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Most anxious and special needs patients can actually be treated in an office.
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AUDIO - Harvey Levy - HSP #131
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VIDEO - Harvey Levy - HSP #131
One of the largest barriers to entry for receiving denitstry is fear. Harvey Levy, DMD MAGD shares his compassionate approach to treating anxious and special needs patients.
Harvey Levy, DMD, MAGD practices general and hospital dentistry in Frederick, Maryland, where he emphasizes comprehensive dental care for individuals with anxiety or special needs. He graduated from Tufts Dental in 1974, GPR at Eastman Dental Center in 1976.
Dr. Levy has earned Mastership and four Lifelong Learning Service Recognitions by the Academy of General Dentistry (AGD) along with eight fellowships, four diplomat certificates, and board certification in Integrative Medicine. His work with anxious patients has earned him the AGD Humanitarian Award, the ADA Access to Care Award, the Maryland Governor’s Doctor of the Year Award, the Maryland State Dental Association’s First Humanitarian Award, Special Care Dentistry’s Saul Kamen Award, and the honor of running the 2002 Olympic Torch.
Dr. Levy also holds nine black belts, and was inducted into the US Martial Arts Hall of Fame.
More info is available at DrHLevyAssoc.com
Howard: It is with great honor today to be interviewing Harvey Levy and we share something in common, we both earned our MAGD. How are you doing today, Harvey?
Harvey: Wonderful. I'm glad to be here. First time we met was when you and I first spoke at the Virginia Dental Association in November 19, 2009. You did one day and I did the next day. You were walking around with a boot, and so you had everybody doing your work for you, I had to do all my own work.
Howard: That's right.
Harvey: It's November [inaudible 00:00:37], Virginia DA.
Howard: That seems like a long time ago. I want to start with just a lot of people will see the MAGD given this podcaster watched around the world in every single country. Tell people what does MAGD mean and why did you spend so much time earning one.
Harvey: I'm just proud to be part of the Academy of General Dentistry where after fellowship while continues the journey of being a perpetual student takes more courses by participation at lecture, could do some teaching and writing if you choose to, and then you become a master in the Academy of General Dentistry. The journey doesn't end there, it goes on to the next level which is LLSR, that's Lifelong Learning and Service Recognition.
Howard: I was in …
Harvey: The MAGD goes on, it's part of the journey.
Howard: Don't they also have now a board certified General Dentist?
Harvey: Yes, they do. I have not participated in the board, military people do very well with that. In private practice, it chose to go the other route which is Lifelong Learning and Service which is similar through and out the masters but it also includes service to the community whether it's to patient's pro bono work and/or service to the dental professionals by serving on boards and committees doing things without remuneration.
Howard: Harvey, one of the reasons I was so excited to talk to you today is that every dentist knows probably the two biggest barriers to entry for a patient to go the dentist is going to be a fear in finance, "Are you going to hurt me and how much does it going to cost?" And you are an expert and you have really spent a lot of time on treating an anxious patient, and a lot of dentist, they don't even want an anxious patient. How did you get interested in that and what would you tell about 7,000 dentists listening to you right now? How do you treat anxious patients? Why do you even go out looking for that challenge? Wouldn’t you rather advertise, "Hey, I want rich people love to go to the dentist. I don't want poor people who are afraid."
Harvey: Let me bifurcate that because you asked me two parts in one sentence, choices that why do I do it then how should they do it. Why do I do it and how do I advise all the people? The question is this, why would patients strive pass 10 other offices to get to yours? What do you offer that they don't? How do you create a niche where you offer something that your competitors or colleagues don't?
In realizing that, the two barriers that keep patients away are fear and finances. If you could overcome their fear by offering something that reduces their anxiety, then the patients would drive pass 10, 20, 30 other offices to yours. In our office, we offer office oral sedation. We don't give any IM or IV although I comment people to do that. We give oral sedation and/or nitrous oxide.
We have done that about 36,000 times, we have 96% success rate for doing that. The other thing that we make available with the other people between my office and their homes don't offer is hospital dentistry. If we fail in an office and we have failed 4% of the time, we take them to the operating room and I just do what I do best which is my general dentistry. I bring my hygienist and assistant, the anesthesiologist puts the patients asleep, all I do is my same general dentistry on their ideal conditions. The patient is asleep and I work faster more effectively, more efficiently that leads a much higher profit margin and the patient gets the service that they could not possibly get under any other circumstances when they're asleep.
What I'm trying to say is we overcome their fear first by offering office sedation, in my office it's just oral pills or get laughing gas. If we fail, we'll take them to the operating room and offer them their out-patient general anesthesia and that we've done 1,600 times hour.
Howard: I know a lot of people are wondering right now, will you talk about your oral sedation and your nitrous oxide protocol?
Harvey: It'd be my pleasure. Two important rules, empty stomach, empty bladder. I've lectured about 125 times and I drive this point home, empty stomach, empty bladder, because I don't want anybody peeing, pooping or puking anywhere in my office. If you're in an empty stomach, they can wrench all they want but they're not going to throw-up, it's not productive throw-up. Empty bladder or [inaudible 00:05:14] pants because we don't want them peeing or saying they have to pee or pooping and say they have to poop, we just call it bluff, nothing comes out because empty stomach, empty bladder.
That way, when we give them the nitrous when sedation and then most of us there are relaxed, nothing productive comes out of your bladder or your stomach, and we can succeed about 96% of the time. The other 4%, usually patients who are somewhere in the autistic spectrum where they say, "Don't touch me. Don't touch me," or they're so medically compromised that it's too dangerous to do it in an office setting. Those autistic special needs in Alzheimer's patients, we're more successful in a safe hospital setting with the lesson they remember, somebody gave them a kiss on the cheek and say, "Goodnight," and two hours later they wake up, all the dentistry is done and they have no idea how it got done.
Howard: Nice. How do you administer nitrous oxide?
Harvey: There are two protocols that we could use, either one, the ADA has one then the nitrous oxide companies like [inaudible 00:06:18] of another. One protocol would be starting off with pure oxygen for a few minutes, oxygenated lungs swell, and then slowly titrate up to nitrous, go to 10% then 20 then 30 then 50. Using finger gestures, yes, no, yes, no, "Do you want to go higher?" They say, "Yes, I can go to 60 or even 70," the machines can perform at 70% nitrous oxide. After we finish the case, we oxygenate them well so they don't have any diffusion anoxia where they not just leaves before oxygen arrives.
We start and finish with pure oxygen for a few minutes. After we take off the mask within a few minutes, it's completely boned out of the system and they can even drive home if they didn't take some sedation pills. Nitrous oxide is a wonderful and safe and inexpensive sedation that has a very high success rate.
Howard: Are you surprised of how many dentist and endodontist and specialist do not have this?
Harvey: It startles me. In fact, I lectured to 350 endodontist the last month at the AAE Convention and out of the 350 endodontist in the room, two of them were using it. I was proposing to them that this could be a practice build up for them as well where why would a patient drive by other general offices to get to your endodontic office? The answer is because you did better endodontic on with them. Okay, why would they drive pass other endodontic offices to go to yours? The answer is if you offer oral sedation, nitrous oxide and/or pills, then patients would drive pass your competitors to come to your office and that seemed to have been well received.
Howard: If your patient focus how could you be an endodontist and not have nitrous oxide, I mean, that just really blows my mind.
Harvey: It startles me. Once or twice a month, my partners are doing endo cases in the OR, we know that our success rate is not as high as the endodontist. We don't pretend it is. We have our success rate which is same as any average general dentist but we can do it while they're sedated in the office or asleep in the hospital operating room. The only difference is we do not have microscopes, we cannot bring a microscope to the operating room, so we do the best and come out with what we've got, we get very good maybe even excellent with cells. No, it's not going to be the same caliber as an endodontist in an endodontic office under a microscope.
Howard: How does the dentist go into a hospital and do dentistry? Do you have to have a hospital privileges or does the anesthesiologist do this for you? How do take in your instruments? Did you rig out an operatory in a hospital? How do you do this?
Harvey: Excellent question, Howard, thank you for asking. First, let me compare to getting office sedation to permit. To get a sedation permit in office, one must jump through a number of hoops including taking a course of having a site visit, having medicines, paying a fee, being ACLS certified, just that you have the opportunity of get office sedation. To go to the hospital, it's 100 times easier, all you have to do is fill out an application with your name and address, prove you are who you say you are, you might have to pay a small fee because some receptionist has to verify your credentials. The hardest thing I have to do to get hospital privileges is prove to the nurse that I know how to scrub and wash my hand. If I can get by the nurse of scrubbing my hands, the rest is easy. You just need a basic life support, not even advance, just an ACLS card and application and you're in the hospital on staff.
Howard: That standard and care in a hospital-like … When you travel around the world, I've had so many dentist from other countries say in your country, if you go in and get surgery on the heart, the cardiovascular surgeon can't do the anesthesia and the heart surgery, you have to have an anesthesiologist. But they always point out the description that oral surgeons are the only surgeon who do the anesthesia and do the surgery and that's not how it's done in a hospital. Would you say standard of care for general anesthesia should be hospitalization with an anesthesiologist in a hospital for the maximum in case something goes wrong?
Harvey: Yeah, as long as you add nurse anesthetist. Because some hospitals on nurse anesthetist with one anesthesiologist monitoring, several nurse anesthetist. They will monitor it. I want to do what I do best which is my general dentistry unless somebody else take care of the heart and lungs. This way, the patient is safely put to sleep by anesthesiologist or anesthetist, then my staff and I do what we do best but more effectively, more efficiently, more profit margin, more successfully. Let the anesthesiologist wake up the patients and the work is done at a situation where it could not possibly have been done in an office setting. We have about 900 new patients a year, most of them are by word of mouth, not from the sedated patients but from the love ones of the caregivers, the families of these patients that we successfully treated either in the office via sedation or in the hospital on out-patient general anesthesia.
Howard: How do you logistically take a high speed, a hand speed, in suction and how do you a root canal in some place other than your dental office? How does that work?
Harvey: As I said, I do not have a microscope to bring to the hospital. The only thing I bring to the hospital besides my own staff is anything unique to that patient such as the denture that I'm going to reserve, the space maintainer, the implant, the crown, the bridge. All the routine material that's repetitive is already in the facility. We gave the hospital list of things we like them to purchase, we say, "Pretend this operating room is a dental operatory, here are the things we'd like you to purchase." The only thing that we bring with us is anything unique to that particular patient.
I also bring my laptop because I like to take X-rays. The hospital has three different kinds of X-ray systems, hand held and a roll in, but I have my own laptop. They take X-rays in the OR, develop that instantly. I use Nexus. We develop the images instantly and we excel by treatment plan, with diagnosis or we'd jump right into work immediately. We do have a backup system we use it called ergonomic self -developing film, that's in case of a computer failure.
At about twice a year, I really need the backup system. During my courses I say this, "This may surprise you but I do not have backup to every system. Pause. Pause. I have a back up to every backup." Because if the backup fails, I don't want to say oh shit I'm in trouble, I want to go to the backup to the back, and that little bit of an additional expense will save me from major expenses later on.
Howard: The hospital has your high speeds and slow speeds and all that stuff, I mean, they're plumbed like a dental operatory?
Harvey: Everything is mobile or portable. They usually wrote a book on Geriatric Industry, and my chapter is called "Portable Dentistry". We talk about both mobile and portable. Paula Friedman is the main author from life chapters on portable dentistry either in a home, nursing home, hospital or surgical center, hospice, et cetera. In a facility that maintains the equipment, we just had it wheeled in the mobile dental cars, the X-ray units, it's just wheeled in and it stays right there.
I don't own it and I don't have the slack to carry it because the hospital wheels it in. The only think I bring is what's unique to that patient. They have everything in duplicate because they have a card and there's airhost leakage, I don't want to have to abort the case because of the leakage. I don't want to be able to say, "Get me the backup card or the backup pen piece, backup post, the backup X-ray units."
Howard: You just showed your book during at your dentistry, when does that come out and where can our listeners get that book?
Harvey: It came out a few months ago by Paula Friedman. If anybody goes to my work site, just Google my name like Harvey Levy, Maryland, it will show you my 25 publications. All of them are free to download except those that are in book form, you have to attain separately. If they do take a look at that, they’ll see two things that you might be familiar with that. Let me show this to you. Two of the articles that I wrote to Dentaltown, they give courtesy published for me, one was in 2013, the other was 2010.
This is one of my greatest marketing tools because it use a lab readings obtained reprint of these two articles. I give out at all my questions, one is called "Circuit Training", it talks about a dozen different things that I use to make this success for an office setting. The other you've published for me is called "Debunking theMyths about Special-Needs Patient Care", where we talk about the myths of fear in finances are debunked point by point.
Howard: Those were great articles.
Harvey: Thank you for that very much.
Howard: Your website is drhlevyassoc.com?
Harvey: Yes, but it has too many letters, just Google my name, it will take you back to my site anyway.
Howard: Which is Harvey Levy, H-A-R-V-E-Y L-E-V-Y, Harvey Levy Maryland.
Harvey: The only other one is the physician in Boston. He's a geneticist so we don't get each other's mail.
Howard: That's only the two Harvey Levys and they're both doctors. Think you guys are related?
Harvey: No because he has a middle name and I don't.
Howard: Really, you don't have a middle name?
Harvey: My wife [inaudible 00:16:36] since my parents never gave me a middle name, I went and got a whole bunch of initials after my name to compensate for that.
Howard: Yeah, I always thought of losing the present [Harry S. Truman 00:16:46] and everybody always say, "What did S stand for?" S was his name, it was just an S, it was [Harry S. Truman 00:16:52], that was the whole middle name. Interesting. On this oral sedation, do you only use one medication or do you use different types of medication, will you talk about that?
Harvey: Of course. Anyone who only has one tool of I think is foolish. At my preaching at my courses is to take more courses to expand your portfolio so you're offering and doing more. We have our favorites, in fact all three of my partners and I have our favorites. We like the benzodiazepine, because the benzodiazepines which it is Halcion, Valium, Ativan and Versed, they're easily reversed by a reversal agent, the Romazicon, the Flumazenil. We've never used a reversal agent but we're prepared to in case. We have a Benzodiazepine overdose for a hypotension.
There are other medicines that we like to use besides the four Benzodiazepines …
Howard: Say the four benzodiazepines again.
Harvey: Okay. Halcion, Triazolam, Valium, Diazepam, Lorazepam which is Ativan and Midazolam which Versed, those are four Benzodiazepines that we commonly use. The only differentiation is that Versed only comes in a liquid form, the other three comes in liquid or pills. We give liquid to the children and pills to the adults in an office setting.
Howard: They can drink the liquid?
Harvey: Yes. In fact, of my 1,600 OR cases began with giving some Versed with a little juice or syrup or something to drink so that the patient was calm enough so that we can then start an IV or give them the mask. When I say we, I'm referring to anesthesia team, I'm just in the room watching a tape or pictures and videos but I don't participate in that, that's the domain of the anesthesiologist or anesthetics. They give them some Versed to drink or the other three mixture, then they're relaxed enough for the anesthesiologist. They then put on the mask and then start the IV or start the IV then put on the mask. This is followed by an intubation, usually it's a nasal intubation so that I can work for as many hours as I want to and the patient stays safely and calmly asleep.
Howard: What was the other family you were talking about, the other family drugs?
Harvey: For years, I use chloral hydrate and Atarax because they were so synergistic. The chloral hydrate was taken off the market a number of years ago. We'd still use Atarax but we use that conjuction with one of the other liquids for people who don't like to take pills.
Howard: Why did they take chloral hydrate off the market?
Harvey: In my understanding, somebody may correct me if I'm wrong, there's a legal case number of years ago where two children died of what was thought to be chloral hydrate overdoses. They stopped producing the chloral hydrate. After the trials were completed, it turns out they both died of Lidocaine toxicity and the chloral hydrate were merely incidental findings. As you know once they start producing something, they're not going to start to press this up again, so chloral hydrate is no longer in common use because of the two cases where people were thought to die of chloral hydrate where it was in fact lidocaine toxicity. We went to best substitutes now.
Howard: We had a lidocaine death here in Phoenix throughout five years ago, it was a kid and they needed to work down on all four quadrants and gave four carpules and dropped them. Dosage is everything. Talk about that, it's all weight dependent, you go by weight. When someone says, "I always gives someone 15 milligrams of this," that's not accurate. It's milligram or kilogram of body weight, right?
Harvey: Yes, but please realize that if we've raised somebody's pain threshold either with nitrous oxide or one of the benzodiazepines, we can give much less local anesthetic. When I'm in the operating room, I use no local anesthetic or whatsoever unless there's an extraction where I want to use it for hemostasis. In the OR, unless I'm doing surgery, I do not use local anesthesia, and in the office, we use less and we would use on the normal circumstances, if they're sedated with higher threshold of pain.
Howard: You said that on the nitrous oxide that you mentioned a porter units, have you heard or seen where they're talking about now going to an nasal cannulas and having a mask on your nose slipping the tube up your nose, have you seen anything about that?
Harvey: Yes, I have. I've seen it. We're using it in the hospital but it's not well received in the office, instead quadrant instrument just come up with something called the silhouette which is a very, very flat, narrow profile. Up until now, I had to get my hand all the way around the mask to get to the mouth and the mask also precluded wearing glasses. If I want safety glasses for protection or prevention for dropping things in the eyes, it would be a problem. Their new silhouette mask is so flat, they can wear glasses and it just barely hovers over the nose and then the flatter profile makes it a lot more appealing.
But we have not started using the nasal cannula because I see how poorly received this in a hospital setting but they don't have a choice there. No, I have not done it but I've seen it.
Howard: You're talking to about 7,000 people, most of them are commuting to work, a lot of the podcast fans have an hour commuting to work. You said they're driving to work and they're saying, "You know what? I don't do this, Harvey, I've never done it," what would be the next step for someone to just go from "I've never done oral sedation," to "Now, I'm going to try to do an oral sedation case, what would you recommend? What would be the next step of this journey after you're giving the message as something they want to do, what should they do next?
Harvey: Take a course then take another course and take another course. The course is available everywhere through the universities, through the Dental Anesthesia Society, Society of Anesthesia, DOCS offered course, there are courses offered everywhere. First, the basic courses then more advanced. I often become a basic course with myself, I have the 12-hour course and they offer several times a year. I offered through the Academy of General Dentistry as a 12-hour course every year, New Jersey Health Professionals Development Institute, many state meetings for Columbian for an 8 or 12-hour course. The bulk of the course is how to succeed in an office setting using nitrous oxide and some sedation medicine.
If you fail with that, come back after lunch or come back the next day we'll talk about doing the work with guaranteed success in the OR. I need to clarify, when I say guaranteed success, I am not talking about specific performance, I will never guarantee it to successfully save the tubes of the root canal or get the tooth out in one piece. I'm saying I guarantee that I will finish the case that we planned because flailing about is not a variable when they are asleep. They're completely asleep and I will complete the case that I started but I do not guarantee a specific performance.
Howard: Harvey, we've put up a 317 courses on Dentaltown and they've been viewed half a million times, I wish you would put up your course on Dentaltown. Have you ever thought about putting it up online?
Harvey: Well, we did to several courses. I have four courses that are available online, three of them were through dentaledu.tv which is just pulling out by university in Naples, Florida. They are going to be reposting those. I do have a 1 hour webinar that's free for everybody called "Access to Care", that's through Viva Learning. That's free for anybody if they want to see how we succeed and improve our access to care. I would love to sticking work with you as well because you’ve been so gracious with me all these years and you’ve been a gentleman printing my articles and I did post a few comments on Dentaltown. I'm a fan of yours.
Howard: Thanks, buddy. You said dentaledu?
Harvey: Yeah. Dentaledu.tv was just bought out by Nova, N-O-V-A University and they're …
Howard: In Fort Lauderdale, Florida?
Harvey: Exactly, yes. Albert Whitehead and Linda Niessen are going through the legal of requirements to have it and made it available to the general public. I have three course of what is office sedation, a separate course is hospital dentistry, and the third one is exodontia with very few fractions and no vast fatigue, that's a whole separate course.
Howard: I've already been Nova in Florida several times, and do you email those two guys?
Harvey: Yes, I do. Linda Niessan was here with me in Maryland and I actually took her seat when she left Maryland, her seat as the [CM 00:25:57] in the Maryland State Dental Associations Council Dental Health. Albert Whitehead and I been corresponding anxiously are waiting for my three courses to be posted and made available.
Howard: Will you send them an email and CC me, email@example.com and I'll see you. Is there any ways we can network together or anything like that?
Harvey: I suspect they would welcome the opportunity to collaborate and cooperate because it's a win-win for everybody, Howard.
Howard: Yeah, and I think the world with Linda, I think she's great. The other one was Viva Learning?
Harvey: Yeah. Viva Learning has a lot of free courses that anybody can log on to Viva Learning. They have many, many free courses …
Howard: Where is that at? Is that a US company?
Harvey: Yeah. I don't have to answer that, but if anybody is interest, Viva Learning, V-I-V-A Learning, they’ll be exposed to nearly a thousand courses. Many of them are free including my one credit course. Mine was sponsored by Dental Ease because I was talking about the use of the hovercraft chair and working with wheelchair patients who don't want to get out of the wheelchair, they don't want to or they can't. I have many patients who are either obese, double amputees, Alzheimer's who don't want to get out, autistic patients who say, "Don't touch me."
We leave them in the comfort through of it in the wheelchair and we move our operatory chair with a push of a finger because it's all hovercraft technology. We have nine of this dentist chairs that we can move to the side of the room or out of the room so that our patients can stay the comfort of their wheelchair without ever having to get out.
Howard: That is so amazing, very amazing. A lot of people are asking about the DOCS course because they do a lot of advertising, a lot of marketing, probably every listener that's listening to us right now has got an email or seen an advertisement about DOCS, what do you think of DOCS? What is DOCS? Talk about DOC. You talked about it universities, you're talking about it online, what's DOCS all about?
Harvey: A DOCS is up, first of all I have to … I have both the fellowship and diplomate with DOCS, so I'm already bias. I have a friendship of working this shift with both [Max Silverman 00:28:14] and [Tony Feck 00:28:15]. I've taken their courses and I'm a diplomate. I'm an advocate and proponent of DOCS but they didn't post response in my programs. We did collaborate in the past and I do promote them. When I offer my course, let's say, if you want to learn more, you can take the DOCS course which is three days, you can take their IV courses also but I'm talking about the oral sedation.
Dental schools offer it, American Dental Anesthesia Society, Society of Dental Anesthesia offers wonderful courses. The DOCS is a wonderful, wonderful opportunity. I do have to say, I don't want it to give anybody a false sense of confidence that they can go out and conquer any case Monday morning, but it's a wonderful follow-up to my very basic cases where DOCS offers a two or three-day program and teaches a lot more than I do in my limited course. The people are wonderful, they have doctors who lecture for the course who just are topnotch and knowledgeable, [Dr. Fang 00:29:14] and [Richard Pasteur 00:29:15], these are just top people.
Howard: Do you know the website URL for DOCS sedation?
Harvey: I think it's DOCS education, D-O-C-S Education.
Howard: What does DOCS stand for, D-O-C-S?
Harvey: That's Oral Conscious Sedation. They do offer IV programs also, but right now I'm just talking about what is the best protocol for oral sedation, what combination of pills and/or nitrous oxide? I use them synergistically in a combination some BT of my 96% success rate over from the 36,000.
Howard: I also want to ask you, you said the word autistic, autism a couple of times, tell them as what they need to think about or know about autism.
Harvey: We have a 2,000 special on these patients and I put them two into categories, the predictable and then undpredictable. With the predictable and that this medicine will work or this restraint will work or this protocol will work, and we're successful in monitoring it and predicting from visit to visit. With autistic patients, they know how to use this. If you see one autistic patient, you’ve seen one autistic patient. Each one is so unique and so different. More often than not, it's counterintuitive with what you would think.
Normally, we could use the Budweiser approach which are jokingly is a little is good, more is better and too much is just about right. With my autistic spectrum patients somehow is a rebound with less reversal effect where the more sedation I give, the more competitive and then cooperative they become. I have a large failure rate on being successful in an office setting with my autistic patients. Many of them end up being successfully and safely treated in a hospital setting because they're on their general anesthesia, all in those that mama didn't give them a kiss on the cheek and they wake up and all their work got done. There's no psychological harms or repercussions of being held down or restrain and things.
We do our finest work on sleeping patients, that includes all of the autism spectrum patients.
Howard: You're talking about oral sedation and nitrous oxide and I think every dentist listening knows those terms and is familiar with the terms, but you also used the terms using body wraps and props, what do those terms mean to you? I would adventure the majority of our listeners have never heard of body wraps and props.
Harvey: Okay. Let me convert the standard image of a straight jacket. Now, take the straight magic and make it rainbow colored and make it all Velco, no medal, no class, it's just a gentle restraint. It's made by a specialized care company which makes them the best products for what I do. They have 7 different sizes of what looks like a colorful blanket. We put this colorful blanket on the operatory chair before the patient is even sedated. They don't sit on the chair, they sit on this colorful rainbow wrap.
Once they're seated, somebody will put very gentle colorful Velcro in cloth braces around the hand, and then we wrap it together. Right now, it's not threatening because it's just a hugging snuggly tied on that situation. They find that they're no longer to flail their hands and hit my staff or themselves for self-injuries behavior. Once their hands are wrapped and restrained, we can then also restrain the head and the feet so they're not going to create any injuries behavior to themselves or my staff. Then, it's just a matter of immobilizing the head, propping them out open and getting the work done.
We use rainbow wrap two to three dozen times every week on patients who either have controlled movements, they're trying to just flatten us, or uncontrolled movements, patients with Huntington's disease or some sort of forms of cerebral palsy where they are unable to control their hand flailing movements.
Howard: This company, are all their customers dentist? They're just at dental specialty or they sell this to other people too?
Harvey: I think the dentist and pediatricians would both benefit from this. Emergency rooms have it also. It's like all the old PD wrap or the PD board but there's no cardboard, wood or metal. It's all non-threatening mesh and Velcro. In my courses, I always take the largest person in the room, I wrap them up and I say, "If you can get out of this, I will pay for your course." In 125 course, there's nobody has ever gotten out. It looks like it's just a piece of cloth mesh and Velcro, it's that effective.
Howard: They're probably not trying to get out because since you have a nine black belts and then the black belt all the famous life break that you would dropkick and then knock them out if they try to get out.
Harvey: That's true but irrelevant. I didn't know that you'd do that.
Howard: That is amazing. Tell us about your Karate background.
Harvey: The passions of my life where I work at and my family. I love my work. I've been doing this since 1974 and I'm as enthusiastic now as I was on day 1. What keeps me so active and energize is that I been training for an hour a day for the last 51 years. I just tested of my 10th black belt. I'm still on process of tested. Yeah, I was inducted into the martial arts hall of fame.
That has a dental application also because in my courses, I teach martial arts techniques to open the mouth of uncooperative patient by using pressure points. For example, if you touch your chin button, in the martial application, we use that to force somebody's chin away from you at a 45 degree angle down. First, you have to mobilize the forehead, vibrate the chin button 45 degrees down and it's very hard to resist that opening. In a martial application, we use that to get out if somebody is choking you. In the dental application, we immobilize the head, push the chin button which is called conception 24 on the pressure point, vibrate it down, and about 98% of the patients will open by doing that.
The other 2%, I have to distract by touching another pressure for that in a different part of the body, either the thumb or [inaudible 00:36:01] 17 or some other points that we use to distract them. The mind goes to the other part of the body that you're physically touching and they say to themselves, "What is going on over there?" They might think about other part of the body are physically touching, they're no longer able to resist this forced opening. Once we open them, we put in any of the many mouth props or kegs of blocks that we use to keep them open. Getting them open is one thing and then inserting a props to keep them open allows us to examine the other side of the mouth.
After we've done our exam or treat them with whatever we need to do, we then rotate the prop to the opposite side and then we work in this side. It's hard to work bilaterally that we usually have to go to the operating room for bilateral. We can use unilateral to switch then we go to the other side. You're right, we do use martial application for touching certain pressure points, concession 24, [inaudible 00:37:00] 17 or points on the fingertip pushing the base of the nail with 90 degrees. It will distract the patient just long enough first to then succeed in opening the mouth of uncooperative or unwilling patients.
Howard: Now, it's very interesting. Speaking of martial arts, I got one more short question. You and I back in the day, the biggest sport was boxing and it was Muhammad Ali and Joe Frazier and all the great earning shavers, all those guys, and now, it's HBO boxing has really taken a back seat to the UFC which is a mix of Karate and wrestling and boxing. What do you think of that journey from HBO boxing, Muhammad Ali to now the UFC?
Harvey: I love the question, it has nothing to do with dentistry. Let me tell you about my own journey. I was always the shortest kid on the block. I'm barely 5 foot 7 and I was never picked for basketball. If I was picked for basketball, I was the ball, if I was picked to baseball, I was the base, to football I was the ball, I was never involved to those sports. By being short, I was able to use the prowess of martial arts where … let me phrase it there for me, how can 100 pound girl fling a 300 pound man across the room effortlessly, repeatedly or without breaking a sweat?
It's all anatomy and physics. With the proper knowledge of anatomy and physics, I could take on people twice my size. I train twice a week for 3 hours each, every Wednesday and Sunday train for three hours. Everyone I trained with is half my age and twice my size. I prevail most of the time because I have knowledge of anatomy and physics that these young and strong guys don't have. In my martial arts career, I have third degree black belts in three different styles.
Punching and kicking is only good to a certain degree, I'm not going to outpunch somebody who is much pretty good than me. When I see an opponent, I see a tree, I'm not going to attack the tree, I'll see the arms, that's a branch I'm not going to attack the branch, then I see the fingertips, I say twig. If I have your twig, if I have your fingers, I have control over your entire body. If I have control over your twig or your Adam's apple, I have control over your entire body. It's not strength, it's knowledge of anatomy and physics.
Some of the greatest fighters are not the biggest strongest guys, it's the Brazilian grapplers because they know how to get you on an unbar or a choke. I've been training Brazilian jujitsu for many years, I'm belted in that as well. 85% of the fights end up on the ground. My ground fighting is you on the ground and I'm not. I love fighting with people who are bigger and stronger than me. My son-in-law to being as 6 foot 820, big strong football player, but if I had his finger, I have control over the fight over the situation.
Howard: I think that has a lot to do with dentistry because when I was at UMKC, the lady in oral surgery that was showing everybody how to remove teeth was this little [Suzanne Waters 00:40:12], this cute little girl, and she was just little bit of cute thing and my god, she could pull any tooth known to man. You have these big old guys, "I can't get it. I can't get it. Let me grab it," and wrench the jaw but she knew leverage, she knew elevators. Her mind, she wanted to get out 99% of all teeth with just a periosteal and a small elevator. You know elevators. She saw her reaching for a forcep just there a mere of failure.
If she had to use a forcep, that's where it stop, a 150 or 151. There was nothing else. Her instructor, [Matt Jurgen 00:40:54] served … You remember [Matt Jurgen 00:40:57]?
Harvey: By reputation.
Howard: Yeah. When he was in Korea, the whole time as an oral surgeon, they only had a small and large elevator and a 150 and 151. Every soldier with a young kid with wasn't he from, he goes, "Okay, that's all I had for four years. Why do you have to layout 30 different forceps to pull the tooth?" he goes. [Suzanne Waters 00:41:21] was that little fighter. You never saw a triceps pop out, you never saw her sweat, she just use leverage. She knew anatomy and she knew leverage and she got out every tooth.
She taught me amazing about it. Both of those people I've mentioned are no longer with us, that is one of the [inaudible 00:41:40] you're hitting 52, your friends and mentors and idols are starting to disappear. I want to completely change course, you’ve been doing this in '70, you graduated in '76 or?
Harvey: Tough '74.
Howard: Tough you says in Boston?
Harvey: Yes, Tough '74.
Howard: That means you're Irish Catholic and graduated with pint of whiskey in your head, is that true?
Harvey: No. My first part, there was Irish Catholic and it was [McMahon & Levy 00:42:11]. For three years, I was an honorary Irishmen when they called the office [McLevy's 00:42:16].
Howard: My question is since you’ve been in this game long, how many years have you been practicing or how many years since in old school?
Harvey: Since '74 then I did a residency then I did another residency. 1976 from that was, I can't do the math. But from '74 to …
Howard: to 2015?
Harvey: … 2015. 41 years.
Howard: 41 years? We just had 5,000 kids walkout of 56 American dental schools, what do you know for decades of doing this that you think they don't? Because right now you and I know that they don't even know what they don't know. Right now, they think they know what's ahead of them, they don't know what they don't know. If that was your granddaughter walking at that school, class of 2015, what would you tell your granddaughter as she entered dentistry? What advice would you give her?
Harvey: I'm glad you asked me that. Let me answer it this way, I have a five-pronged approach because I discussed this with people in my courses. Number one, be a sponge, absorb as much as you can. Next, be a crab, keep your hands out of your pocket, touch things, do things. If you're a sponge, now you're a crab. Next two things are be a student and be a teacher.
Be a student, be a perpetual student, take a course, take another course, take more courses, don't stop taking courses, it's a lifelong journey it doesn't end a year after school. The fourth thing is to be a teacher because in my life, the best way to learn something is to have a teacher. You don't know something until you’ve got to teach it to somebody else. You're a sponge, you're a crab, you're a student, you're a teacher, and the pinnacle is niche, create a niche. Do something that the other 10 dentist on your neighborhood don't do so that the patients would drive pass their office to get to yours.
I'm not saying what your niche should be, but do something that they don't do. For me, it's seeing anxious expression on these patients offering oral sedation, offering hospital anesthesia because patients will drive for an hour radius to drive pass many cities, many towns, hundreds or thousands of dentist to come to my office because I offer something that all the others don't. Why else would they come to me, I'm not the best looking or the youngest or handsomest or the cheapest fees, I'm offering something they don't. Find something that you're passionate about, make it your niche and be better than the dentist next on either side of you.
Howard: I hear them talking on dental all day long, this is the mud they're going to throw at you, they're going to say, "Yeah. But , Harvey, I graduated $250,000 in student loans, you probably didn't have student loans." What would you say to that?
Harvey: I don't understand the question.
Howard: A lot of them are saying that our age generation people graduated without hardly any student loans, dental school is much cheaper, much less expensive, and they just feel almost victimized that they're walking out of school $250,000 of student loans. What financial advice would you give them if a kid come out of school and there were $250,000 in debt? A lot of things on their mind is they think, "Well, if I go into an office, I'm already $250,000 over with student loans. If I bought a CEREC machine in CAD chemistry then that's another 150. If I bought a CBCT 3D X-ray machine, that's another 150. If I bought a WaterLase laser, that's $75,000, I could walk out of school and but three things and double my indebtedness." Do you think they should buy them anyway, double down? Do you think they should open their own practice?
Do you think they should associating get out of debt doing the military for four years, work at corporate industry? What advice would you give them to address specifically their $250,000 of student loans?
Harvey: In my lectures, I talk about the expensive equipment and I showed the wrap which is about $150 and I've used it about a thousand times, so it's plenty for usage. The disposable props, it's two time depressors wrapped in foam cost me $1, if I use 25 a week it's $25 and that's making me more successful and it's very, very inexpensive. To answer that question, I would throw a question right back at you and say if you're pondering that question to yourself, ask yourself this, "To whom do I owe what?" Sure you have debts to pay but I would not encourage incurring additional debt, I'd say find a giant, find a mentor, work for that person, learn as much as you can, be a sponge, get your hands out of your pocket and be a crab, be a perpetual student, let's start writing articles, getting lectures, get on the circuit.
When you teach something, you have to learn it then you become more skilled at it. Eventually when the debt passed down, you find what you're passionate about. It doesn't have to be something expensive, you don't have to be an implantologist, aesthetic dentist which may be more expensive. I do not own any of those things that you mentioned, they're all wonderful. I comment the people who do it. I do not own a CAD chem, my lasers are the inexpensive soft tissue lasers, I comment people will have the other ones but I chose not to because my passion happens to not be on most of the more expensive ones.
I'm very happy with what I do. I see a dentist who have very high income and very unhappy. I'm extremely pleased because I'm a big fish in a small pond. I used to teach the University of Pennsylvania full time. After one year of that, I realize that I didn't have much control of much saying, so I gave up being a University of Pennsylvania professor to being a dentist in a smaller quiet town where I have more control. I decide what I want to do or what I don't what to do, what I want to but, what I don't want to but, what debts I choose to incur. I do not have much debt.
Sure, you have to pay back your dental school debt, but above and beyond that, you pair it down, find what you're passionate about and make it invest within your future.
Howard: Well said, very well said. A lot of people that came out of school dentist saying, "Yeah, but Howard, when you got out of school you know they're going to have a corporate industry." I'm like, "Actually, they did when I got out of school in 1987."Orthodontic Centers of America was on the New York stock exchange and there was a dozens of them on NASDAQ, and then after the years went by, every one of them disappeared. There's another 10-year law over that really didn't exist, now they're back.
Do you think they're back like they were the first round and then what's going to happen to the second rounds? Do you think history is repeating itself or do you think it's different this time? Do you think it's a different dental economy than it was 40 years ago?
Harvey: I believe and that every sword is double edged, nothing is all good or all bad. The same sword that's used for hurting is used for healing, same scalpel for hurting for healing. The corporate industry has advantages and has disadvantages. I choose not to participate in it, I can see that it does have advantages for some people who need it but I don't advocate it, I don't promote it because I think there are better alternatives to that. I'm might say something a little bit arrogant but I'm going to put it out anyway. Cream rises to the top, if you're good and you're doing good work, you do not need crutches.
Corporate industry is a great backup or feel safe to those that need it. I myself don't need it and I don't advocate it because I have developed a niche with people who come to me whether I'm involved with corporate or industry or not. I'm not a proponent of that although I do see how it would be useful to some people. My pitch is be good on what you're doing, become excellent about it, develop your niche and people will come to you whether you accept their insurance or not, whether your part of corporate industry or not because cream will rise to the top. It's not much competition up there.
There's a lot of competition way at the bottom where everybody is doing the same thing. It's not much competition if you have set yourself apart from your colleagues and competitors.
Howard: I want to point out one thing to these kids. When you're thinking about $250,000 of student loans, you think about money, money and then you're thinking about taking insurance maybe, as you're thinking about price in all those stuff, you and I have been around the block to know that all of that flies out the window when you're dealing with fear. When you go to the market and you have a solution with feared industry is as big as finance of dentistry.
The other thing that's where we look about putting to sleep is every single time I've ever told a patient in 20 years, I say, "We can put you to sleep." They'd say, "If you're going to put me to sleep, do it all, do the whole thing." Because they're most afraid that this might be their only shot, they finally met this guy and they go, "If you're going to put me to sleep, do it all." Would you say that your IV sedation cases are bigger than the other dentist, non-IV sedation cases because of that reason they just said, "If you're going to through all that trouble, just do it all"?
Harvey: Let me say this, we have excellent records of the income drawn from the office versus putting people to sleep, and we have confirmed that we quadruple our income without working any faster or harder which is working more efficiently. When we're in the operating room, the patients have one stop shopping whether this is executive or lawyer which is ones that have 80 hours of work done all in one sitting because he put be with the parking spaces, he doesn't want to have meals multiple times. Our income is literally quadrupled working 6-hand and not 4-handed, my two hands, my sterile assistant and my unsterile assistant or the hygienist, everything is six handed. From the time to path goes in the mouth to the time the path goes out of the mouth, we've calibrated the work done relative to the amount of time spent. Right now, it's over $3,500 per hour which is four times what we do in an office setting.
I'm not working any faster, I'm like the duck. Above the surface, I'm calm and serene. Nobody knows that below the surface we’re paddling with a frenzy because it worth maximum efficiency. When somebody wants all the work done while they're asleep, I calibrate how much time it would take me in the office, I divide it by 4, that's how much time I allocate. If you present me with a treatment plan and I know it's going to take 8 hours in the office knowing that I might not even finish the case because you're flailing your hands or you're a no show or whatever, I'll take that 8 hour figure, divide it by 4 and I'm going to give you a 2-hour sleep appointment.
Now, my only overhead is my assistant's salary and the gas to get from my office to the hospital and back. If I'm grossing 3,500 an hour, let's say even if my overhead is 50%, it's not, I'm going to make that up, could you live with half of $3,500 an hour knowing that you're not reimbursed for your driving time at the time it takes for you to dictate the case and proofread and electronically sign a case? It is an extraordinary practice builder to accommodate to treat patients that cannot be treated in your office or anybody else's office. We've done 1,600 of this OR cases on patients that would have remained untreated or they would have gone to all the surgeons who would have pulled the teeth. I do pull teeth but I also do filling-ins, cleaning, saving, I'll do the perio, I'll do the endo.
I'm limited only by two things, Howard, my confidence and my competence. Since I'm not a specialist, I'm not limited to what I can do. I can do whatever I'm feeling confidence and the confidence to do. The time I feel confident to do a case, I'll ask an endodontist to join me in the OR just for that one session. We got one big privilege as the endodontist would do the case and this privilege is suspended by a close of business that day. I'll proceed to do the core and the crown or whatever else I have to do, then to follow a visit to submit the appliances or crown the bridge, et cetera. It is an extraordinary practice builder without spending one penny of my money other than gas to get to the hospital or surgical center and back.
Howard: I just think that when you're talking about niche markets, a lot of people will but $75,000 over laser because they think they're going to be a laser dentist and that would be great marketing or to buy $150,000 CAD chemistry because they think if they put same dentistry on their flyer or website, that's going to be a huge think. I think that's a lot of money for a little bang when you're timed out, when you say, "We'll put you to sleep. We'll do conscious sedation, we have laughing gas and we'll give you a pill." I think that market is huge. I think that market is about the same size with the ones it's only about money, price, they want an HMO, PBO, price, price, price.
Theory is huge and you keep eloquently saying. You don't have to buy any expensive toys. You just got to spend a lot of time in training. It's a huge market, fear is irrational. I know people who have families, there's this one family [inaudible 00:56:14], they can't have any functions at their friend's house because one of the sibling's wife thinks there's a ghost in the house. She totally believes it. Have you ever thought about where fear of dentistry comes from? Because these people are very irrational and they'll drive an hour if they think something will solve their irrational. Where do you think all this dental fear and anxiety comes from?
Harvey: There are two categories of fear, Howard, fear of the known and fear of the unknown. Fear of the known is somebody who had a bad experience years ago and that experience stays with them. Maybe as a child, somebody held them down, and now they're adult, they still have that fear of the known where they have a bad memory to drop on. There's fear of the unknown, you don't know what you don't know but you're afraid that something bad might happen if you will lose control, lose consciousness or put to sleep or your big brother told you to be afraid. We can come to that both fear to known, and the unknown, the same way. We give them some medicines to relax them, coming on empty stomach, empty bladder, we'll wrap you if we think you're going to flail your hands or hurt somebody, give them some nitrous oxide, 96% of the time, the work again is done.
If you want no doubt with assurance that all the work we done and while I'm sitting while you're thinking that, I'll meet you at the surgical center or the hospital, take a nap. When you wake up, we are done. You’ve got your work done successfully, you weren’t held or restrained, those psychological repercussions there was no fear known or unknown or otherwise. We made a good living because we just quadrupled their income to that time interval and it's a win-win for everybody. Howard, 1 out of 3 people in this country don't go to the dentist because of fear and/or finances.
If we can overcome either of those barriers, you're talking about 1/6 of the conscious population. You're going to have to hire extra staff to see all the people that would come in if you just open your doors crack.
Howard: When you do oral sedation and you nitrous oxide, do you charge an extra fee for that or are you making your money off the root canal filling crown and cleanings, whatever, or is that a separate fee?
Harvey: Okay. Excellent question, let me give you two part answer, directly and indirectly. Directly, we do charge $4 per minute for the nitrous oxide flow. For the time we turn on the gas to the time we turn it off, we have the flow meter running at $4 a minute. Whether insurance pays for them or not, the patient has to agree to pay the $4 per minute. On the 1 hour case, it's 60 times $4, so we'll attack on $240 to the cost of the treatment itself. I choose not to charge for prescription and then some people charge a flat behind in those chart $4 a minute, that's direct.
Indirectly, I have a better event, the word of mouth gives me 900 pay to new patients a year with a zero advertising budget. They go home and then that's where they tell people at the dinner table, people that work the next day. "I got my dental worked on yesterday," he said. "But I thought you are afraid to go?" He said, "Yeah, but I went to Dr. Levy who gave me some pills and laughing gas and I was so relaxed. At the end of the case I said when are you going to start and he tell me we're all done."
Or "I went to the hospital, my wife drove me home and now I'm at work the next day, all the work was done while I was sedated or asleep." Look at the income drawn by 900 new patients for this year advertising budget. We are starting to use new solution range which is helping us but I'm not going to consider that part of my marketing at this point because it's word of mouth that's getting me all these new patients.
Howard: That is amazing and that is one hour. We just got the one hour deadline. Your resume is who's who dentistry, the AGD gave you the Humanitarian Award, the ADA, the Access to Cure Award, the Maryland's Governor Doctor of the Year Award, the Maryland State Dental Association's First Humanitarian Award, Special Care Dentistry Saul Kamen Award. You even were running the 2002 Olympic torch. You have nine black belts inducting you as Martial Arts Hall of Fame. Seriously, dude, you are amazing. You are amazing.
You know what, seriously? We just hit 200,000 members on Dentaltown and we just passed 35,000 download the Dentaltown app. I wish you would find a way to put one of your courses on Dentaltown just because I'm going to turn about 7,000 people on you today. I think if you put an online to see course for more people, because more people should get to know you, more people should listen to you. Seriously, dude, thank you for everything you’ve done for dentistry. You're just an amazing and it's an honor that you spent an hour with me today.
Harvey: Howard, I've been admiring you unofficially before 2009 and personally since 2009. You're one of my role models and I admire what you do. You provide a tremendous service to the dental community and I respect that and I'm a fan of yours.
Howard: I know everyone [inaudible 01:01:19] because me and my four boys, we all wrestled through high school. I did a [inaudible 01:01:24]. We're a wrestling family, and wrestlers know one thing, they don't want to mix up with the karate guy. Thanks again for all you do and I hope to see you on Dentaltown someday. Email me and [Linda Niessen 01:01:38]. By the way, anybody listening, you can always email me, firstname.lastname@example.org. If not, I will see you on the boards. Thanks, Harvey.
Harvey: Thank you, Howard, for the pleasure and the opportunity to share.
Howard: All right, bye-bye.