that has a sensitivity to sunlight where at five minutes that you could start seeing any type of redness or anything like that. The five minutes is enough for you, but it's not an absolute must. Like I said, we get most of our vitamin D from the diet, but I think a little bit of natural sunlight, just a little bit, five to ten minutes of those sun exposed areas. Just the arms, face...

Howard: I want to ask you some more urban legend questions.

Dustin: Yeah.

Howard: You know, again, these are real patients asking real questions.

Dustin: I'm going to try to answer them, yeah I'll do my best. 

34.51 Howard: That bachelors have a higher mortality rate from the skin cancer, for melanoma's because they don't have a lover who noticed a spot on their back. For instance, I have two dentist friends who were legends. One was in Ohio where you went to school and one was in San Diego and the guy in San Diego, I think he was one of the first dentists ever in the world that reached to placing thirty thousand implants. And he was Polish and it was right in the middle of his back. 

Dustin: Yeah.

Howard: And he said, whenever I was around another human, I had a shirt on. 

Dustin: Yeah.

Howard: Both guys had the same thing that are both bachelor men. No one ever saw her back. Both of them wondered if I would have been married, do you think my spouse would have said, “hey, there's something on your back.” So my question, my specific question...

Dustin: Being single, does that put you at risk? 

Howard: Does being single...

Dustin: Yeah.

Howard: ...have a higher mortality rate because you don't have a lover noticing something.

Dustin: You know, in theory that makes sense. I don't know the true numbers on that, but in theory that makes sense, thinking about it. We recommend that spouses in couples, they do skin checks on each other. We've recommended, you know monthly. We teach patients what to look for, you know, we have what we call the a, b, c, d, e's of melanoma. I don't know if you've ever heard that.

Howard: I have.

Dustin: So the, a, b, c, d, e's of melanoma are something that we tell patients to look for. A stands for asymmetry. So if I cut it down the middle, is it a mirror image of itself? And whenever something offends any of these rules of the a, b, c, d, e's, that's when we say we want you to make note of that. I want you to come in and let us know where you saw that. 

Howard: I think that's the most natural thing for him because everything is symmetry. A pine tree, a Christmas tree, two hands, two feet. I think when someone's like nose deviates to the left, or I think asymmetry is for some reason, I just think humans pick up asymmetry like that.

Dustin: We do, we do. So that's absolutely one of the things that we look for because generally speaking, if we're thinking it could be a melanoma. That asymmetry means if it went from something perfectly symmetrical, perfect circle and now it's starting to get maybe a little bit, almost like a mickey mouse ear, over on the side of that perfect circle. That means that there's activity that's occurring at that area. Maybe that two o'clock position. Well, is that activity normal, or does it make sense that all of a sudden you're getting this new activity that sprout now on its own. It's not growing as a whole, kind of progressing in a natural evolution with itself. You're starting to see a little bit maybe increased activity there and that kind of brings me to the next part of that a, b, c. Is the b. The border. So is the border nice and smooth or is it kind of irregular? Does it have almost finger-like projections or is it jagged? Is it not a nice smooth contour border? Usually whenever you see a muddled or kind of a jagged border, that means that there is some activity that's a little bit bad or atypical. So that's another feature we look for. Now only is it asymmetric or is it symmetric. Does it have a smooth or a jagged border? I like smooth. I don't like the jagged. So that's another thing that we look for. C is color. color variegation. So what I mean by that is, is it more than one color. Is it you know brown and black? Is it brown and white? Is it brown and blue? Brown and red? Multi-toned? These are things that would be suggestive of potential risk for melanoma.

Howard: So you want it one color?

Dustin: I want homogeneous. I want it nice one color. Now, nothing once you look, if you look close enough is one perfect color, but I'm saying grossly from the naked eye looking at it, generally speaking that it look like it's homogeneous or one toned, but once you get up close enough to anything, you can see multiple colors of course, or at least tones of that color. But I'm talking is it brown and black? Is it tan and brown? Is at tan and blue, tan and white. Is there multiple colors within that lesion or maybe a new color within it? You know, these are things that we're looking for. The d, that's diameter. So diameter of six millimetres or greater. So size, so...

Howard: Six centimetres?

Dustin: Six millimetres.

Howard: Oh, six millimetres.

Dustin: a Pencil eraser...

Howard: Two point five, four millimetres is an inch. 

Dustin: Two point five four centimetres is an inch.

Howard: Two point five four centimetres is an inch.

Dustin: Yeah. So six millimetres. So just over half a centimetre. It's a pencil eraser essentially. So if I could take that pencil eraser, stick it over that pigmented spot, in general, that's a reassuring feature. Not a guarantee... 

Howard: So if you can cover it up with a pencil eraser...

Dustin: That's basically six millimetres. 

Howard: That would be good?

Dustin: Yeah, absolutely. 

Howard: But if you put your...I don't even think they sell erasers any more right. You know anybody that uses a pencil? You're giving away that you're an old man, but you're ballpoint pen?

Dustin: That's just, you know, to give some people some, because sometimes they'll say, well, you know, when I'm doing a quick look, what is six millimetre? And it generally, it's basically a pencil eraser diameter. Again, it's not a guarantee, but if it's greater than that, oh, I want to hear about it. The e. A, b, c, d, e's is evolution. Is it changing in any way? Is it a moll that you've had that's changing in any way. Is it evolving? If it's changing and all, I want to know about it. So those are the self-checks that I have a patient do and I want him to look for all those and they apply it. So they see a pigment spot. Okay. Does that look like it's symmetric? Does the border looks smooth or jagged? Is it one color or is it six millimetres or less? And has it changed at all? I want him to look at all those. Sometimes change, if it's kind of equal to all the other change. It's growing, but maybe it's growing in proportion to everything else. More reassuring feature. 

Howard: Some people say...Some people wonder, well, what have you got like a mole or skin tag? Would it just be smarter just to cut that off? If you're born with the moll, and some people who have three or four of them, are they higher risk ...

Dustin: Would it make sense just to cut that thing out and prevent any possibility? No. You know, we kind of look at the morbidity associated with just taking out just a mole in general, versus allowing them to sit and monitoring them. Now if there's any of these features that we see that we mentioned there, or any other historical features from just a patient reporting or risk factors of previous skin or risks maybe through medications or medical history, then we may biopsy and if it came back abnormal or atypical, then we may recommend that we get that removed or excised. And what that is, is not only treatment of the typical nevi or mole, but it also, you can think of that as a prevention of the potential to go down a path to evolving into a melanoma. So just at face value any mole, just to excise, is not a recommendation we have. We do recommend that if you get any mole, you know, if you have moles at all, if you're concerned or questioning them at all, you can come in and let us look at them at the dermatology office. 

Howard: And by the way Tom, You know where Fortieth street is? I mean it starts up at Corpus Christi, goes down past Fries at Ray road. Then you go down to Chandler and there's Safeway and Fries and then you keep going towards Pecos. Halfway between Chandler and Pecos is a medical dental building. So you just turn there. They're right in there. I know all my questions annoy you, because...

Dustin: No.

Howard: I mean I'm fifty-five, so I've heard a lot of these questions and practicing for 30 years. I can't tell you how many times I heard this. It will be like a seventy, eighty, ninety year old woman golfer at Ahwatukee lakes. And she'll say, well, you know, I don't have to worry about skin cancer because it's the burns you got when you were ten...

Dustin: Yeah.

Howard: ...thirty, forty years later, killed you when you were fifty. 

Dustin: I've made it passed that hump.

Howard: So, now that I'm seventy years old...

Dustin: Yeah.

Howard: ...if I got too much radiation now, it wouldn't be cancer. I was a hundred and ten... 

Dustin: Actually seventeen years old in the seventies is the most common time for melanoma 

Howard: But is that true though? But when she is seventy and gets a melanoma, was that from a bad burn when she was in a bikini at twenty?

Dustin: So, beautiful point. Remember earlier I was saying melanoma is kind of the odd ball because we see a lot of those arise. Not all, but a lot of them are rise in areas where we generally don't have exposed skin. Chest, back, butt, thighs. Areas were we're saying that's that can't totally be related to just sun. Correct. But the way we've tried to explain why we see this occurring as we think of the guy or the girl that lives in, we'll say Pennsylvania again. It's springtime, it's April. We had our first couple of weeks of nice sun. What does the guy do, goes out on the lawn, takes his shirt off, mows the lawn. Gets a nice burn. What does the lady do? Maybe she goes and lays out in the sun and gets a nice burnt on the thighs. And then you start looking at the numbers of the most common locations anatomically speaking for Melanomas, for guy or girl, you started saying, Okay well, back, chest, neck, scalp, guys. Thighs, butt, back, abdomen, females. You've start wondering is there an association with those few sun exposures that aren't commonly exposed areas, but when they do get exposed they might get a little bit of a burn there. And that's what we do think is actually occurring. So it is those rare or less common times that they get exposed, but they get a little bit of a burn there. Not necessarily when they're ten, but we think it's just those few bad burns on areas that aren't in general. 

Howard: So you're saying then, that the woman should be mowing the lawn...

Dustin: Yeah.

Howard: ...and the guys should be laying in the lawn chair drinking the beer. That's all I took from that so...

Dustin: I think all duties should be equal.

Howard: So, back to risk factors. And come on guys, you just got to get checked every year. I mean, they're right there. 

Dustin: I think the good point out here, like with the seventy year old Golfer, I golf all the time. I love being outside. I've been in the Ahwatukee area to the baseball fields with the nine and ten year old baseball players. We come down here with Pop Warner football. We get involved in the community, but a lot of people, were outside. That's why we're here in Arizona. It's a beautiful place. We get to be outdoors and active, which I love people being healthy and active. But with that I get a certain subset of people, even family members I can relate to where they think that maybe they're a little fearful or hesitant to go into a dermatologist. Maybe because they have this, some of the skin changes of being outside and having poor sun behaviour habits. Don't let that keep you from coming in. If you have a tan or a burn or anything like that, you're the person that we want to see in there. 

Howard: And nobody should make you feel bad. I mean, based on a summary of the five people you spend the most time with and if you spending a lot of time with someone that makes you feel bad or is toxic, the number one thing you need to do in your life is get that person out of your life. And if you go to a doctor, and look when I was little, all the OBGYN's were men, and all the women said they didn't listen to them. Now, I'm a half a century later, all your OB GYNs are women. 

Dustin: Yeah. 

Howard: And in fact, I mean think about that. From the culture, I mean you know, when you say, well, I'm having post traumatic depression from having my baby. And you know, they'd say quit being hysterical. Hysteria, Greek for uterus. That's saying quit thinking like a uterus.

Dustin: Yeah. postpartum blues. 

Howard: So, everyone knows half a century ago, all the doctors were male and the woman didn't listen. So if you go to your doctor and you don't feel like you can talk about anything, no matter how personal or private. And sometimes if you're there and you want to ask a private question but you’re in the exam room, the doors open, say, hey, shut the door. And if the assistant sat there and you say, I don't want to even ask you this in front of the assistant. You're in charge, you're the customer, you can go anywhere you want. If you say, I don't even want to talk to you in the exam room. I just want to go to your private office. 

Dustin: Yup.

Howard: Just you're in control or...

Dustin: yeah. Or maybe may call and they say, I'd really like to talk to the doctor if I could. Maybe I don't want this message re-laid. Could I talk to them personally. I think, you know, for our group affiliated dermatology or what attracted me to come to this group and work with him was it's a family based community based group. We're talking, everybody's got kids. We go out as a community, we get involved, we offer free education to the school systems. 

Howard: How many kids do you have?

Dustin: Me? I don't have any kids yet. 

Howard: My gosh, you’re a genius. Ryan give this the genius award, my gosh. A lot of people in Ahwatukee, and by the way, if you're listening to this on Youtube, subscribe to Youtube channel, youtube.com forward slash. Ahwatukee Uncensored. But remember we're on Itunes so the show's really taking off because a lot of people have an hour commute to work and that's my other question. What if it's not convenient? I live in Ahwatukee, but I don't want to go to your Ahwatukee location. I'd rather go see you on my lunch or like where? Where are your other five locations? 

Dustin: So, that's a great question and like I said, we're such a huge presence in the local communities. We really do have a nice spread of locations to make it more convenient to the patient. We have a location in Gilbert off South Higley. We have a location in lower Scottsdale, right across from the Thompson Peak Honorhealth Hospital in the Grayhawk medical center building. It's North Seventy-Third street up there. And we have a location in Deer Valley across from Honorhealth Deer Valley Hospital. So that's an easy connect.

Howard: I'm so sorry. I've lived here for thirty years. Where is Deer Valley. 

Dustin: So the Deer Valley Hospital is off the One O One. It's on exit, I believe, Twenty Three off the One O One. It's right there on your left. 

Howard: So real North Phoenix?

Dustin: Phoenix. Exactly. Over like Pinnacle High School over that way. That's where that... 

Howard: You would not believe what a Ahwatukee recluse I am. I mean, the only time I leave Ahwatukee is to go to the airport...

Dustin: You’re in the Ahwatukee bubble! You’re in the Ahwatukee bubble.

Howard: I grew up in a small town in Wichita, Kansas, this is eighty-five thousand people. This would be the third largest town in Kansas. 

Dustin: Yeah. When you have everything you need within a certain distance, you know, why go elsewhere? 

Howard: So, in Ahwatukee, you've got Gilbert, you've got North Scottsdale, you've got North Phoenix.

Dustin: Yeah, we have one in Anthem, which is North on the Seventeen. 

Howard: On the way to Flagstaff?

Dustin: Exactly. So that's probably, I'd say off the One O One and Seventeen. I'd say it's about ten, twelve miles.

Howard: You Know, a lot of the people call Anthem North Ahwatukee.

Dustin: North Ahwatukee. 

Howard: I mean they really do. 

Dustin: I can see why they would. I love Anthem. Anthem is such a cool little community. I kind of see a lot of similarities to Ahwatukee and Anthem. I will see a lot of families there in Anthem. It's actually, it was just a booming place right before the bubble, you know before the bubble pops. 

Howard: But you know, those are all say bubbles. They're up and down and they're always going to happen. 

Dustin: Yeah I know, it's a great place. 

Howard: The fact that Bill Gates, I guess the richest man, I mean it goes between Bill Gates and Jeff Bezos depending on what Microsoft stock's trading at

Dustin: Yeah right. 

Howard: So like Amazon stocks take like 10% in the last few weeks. 

Dustin: 4% last Friday. 

Howard: Yeah, so now I just read that Bill's back to number one, but he just bought twenty thousand acres of land... 

Dustin: I heard about that. 

Howard: ...off the side of that. And then they're going to build the interstate straight from here to Vegas. So, Anthem will be back, but it's a beautiful city. 

Dustin: It is. 

Howard: What's your sixth location?

Dustin: The other location is a surprise.

Howard: Oh, that surprises me. I had a patient once who put on her eyeliner that was too high, and she looked surprised. 

Dustin: Did she? 

Howard: Yeah.

Dustin: Wow, she surprised me for it. 

Howard: So surprises is West of Sun City...

Dustin: Yes.

Howard: ...or North of Sunset? 

Dustin: I believe it's West End, maybe a little North, little North West. 

Howard: West, North. That's about where Gates bought that deal. 

Dustin: It makes sense. Like you said, there's a lot of land out there, but it is booming, is growing. 

Howard: You know, this whole area's booming. I mean, out of the whole world, Google chose Phoenix for their driverless car program. Bill Gates could have gotten anywhere he wanted to and he wants to build a high tech centre out there. And what my dentist friends are telling me in Silicon Valley, is that you can't even get an employee because if I hired you, even paid you a gazillion dollars, you can't afford to buy anything. You can't afford to live there.

Dustin: No, taxes are ridiculous. 

Howard: Taxes, price of real estate...

Dustin: This is part of the country, you know, I heard actually U Haul, you can't get them. There so difficult in San Francisco right now.

Howard: Is that right?

Dustin: Yeah, everybody's leaving. They're coming to places like we are now.

Howard: I went to...these are true stories of visiting dentist friends. One time, in Manhattan, he told me what he paid for his rent and we went in this hundred year old building, went up to this creepy little elevator... 

Dustin: Shoe-box right.

Howard: Shoe-box with one little window. And I'm like, dude, you could be... that could be a mortgage on a mansion. And then the same thing in San Francisco. The Guy, it was so small, it was like three people and they were on air mattresses. 

Dustin: I worked at Cornell Columbia Hospital in New York City. And when I was there, I split with a guy who was at NYU dental. It was a ridiculous price and it was, yeah, it was air mattress size, you know, place to stay in. You’re going to blow it up and deflate it.

Howard: This and this is going to be the next Silicon Valley. 

Dustin: I think it is. The nice thing is it's such a newer development, everything's being planned so well. You know, if you look at whenever we have maybe the waste management golf tournament or another big event where you bring in a million people over a three, four day period and you see... might see a little bit more congestion, but you don't see where everything's just shut down and the you can't drive. We're able to accommodate it. But it's not a Boston type of design.

Howard: What's the biggest event that attracts the most people in Arizona? 

Dustin: Is it the Horse Show? 

Howard: The horse show?

Dustin: Yeah.

Howard: No one ever gets it.

Dustin: Is it that? What is it? 

Howard: It's the Nascar.

Dustin: Is it? You're kidding me. You mean one day, one single day. Total though we had over seven hundred and fifty thousand in the golf tournament. 

Howard: Right. That Nascar event. I mean that's a religion. 

Dustin: Yeah. 

Howard: What's that one thing, burning man out in the middle of the desert? 

Dustin: Burning man. I know.

Howard: I mean it's, it's insane. I mean, people drive here. 

Dustin: Absolutely. 

Howard: I mean when I've gone out there...You're born and raised in Philadelphia. I, remember seeing three green RV's that had Philadelphia Eagles on them there. 

Dustin: Yeah.

Howard: And they're out there (inaudible 54:40) and all that stuff. I said, you did not drive that from Philadelphia. And they go, Oh, yes we did. 

Dustin: Yes we did.

Howard: For a car race? 

Dustin: Yeah, absolutely. Yeah, you're right, it can be...

Howard: Oh, by the way, where in Philadelphia were you born? 

Dustin: So I was actually outside of that, so actually the county is what people might associate, Cameron County was the location. It's more North central PA.

Howard: Cameron County? And then you went to college in Ohio? 

Dustin: No, Coastal Carolina. I went down there...

Howard: So you went to South Carolina. What city there?

Dustin: So that was in Myrtle Beach.

Howard: Oh my god. Is there more golf courses in myrtle beach? 

Dustin: Per square mile there are more golf courses in Myrtle Beach in anywhere else in the world. 

Howard: So, Philadelphia to Myrtle Beach and then college and then...

Dustin: College there, and then I did med school in the upstate of South Carolina and then I went to Ohio University and worked at that hospital. Worked in the hospital and then it came out here to Arizona. 

Howard: Well, I mean, it's not everyday you meet someone that's lived in five different states...

Dustin: Yeah, yeah. By way of everywhere.

Howard: So are you glad you're here? How long you've been here? 

Dustin: Oh my god yes. Almost two years now. Every now and then I do have to pinch myself because just having great people, safe community. You know, it's a stable community, good education system and it's only getting better. Very fluent. There's a tremendous opportunity to really plant some roots, get a family, have kids, and really settle down. This is the ideal place. And I love the outdoors, you know, golfing is one of my passions that I have... 

Howard: He lives in Myrtle Beach.

Dustin: I got recruited for golf there at Coastal. Actually Dustin Johnson was on the golf team when I was getting recruited. 

Howard: You got recruited for golf?

Dustin: Yes, Dustin Johnson's the number one golfer in the world right now. He was going to that school at the time. So it's a big golf school. 

Howard: So what do you like more? You are a wrestler. You're wrestling or your golf? 

Dustin: You compare anything to wrestling, it's going to be tough to see, it's so difficult. But what was more, maybe more of a life lesson type of a sport. Wrestling hands down because of the mental stamina that you had to have to match the physical component of it was unparalleled, but golf was just too enjoyable. 

Howard: I could not have been a dentist if I wasn't on the wrestling team.

Dustin: And tell me, everything is easy after wrestling.

Howard: And you know why?

Dustin: Why, did you lose a tooth wrestling, and went ahead and made a moment?

Howard: No, this is a true story. So, I was born in sixty-two. When it was seventy-two, my Dad bought this new franchise that nobody heard of. Because that's when franchises were rolling out...

Dustin: Yeah.

Howard: And the franchises were rolling out because the federal government was building these interstates. And before there were interstates, nobody really was... they born, raised, reared and died, and never went a hundred miles away from home. 

Dustin: Yup.

Howard: So then people would walk out and they'd see this interstate in Kansas. They said, well, that'll take you all the way to Disneyland. 

Dustin: Yeah.

Howard: So that's when people started moving. And then when they got to the next town, they wanted something familiar because you wouldn't know what Joe's bar and grill was. So my dad bought a franchise, probably never heard of it. Sonic Drive-in 

Dustin: And I haven't heard of it. 

Howard: And he was expanding those out and I think he got up to nine and all the franchise. My dad got so mad at me that I wouldn't drop out of high school because he wanted to put me in a franchise

Dustin: Going on with the family business. 

Speaker 1: He wanted to go to Abilene Kansas, Carney Nebraska, Childress Texas. And he's like, why are you in school? This is stupid. And then he'd look at my and be like, Algebra. And he goes, this is stupid. But I wanted to wrestle and you couldn't wrestle unless, not only were you in school, but you had to have above...

Dustin: You had to maintain grades. 

Howard: A two point five. So I only stayed in school to wrestle. 

Dustin: Wow. 

Howard: And then, my dad lived next door to a dentist and I would go to work with my dad and he'd make a cheeseburger and a french fry. And I'd go to work with Kenny Anderson and he take an x ray of a tooth and work on it with his hands and do surgery on a tooth and I just like that... 

Dustin: A different world. 

Howard: I said I love you more than Kenny Anderson, but I don't want to make French fries and onion ring my whole life. So the bottom line is, and then I see that today because I mean, let's just keep it real. There are a lot of businesses, whether they be yard maintenance...

Dustin: Landscaping boomed out of here.

59.10Howard: Landscaper where the father is putting a ton of pressure on those kids. Look, I need a hired hand. I can pay you $20 cash an hour under the table. You could buy a nice car. Why are you going to desert vista? I need someone hammering. I got kids said to me every time one of my dad's workers called in sick. 

Dustin: You paying for school right now, and I could be paying you and you can be making money, right? It's two different kind of worlds, you know, and it is your right and it's tough. 

Howard: What would you tell that kid that at Desert Vista Mountain Point, who's dad's saying, “dude, I can you pay you twenty. We install sheetrock. We install roofs. We do land maintenance.” 

Dustin: I've done those jobs myself. Those were my winter jobs when I'd been on school break. I do construction where I, you know, hauled out all the heavy stuff in the scrap and cleaned up. And I've had friends that went and worked with their dads. So my dad was a logger and he worked with his dad that logged.

Howard: A logger?

Dustin: Yeah.

Howard: In Philadelphia? 

Dustin: Yeah, North Central, I guess we're a little bit outside...

Howard: I mean (inaudible 01:00:10)

Dustin: Yeah, the least populated county in the state, 97% and half percent forest. So my dad did that and he was, you know, he was pushed into it, like you said, where he wasn't allowed to do sports and it was, you know, that going into the family business you need to help contribute to the family to provide. But I would say, you know, one that is a unique and special thing for a son to work with a father in any job. I think that's something that I would absolutely cherish and I would respect anybody that went into that and chose to do that because I think that's a special thing. Not many people have the opportunity to do. If they want to do that, if their kid wants to do that. But if they think that there's something else that they're passionate about, well then I think then any father, at least I would hope would want their kid or you know, son or daughter to pursue what makes them passionate and maybe get them up every morning. So if that's something other than that. 

Howard: And that is the one thing... 

Dustin: It's not a bad thing for if the, you know, there's times that your parents will get mad at you, that might not be a bad one for them to be mad at you. If they do they'll probably get over it. 

Howard: You know, one of the luckiest things about my life is I've never worked a day in my life because all through from age ten to twenty, when I went to work at Sonic, I was with my dad. I got free hamburgers and cheeseburgers and those carbs were gorgeous.

Dustin: Yup.

Howard: So I mean, that versus staying at home and then...But I'm so glad I followed...

Dustin: But the learning experience, right? So like you got to see you if your dad, I'm sure the management and kind of running things and knowing how that all works and if you saw that at from ten to twenty, you’re probably thirty years ahead of kids your age, you know, people that don't learn a lot of life lessons, a lot of lessons on all that business and all that works. Boy, that is a great opportunity if you do have a parent that's in a business and I think that's a benefit of going in when you're younger, at least being exposed to that stuff. I'm certain that's what you were.

Howard: I saw that when Dennis got out of school, if they grew up on a Kansas farm and mom was sitting at the kitchen table with a calculator doing all the bills while dad was riding the tractor, when they opened up their own dental office, they were fine. But if their dad and mom were both employees and went to work eight to five, they were at a serious disadvantage. 

Dustin: Yup.

Howard: But, I can't believe we went way over an hour. I could talk to you for forty days, forty nights. 

Dustin: Ah, you know.

Howard: Your website is affderm.com.

Dustin: Yeah, like affiliated dermatologist.

Howard: Affiliated dermatologist. 

Dustin: .com

Howard: So affiliated has two f's. So AFF, derm for dermatologists. I'm trying to give you this as a mnemonic device. So it's AFF for affiliated then derm for dermatology dot com. 

Dustin: Absolutely. 

Howard: They have six locations that they're killing it in Ahwatukee. They're in Gilbert, North Scottsdale, Deer Valley, Anthem, Surprise. My final question is, before we started this show, you were telling me that the people in Ahwatukee were ten times nicer than the people in Gilbert, North Scottsdale, Deer Valley, Anthem and Surprise. Why do you think that is? 

Dustin: I think that is because they're always smiling. I think it's the dentists in this area. 

Howard: Touchè. That was a good one. Hey seriously man, thank you so much. 

Dustin: Absolutely, thank's for inviting me.

Howard: Ryan, thank you buddy.



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