Dentistry Uncensored with Howard Farran

How to perform dentistry faster, easier, higher in quality and lower in cost. Subscribe to the podcast: https://podcasts.apple.com/us/podcast/dentistry-uncensored-with-howard-farran/id916907356

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Dr. Fred Margolis received his B.S. and D.D.S. from The Ohio State University and his certificate in pediatric dentistry from the University of Illinois College of Dentistry. Dr. Margolis has been a Clinical Instructor at Loyola University's Oral Health Center and is an Adjunct Clinical Assistant Professor at the University of Illinois College of Dentistry. Dr. Margolis is director of the Institute for Advanced Dental Education, Ltd. and on the faculty of the University of Genoa School of Dentistry, Italy. He was recently selected by Dentistry Today Journal as a "top clinician in continuing education for 2015." He is co-author of Pediatric Laser Dentistry, which is published by Quintessence. Dr. Margolis is in private practice of pediatric dentistry in Highland Park, Illinois.

www.dentaled.org

kidzdr@comcast.net

Howard: It is a huge honor today to be interviewing Fred Margolis, who lives in Chicago and he's probably pretty excited right now, because this is June 3rd and tonight is the first game of the Stanley Cup Playoffs with your Chicago Blackhawks and the Tampa Bay ... Is it Tampa Bay Lightening?

Fred: I'm not sure, Howard.

Howard: It's Tampa Bay, but are you going to watch the game tonight?

Fred: Absolutely. 

Howard: I'm watching it with two dentists, Tom [Matter 00:00:37] and Tim Taylor were pretty excited. Tom's from Chicago. He's a big hockey fan, but you know, Fred, what's the most interesting about you and why I wanted to get you on here so much is I love your passion. I mean you have an incredibly amazing history, but nobody ... I never thought of lasers and pediatric dentistry and you're a pediatric dentist and you're into lasers. You might be the only guy I think I've ever heard of, let alone met or interviewed, who's big into lasers and is a pediatric dentist. I don't know of a single pediatric dentist that has a laser. How did all that happen?

Fred: Well, back in the year 2000, I was reading Dental Products report. They were talking about the Erbium laser for hard tissue and soft tissue cavity preparations and gingival surgery and so forth. I called three friends of mine. I called Dentist [Petrini 00:01:37] who at that time general dentist, who at that time was the president of the Academy of Laser Dentistry, and I said is it time for a pediatric dentist to get involved in lasers? He said, "Fred, it's a perfect time, because the Erbium laser can do both hard tissue cavity preparation and soft tissue surgery."

Then I called Bob Peck, periodontist and past president of the Academy of Laser Dentistry, and he's used a CO2 laser for many years on several of my patients that had Dilantin hyperplasia and he's been able to remove the excessive growth of the tissue with his CO2 laser. I said, "Bob, you and Leo [Messerodino 00:02:18] wrote the book in 1995. It's the first book that I know of that talks about lasers that are approved by the Food and Drug Administration and there were only two paragraphs about the Erbium laser." Why? Because the Erbium laser wasn't approved by the FDA until 1997, and then he said, "I think it's a perfect time for pediatric dentist now that the Erbium lasers are out."

I called a third friend of mine, Harvey [Whigdore 00:02:53] in Chicago. Harvey had been doing research, general dentist, had been doing research on lasers for over 20 years. Facetiously he said to me, "Fred, I think you should wait another 20 years till I perfected the CO2 laser where it's not going to burn up the pulp." We're very fortunate that a year and a half ago, a company called Convergeadent, Convergent Dental rather, came out with the Solea laser which is a 9.3 microns. This doesn't mean anything to you and I, except that from the physics, it will prepare hard and soft tissue and not burn up the pulp.

The other thing I wanted is, you know, so many articles that you may have seen that I've written have to do with local anesthesia and different types of techniques for example, the STA program, STA technique computerized, the peri-jet and so forth, well, with the laser I can numb a tooth in 30 seconds. No numb feeling for that patient. That's really important for my pedo patients, because you can tell those patients and my special needs adults, you can tell them 100 times not to bite their lip or tongue and what happens? The next day they'll call your office right and say, "Gee, Johnny's lip is a swollen and that's the side you gave him the local anesthetic on." 

From that aspect itself, then I was giving a lecture for the World Clinic Laser Institute out in Huntington Beach California, and this is about probably seven years ago with a dentist from Italy named [Giovanni Olidi 00:04:42]. He's a general dentist, his wife Maria Danielle Geneva is a pediatric dentist. They practice together in Rome and after the lecture, Giovanni put his arm around me and said, "Fred, let's write a book on lasers." Three years ago, Quintessence's published our book. It's the first book on pediatric laser dentistry. It's a textbook used now by many schools that have laser programs including a friend of mine started teaching in South Africa in Johannesburg after I gave a lecture in Cape Town in Johannesburg. He's a pediatric dentist, got very excited about laser dentistry. 

Those are some of the things. In 2000, we got our first laser. My partner at the time and I only overlapped our practice one and a half days a week, and yet by the second year, we bought our second laser. It was an Erbium laser also. Now Erbium lasers, Howard, is a specific type of laser that can go ahead and again prepare cavities, number the tooth, we call it laser anesthesia and also soft tissue. 

I wanted to answer your question about pediatric dentists and involvement in laser dentistry. Larry [Contell 00:06:09] and I, this will be our fifth year in a row that we've lectured at the Academy of Laser Dentistry and given an all day program. Sometimes we have other pediatric and general dentists who lecture that day on pediatric and orthodontic use of lasers, and the second day we do a hands on clinic. The last two years, our hands on program, the workshops were sold out. What's nice about the Academy of Laser Dentistry is they have lasers there from around the world. Some are not even approved yet by the FDA, but we get to try them, our new toys, how dentists are with their toys. We get to try them out, see which ones will fit best into our practice and decide based on the cost and based on the return on investment which one we should get for our practice. 

By the way, I just want to tell you that I just ordered five minutes before we got online, I just ordered two of your books. This is my order form. I'm going to give my associate one and I'm going to take the other one and it's got rave reviews and I really appreciate the work that you do.

Howard: Oh, thank you very much for that. That was an amazing introduction. A couple things that you said, and I'm trying to guess questions for ... Viewers of these podcasts usually listen to 5000 people around the people. When you talk about FDA approval, okay, you're an American, you practice in Chicago, does a dentist in Johannesburg South Africa or Rome, should they really care or not whether a laser is FDA approved in the United States? Is that just a regional political thing or is that really an endorsement in saying this is a good technology? I mean should a dentist in South Africa wait for an FDA approval on a laser in America?

Fred: I don't think so, and the reason for it is because I've learned in recent months that the FDA, what they're approving is the marketing. In other words, you can't say this laser will do this this, that and the other thing unless you can prove it. That doesn't mean that in Europe when they use to sell a laser that eventually came to the United States, but it started out in Europe. They've had Erbium lasers for years in Asia that we couldn't buy in the United States, because it didn't have FDA approval. 

Let me give you a perfect example of that. I was sitting on a bus on the American Academy of Pediatric Dentistry's meeting, going to a dinner dance, sitting next to me happened to be a business man who owned a company that makes fluoride varnish. I said to him, "I know fluoride varnish, we use it off label for prevention carries, because it was really invented for hypersensitivity as you know." I said, "You're never going to take out a patent on fluoride varnish are you?" He said, "Why should I spend $3 million on a patent if it's all ready the standard of care?" Maybe that's a poor analogy, but ...

Howard: No, that's a very good analogy, because what is Ivoclar's ... They have a fluoride clorhexidine varnish. You know the name of that?

Fred: I don't remember off the top.

Howard: Everyone in Germany and Lichtenstein and Europe, it's huge and people apply it every three months and it reduces decay and all that kind of stuff. Yeah, they can't say that in the United States. Leanne Brady here in Arizona, she uses that and swears by it, but you're right. It would be bloody expensive for Ivoclar to try to get a claim like that approved. For our viewers, you're throwing around the word Erbium. Talk about what is the difference between an Erbium laser and a carbon dioxide, a CO2 laser and other types of lasers and probably the most popular sold laser is the ADM laser for soft tissue. Give us a laser tutorial.

Fred: Absolutely. Right now the top three types of lasers according to wavelength in the United States would be a diode, which is soft tissue only. Now they have diodes, they have diodes this big, Howard, or this small if you will that are pocket. You can go from operatory to operatory and they have diodes that are about as big as a toaster oven and everywhere in between. The diode laser, there are two types of fibers with the diode. One is a fiber that you cleave the fiber like we were back in chemistry class in high school and you had to score it and cleave it. Well, that type of fiber, and then there are others that I like even better that are disposable tips. The assistant and/or you don't have to take the time between patients and clean them.

Now, advantages and disadvantages to either. One is the cost is less expensive if you don't have the disposable tips and if you're cleaving the long, four foot fiber. What do those lasers do? You're a general dentist, correct?

Howard: Correct.

Fred: Okay, it will work for trophing. It will do gingivectomies, diode lasers. It will do frenectomy. Any soft tissue work. It will also in over 35 states and I want to point this out, that in over 35 states now, hygienists are allowed to do non-surgical periodontal treatments. After scaling and curettage, they hygienist or dentist goes in and makes sure that the bacteria are killed. The laser kills 90% plus of the bacteria. 

Let's go on to the next type of laser which is the Erbium according to wavelength. Now, there are two wavelengths of Erbium laser. Biolase has the I guess it would be a patent on a laser that's a 2780 nano-meter laser, and the other Erbium lasers, Erbium YAG they're called, are 2940. The difference to you and I is minimal. They both cut hard tissue, soft tissue. I saw a general dentist via video at a meeting, he showed how he did a taurus removal with the Erbium laser, how another dentist did an apicoectomy. Now this of course he used anesthetic to make the flap, but he did the apical as far as removal of the bone and getting down to the root with the Erbium laser.

About two years ago, Convergent Dental came out with the Solea which is a 9.3 micron laser. The Solea is the first laser in the world that will do hard tissue and soft tissue without burning up the pulp. What's the advantage? It's faster than the Erbium on soft tissue, and it's faster on hard tissue. You cannot remove any amalgam directly with the laser. What I do is I take the laser and either the Erbium or the CO2 and I perform laser anesthesia and then we go ahead, take the high speed drill, cut out the old amalgam, the tooth's numb all ready from the laser anesthesia, go back to the tooth and finish the prep with either the laser and 75% of the time, I'm going ahead and picking up a hand piece and getting the contours I want and so forth, but the patient's numb. 

Can I give an example of the laser use in children?

Howard: Absolutely.

Fred: I like to tell about this anecdote. I went to a dinner meeting sponsored by one of the laser companies and I wasn't the speaker, but being the very introverted person that I am, I went around the room and introduced myself to the 12 dentists that were there. Two days later, I get a call from Dr. John. Dr. John says, "Fred, I just met you two days ago, but I have a patient, an eight year old in my chair, that needs a root canal on tooth number three." That's the upper right, first permanent molar. He said, "Her knees are shaking and I really don't want her to be in any pain. I heard the lecture about the laser. I was wondering if you could see the patient." I said, "Send her on over and I don't molar root canals, but we can get her out of pain, do a pulpectomy and refer to the endodontist." 

She came in with her father who brought the x-ray. I explained that to his daughter and to the father, that we were going to use a laser which will allow me to go ahead and repair the tooth, remove the decay, and get her comfortable. Jenny, if you have any problems, any discomfort I want you to raise your left hand. I said, "Dad, I don't have enough laser glasses for everyone. You'll have to wait out in the reception room." You like that one, Howard? Yeah, that works.

In any case, when mom brought the rest of the x-rays and mom and dad came in to the operatory, I had gone ahead with the Erbium laser, prepared the tooth, gone into the pulp, did my pulpotomy, she never raised her hand once. Mom and dad, and this was a hot tooth, mom and dad came into the room and said, "Jenny, how was it?" She said, "It was fun." Now, I don't know how many of your patients, but most of us, we have patients that have hot teeth either primary or permanent and it's not so much fun. In any case, that's a good case and point. 

I like it for my autistic patients as I mentioned, because the tooth is numb, but they don't have that numb feeling. I use it on my wife. I used it on my sons. If I can use it on my wife and she'll still let me stay in the house, I think that's great, you know? She swears that she didn't feel anything. 

Howard: Is this Solea laser made by Convergent, is that out of Utah? Because it seems like going back in the day, I mean I got out of school '87, that most of the laser companies came out of Utah, because Salt Lake had a physics laser instructor and he was kind of the American ... That was the hot bed of lasers. 

Fred: Right, they're out of Massachusetts.

Howard: They're out of Massachusetts?

Fred: Yes.

Howard: It seems like every time I meet a laser scientist, his teacher was from Salt Lake.

Fred: That could.

Howard: Yeah, okay, and how much would that Solea laser be? How much would something like that cost?

Fred: I don't like to quote prices, okay, but I will say the Erbium and the CO2 lasers, the CO2 Solea are much more expensive then a diode. You know Barry [Friedberg 00:18:32]? 

Howard: Absolutely. 

Fred: Okay, Barry and I were partners at one time when I first got out school.

Howard: I'm in Phoenix. He has a retirement home in Scottsdale.  

Fred: That's right, exactly. I called up Barry one time and I said, "Barry, I'm setting up a new office. Which computer should I buy?" He said, "What do you want to do with it?" When people email me or call me and say, "Fred, which laser should I buy?" "What do you want to do with it? If it's soft tissue only then you buy a diode." 

Now, getting back to diodes for a second, if you wanted to do hard tissue and soft tissue, then you buy the Erbium or the CO2, but getting back to diodes. You can spend $2,000, you can spend $10,000. What's the difference? They have a laser, in fact I have one in my practice, that's made by Fontana, it's called the 1064. 1064 nano-meters is the same wavelength as an ND-YAG. Now ND-YAGs are still used. It's for soft tissue only, but they're more expensive and they're as large as CO2 or an Erbium laser. Most people are going to the smaller size so they can carry it from operatory to operatory.

The other thing is the less expensive diode lasers like the pen-sized, everything has advantages and disadvantages, right? Okay, the advantage is it's pen-sized. You take it from operatory to operatory. The disadvantage is because of the maximum wattage that comes out the end, it's much slower than some of the other diodes. There are quite a few companies that make diode lasers and market them and sell them in the United States, and I was going to say this at the end, but if anyone wants to contact me by email or phone I'll be glad to help them with any decision making or any suggestions. I can actually send them set ups as far as what they should have their laser on like how many watts and how much water to use for procedures.

It's all in my textbook Pediatric Laser Dentistry by Quintessence, but I'll be glad to send them a little PDF of that section.

Howard: How would they contact you? You're willing to give out your email or phone on the podcast?

Fred: Yeah, my emails kidzdr like kids Dr at comcast.net, and I have my own teaching institute and that website is dentaled.org. We do offer free webcasts, by the way, once a month. We started that last year. I'm very proud of the programs. We've had six different speakers.

Howard: You should start a thread on Dental Town about that. We're coming up on 200,000 members. We're at 198,900 now and from every country on earth. We have 52 forums. Root canals, fillings, crowns, pediatric dentistry and one of them is lasers, and you should start a forum and post a link on how to order your book and your website and your institute and you should really do that. I think that would be amazing marketing for you.

Fred: Well, thank you. That's very generous of you.

Howard: Yeah, and so what's interesting ... What I'm hearing you say a lot is what really got you the most excited about lasers and pediatric dentistry was the anesthesia. The analgesia effect. Can you explain how does a laser numb a tooth? Do you even know?

Fred: That's a good question. In 2001, I went to my first Academy of Laser Dentistry meeting and they had researchers from all around the world and at the end of the day, you got to ask them questions, the panel of specialists, got to ask questions about lasers. I said, "How does the laser numb the tooth?" They look at each other and said, "We don't know." 

There are two theories. One is that there's an ionic transfer sodium potassium transfer at the pulpal level that blocks the sensory innervation. The other most common theory is the Gate theory where the laser somehow at the pulpal level blocks the sensory innervation from the tooth to the brain, and you know? It reminds me of those story, Howard, that when I came back from that presentation in 2001, I said to our oral surgeon, we had a group practice at the time, I said, "Ken, I'm really nervous. They don't know how the laser numbs the tooth." He says, "Fred, we've been using nitrous oxide for what? 150 years? We don't know how it works. We've been using general anesthesia for years, we don't know how it works." I said, "Oh, okay, well, I feel better." In fact, he says, "I'm going to refer all the frenectomies to you." I said, "Why?" He says, "Because you have a laser, you're getting less bleeding and faster healing." 

Now the reason we get faster healing from a physics point of view is because if the tissue is here and you take the laser, the depth of penetration is much less than an electric knife or electric surge and that's why when Gordon Christensen, I've lectured with him and I've lectured for him, and I was his host when he came to Chicago one time for one of my volunteer programs, Dental Volunteers for Israel, and Gordon stood up and he's talking about lasers. This was 8-9 years ago and he said, "You don't have to buy a laser. You can go out and buy an electric knife or electric surge. It will do the same thing." Well, it will do the same thing, but you know the charring you get, right? 

Howard: Oh, yeah.

Fred: Well, when you get charring with a laser that means your wattage was too high. It won't hurt the patient, but it's slower healing. I mean we get incredible results. I take care of babies that are two days old, three days old. Larry Cotteller that I teach with from New York, there are several masters in the world in laser dentistry and he and I are two of them. I'm proud to say we got the Leon Goldman award last year from the Academy of Laser Dentistry for clinical excellence. That really made me very, very pleased.

In any case, so, we're training dentists throughout the world to come to this academy meeting and also to local meetings. I was just in Cleveland talking to the Alpha Omega group there. I visited several universities and certified ... I'm fortunate that I'm one of 20 some dentists in the United States that can certify other dentists in lasers and I certified lasers at Nova University, Michigan State, University of Illinois, Detroit Children's Hospital, and I'm going to Mott Children's Hospital in Flint Michigan in a couple months. This is my legacy. If I can teach and you'll agree with this, if I can teach someone how to do something better, I mean this is what I feel ... Let's get to the bottom line. That's what this is all about, right? Is teaching our colleagues that gee, maybe there's a better way to do it, a faster way, easier, and more comfortable for the patient. 

Howard: Well, you should create an online course on Dental Town or a series course, because we just put up our 307th course and we just passed 500,000 views. If you put up your laser course whether that be an hour or a full curriculum or a full series or whatever, I can guarantee you that dentist from every single country on earth would be watching it from here to Kathmandu to Tanzania, Ethiopia, everywhere.

Fred: Well, thank you. After this podcast, if you wouldn't mind, email me the information of who to get in touch with to get that started.

Howard: Yeah, his name ... I'll email it to you. His name is Howard Goldstein. He's a dentist in Bethlehem Pennsylvania and his email is hogo, because I'm Howard and he's Howard, so I go by howard@dentaltown.com and he goes by hogo@dentaltown.com. Anybody listening that would love to teach, you know, growing up Catholic, one of my favorite saints was. I'm 100% Irish, was St. Patrick. His three leaf clover, that was the prop to the teach the trinity, the father, the son, the holy spirit, and teaching is just really neat. Now, the three leaf clover is no longer the teaching mechanism, it's these webcasts, it's the smart phone, and what's amazing is there's 2 million dentists and I've lectured in 50 countries, 500,000 of the dentist are on desktops like we are, but a 1.5 million don't economically have that desktop, but they all have a smart phone and it's amazing so they're watching these dental town courses and dental schools all over on their Samsung or their iPhone and you could be teaching them laser around the world. 

One thing I want to go back and clear through, again, these questions ... I always try and estimate, you know, somebody is right now they're on their StairMaster, they're on their treadmill, they're on an hour commute to work, what is the difference between an Erbium laser and an CO2 laser?

Fred: Okay, it's a different wavelength. The Erbium laser ... Most of the Erbium lasers have a tip on the end. Biolase does have one called a Turbo hand piece where the tip is embedded into the hand piece which is great for pediatric dentistry, because only about 1.5 millimeters of a tip is exposed verses 5-6 millimeters in a child biting down. With the CO2 laser that's on the market, the Solea, there's no tip. The beam comes right out of the hand piece. You get a contra-angle and straight hand piece and you're about anywhere from 1 inch to 2 inches away from the soft tissue or hard tissue and you're going ahead and they have different settings. 

What's so neat now with computerization is people call me up or at a lecture and they say, "Gee, what settings was this Uncle Fred?" Well, I send them pictures of my presets. You can do presets so when you sit down you don't have to go through 20 settings. You just say, okay, like my associate the other day, she said, "Well, what setting should I use for the Solea?" I said, "Well, it's a primary molar so you're going to put in on the dentin setting and it will give you all the read outs." What's different about the Solea different than any other laser is that when you step on the foot pedal, that controls the wattage, where as the other lasers, you have to control with your finger. This way you have a foot control and it's like gassing the pedal.

Howard: You're saying that three out of four times, you still will pick up a hand piece to refine the prep?

Fred: Yes, like yesterday I did ... Yesterday I did a zirconium crown on a primary molar. I used the laser for laser analgesia, picked up the hand piece, prepared the tooth for the crown, went back to the laser, made sure all the carries was removed, checked it with my mirror and explorer and spoon excavator and then seated the crown. 

Howard: Interesting, and so you've talked about laser for anesthesia. You talked about laser for preparing the tooth. I have a friend and I don't want to say his name, because I don't want to throw him under a bus and get caught for this, but he's a podiatrist and he says that the secret to his very successful practice is he always advertises laser foot surgery and he said that it doesn't really ... He says, "I can do it with a laser. I can do it with a scalpel and a burr." He says the laser is profound in marketing. He says for some reason people would rather have their corn removed with a laser than a hand piece. Have you ever ... Do you ever think about the marketing effects of this laser?

Fred: Yes, in fact I'm glad you mentioned that. My previous practice that I had for 32 years. I sold it three years ago and by the way, I set up a new office, renting space from a general dentist just like I started 35 years ago, but this one's walking distance from house which is nice. In any case, practice differentiation from my office when I had an office in Buffalo Grove for 32 year, you could walk to five other pediatric dentists' practices. We were the only practice that had a hard tissue laser. Word spreads, you know, by word of mouth, by newspaper, display ads, we offer laser dentistry and so forth. 

The other little trick I wanted to tell you and the listeners is, Howard, I don't know about you, but one of my pet peeves is when a parent or a teenager pulls out their cell phone while I'm trying to do a consult on them or their family. Does that bother you?

Howard: Yeah.

Fred: Here's what I did. I made a sign and everyone listening can steal this idea. I made a sign on the computer. It says, "No cell phones allowed. Laser in use." Now one of my former hygienists came down from Milwaukee, she had retired, and she says, "Uncle Fred," because all my patients call me Uncle Fred, "Uncle Fred, what happens if my cell phone goes off and you're using the laser?" I said, "Dawn, let's not find out." In any case, and I've told ... I look them straight in the face, I said, "Mr. Smith, we use lasers in our office and I'm going to have to ask you to turn off your cell phone." 

The glasses from a pediatric dentist standpoint, whenever I lecture, I say to the audience, by the way, how many of you at some point in time do not want the parents in the operatory? Anywhere from a couple people to half depending on where they went to school and their inclination raise their hand. I said, "Well, the sign is up which legally it has to be. Class 4 Laser in use. Danger. I say to the parents, 'Mr and Mrs Smith, I'm sorry we don't have enough laser glasses, we'll have to let you wait outside in the reception room.'" 99% of them will not even balk at that.

The other day, I was treating a baby. It was Monday. We do frenectomies on the babies that are lip-tied and tongue-tied which is something I want to talk about. The mother said, "Can I stay in the room and have dad hold the baby?" I said, "I really don't have enough laser glasses for both of you." That was true, but that's a way to get one of the parents that a little more squeamish perhaps or the opposite, the domineering parent out of the operatory. 

Howard: As a pediatric dentist, is one of the big major keys to patient management of a child is getting the parent out of the room?

Fred: No, no. I would say not. For example my special needs patients, I always have the parents in. Now, some of the adult special needs that I see like the autistic and so forth, they don't want the parents to be in. They're big boys and big girls and they say good bye, mom and dad. One of them we did crown and bridge. He had implants done by a friend of mine and so forth. It just depends on the patient, but usually for special needs patients I'll have the mother or father there, because many times they help the hold the hands offer physiological and sometimes physical support.

Howard: Yeah, I'm 52 and my special needs sister is 51 and I think she likes to be independent. She's always, "Get out." Meaning everybody leave her alone. She wants to be independent I guess. She's like that. I want to ask you another thing since you've been a pediatric dentist for three decades, how long did you say your practice ... You'd run it for 33 years?

Fred: That practice, yes.

Howard: When I think of controversy among pediatric dentistry that you would have to deal with with the consumer would be amalgam versus composite. Some of us older guys like me are end of the day I just think amalgams last twice as long as plastic composites, but what do you think of the amalgam controversy because it's very loud? I would say that it feels like here in Phoenix, it's about 25% of the state is just they're up in arms about water fluoridation, they don't want fluoride in the water and they don't want any amalgam in their mouth. Do you think amalgam or water fluoridation ... Do you think they're toxic or do you think they're good beneficial? What are your views on water fluoridation towards pediatric decay and amalgam?

Fred: Well, let's talk about water fluoridation first. The babies under age three, I have them use nursery water. The reason for it is there's no fluoride in that water, but after age three we introduce, and this is according the American Dental Association also, we introduce fluoride both little bit, half a pea size amount on the toothbrush, and fluoride water, fluoridated water.

Howard: What is nursery water?

Fred: Nursery water is bottled water that does not fluoride. 

Howard: Just reverse osmosis? 

Fred: I don't know how they do it, but there's no fluoride in it. All nursery water has no fluoride so we don't have to worry about that.

Howard: You're saying the American Academy of Pediatric Dentistry recommends no fluoridated water till age three?

Fred: Actually the ADA.

Howard: The American Dental Association.

Fred: Yeah, it use to be two then two and half, now three. Okay, so, as far as amalgam, I think amalgam is wonderful. I still have some in my mouth that are 40 years old. I think it's a wonderful material to use. In certain cases, we can ... In most cases, we can offer the white tooth called filling, resins, or amalgam. I like the amalgam for larger restorations that perhaps the patient can't afford a crown, but the amalgam is going to be stronger and last longer I feel than a composite. Gordon Christensen and everyone else has shown this. 

Now the other thing is when I got back from dental boot camp many years ago with Walter ...

Howard: Walter Haley.

Fred: Right, Walter Haley.

Howard: In Texas.

Fred: Steve Anderson, right, and we divided up our practice and half of us went one time of the year and the other half the other. When my partner at the time, George and I came back from dental boot camp, I said, "George, would you rather if were your child and if it was mild to moderate caries, would you rather have a composite or an amalgam in your child's mouth?" He said, "Composite." Here's what we started doing, informed consent, right? We tell the parents, "Mrs. Smith, we have two types of fillings. One is a silver amalgam filling, the other is a white tooth colored resin filling. Which would you rather have? The cost is the same." No difference in price so the parents 99% of the time will say I don't want metal in my child's mouth, I have a lot of those families or they'll say, yeah, let's go with the white filling, I think it will look nicer. 

Of course there's so companies as you know like Cosmo-Dent that came out with colored fillings for children called fun fill, they're composites. Now there's a company VOCO that has [inaudible 00:40:13] that are colored also. I've used those for years, but here's what I do. I don't ask the child first. I say to the parent, "We have colored fillings for the primary, the baby molars. If you would like, I can offer yellow, green, blue, purple to your child." They say, "No, lets stick with the white." Fine, because I don't want to get in the middle of that fight. 

Informed consent and you have something else to offer.

Howard: I want to ask you another controversial question on the message boards. Some dentists they hear patients ... I don't want to [inaudible 00:40:55] but they don't like formocresol. Some people believe that formocresol could be carcinogenic. What are your views on formocresol for a pulpotomy and do you think it's carcinogenic?

Fred: Yeah, I appreciate you ask. In my lectures, I have research, evidence based dentistry where they have taken teeth that had pulpotomies and measured the level of the blood afterwards and there was no evidence that the formocresol every got to the blood, but being the type of practice I have and the education level of the parents, a lot of them like I said are holistic, I had one mother call me up, this was about three year ago, and she said, "I know that my son's having general anesthesia with an anesthesiologist and I know you're going to do full mouth rehabilitation, and I know he's going to need root canal treatments on those primary incisors, I don't want any formocresol in his mouth." That's when I started to use Bio-Dent, biotin of course if for dry mouth, Bio-Dent bis

Howard, I have done non-vital primary molars and interiors with Bio-Dent and got 80% success or higher, but here's the caveat, and that is no internal or external resorption, and the parents are willing to bring the child back in two weeks, one month and two months for post op checks. If I'm at [Wyoma 00:42:50] university doing a hospital case with my residents and I may not see that patient again, well, if it's a non-vital tooth, that tooth's going to come out. If it's vital, we'll do a pulpotomy. 

It depends on your patient population and also I've had really good success with Bio-Dent. 

The other nice thing is I use the laser with it and I go into the orifice with the laser. Some dentist friends of mine, laser dentist will go into the canals, but I do pulpotomies with the laser and pulpectomies on the anteriors of primary teeth with the laser, because it's killing over 90% of the bacteria.

Howard: You're so good and thank you so much for spending time with me. I'm just going to keep going with even more controversial questions. On these general anesthesia cases, some ... It's mostly just dentistry or like an oral surgeon does anesthesia and removes the four wisdom teeth, but when you go into the hospitals, they always separate those skills. They say an anesthesiologist will do the anesthesia and the surgeon will do the surgery and most hospitals do not let you do the anesthesia and the surgery. Do you still see that common in the United States? What do you think of a pediatric dentist doing the sedation and during the full mouth in your office versus going to a hospital and having a board certified anesthesiologist do the anesthesia then you do the dentistry? 

Fred: I'm going to answer you in two ways.

Number one, we have two dentist anesthesiologists in Chicago. Mike [Higgins 00:44:35] and Zack [Massia 00:44:36] that go from office to office and they provide general anesthesia for the healthy patients, the ASA1 and 2s. They bring all the supplies, all the emergency equipment and so forth, but also in the state of Illinois as in many other states, I am licenses in the state of Illinois to do conscious sedation. I can use conscious sedation to sedate a patient, but I'm talking about I still do quadrant technique. In 45 minutes, I don't have time to do a while mouth, so I give the parents an alternative. If you want to try to conscious sedation first that's fine, sometimes we can just use nitrous oxide as sedation. We sometimes we use nitrous oxide and like [Madaslam Hurst 00:45:24] said I use with the children, and the parents are given all the instructions and go over everything and PO after midnight and so forth. We've been very, very successful with that, but as Dr. [Primosh 00:45:40] taught me from university of Florida when he came up and lectured to the Illinois Academy of Pediatric Dentistry, it's 80% effective. I tell the parents 80% of the time this is going to work. If it doesn't we can have the anesthesiologist come in.

Howard: I was going to ask ... Yeah, I have one of those two ... I'd like to podcast interview one of these dentist anesthesiologists.

Fred: Okay, I'll get you your names.

Howard: There's a few orig rams I know, university of Oregon health Science has a specialty program and I know they have been fighting for there's nine specialties by the ADA and they've been trying to get their own specialty.

Fred: Exactly.

Howard: Have you been following that? 

Fred: Yes, and Ohio State University, my Alma mater, they have an anesthesia program. In fact I went to school with the fellow who is head of the program and that's where Dr. Massia trained, one of the two in Chicago. 

Howard: They also ... I'm living in Phoenix for 28 years, I don't know who's crazier fans, Ohio State or Nebraska, because whenever they're in a bowl game in Tempe, the whole town turns their colors. I mean it's just oh my God, and 90% of the people that come don't even have a ticket to the game. The stadium only holds so many people, but my God are Ohio State big red football fans. They're just amazing.

Also, so, a dentist is listening this and he's probably hoping you put some online courses up, but to learn more also there's your website, dentaled.org. There's also two associations, WCLI, ALD, will you talk about those and what are those like and what if a dentist was going to join one, what's the difference between the two?

Fred: Okay, the WCLI which is the World Clinic Laser Institute is a Biolase run educational program. They have them throughout the world where they market and sell their lasers whereas the Academy of Laser Dentistry is all the laser companies including Biolase are represented. What's neat about their workshops that Dr. Cottenell and I have been giving is we've had all the different laser companies set up so that we can go from laser to laser and the students can try different lasers and say, gee, this one's faster, this one's slower, I like the hand piece better on this one and so forth and so on. 

Howard: You know what I actually like most about the lasers and this is kind of off the wall, but in all honestly is humans, they burn out, long careers, they fry, and when you trade time for money it leads to disease and depression and alcoholism and substance abuse and what I like the most about the lasers is if a dentist buys a toy and it makes them run 30 red lights on the way to work and get speeding tickets going to work and the people will come to me, you think I should get a laser? I always ask them the same question as you not what you would do with it, but what do you think? If they just sit there and go man, I just think it would be really, really cool. Then I'm like you have to get a laser, because you don't want to sit there and go into work and be bored. 

I always remember my four boys. You go put them in the sandbox or the swimming pool with no toys, they're out in ten minutes. You put them in the sandbox and you throw in the Tonka trucks and the pails and the shovels and all the toys and a garden hose with water and my God we'd be out there for six hours. Same thing with the swimming pool, even the bathtub. The more toys, the more fun it was and my gosh, I tell dentist, don't look at the price. If you think it's really cool and you think it'd be fun, well, that's going to be a ten time investment. Think about the dentist who burns out and sells their practice and becomes an alcoholic versus the one who loves going to work and states in it till the day they die.

When you look at the titans who built America, whether it be Rockefeller or Carnegie or Ford or any of these guys, they all worked 80 hour weeks until they dropped dead in their late 70s, 80s. I mean Rockefeller was 96. Sam Walton was found dead at his desk. France's President Menton was found dead at his desk. I mean these guys loved what they were doing until the last day. 

I think lasers are ... Like I say, psychology, human, if you love them and then the marketing, the unique selling proposition to be a laser dentist, that's just huge. 

Fred: You know, Howard, excuse me. I wanted to get this thought out, because this is exactly what you're stating. When I write my articles on laser dentistry, one of the things I emphasize is avoiding burnout. We had a laser dentist come from Indiana to take my certification course a couple years a go. He walked in and said, "Dr. Margolis, lasers have revolutionized my practice." I'm sure it's revolutionized him also. I get wonderful emails, "Oh, I did ten frenectomies and four quadrants of dentistry." The other nice thing is because the patient doesn't have the numb feeling, you can do multi-quadrants. Even though the laser costs more than the injection of local anesthetic, you can still sit there and do many quadrants and immediately. You don't have to wait three minutes or ten minutes or whatever.

Howard: Last year I had the most interesting guest in my seminar before. This dentist came up to me and he was old. He was 92, and he was actually in Auschwitz survivor and from Poland. I said, "you're still practicing at 92?" Guess what he said to me? He said, "You know when I turned 85, I thought I should retire, but then I upgraded my 2D Pano to 3D Cone-beam and started doing surgical guide and implants and I'd never placed an implant before and it's so damn fun." Here he is 7 years past, because he was going to retire at 85, and here he is 92 and said, "How many implants do you place a month?" He goes, "Not a lot, maybe 25 or 30." I'm like oh my god, this guy's 92 and he's in the top 1% of placing implants and he was so fire.

I think listening to him and I had lunch with, he probably got tired of all the fillings, the crowns, everything he'd been doing forever, but what was totally new to him now was 3D x-rays, surgical guided implants, he'd never done it so he was like a little boy again and he was just playing and my God, I don't think anybody in the room was having more fun in dentistry than a 92 year old man. I mean that's very important.

Another thing I want to talk about, on these certifications, Uncle Fred, is that something you do because it's a legal state mandatory thing or is this something that you recommend getting certified?

Fred: Every state has their own obviously dental practice acts. Let me give you an example. We had a pediatric laser dentist come from Las Vegas and in Nevada, the dental practice act says that you have to be certified according to the Academy of Laser Dentistry certification processes in order to use your laser. She bought her laser, it sat in the closet from October till March when she came and took my laser course, certification course, and then could take it out of the box and start using it. Every state has it's own requirement. 

In Illinois for example, hygienists can use the laser for non-surgical as I mentioned and I fly in, every November, I fly in a hygienist who teaches the Academy of Laser Dentistry and she's a general dentist practice, but she teaches the hygiene portion of the diode lasers while I do the hands on with the dentists for the diode. You have to check with your state or let me give you, and the listeners, the website for the Academy of Laser Dentistry which is laserdentistry.org. Very easy, and you can ask them which states are covered as far as the certification.

Howard: You're talking about lasers and you just mentioned hygienists so you have to finish the story. Everybody's hearing about perio and LANAP. Can you talk about LANAP? Can you explain what LANAP is and then tell us what your opinion is of it?

Fred: Okay, LANAP is a technique for the re-attachment of the gingival tissue, the attached gingiva to the surface of the tooth. LANAP is owned by, that phrase or acronym, is owned by a company called Millennium. They have a wonderful laser, but many periodontists tell me that they can do the LANAP procedure without having that particular laser. 

Howard: Is it an Erbium laser?

Fred: No, it's actually an ND-YAG.

Howard: An ND-YAG, okay.

Fred: Yeah, an ND-YAG, so it's 1064 nano-meters. Now, I don't want you and I to get sued so I will just say that the hearsay is that you can do LANAP procedures without having a Millennium. The dentist would have to do their own.

Howard: But does the Millennium laser work? I mean if you do LANAP and you used the Millennial laser and Erbium, you said, but do your periodontist friends think it does work though? I mean is that a viable treatment? Yes, in fact, I have a general dentist who's a member of our dental fraternity and she came and took my introductory course and then she went to Millennium and took their full course on LANAP procedures and she swears by it. In fact, I think she teaches for them now. It is viable. It is a real procedure and it does work.

Fred: You know why I'm not a member of any dental fraternities?

Howard: No.

Fred: Because I would never join a fraternity that would accept me as a member. Old Rodney Dangerfield joke right? He said he would never join a country club that would take him as a member. We're down to three minutes, so what would your close be? I want your close to be talk about your dentaled.org. Tell us if a dentist wanted to learn more, what is this dentist, he's driving to work right now, if she goes back to her office and logs on to dentaled.org, what's on that website? What is she going to see and how is she going to learn more about lasers on dentaled.org?

Howard: Okay, well, first of all it will offer under webcasts, it will offer the webcasts we've done. All of them, but one so far have been free. The one that wasn't free is $59 and that was sponsored last month by the Ontario Academy of General Dentistry. They're on various subjects anywhere from cosmetic dentistry, has nothing to do with lasers, to implants, to we had a PhD in bio materials as a speaker, as a webcast presenter, and I've given several of them myself on different areas of pediatric dentistry. Then we also have all my publications. You can download in a PDF file for example, I put my newest article that you were nice enough to have published, thank you, on class 2 composites and that's now on there. Anyone can go there and see the references and learn more about that particular subject.

We also have courses and the course schedule of where I'm going to be in the next year lecturing and how they can find more about us. We also have books and DVDs. We have DVDs on the laser procedures we just talked about that I had professionally made.

Fred: If dentists want to get certified, can he just fly to Uncle Fred's office in Chicago?

Howard: Yes.

Fred: Or do you recommend you go to their office?

Howard: No, they come here.

Fred: They come there?

Howard: Because some of the lasers I can't transport they're so big. Right, is that a three hour program? A one day? A two day? How long does it take to get certified?

Fred: The introductory course that's recommended by the Academy of Laser Dentistry is three hours minimal. I give a three hour course as an intro course, but they can bypass that by reading articles that I will assign them on laser dentistry and then take the 12 hour certification course. That's the minimum, 12 hours. 

What we do is we do an all day Friday and half a day Saturday and then they can fly home Saturday afternoon or spend the weekend in Chicago.

Howard: How many Chicago style hot dogs do you get to eat during that course?

Fred: As many as you want.

Howard: When I think of Chicago, I just think of their Chicago style hot dogs. I also love the debate whenever you go into a Chicago pizzeria or a New York pizzeria and how those guys are playing for blood on who has the best pizza. Chicago or New York?

Fred: Right.

Howard: That was just an amazing hour, and so the last ... I only got you for 20 more seconds. Just your final close, why should this lady driving to work right now buy a laser? She's a general dentist in Oklahoma City and she's got out of dental school five years ago, she's 30 years old, why should she get into lasers?

Fred: All right, number one, practice differentiation i.e. marketing. Number two, avoid burnout. Number three, no trauma psychologically on our part because we can use the laser for laser analgesia. Number four, greater earnings. When I started using the laser, we started charging more for hard tissue for cavity preparation. It was that or raise or my fee, but if I raised my fee then it's not competitive with the others. We have a sheet that we hand out explaining the laser and it is not covered by insurance and we would charge a nominal fee for appointment for use of the laser for hard tissue. For soft tissue, Howard, I've been a laser dentist now for almost 15 years, I've never had to place a PerioPeak. Once in awhile if I'm doing deep a mucous seal or orunmila excision I'll put in a suture but that's very rare. 

So saves time, saves money, earns money, more fun, and I want to close by telling you that the mothers that have the babies, they can't nurse or can't take a bottle because they're lip-tied or tongue-tied in three minutes procedures done, little or no bleeding and they can breast feed right away. That's another way to grow your practice.

Howard: That was an awesome close and I want to throw in a close for me and my close is that in my journey, got out of school in '87. It was 1998, I was having these arguments with some of my dental friends in my zip code that electric surges cause a lot of post operative discomfort and they were saying that they never experienced that. I kept thinking I was doing the electric surge wrong, I needed more water, different settings. I bought another electric surge, a different type, because my friend had a different type and I kept getting it. One day I was taking him out for lunch and I was telling him that in his waiting room and his receptionist says, "Well, we get a ton of post operative. We get a ton. They're always calling for refills on their pain meds." 

But by the time that dentist saw them two weeks later for a crown seat, it had stopped, and what I realized the problem was that the receptionist when a patient's calling and they didn't have time to go pull a chart and make an entry, the friend called and said that tissue you burned off with electric surge hurt like hell and wanted to know if he could get a refill on his pain med or anything like that. I went back and thought I wonder how many conversations are not being entered at the receptionist and I told them from '87 to '99 every time a patient calls you have to pull the chart and enter the note. When I see this patient again, I need to see what's going on and logistically it just couldn't happen. The only way I solved it in 1999, I threw out all my charts and went paperless, because if Fred Margolis called up I could just enter Fred Margolis and I can enter the note.

I realized it was so crucial to digitally capture these on going communications, because my outstanding dentist friends with great hearts and minds and souls just absolutely were oblivious that this was an issue, because nobody was pulling a chart and saying, "Hey, that guy you did, that hurts like hell. That was a lot of pain." 

On that note, we are out of time. Fred, it was an hour that you spent an hour with me. You're a legendary career. Congratulations on your award and I hope to see you put up a course someday on Dental Town or start a post with your handouts or whatever. That would be amazing.

Fred: That would be my pleasure, and thank you, Howard, for your time and efforts.

Howard: All right, have a great day.

Fred: You to.

Howard: Bye-bye.