Dr. Howard Farran and Josh Wren discuss the intricacies of pediatric dentistry.
Audio Podcast:
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Howard Speaks Audio Podcast #4 with Dr. Josh Wren
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Video Podcast:
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Howard Speaks Video Podcast #4 with Dr. Josh Wren
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About Dr. Josh Wren:
Dr. Wren received his undergraduate degree in biology from the University of Mississippi and his doctor of dental medicine degree from the University Of Mississippi School Of Dentistry. He then completed the pediatric dentistry residency program at the University of Kentucky College Of Dentistry, where he obtained his specialty certificate in pediatric dentistry. After residency, Dr. Wren started Wren Pediatric Dentistry in Brandon, Mississippi. His specific interests include preventive dentistry and early orthodontic treatment. Dr. Wren has over 200 hours of continuing education in orthodontics. He is a diplomate of the American Board of Pediatric Dentistry and Mississippi representative to the Southeastern Society of Pediatric Dentistry.
Podcast Transcription (Download Here):
Howard Farran: Today it is very exciting. I get to interview one of my idols, Ironman Josh Wren, pediatric dentist down in Mississippi. Josh and I share a passion for making dentistry faster, easier, higher quality, but also lower in cost so you can treat the masses. He has just some online courses on DentalTown on pediatric dentistry, amazing stuff. Josh, I am so excited I get to spend the hour with you. Let’s just start with the 4,000 pound elephant in the room. A lot of dentists out there, they would rather just go out there and chase a car and bite a bumper than treat a two-year-old screaming kid with a toothache and do a pulpotomy. I always tell people that my two oldest sisters are Catholic nuns and the reasons I want to be a moral, ethical guy is because I fear that if I went to hell I would be in charge of the Pedo Clinic with Joseph Stalin and Idi Amin and Adolph Hitler for eternity and so thank you so much for being one of the nine recognized specialties in dentistry, in pediatric dentistry. Josh, how do you do it? How do you work on kids with toothaches?
Josh Wren: No problem, Howard.
Howard Farran: And what made you pick that? Were you just a glutton for punishment? I know you are, because you are an Ironman. What made you go into pediatric dentistry?
Josh Wren: Just to feel the enjoyment of alleviating dental fear from a child and let them have a lifelong, healthy smile for the rest of their life without being terrified to go to the dentist. There are so many adults that were traumatized as children, perhaps not treated the right way, perhaps using a papoose board with not profound anesthesia or whatever the case may be. I have a passion to get that child past that level into teenage and adulthood years being able to go to the dentist and not being terrified every time they step into the dental office. You know, I hear a lot of adults still to this day say the smell of a dental office makes my teeth hurt or the smell of a dental office makes me terrified, makes my blood pressure go up. That is what we are here for as pediatric dentists, to make that patient, to alleviate those fears from that patient.
Howard Farran: That is fantastic. You mentioned right out of the gate papoose board. Is that still common in a pediatric practice or has that been replaced?
Josh Wren: I believe it is.
Howard Farran: Pardon?
Josh Wren: I believe it is. I believe it is, maybe not from the usual group on DentalTown. We are the cream of the crop as I say on DentalTown. We are the ones wanting to learn more about it and do things easier, faster, cheaper, as you say. But throughout the country, those that are not on DentalTown, I would say it is very common for use of the papoose board. It is one thing to use it for patient safety, but it is another thing to use it for patient true restraint, you know, restraining the patient. Under oral conscious sedation it is still considered, I believe, the standard care to use a papoose board. I haven’t used one since residency. I don’t believe in the use of a papoose board. If we are going to do any form of restraint, it is mom in the room restraining that child for a procedure, just due to the litigious society as well.
Howard Farran: And that is true, you know, most dentists when they go home at 5 o’clock, they are done. They are burned out. They want to watch ESPN and drink a beer. The dentists that go home and log in to DentalTown for an hour or two, that is truly the cream of the crop and you are the cream of the crop leading the way on the message boards on pediatric dentistry and thank you Josh for all that you do for not only dentistry and your own patients, but for DentalTown. So what do you want to talk about today? What comes to your mind? What do general dentists need to know about pediatric dentistry?
Josh Wren: Well one thing that I have seen a lot of, especially in the past few days on DentalTown on the pediatric message boards is negative reviews. So I think one of the big problems with social media and Google Plus and Google Reviews and all of these things is the unknown of which parent is going to go home and vent on social media about the dental experience for their child, whether it be through secondhand information or whether they were present and the facts got skewed or whatever. I think that is one of the bigger challenges we face in not only pediatric dentistry, but all of the specialties, in general dentistry as well. I think that is one concern I have and I know you have talked about it, handing a card when the patient leaves with specific instructions on giving you a review if they leave the office happy, that is the time to strike. Maybe that could combat a few of the bad apples or negative reviews that are out there about you. But I think that is one problem, and I have seen it on the pediatric message boards, I think three threads about negative reviews. And first of all, thank you for allowing me to be a moderator on the pediatric message boards. I log in probably one hundred times a day to check the boards and there is a wealth of information on there. It is awesome.
Howard Farran: The honor is all mine. So you talked about, yes, we do have a card when you cement that upper single crown on a woman who was afraid that it wasn’t going to match and look like some man wearing a bad wig for the rest of her life and she is all verklempt and happy and, you know, you just say, “Oh, do me a favor and do this.” And you want them to do it outside of the office. Google is so smart. You don’t want them doing that on your dental office Wi-Fi. Google is going to pick that up. You don’t want them doing it from your dental office computer. You want them to do this. But most people don’t know how to do it. I mean, I find in my office almost no one has ever wrote a review before and a lot of times it is the first one. So yeah, we manage to get a lot of good ones and the bad ones, we call them. We try to call them, because they can take it down. So what are your thoughts on managing online reviews?
Josh Wren: Oh, we ask. We ask for specific reviews and we use a company called Demandforce. There has been a great deal of information on DentalTown about Demandforce and Lighthouse 360 for patient reactivation or patient reminder system, but also Demandforce has a built-in review system to where the patient who is sitting that day in your office gets a review request sent by email and text message. So we don’t have, if a patient leaves with a positive experience, they get a review. If a patient leaves maybe with information they didn’t want to hear, they also get a review. So we don’t pick and choose who gets the reviews. Everybody gets the reviews. If it is inaccurate information or if it is attacking information or defaming in any way, an office staff member or whatever, we can get that taken down. But we don’t have to do that very often. We have done that twice in about five years where we have had to take down the negative.
Howard Farran: And we know that women are probably two-thirds of the market for online reviews. They seem to value this more than men. So tell me Josh, when you are a pediatric dentist, what percent of your new patients are you getting from pediatricians versus general dentists?
Josh Wren: I get approximately 80 to 90 new patients a month. I would say five percent of those patients are referred from general dentists and I would say approximately 15% to 20% are referred from pediatricians and the rest are referred from existing patients I would say, or reviews.
Howard Farran: Wow.
Josh Wren: Or parents reviewing the information online. We have a big online presence with Demandforce. If they Google “Wren Pediatric Dentistry reviews”, there is, I think the number this morning was 147 reviews. And the vast majority of those are very positive.
Howard Farran: I think that is very neat, how your name is Josh Wren and you are wearing a red wren bird on your shirt. You are a natural born marketer. That is all good.
Josh Wren: Thank you.
Howard Farran: So when dentists refer you a patient, what percent of dentists refer you a patient, just blanket give you all of the children versus just give you that one child that they couldn’t work on because it went south?
Josh Wren: Yeah, there is one particular practice that refers me every child under 12 that comes into their office. The rest are deemed behavior management patients, which could mean simple nitrous oxide and tell-show-do in the office. Tell-show-do is a big hit in our office. Tell-show-do works 90% of the time. Along with the use of euphemisms. A drill is not a drill, it is a water whistle. You show them water squirting out of the whistle without a bur engaged and, “Hey, this is what we are going to clean your tooth with is a water whistle.” Ninety percent of patients referred to our office for behavior management and the number is 90%, I am not inflating that number, can be treated with 50% nitrous oxide and tell-show-do just fine, unless they have a mouth full of decay where it is going to be four appointments. In those cases we use general anesthesia.
Howard Farran: And do all four quadrants at once?
Josh Wren: Correct. All four quadrants at once.
Howard Farran: Wow.
Josh Wren: An hour to an hour and a half.
Howard Farran: So you have really got to weight out the dosage of the anesthetic, a small child, I mean how many carpules of anesthetic does a child like that get? Are you used to one quadrant at a time to keep the breakdown of the anesthetic or how do you manage that?
Josh Wren: We do half-mouth dentistry.
Howard Farran: Half-mouth, right side, left side?
Josh Wren: That is correct and we use the Isolite, which makes that a lot easier, no rubber dam. We use the Isolite so we can work on the right side all at one time. Numb it up, if you have a 330, do everything you can with a 330 before you switch burs. We have a spreadsheet where every single patient gets weighed before we do operative or restorative appointments. So any kind of treatment _____appointment, whether it is four bicuspid extractions, that patient gets weighed. We know exactly how much local anesthetic we can give.
Howard Farran: And are you weighing in kilograms or pounds?
Josh Wren: We are weighing them in pounds and them just converting it to kilograms. The spreadsheet does that for you and then it will say you can give 2.2 carpules of 4% Septocaine or you can give 2.8 carpules of 2% Lidocaine.
Howard Farran: Really? That is the only difference in Septocaine and Lidocaine is 2.2 or where those just random numbers?
Josh Wren: Those were random numbers.
Howard Farran: Oh, okay.
Josh Wren: But it is not that much. For a four percent versus two percent, it is not true double.
Howard Farran: Really?
Josh Wren: You can give seven milligrams per kilograms is the max dose on Septocaine and 4.4 milligrams per kilogram is the max dose on Lidocaine.
Howard Farran: Wow, I have already learned something and I read all of your posts.
Josh Wren: And we use Septocaine almost exclusively, unless the patient is 30 pounds or less, maybe 35 pounds or less, we use Septocaine.
Howard Farran: With epinephrine?
Josh Wren: With 1 to 100,000 epinephrine. We have been considering switching to 1 to 200,000 epinephrine _____ from some other people on DentalTown. So I’m not sure what I am going to do there.
Howard Farran: So they sell 1 to 200 on Septocaine?
Josh Wren: Correct.
Howard Farran: And a 1 to 100. Do they also sell a 1 to 50?
Josh Wren: I am not sure. I am not sure. I have used 1 to 100,000 for about six or seven years now.
Howard Farran: And by the way, if pediatric dentistry is an area you really want to massively improve, you can actually on DentalTown, you can follow Josh Wren so that whenever he posts, you get an email notification that there is more amazing information from Josh. That is a neat feature we have on DentalTown.
Josh Wren: Thanks Howard. And the app, if you don’t have the app, download the app. My gosh, you can check on your phone anytime, whether you are in the airport or whatever to pull up the DentalTown app. So download that. And one other thing Howard, Wednesday the new course is coming out, the new online CE course. It is pulp therapy, painless anesthesia and stainless steel crowns for the pediatric patient.
Howard Farran: And give them the title of all of your online courses.
Josh Wren: Excuse me?
Howard Farran: Give them the title of your other online CE with DentalTown.
Josh Wren: Simple Space Maintenance. As you know Howard, we get tons and tons of questions. You follow on the pediatric board, there are tons and tons of questions on do I need a space maintainer here in this case and what space maintainer do I need to use? That course is great for those kinds of questions. It even teaches you how to fabricate your own space maintainers. We believe in low costs to keep our costs low, so I make all of my own lower lingual holding arches, wire nances, acrylic button nances, nances with Z springs to kick out unilateral cross bites. I make all of my own appliances here in our lab. But that course, Simple Space Maintenance is great to answer those kinds of questions.
Howard Farran: Now Josh, not to throw you under a bus, but are you really making all of those or did you teach your assistant how to make those for you?
Josh Wren: I have one assistant that makes those, but I am a little type-A and I tend to make all of my own space maintainers.
Howard Farran: And how long does it take you to make a space maintainer?
Josh Wren: For a lower lingual holding arch it takes me about three to four minutes.
Howard Farran: Oh my gosh, yeah your online CE course where the dentists can actually see you make that is just amazing. And then your new course is coming out this week.
Josh Wren: On Wednesday.
Howard Farran: That is fantastic. So another question people are asking on the message boards, sometimes you hear that a pulpotomy if you use it with formocresol or something like that, that that might be a carcinogen and you should use it with something else. Talk about that. Are you worried that some agents on a pulpotomy could be a carcinogen?
Josh Wren: I am. Despite all of the, I mean a lot of studies have come out where the level of formaldehyde in the bloodstream even after a general anesthesia case where you are doing eight pulpotomies with formocresol, the postop, the testing of the blood has shown no increase, no blood spike of the ingredients in formocresol. But just due to all of the negative publicity surrounding it and some of the questions we were actually getting asked by patients, I have chosen to stay away from formocresol. I haven’t used formocresol since residency.
Howard Farran: Wow.
Josh Wren: I switched over to ferric sulfate, I use ViscoStat by Ultradent. I have been using that for about six or seven years with good success.
Howard Farran: Have you met Dan Fisher?
Josh Wren: I don’t, I have never met Dan. I have heard a lot of great things about him.
Howard Farran: Oh, Dan is just an amazing man. He is up there in South Bend, Utah, a suburb of Salt Lake City. Since I will be 52 next month, I am old enough to where during his lectures he used to cut himself and put it on his cut showing how it coagulates it so fast. This is the guy, so he made that and he invented that. I think that was his first product. He invented that in his apartment complex at his kitchen table. So go through that technique. So you will do a pulpotomy then you put the brush, Dan, man everything you buy from Dan _____ has got a little brush applicator tip. Is that what you are squeezing out with?
Josh Wren: Oh yeah, they all fit every syringe he has got. It is awesome.
Howard Farran: One time I was eating with Dan pancakes at the IHOP and when it came to the maple syrup he pulled out one of those syringes and just started brushing it on the pancake.
Josh Wren: I believe it. But the steps that, I will be honest with you, the first year or two I had more failures, more internal resorption associated with it. On the message board there is _____ internal resorption scares all over the place with therapeutic pulpotomies for primary teeth. And I was having that trouble the first year or two until finally one of my colleagues Neil Quinton, who is on DentalTown as QDog, he said, “Josh, what you have to do, I had this struggle a couple of years ago. What you have to do is you have to go down into each canal two to three millimeters with a 2 round bur, get every bit of the pulp tissue tags that you can from that spot coronal and then use your ViscoStat, have no coagulum left behind.” No coagulum. A lot of times people just get down to the pulp stumps, brush the ViscoStat on there, you are actually on top of vital tissue and then you are getting your internal resorption. If you go down a little bit further where the pulp shrinks down and really constricts, at that point you don’t have as much vital tissue. That is my theory, Neil didn’t tell me that. But that is my theory that you don’t have as much coagulum and medicament left behind. You do a good air water rinse, put your temporary agent in there, whether it be IRM or Tempit and then your stainless steel crown on top of that.
Howard Farran: And are you doing the number 2 round bur high speed or slow speed?
Josh Wren: Slow speed.
Howard Farran: Okay, slow speed. Okay, very good. And then ViscoStat and then you put the ViscoStat and then you rinse that off?
Josh Wren: I do. I scrub the ViscoStat on there for about 15 seconds and then we rinse it off with a thorough air water rinsing, thorough air water blast and then put your temporary material in there, in the canal, in the chamber.
Howard Farran: And what is that usually for you? Is that IRM?
Josh Wren: I use Tempit.
Howard Farran: Tempit?
Josh Wren: It is just easier. I don’t like mixing.
Howard Farran: Made by who?
Josh Wren: Who is Tempit made by? I am not even sure. But Tempit and then we use usually a stainless steel crown on top of that. That is another debate, whether you can restore those with composite or you need full coverage and I still use the full coverage on this.
Howard Farran: So have you tried direct adhesive composite and what was your results with that?
Josh Wren: Miserable failure.
Howard Farran: Miserable failure? And what about the chrome steel that are tooth colored?
Josh Wren: Oh, I love them. The new zirconias that are made by, EZ Pedo makes them, NuSmile makes them, Kinder Krowns makes them. They are great. I have been using those for the mothers that value aesthetics, I use the zirconia crowns for.
Howard Farran: And do you charge a higher fee for that?
Josh Wren: We do. It is about, I would say close to 50% higher.
Howard Farran: Fifty percent higher, okay.
Josh Wren: Right.
Howard Farran: And go on.
Josh Wren: I would just say around $200 for a stainless steel crown, around $300 for a zirconia crown, just for those out there who are wondering what we charge for those.
Howard Farran: And do you have amalgam in your practice?
Josh Wren: We do not. I haven’t used amalgam in about five years.
Howard Farran: And what are your thoughts on that?
Josh Wren: I love the bonding systems. I think if you have a properly isolated tooth with an Isolite or a rubber dam, that the composites last as long as a pediatric primary tooth is needed for sure. But I believe heavily in them for six year molars too with thorough isolation. I don’t believe in _____ isolation or mirror isolations for a seven-year-old needing a resin on tooth number 19. But I think properly isolated, a resin can last a long time.
Howard Farran: So Josh, back to that six year molar on a sealant. A lot of people, there are people on the message board that said if you don’t go in there with a bur and do a preventative resin restoration, which is basically just an occlusal, that you know, if you do an preventative resin restoration, you take a 330 and clean out all of the fissures, in five years 99% of them are still there and if you just do a sealant and you acid etch, fix some fissures filled with junk and do a sealant, that in three years they have all failed. Talk about that. How do you weigh in on that?
Josh Wren: I would even add to that, not in three years those fail. If you etch and bond on top of organic material in the grooves, it is going to fail within a few days. So I do, I clean the grooves out with either an abrasion or usually a fissurotomy bur and etch and bond and seal. I don’t believe in not treating the grooves at all.
Howard Farran: So then you do not believe in sealants?
Josh Wren: I do believe in sealants, but I believe in sealants with a fissurotomy. Because I will place sealant material.
Howard Farran: But isn’t that an occlusal composite?
Josh Wren: We had this debate with the insurance company around four years ago with one of the particular insurance companies and they say no it is not, not unless you are into dentin do not bill an occlusal composite. Still charge it out as a D1351, a sealant. Don’t charge it out as a resin. So that is my terminology here, I guess it is from an insurance standpoint.
Howard Farran: Well that would probably legally be correct, but if you clean it out with a fissurotomy bur, aren’t you always in dentin?
Josh Wren: No.
Howard Farran: No?
Josh Wren: You can be still in enamel, but you are right. It is a composite. At that point, in my opinion, it is truly a composite.
Howard Farran: I would say it is in my own eyes, and again, my eyes are 51 years old and I have to wear magnification 3.5. But I take air abrasion and clean out the pits and fissures. It always blows it out to dentin. Is that just because the air abrasion is cleaning out too much or strong enough to remove enamel and that is why you are always in dentin and if I used a fissurotomy bur I could clean that out without being in dentin?
Josh Wren: You know, that is a good question. I am not sure. I haven’t used air abrasion in quite a while. I just lightly, as light as I can, go through the grooves trying my best not to remove hardly any tooth structure, just to clean out the grooves. But that is a good question.
Howard Farran: And how long are you seeing your fissurotomy staying in enamel, cleaned out grooves all in enamel, billing it out as a sealant, how long is that going to last on a 6 year molar?
Josh Wren: I think that is going to last as long as it needs to, unless they are chewing on ice or something like that. I think that they are holding up well.
Howard Farran: But what is well? Is that five years, ten years? I mean obviously it is not going to stay in there until they are 100.
Josh Wren: Right. I hope, I have been at this in my own practice for seven years. So I don’t have the ten year follow ups yet, but hopefully they will last a long time. And part of that is your bonding and your sealant material. You need a good one, something like Clinpro from 3M or something like that. I wouldn’t go use the cheapest composite you can buy out of just any catalogue.
Howard Farran: Okay.
Josh Wren: And to add to that, I have been using a lot of flowable composite, Filtek flowable composite instead of a sealant material just for the filler, for the additive filler.
Howard Farran: For the sealant or for the preventative resin restoration and fissurotomy?
Josh Wren: Exactly, for the PRR. Which, I still love that term, but insurance companies don’t want to recognize it.
Howard Farran: And Josh, you and I have had this conversation many times. I remember sitting with you just a few months ago having this talk. But you know, when we talk about pediatric dentists there are 2 million dentists around the world and a lot of dentists in Asia, Africa, Latin America, what are your thoughts on amalgam? Should they be able to do low-cost, I mean, can they get it done with bonding?
Josh Wren: I think they can get it done with bonding if they have the materials. I mean a rubber dam and rubber dam clamp is not that expensive. But if they are not going to use a rubber dam and rubber dam clamp, if they are just going to use cheap retraction with a mirror, I think the chrome steel crown is the way to go. You are talking about a low-cost material that is going to last a long, long time, even on six year molars, badly broken out six year molars.
Howard Farran: Now, do you think amalgam is not good for a child? I mean, do you feel it is unhealthy or you just think it is a cosmetic issue and the mom prefers tooth colored?
Josh Wren: Exactly. I don’t believe it is a health scare at all. I would not hesitate to put it my child’s mouth, my four-year-old girl’s mouth if needed. I just don’t see the point with good isolation. Now, without good isolation, amalgam all day long.
Howard Farran: And I left, all of mine are gold, but I did leave one amalgam in my mouth just so I can always tell mom, “Yeah, I don’t do that, but I have one in my mouth and there is no problem with it.” It is funny, everybody that is concerned about mercury, how you get mercury in your bloodstream is eating seafood.
Josh Wren: Exactly.
Howard Farran: And not from a dental amalgam, it is from eating shrimp and lobster and tuna. In fact, they are about this close in America to put a warning label on cans of tuna that you shouldn’t eat it if you are pregnant. And I actually thought I was pregnant and it turned out they did an ultrasound and I am retaining food. I am not pregnant. So that was a relief.
Josh Wren: You and me both have that problem.
Howard Farran: No, you looked ripped when I saw you last. You just did another Ironman or a half Ironman. You did the Ironman in Florida and then you just did a half a while back.
Josh Wren: That is correct, I did a half in Knoxville, which was extremely hilly and I have another full coming up at the end of September in Chattanooga.
Howard Farran: My dream is this year the Arizona, I only do one Ironman a year, I do it in Arizona. This year seven dentists, seven townies are doing it. And you said you are going to do it next year with us, 2015?
Josh Wren: That is my goal.
Howard Farran: Can I hold you to that?
Josh Wren: You can.
Howard Farran: Alright, you can stay at my house. I am only ten miles from the entrance still. So what else do you want to talk, general dentists on pediatric dentistry? Where do you want to go next with this?
Josh Wren: Wherever you want to go with it. One thing is, in my opinion, pediatric dentistry is easier than general dentistry. I mean, it really is. As far as it is behavior management. It is knowing how to talk to the kid, being comfortable with a kid. Not having mom back during the appointment makes things 20 time easier, as long as you have the right _____.
Howard Farran: But you said you bring mom back there for the restraint and now you said you don’t want mom back there. So talk about that.
Josh Wren: If any restraint is needed, mom is in the room. For example, if it is a two-year-old that fractured tooth number F into the pulp and we are not going to do a pulpectomy and a cosmetic crown, mom wants the tooth pulled, mom is back there restraining the child.
Howard Farran: And is mom sitting in the chair holding her, or is mom facing the child holding her down?
Josh Wren: More times than not, mom is sitting in the chair with child on top of her chest. Which is a nightmare. I mean, to be honest with you, that is the least favorite part of my job. Because I know mom is in tears because her baby is hurting and is having to have a tooth pulled and I can’t stand it. I probably despise doing that more than anything in dentistry.
Howard Farran: And it is tough. I mean, I only had one accident with one of my four boys. He fell off a bike and I started crying before he did. I think he only started crying because I started.
Josh Wren: That is right.
Howard Farran: It is a hardwired thing in the mom and dad. Let’s switch to a…
Josh Wren: That’s right. But I… Go ahead.
Howard Farran: No, you go ahead.
Josh Wren: But I just think that is the biggest barrier to general dentists not treating kids a lot of times. I am not sure if it is a comfort thing, I am not sure if the right protocols are not in place, I am not sure if mom is back there interfering with the communication between the dentist and the child. But I have just seen a lot of reports on that and it does make your job a lot easier when you have that one-on-one communication with the child without mom interfering, using your own phrasing. The child can leave the appointment and never feel a thing and trust you for the rest of their life if mom is not in the room. It is funny, they trust the daycares with their children. They drop their child off at the daycare, send them off in to the teacher and trust that that teacher is going to do the right thing, teach their child well. And a lot of times we are just asking for that same trust, you know?
Howard Farran: Yeah, I remember dropping off my oldest boy for the first time at, not kindergarten, preschool. It was the first day and I went to drop him off and Eric was crying, he was hanging on to me and all of that sort of stuff. And I said, “He is upset.” And a little sixteen-year-old girl said, “Well, if you just leave he would be fine.” And I am sitting there thinking, “Yeah, I am a dentist. I should know that.” So I put him down and I ran out, but then I went to the window and I peeked in the window and sure enough, the instant I was gone, Eric was running off playing with three other guys. So yeah, those kids have a trained response. They always know if they cry, mom is going to come running. So once they don’t see mom, they realize that strategy isn’t going to work with a completely new person like Josh Wren. So Josh, I want to change subjects completely. When we think about dentistry for kids, you can’t think of dentistry for kids without bringing up Medicaid, Medicare, things like that. Do you participate in any Medicaid/Medicare? Are there fees enough for you to get involved with that, or is that just not working?
Josh Wren: They are not. Their fees are okay, it can work with high-volume dentistry, which is high-stress dentistry. A lot of hospital work, you know, you are seeing a lot of two and three-year-olds for full mouth dental rehabs. And it just didn’t work for me. I did it for three years until September 2010 and then I chose to opt out of Medicaid, just to change my practice style to more orthodontics and some PPO and fee for service dentistry instead of the Medicaid. And one of the things that caused me to do that was the guy I mentioned earlier, Neil Quinton, just going through a Medicaid audit, you know, and them getting back with him saying, “You owe X amount of money. We deemed 40% of your crowns unnecessary that you did in hospital dentistry.” You know, without having any proof whatsoever. They had non-qualified people reviewing the documents. They had general dentists, not pediatric dentists. And not only not pediatric dentists, they weren’t board certified pediatric dentists. They weren’t capable of interpreting the information given. They told him he owed X amount of money. Well, eight of my colleagues went through the same thing at the same point in time. And then I started reading more and more on DentalTown about some of these scares. That is the main reason I chose just to get out of it. I was doing everything as ethically and morally and documenting everything by the book, but I still worried about it and I thought that was a part of my practice that I didn’t need at that point.
Howard Farran: Well, if we have learned anything throughout human history, it is that if you get in bed with the government, you are going to get screwed.
Josh Wren: That is exactly right.
Howard Farran: Yeah, and that is sad, but it is so true. So what else do you want to talk about? We are at the halftime now, we are 30 minutes in, we have got 29 minutes to go. Where else do you want to take these general dentists in the world of, and my series is Uncomplicating Dentistry. How can they uncomplicate pediatric dentistry?
Josh Wren: Let’s go along with the same lines about the government run insurance and let’s talk about private commercial insurance and the struggles we are dealing with there. The premiums are going up and the reimbursement rates are staying the same. That presents a major problem for a lot of people. One of our problems is whether to become in-network with certain insurances, just like general dentists are. I would say ten years ago as pediatric dentists, we did not have to sign up to be in-network with some of these companies, with the Delta Dentals, with the Blue Cross Blue Shield and now we are starting to see that we have to, whether it be from corporations starting to establish general dentistry for kids or some of the Small Smiles and _____ Smiles opening up and they are in-network with every insurance company. And some of the general dentists are, quite frankly, out there starving and the pediatric patients that they used to send us they are no longer sending us anymore. They are wanting to treat them themselves in their office. So you know, those things may lead pediatric dentists to join more networks, to join more insurance companies. So that is a struggle I think some of us are dealing with. And as we have talked about in the past, new dental schools opening up every day, new residencies opening up every day. The mid-level provider scare, more people being treated by mid-level providers in certain states. You know, that may work its way down throughout the rest of the country like it is in Minnesota. What are your thoughts on the mid-level provider, Howard?
Howard Farran: Well, I think right now in 2014 it kind of reminds me of when the hygienists went into independent practice. It was a big uproar and only, like, five hygienists in the United States did it and it was in Colorado and the mid-level providers, you know, it is early. We haven’t seen the impact from it yet. But what percent of your patients have insurance? What percent don’t even have insurance? I mean, we keep seeing national numbers that half of America, there are 330 million people, half of Americans don’t have any form of insurance. So is your practice, half of them don’t even have insurance or are you seeing it is the half with insurance that are coming in to the dentist?
Josh Wren: That is what I think it is. I think it is the half with insurance that are coming in. Our practice is about 12 to 14% no insurance and the rest are insured.
Howard Farran: So that is a big sample size showing that if a person has a subsidy, a form of insurance of someone else paying for it, that they are far more likely to go see dentistry.
Josh Wren: I agree. And we offer incentives for those without insurance. We offer 20% discounts from the hours of 10 to 12 for those without insurance and we advertise that just as a way to get those patients, to get them a dental _____ as well.
Howard Farran: And another big controversial thing, I get attacked by this all of the time back here. I was involved with getting Phoenix fluorinated back in 1989 and then again last year. I have had a lot of people upset with me about that. What do you think about community water fluorination and do you think that it is health risk, do you think it is a benefit? What are your thoughts as a pediatric dentist?
Josh Wren: I think it is a big benefit. I don’t want to pigeon-hole anybody, but the parents that come in that say they are against fluoride, well those are the children that do have active decay and a lot of rampant decay. I think water fluorination is the best thing to happen to dentistry maybe ever. I really do. I think it is preventing caries like crazy. I don’t know the percentage. And topical fluoride and the use of fluoride varnish. I think those are big. We have a see-saw where there is so much sugar in the diet, sugar, sugar, sugar, sugar, sugar, sugar, and the fluoride has to balance that out somewhere and _____ (36:20-36:26) come to the dentist and that sort of thing. If not, you are going to deal with a lot of active decay. I am not scared whatsoever about detriments to the body that fluoride is causing. I am really not.
Howard Farran: Let’s talk about fluoride treatments in your office. Are you using a fluoride varnish? Are you using fluoride trays? Are you doing a fluoride rinse? And how often does a child need that? Some people say that it is only effective when it is done every three months, some people say it is effective done every six months. Talk about that.
Josh Wren: Yeah, that is another insurance thing that we are having to deal with. Some companies, most companies now, are going to a once a year fluoride treatment. Well, in my opinion, there is no benefit to a once a year, in-office fluoride varnish. And we use fluoride varnish exclusively.
Howard Farran: And say, what do you mean by fluoride varnish? So it is a sticky varnish application as opposed to the foam and the tray or the rinse? Why do you go and do a fluoride varnish and not the spray foam in a tray or a rinse where they swish for 60 seconds?
Josh Wren: The fluoride varnish, it adheres to the teeth a lot better and the effects of the fluoride varnish last for about six to eight hours, even if the patient eats or drinks after the fluoride varnish.
Howard Farran: And what brand are you using?
Josh Wren: I am using 3M Vanish.
Howard Farran: 3M Vanish. And you should tell them how you apply that and how long that takes.
Josh Wren: Okay, it comes with the little brush and after you remove any plaque on the teeth with your regular prophy, you get the teeth dry just with a cotton roll or cotton gauze and then you just apply it, you dip the little brush into the fluoride varnish. It comes, I think it is 0.2 mL and a little dispenser and you just apply it all on the buccal surface of all of the teeth. We then do the lingual surface, palatal surface of the teeth and then we actually floss the varnish down in between the teeth after that. Very quick and easy. It is not readily evident that it is on there, but you do need to tell the parent when the patient leaves because they say, “Oh, let me see your teeth,” and then there is sticky junk all over their teeth and parents think it is plaque or something. And so you need to tell them that is what the sticky stuff is that is on their teeth.
Howard Farran: And what code, do you bill that out separately or is that part of the cleaning fee?
Josh Wren: We do, we bill it out separately. It is D1208 for the varnish.
Howard Farran: D1208.
Josh Wren: There is a D1206 and there is a D1208.
Howard Farran: And what is the difference for the two?
Josh Wren: I believe the old 1203 has become the 1208, which is any topical fluoride and they form the D1206 as the fluoride varnish code.
Howard Farran: Okay, and yeah, obviously that works a lot better if you are getting it twice a year than if you get it once a year.
Josh Wren: Oh, it does. And we still recommend it every three months for high cavity risk children.
Howard Farran: So are you still seeing baby bottle tooth decay or are the patients educated enough to where you see that fading away or is that still an issue?
Josh Wren: Once or twice a month in my practice in Mississippi we still see baby bottle tooth decay. It usually is in the lower socioeconomic status. It is the ones that think 100% fruit juice is okay, but it is not real juice.
Howard Farran: Right, yeah.
Josh Wren: So we still do see that.
Howard Farran: Yeah, that is sad. That has been going around for a long time. So I also know that you are very focused on your staff. You take staff management as serious as anyone. Talk about that for a while.
Josh Wren: I do. Staff loyalty is big in our practice and the way I treat them is big in our practice. I do not like staff turnover at all, just as you have spoken and recently put on social media all of the wonderful years your staff has put in with you. I strive to do that same thing. Just treat the staff good, have fun at work, don’t let it be a stressful environment. My God, we dance around and sing and watch Madagascar and have rhyming games with the staff while the patient is in the room and the patient joins in on it. We have a fun environment here and I think that is what it takes to keep staff happy. It is not necessarily always about the money or the benefits. A lot of times it is about whether they dread coming in to work or whether they are happy to come in to work quite honestly. That is what I hear from my staff. My new office manager, Howard, is 21 years old. I have a 21-year-old office manager that is the sharpest employee I have ever had. She was out on maternity leave for four weeks. She said she was ready to come back to work. She was going to originally take eight weeks off, she came back after four. She said, “I am ready to come up there and have some fun and be around you guys.” I think that is what it is all about. That person, in my opinion, will be here forever as long as I keep treating her right and she keeps having fun at work.
Howard Farran: Yeah, and that helps so much with relationships with your patients. I mean, they bring you their child when they are two or three and they are going to be there until they are 18 years old. It is nice to always come in and see the same dentist, same receptionist, same assistant, I have got to tell you. So let’s talk about that. When does a child need to see the dentist? Sometimes you hear not until the first tooth appears. Sometimes you hear on the first birthday, the second birthday. What are your thoughts on that?
Josh Wren: We are active in the OB/GYN’s classes in the communities. So we start getting the education out there before the patient is born. Whether it is cleaning the mouth out with xylitol wipes before there are teeth in the mouth and then to present to the dentist no later than six months after the first tooth comes in. Instead of saying a set age, one year old, which is a good number and it was a good advertising or educational campaign for the APD to put out. But some children don’t have teeth yet at one years old and some need intervention before one years old. If the tooth comes in at two months, we want to see them at six to eight months. The cavities can form very, very quickly. So that is my general rule, is six months after the first tooth arrives. But start healthcare at home before you ever even come to the dentist. And we try to get all of that information out there to the pediatricians. Pediatricians, usually on average, see the kid six to ten times before the dentist ever sees the child. So if we can get the material out there to the pediatrician to give to the patient, that is fine with us. We don’t necessarily care about the patient coming in to the office when they are born or at their two-week check or whatever, but we want that information disseminated to parents out there where they can start the good at-home care.
Howard Farran: And Josh, are you seeing the first tooth appear faster and earlier in girls than boys?
Josh Wren: No doubt about it.
Howard Farran: No doubt about it?
Josh Wren: No doubt about it. I saw, about two weeks ago, I saw a 3 year 11 month old African-American female that had already lost O and P, and E and F and had already been replaced by 8, 9 and 24 and 25. I hadn’t seen that. I had seen 9-year-old boys, white males, that had not lost a tooth.
Howard Farran: Right.
Josh Wren: So there is definitely a gender and a race predilection for when teeth come in.
Howard Farran: Absolutely. I have noticed that big time. And which tooth are you seeing come in? What should they expect to be seeing, which tooth coming in first? What is your general eruption pattern of what you are seeing come in first?
Josh Wren: It is E and F, and O and P. Which one comes in first is kind of debatable, but most people say that you will see those bottom front two teeth, O and P, come in first. And then you will see E and F and then you will see D and G come in beside it there.
Howard Farran: And do you also see, it seems to be that babies look a little more Class III when they are little and then they grow out of it. I mean, overbite, their mandible seems to be growing small. It seems like a lot of concerned parents come in like, “My son is going to have a weak chin,” and then they kind of grow out of it. Do you see that mandible growing slower than the maxilla?
Josh Wren: Yeah, we do. We definitely do. The growth rate, it starts later but grows longer. So I am not worried about the Class II at such a young, early age. They are saying it is an adaption thing. It is for suckling is what it is. I mean, the lower jaw is set further back. That is what they are hypothesizing in the growth and development world, that it is a suckling thing to let them suckle better.
Howard Farran: And also we were talking a couple of months ago about current trends in pediatric dentistry, indirect pulp therapy versus prophylactic pulpotomies.
Josh Wren: Yeah, when I was trained in residency at the University of Kentucky, a lot of the professors still taught to us prophylactic pulpotomies. One professor in particular, I don’t want to call out the whole program, because the whole program didn’t do that. But anytime you are close to the pulp on a primary tooth, do the pulpotomy and then cover it with a stainless steel crown. That has turned a 180. Now even if there is still decay present, if you are close to the pulp, clean the DEJ around circumferentially as good as you can, get it as clean as it can be. Any decay remaining on top of the tooth you leave behind. You put a glass ionomer on top of the tooth and then you restore. Long term studies are showing that that has a success rate 95-98%, whereas the standard pulpotomy, even followed by a stainless steel crown has a success rate of 88-92%. So we are starting to see really long-term studies showing that indirect pulp therapy is the way to go in the absence of symptoms.
Howard Farran: And also what about a, we are talking about a solo practice model being a thing. What are your thoughts on solo versus…?
Josh Wren: I think it is going to become a thing of the past. And I know that has been an active topic on DentalTown. In the pediatric message boards, we are a little further behind the system I believe. There are very few group practices that are pediatric practices. Most of us are all individual practices. Well, I believe with the number of pediatric dentists coming out that a solo practice will probably be a thing of the past. I think if you can find somebody that is compatible with your treatment philosophies and your personalities that the group practices in 20 to 30 years will greatly outnumber the solo practices.
Howard Farran: And do you say that because then you could have extended hours? I mean, what are your hours now and how much do you have to be available evenings and weekends?
Josh Wren: Definitely. I am available 24/7 unless I have the other pediatric dentist’s office in my town covering call for me. I have my cell phone number on our voicemail. I still work boutique hours if you will. I work 8:30 to 5 and have an hour for lunch, 12 to 1. But I think that is a definite benefit to having a group practice.
Howard Farran: Are you open on Saturdays?
Josh Wren: I am not. I am very seldomly open on Fridays.
Howard Farran: So you are mostly Monday through Thursday?
Josh Wren: Right. But I don’t think we are going to have a choice in a few years. I really don’t. I think we are going to have to extend hours. I just don’t see things getting better without extending hours. I don’t think we can raise our fees and decrease our hours or anything like that. I don’t think we can work less and make more, you know? Like I thought we were going to be able to five years.
Howard Farran: And how often are you getting calls on evenings and Friday, Saturday, Sunday?
Josh Wren: You know, very rare. Every new patient that leaves, I hand them my business card and write my cell phone number on the back of it and hand it to them and say, “Call me if you have any questions.” And I started that when I opened up my practice. And I would say I get maybe two calls a month, something like that. More times than not it is a general question that can easily be answered and I don’t have to come into the office.
Howard Farran: Yeah, I have always thought and found it strange that so many dentists are unlisted, don’t give out their home number, blah, blah, blah. And to me, I think at least in Phoenix, Arizona, people are very respectful of a dentist’s time. I give everybody my business card. It has got my email, my cell phone number and it is not abused at all. I had one funny one the other day. All of a sudden my phone started ringing in my pocket and it was the lady in the chair. She didn’t believe that was my real cell phone number. So she was going to catch me right there. And my phone starts ringing, I look at it and go, “Oh, that is a local call.” And then I answered and she goes, “Oh, that really is your cell phone number.” I thought that was hysterical.
Josh Wren: Yeah.
Howard Farran: So we are down to 10 minutes Zach, uh, Josh Wren. I just called you my son’s name, Zach. Josh, ten minutes. Wrap this thing up. What else can a dentist do to uncomplicate pediatric dentistry?
Josh Wren: You know, other than following the message boards on DentalTown, go find a local pediatric dentist on your day off or take a day off. Go watch them work. Go watch their office work. If it is a pediatric dentist with a good reputation, go watch them work and see how they communicate with the kids. See their verbiage, see their terminology. That is going to improve your skills with pediatric patients more than anything in my opinion. I welcome general dentists to come to my office to watch whenever they want if they are confused about certain procedures. I will call them and say, “I have a pulpotomy or a pulpectomy coming in tomorrow morning. Do you have a chance to swing by?” or something like that if they are confused on a procedure; how it should work, how to treat the patient, how to give anesthesia. That sort of thing.
Howard Farran: And that also speaks volumes about you and it is also only the street-smart dentist who does that. I think the book-smart dentists, they have always got to fly to another city and drop 5 grand and close their office and make a mountain out of a molehill. And I have seen that, too. I am street smart and for 25 years, there are just so many dentists. I mean, I remember back in my early career, you know, an endodontist Brad Gillman. He had an open-door policy. I think most dentists would fear that an endodontist wouldn’t want to show you how they do endo because then you wouldn’t refer to them and that is just completely the opposite is true. Here you are a pediatric dentist and I think a lot of general dentists in your state would think, “Oh, well he would never show me because he wants me to refer to him.” And here you are exactly the opposite, open-door policy. You love people, you love to share. And you know, with 7 billion people on earth, someone other than Josh Wren has got to do a pulpotomy, too.
Josh Wren: Exactly. And it is all about the patient. Do whatever is best and easier for the patient. That is what it is all about. Of course, we have got to keep our doors open, but you know, if it can make the experience better for a pediatric patient in another office, I could care less who does the procedure, as long as they do it right.
Howard Farran: Now if a child walks in your office versus a general dentist’s office, does that office look more pediatric oriented? I mean, talk about that. I mean, is your office waiting room more geared towards children and how much of an effect does that have?
Josh Wren: It is. That is who it is geared for. It is geared for the children, but our front desk knows to cater to the parent. The office aesthetics is geared towards children, but we cater to the parent if that makes any sense. So when they walk in, they have toys to play with, books to read. Mom has magazines to read, is offered coffee or bottled water. But you can tell when you walk in the door, pictures of giraffes painted on the wall or games to play with, that sort of thing. It is all fun and games when they walk in the door, nothing serious when they come in the door. Everything is fun and we are very interactive with the patients and we are silly. It often times reminds me of Patch Adams. I am not sure if you are familiar with that.
Howard Farran: Sure, absolutely. Robin Williams.
Josh Wren: Exactly. That really molded me early on. I walk around acting just as goofy as he did. The kids leave here thinking, “Where was the dentist? I don’t see the dentist today.” Well, it is that goofy guy walking around dancing and singing. You know, but in my opinion they know they were at a pediatric place. So it is all about the experience for the children.
Howard Farran: So do you wear scrubs or do you wear a dress suit or what do you wear?
Josh Wren: No, scrubs. Monogrammed scrubs. The same monogram you see here with the bird and the Wren Pediatric Dentistry on my arm. No white coat, loupes during procedures, not for hygiene. It is very unintimidating attire and of course if helps with my being 5’6”. I am not 6’6”.
Howard Farran: And if Josh Wren sees a hundred patients, you said earlier 50%, oh no, you said 100 patients referred to you for behavioral problems, 50% you can manage on nitrous. But let’s take your whole practice. What percent of your children get nitrous, what percent have to be taken to a hospital or hospital dentistry, and if you do hospital dentistry, do you do the IV or do you have an anesthesiologist do that?
Josh Wren: I work with an anesthesiologist that does the IV and the intubation. We did an anesthesia rotation in residency so we started our fair share of IVs and I have intubated quite a few patients. But we work with an anesthesiologist. They do all of that and we do the dentistry. To answer the question about what percentage, I would say around 3 to 5%. That is not a set number. I am not sure. That is not an exact number that have to undergo general anesthesia. I would say other than that, children that need restorative treatment or extractions, 95 to 99% get nitrous oxide. I just think it makes the appointment more pleasurable, helps calm them down even if they don’t appear nervous. And it is 50% nitrous every time. Nitrous nose goes on, 50% nitrous from the start. _____ quite the numbers and I have had two patients vomit in seven years. I mean, it almost doesn’t happen. That is the biggest side effect.
Howard Farran: What I am most proud of is the very few times that I have had a pediatric patient vomit, I was fast enough to push the jaw over and it all went on Jan.
Josh Wren: Smart man.
Howard Farran: I am proud to say I have never got a drop on me. I am very proud of that. So you are saying basically if they are going to get a shot and pulpotomy and extraction, they are going to be on nitrous at 50% nitrous and 50% oxygen?
Josh Wren: They are, and they are going to be watching their favorite movie that is playing on the TV every single time.
Howard Farran: And one out of 20, 3 to 5% are going to have to go to a hospital setting with a board certified anesthesiologist and they are going to intubate them?
Josh Wren: I would say less percent than that, but that would be the approximate percentage of patients that were referred to me that would need general anesthesia, I would say, is around 5%.
Howard Farran: And what are they intubating them with?
Josh Wren: So that is about right, Howard.
Howard Farran: And what would the anesthesia be if they are being intubated, for clarity?
Josh Wren: The anesthesia would be _____ to intubate and then they would use _____ and maybe propofol.
Howard Farran: Okay, so you are down to three minutes. Wrap it all up for three minutes. If someone was only going to hear Josh Wren for three minutes, uncomplicate dentistry and wrap up our hour.
Josh Wren: Go check out and talk to your local pediatric dentist. Take a look and watch them do what they do. Get on DentalTown, search around. Watch some CE on there. Again, we have got another one. You would probably learn more about pediatric dentistry from an hour course on DentalTown than you could by searching all of the message boards. But search if it is a question that has been asked on DentalTown on the pediatric message boards. So yeah, go see your pediatric dentist. Feel comfortable with it. You are going to have to see pediatric patients in the upcoming years, so make it pleasurable for yourself.
Howard Farran: Well, Ironman Josh Wren, it has been an extreme honor to interview you today for an hour. I am sure all of the readers loved it. If someone wanted to just email you a direct question, can they do that?
Josh Wren: Absolutely, it is jxwren78@gmail.com. Email anytime.
Howard Farran: And what is that 78 come from?
Josh Wren: And look us up at wrenpediatricdentistry.com and we are also on Facebook. Excuse me, Howard?
Howard Farran: What does the 78 come from? Is that the year you were born?
Josh Wren: It is.
Howard Farran: Okay, I thought so. That was a slap in my face, since mine is ’62. But hey Josh, thanks for a great hour. I can’t wait to see you on the message boards.
Josh Wren: Thanks Howard, you rock.
Howard Farran: Alright buddy, goodbye.
Josh Wren: Take care.