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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Howard:

It is a huge honor today to be interviewing Bethany ... let me see if I got this right ... Valachi, who has the website posturedontics.com. That's P-O-S-T-U-R-E-dontics.com. The reason I wanted to get you is because not only I heard amazing things about you for a long time, but you like to talk about preventing low back pain in dentistry. It's not just that I'm 53, so all my old, fat friends happen to have lower back problems.

I see kids out of school. I got a very good friend who's only been out of school three years, and he just bought a microscope because he wants to look straight into the microscope because his lower back is just killing him, and he's a puppy. He's not even 30. I think he's 28 years old, and he's worried about that he won't be able to practice as long as I have. So, I want to ask you: What's worse? Lower back pain, or marrying a dentist?

Bethany:

Well, since my husband is going to be watching this. No. The way I got into this, actually, Howard, was that at the age of 35, my husband was forced to contemplate selling his dental practice due to severe low back pain. He was going to have to retire from the field of dentistry. So this was a very sobering thing for both of us, and by implementing ergonomic strategies, very specific exercises, due to the unique muscle imbalances to which dentists are prone, by those few things, his back pain completely resolved. Eighteen years later, he's practicing dentistry with no low back pain.

Howard:

Well, then what did you do? You're going to have to tell us the secret recipe. Or do we have to go to posturedontics.com? What is on posturedontics.com?

Bethany:

Posturedontics.com just has a lot of dental ergonomic education and resources. It's filled with articles, DVDs, books that I've written on how to prevent work-related pain in dentistry through not only proper equipment adjustment, but very specific exercise. A lot of dentists hire a personal trainer, and they give them exercises that aren't a problem for the general public, but for dentists, it will throw them into the vicious pain cycle. Not many dentists realize this.

Howard:

You pointed this out to me first back in 2005, when you did the Dentaltown continue education course "Preventing Lower Back Pain in Dentistry". Is that course still pretty much a gold standard, or has a lot changed from 2005 to 2016?

Bethany:

The ergonomic concepts are still the same. However, the available equipment, operator stools, that are available now have changed slightly, and there are some nicer, newer options since 2005. Also, the research on exercises that help prevent low back pain in dentistry have changed since 2005. I have the very newest exercises to help dentists prevent low back pain in my newest DVD, "Home Exercise for the Dental Profession".

Howard:

Hold it up again. "On The Ball Home Exercises: Help Prevent Pain and Work More Comfortably with Research-Based Exercise by Bethany Valachi, PT, MS, CEAS, with Jonathan Erhardt." Email me a jpeg of that, and I'll post it on ... I can put it in front of 300,000 dentists with Dentaltown, Facebook, Twitter, LinkedIn, Pinterest, all that kind of stuff. When did that come out?

Bethany:

The latest was 2012. This is all...

Howard:

That's a DVD?

Bethany:

It's a DVD; 24 exercises to help dental professionals prevent neck pain, low back pain, and, Howard, this is not just random exercises. This is all evidence-based. I spent three years researching the specific exercises that would help correct the muscle imbalances and prevent pain in dental professionals. It's based on a very specific muscle imbalance that dentists are prone to. One of them is in the neck and shoulder muscles.

You see here that these are the primary shoulder girdle stabilizers, the middle and lower traps, but these become very weak in dental professionals. Down here, this is the compensation that occurs, and every dentist will relate to this. The upper traps get hard, and tight, and painful levator scapulae. So, this is just a correction of these muscle imbalances that aren't a problem for the general public.

Howard:

How much is that DVD, and how long is it? How much is it?

Bethany:

The DVD, again, it's three complete exercise routines, 24 exercises. It comes with a Swiss ball, exercise bands, door anchors, exercise cue cards that have all the exercises on both sides, and the DVD runs an hour and a half. It's $127 for the complete kit that includes the exercise ball and both the exercise bands, all the materials, for $127. However, if you go on the website, this month there is a special for $20 off, so it's $107.

Howard:

That's at posturedontics.com?

Bethany:

Correct.

Howard:

You can do all of these exercises while sitting at the bar at the Waffle House?

Bethany:

It would be nice, wouldn't it?

Howard:

Or would you have to go to the iHop to do this?

Bethany:

So, the nice thing about this, Howard, is you can complete these exercises in your home, which is nice because a lot of us ... It's hard to go to the gym everyday. Weather constraints, time constraints. It's nice to be able to have all of your equipment that you can correct all these imbalances in the comfort of your own home. The exercise ball, a couple of exercise bands, and the door anchor, and you've got it.

Howard:

When you say ... Necessity is the mother of invention, so your heart and soul got poured into this because your lover, your husband ... This was an issue. Is this an issue mostly for dentists, or is it the same for a hygienist and assistants and anyone in clinical?

Bethany:

It is very similar for hygienists and dentists. However, assistants develop a slightly different muscle imbalance due to their challenges chair-side ... Their positional challenges chair-side, where they are slightly rotated, slightly leaning to one side, so they actually develop very different imbalances, and that's a whole other lecture altogether. I have seven different lectures, so ...

Howard:

Well, you know what? Your course in 2005 was just amazing. If you ever want to redo that, take it down, update it, or different lengths, whatever, I would love it, because I know it's a plague in dentistry. I also think that the young dentists ... Most dentists listening to my podcast are 30 and under. I think they always think a disability is from a one-time acute thing like a car wreck. They skied into tree. They think of it as like that, but mostly your disabilities aren't from a car wreck or falling off the roof or anything. It's these long term ... It's kind of like in business, they say, "If you want to change something big, you've got to change something small every single day for years and years and decades, and ... "

Bethany:

Yeah. You hit the nail on the head, because it is that every single day that prolongs static posturing, chair-side, that just causes this micro trauma that builds and builds and builds, and it's the micro trauma that you don't even feel happening day in and day out until the micro trauma has accumulated to such a point that you have the painful episode, and by then, structural damage has occurred, and so it is tempting these young grads from dental school to feel invincible, because they're not having the pain. Well there's a parallel here, because if your patient isn't having pain, is there nothing wrong? No. Every dentist knows that structural damage can be happening even though the patient isn't having pain. That's why you advocate prevention.

It's the same concept in managing your musculoskeletal health. You've got to be implementing these things hopefully before the painful episode, but even then, a lot can be done to reverse and correct and eliminate work related pain in dentistry. It doesn't have to be a consequence. Work related pain does not have to be a consequence of dentistry, but so many people experience this that they just accept it passively as a byproduct of dentistry, and some doctors even wear it like a badge of honor on their sleeve like, "I had a surgical infusion in my neck," and anyway, it's not something that needs to be.

Howard:

Bethany, when I was a kid, and I used to go in in high school, visiting dentists because I wanted to be a dentist, they were all ... Two guys were sitting down, and six were standing up, so it was ... Really, I can say in the '60s and '70s, dentistry, it was a stand-up profession. One of my friends, Dr. [Paltzar 00:10:51], who practiced right by our church and high school, he didn't even have a stool for him to sit on. Everything was done stand-up, and now it's all sit-down. What was better? Stand-up in the '50s and 60's or sit-down in modern day?

Bethany:

That's a great question. When doctors stood, about a third of them reported low back pain and hip and knee pain, as well. In the 1960s, they sat the team members down to increase efficiency and productivity, and we have exactly the same ... Excuse me, two out of three doctors complained of low back pain, so today, we still have two out of three doctors complaining of low back pain when they're seated, so ...

Howard:

When it was stand-up, it was one out of three complained, or ... ?

Bethany:

No, I'm sorry, I misspoke. It's two out of three doctors.

Howard:

It didn't change?

Bethany:

It didn't ...

Howard:

Two out of three complained with stand-up, and two out of three complained with sit-down, which would explain the assistant having issues, because a lot of assistants, when I go into dental offices, it seemed like the doctor is sitting, but ... I don't know what the percent would be, but a lot of assistants stand up, especially during some procedures like extraction and placing implants, surgeries.

Bethany:

That's one of the best things that you can do for your assistant for their career longevity is to have them alternate between standing and sitting, and it's also based on the research. A doctor in Israel did a great study that compared doctors who sat all day to treat their patients, and then doctors who alternated between standing and sitting to treat their patients. They found that doctors who alternated between standing and sitting had significantly less low back pain than the doctors who sat all day.

Howard:

What I heard you say is when you go to a bar, you should sit on a stool for the odd beers and stand next to the stool during the even beers. Is that what you just said?

Bethany:

That's right. [inaudible 00:12:49]

Howard:

Talk about chairs. When I got out of school in 1987, all dental chairs were pretty much the same. I don't even know if they had more than one model. You basically picked your chair based on the color of the vinyl. That was your only option, was color. Now, when you go to dental conventions, there's all these fancy chairs. Some of them look like you're mounting a horse on a saddle. Some of them are triangular. What do you think about all these chair technologies? Is that part of the solution?

Bethany:

It is. It is part of the solution, Howard, and it's very important that you're selecting an ergonomic stool but also that you're adjusting it correctly. For instance, up to twenty or so years ago, operator stools didn't even tilt, and studies show that the best positioning for an operator is with a lightly tilted seat pan that angles downward. A slightly tilted seat pan.

Howard:

That was written by your husband?

Bethany:

By me.

Howard:

It says "Keith."

Bethany:

Oh, okay, by me and my husband.

Howard:

Oh. Keith and Bethany. Okay. I'm sorry.

Bethany:

Compare that to this, ...

Howard:

Oh, nice picture [crosstalk 00:14:01] ...

Bethany:

... and you can see, that is a flat seat pan, and you see what the flat seat pan does to the lumbar curve. It flattens it. Right? Angling the seat pan slightly down enables a much more natural curve of the low back. We want to angle the seat pan down, but the reason for these saddle stools is it enables actually the only way to practice dentistry in a completely neutral posture, because it lifts your pelvis in a neutral position, and the spine naturally balances on a neutral pelvis. That's one of the seating options that I advocate very strongly, is a saddle type stool, or a ...

Howard:

You recommend a saddle type stool, so ... Is that what you just said?

Bethany:

I do, but remember that a saddle stool, you don't want to tilt forward or backward because it already has you in a neutral position, so you just leave it flat. I would also tell some men who trial different saddles, some of them are going to be uncomfortable on a saddle stool just for gender reasons. There's different types of saddles. Some have splits in the middle. Some have a lot of cushioning, which is what my husband likes, so trial some different saddles. Don't just trial one and think that's it, because there are many different contours and shapes and padding of saddles, so just try several.

Howard:

Then, is it safe to say, if you're sitting in a chair ... Old school, there would be a back support. You would think that's good. You would sit on a flat stool and have some back support, but you're saying the research, actually, better. Take away that back support, and sit on a saddle. Is that what you're saying?

Bethany:

Probably the ideal combination is a saddle with a back rest so you can rest the lumbar muscles, but again, as I said, the reason that stools have a back support is to reinforce the lumbar curve, because we know the lumbar curves when you sit on a flat seat. With a saddle, the pelvis is in a neutral position, and you already have a low back curve, so it doesn't need to be reinforced. It's already there.

Howard:

Sometimes, you go in these dental offices. When this ... I don't want to call it a fad, but when this new, emerging technology started coming out, starting about ten years ago, if you went into twenty dental offices, one girl would be sitting on a ball. That was kind of crazy, because when she stood up and rolling all over the place, so now I see it's even more common now. I'd say now, instead of one to twenty, I'd say it's maybe on in ten offices, you see the girl, and she's got a ball that's sitting in a rack on four wheels, so it kind of has the rolling of a chair, but she's sitting on a ball. What do you think of sitting on a ball?

Bethany:

Well, the balls ...

Howard:

Are you sitting on a ball now?

Bethany:

I'm not sitting on a ball, but the ball ... From a physical therapy standpoint, the ball has many great advantages for training the [inaudible 00:17:31] and that, but that's when you're using it as an exercise tool. When you're using it chair side, and you're just sitting on it, and it's fixed, it doesn't have quite that benefit that you do when you exercise with it, and that's the misperception is that the ball is doing these benefits for you when you sit on it as you do when you exercise on it. Here's what we found because my ...

Howard:

You're saying when they're selling this stuff that they're using research from the ball being used as exercise, but there's not really exercise, but there's not really research showing it as when you're using it as sitting at your cubicle?

Bethany:

Really, there have been studies that show both, Howard. There have been studies that show that the exercise ball used when it's as a chair ... There have been those that show that it's not more beneficial than a regular chair, and there's also been studies that show it does have some benefits, so quite honestly, the jury's still out. In dentistry, I want to just share that we evaluate dental products. Manufacturers send us these for ergonomic evaluation, and what we found is that operators typically over 5'6", the extenders on the legs don't go high enough to sit with the thighs sloping slightly downward which is where we need to be high enough so that the thighs are sloping slightly downward.

The other problem with the exercise ball is ... very difficult to get into the 12 o'clock position. If you can't get into the 12 o'clock position, forget it, because you're ergonomically going to be challenged reaching over the patient's chest, reaching over the head, and ... Those are the two problems I've seen. The two instances that I've seen the ball chair work really well in an office are in an orthopedo office in the big bay where they can just scoot from patient to patient to patient, and they can easily get into that 12 o'clock position, and usually, the patients aren't positioned quite as high, and the front office.

Howard:

You're saying, the 12 o'clock position, that's when you're looking straight down the spine, that the patient's head is in your lap. You're saying that's a better position?

Bethany:

It is.

Howard:

To do your clinical dentistry?

Bethany:

Yes. Yes. In the 10 o'clock position, you're reaching over a chest or over a forehead. In the 12 o'clock position, you can be positioned with the arms relaxed neutrally at the sides. The reason that most doctors don't go there, into the 12 o'clock position, is because they haven't learned how to properly position the patient and how to gain control of the occlusal plane. What I mean by that is I've seen the worst postures repeatedly when doctors and hygienists are working on the upper arch. If the upper arch isn't positioned behind the vertical, and what I mean by that ...

This is an exercise I do with my dental students at the university, and we position for maybe the occlusal of number three, and I ask them to position the patient and then place their mirror handle on the occlusal plane of the upper arch, and they place the mirror handle on the occlusal plane, and it needs to be about 20 to 25 degrees behind the vertical in order for them to visualize in their mirror without leaning forward over the patient. That is the problem. Most people, in order to get the occlusal plane behind the vertical this far, they have to really recline the patient far, and the patient's ... "Oh my God, they're gonna freak out. They're going to not enjoy coming here," and this is where proper positioning comes in. You've got to have a neck cushion that enables that positioning comfortably for the patient.

Howard:

I first noticed my posture wasn't right when I started developing cauliflower ears just from doing endo. I knew my head was in the wrong position.

I want to talk you about another thing. Old guys, they're talking around, and one of the dentists is complaining about lower back pain. One of the other dentists will reach over and grab his fat belly. Mine's been grabbed by several dentists, said, "That's the reason you're having lower back pain." They grab my belly. How much of this is posture, and how much of this is having a big, fat belly?

Bethany:

Excellent question. For every ten ...

Howard:

You were too polite to bring it up. You said, "I'm not going to bring this up. I might offend fat ass," but what is the answer to that question?

Bethany:

For every ten pounds of excess abdominal that you carry, it translates to 100 pounds of force in the low back. Every ten pounds of excess poundage in the abdominal region translates to 100 pounds of excess force in the low back. This is why we see so many pregnant women in the physical therapy clinic with low back pain.

Howard:

You just made my day because I feel manly that I'm carrying 500 pounds of extra force. I have to be a really manly man to be able to ...

Bethany:

That's pretty good.

Howard:

This is geometry, then. This is leverage. The weight versus the distance ... This is leverage, what you're talking about?

Bethany:

Uh-huh (affirmative). Bio-mechanics. Leverage. Bio-mechanics. Physics. Yeah.

Howard:

What percent of these dentists ... When you say one third of the dentists are complaining about lower back ... Tell them you're the expert with posturedontics.com, what percent of your clients, dentists, that worked with over the decades, have you said, "A big part of this is you just need to lose some weight"?

Bethany:

I've said that to some. I do in-office consultations, and when I do these consultations, you tell it like it is, but usually, in addition to losing weight, there's so many other things that need to be addressed. Usually, it's the big four. It's their doing the wrong exercise or no exercise. They have loops that cause them to go into a forward head posture.

Howard:

I know.

Bethany:

Their non-ergonomic loop create pain, and this is what people don't talk about either. They're positioning the patient incorrectly, or they are sitting too low in relation ...

Howard:

The four again ... Number one was what?

Bethany:

The wrong type of exercise.

Howard:

Wrong exercise. Number two was ... ?

Bethany:

Non-ergonomic loops.

Howard:

Loops. Number three?

Bethany:

Poor patient positioning.

Howard:

Patient position. Number four?

Bethany:

Sitting too low?

Howard:

That would be doctor position?

Bethany:

Doctor position, sitting ...

Howard:

Doctor position. Well, it's sad. Everything has a trade off. Since I got out of school until now, one of the most recommended ways to improve the quality of your dentistry is to improve the magnification, so you start with loops and two and a half. Then you go to three and a half or 3.8 or 4.5, and now the endodontists are all using microscopes where they can go 7x, 10x, 15x, but I've noticed that as I went from two and a half loops to 3.8 to 4.5, that's a quarter pound of something sitting on the front of your head, and it does. You do that, and you feel that in the back of your neck.

Bethany:

There's two reasons for that, Howard, and you've nailed one of them, that the [lumbaral 00:25:51] scopes are heavier than the shorter scopes, but also, it's harder to mount a scope with a good declination angle, and let me show you ... A steep declination angle like this, it's hard to mount it steeply to enable a good head posture with long barrels. With long barrel loops, we end up compromising, and they can only mount them this steeply. Does that make sense?

Howard:

That makes very good sense.

Bethany:

You can imagine, if they're not mounted steeply, you're forced into a forward head posture, and then that just exponentially increases the forces on the cervical discs, and this is why if you really want to opt for high magnification, you need to opt for flip-ups. You can see how steeply these are angled downward. Right?

Howard:

Right.

Bethany:

The more steeply that the scope is angled downward, you can have a more neutral posture.

Howard:

Who are the main loop makers, and who makes this, what do you call it, flip, flip ... ?

Bethany:

The flip-up loops?

Howard:

Flip-up loops. Who is making the flip-up loops?

Bethany:

One of the leaders in the industry is SurgiTel. It's important to realize that not only do you need a steep declination angle, but it needs to be [inaudible 00:27:26] adjustable. If the scope is sitting up here in relation to your pupil, you're going to have to lean forward to see through it. People don't realize this, and so they buy these cheap Chinese knockoffs through the mail where the scope is sitting way up here. Let me see if I can move it. Is sitting way up here, and so they have to learn forward just to see through it. SurgiTel created this little slide so that you can slide the scope lower in relation to your pupil so that you can optimize the declination angle. Q-Optics also has a good flip-up with steep [crosstalk 00:28:14] ...

Howard:

Who does?

Bethany:

Q-Optics. SurgiTel ...

Howard:

How do you spell Q-Optics?

Bethany:

Q dash O-P-T-I-C-S.

Howard:

Okay. Do you work with SurgiTel?

Bethany:

They do sponsor some of my seminars, but it's important to me, Howard, that I ... Since my lectures are entirely evidence-based and unbiased, it's important to me that I don't take money directly from a manufacturer, so everything that's financially arranged is between the manufacturer and any dental organization that I lecture for. I try to keep this very unbiased because I think it compromises the message.

Howard:

They're out of Ann Arbor, Michigan, SurgiTel.

Bethany:

Yep.

Howard:

Who are the other big loop makers?

Bethany:

Are you talking about ergonomic or non-ergonomic?

Howard:

Non-ergonomic.

Bethany:

How about we just talk about ergonomic?

Howard:

Okay. Because I think that the other players, they need to go back to the drawing board, at least with weight. But you're saying angulation. I was thinking weight. It's just too much, and then you strap a light on your head. I've got these long Oscar Meyer Weiners hanging off my eyeballs and a light on my head, and then I'm sitting there having to go to Yoga every morning. I have to get up at 5:00 to be at class at 5:30 because if I start laying off [inaudible 00:29:48] from Yoga, my neck is jacked. My shoulders are jacked. My traps are ... I also notice this. In some procedures, like a filling or an exam, like wisdom teeth. I haven't spent ten minutes out all four wisdom teeth in probably a decade. Usually, my time is one minute a tooth, but when I sit down and do a root canal, holy crap. One hour of holding that position could jack up.

Bethany:

Mm-hmm (affirmative). Yeah.

Howard:

You're not going to take off your loops because you know you can't do a good job if you can't see what you're ... You don't want to be known as the Stevie Wonder dentist of Phoenix, so it's a quality health compromise. We're trying to do a good job, so we're wearing ... That's interesting to me, because you just [edumucated 00:30:44] me. I thought it was the weight, but you were saying it's ... Is it more weight or is it more the angle?

Bethany:

I would ...

Howard:

Or is it both?

Bethany:

Coming from a physical therapy, bio-mechanical perspective and what I've seen clinically in my outcomes from my consultations, I would say 90% of the problem in loops among dental professionals is they don't have a steep enough declination angle, and it's causing excessive forward head posture. Studies have been done that showed that forward head postures that are greater than twenty degrees are significantly associated with neck pain, and I see it all the time in my consultations.

Howard:

Go through all your initials, end of your name, because if you're listening, this woman knows what she's talking about. I first saw her course eleven years ago on Dentaltown, but you're a PT, so you're a physical therapist.

Bethany:

Mm-hmm (affirmative).

Howard:

The MS is the masters in science?

Bethany:

Right.

Howard:

What's the CEAS?

Bethany:

Certified Ergonomic Assessment Specialists, and I'm ...

Howard:

I'm sorry ... Go ahead.

Bethany:

I'm currently in a doctorate program, and I'll be graduating in summer. That will be coming up. [crosstalk 00:32:09]

Howard:

Well, congratulations on that, Bethany. You and your husband will both be doctors. In fact, I'm sorry. I didn't even read your bio at the beginning.

Bethany is author of the book Practice Dentistry Pain-Free: Evidence-Based Strategies to Prevent Pain and Extend Your Career and clinical instructor of ergonomics at OHSU School of Dentistry in Portland, Oregon, a physical therapist who has worked exclusively with dental professionals for over 15 years. She is recognized internationally as an expert in dental ergonomics, has been invited and lectured over 400 conferences worldwide including Dubai, Poland, Belgium, Ireland, Jamaica. She has published more than 50 articles in peer reviewed dental journals and has developed patient positioning and exercise DVDs specifically for dental professionals. She offers free newsletters, articles, videos, product reviews on her website at posturedontics.com.

I loved the lecturing in all those places. Jamaica, that's probably the most beautiful one on that list, huh? Is is not?

Bethany:

It was gorgeous.

Howard:

It's just Jamaican me crazy just thinking about it. What would you recommend with loops right now? You've got a young kid. He's in school. These podcasts are devoured by dental students. What should they buy?

Bethany:

At our school, we have started limiting the benders that are allowed to come to our school and so, loops. We have narrowed it down to four vendors. The only ones that consistently sell ergonomic loops that will keep the students in that same zero to 20 degree forward head posture. The students are ... I tell them these are all flip-up loops. They're all flip-ups ...

Howard:

They all have to be flip-up.

Bethany:

There are only four manufacturers.

Howard:

Who are they?

Bethany:

They are SurgiTel, Q-Optics, HEINE ...

Howard:

SurgiTel. Q dash Optics.

Bethany:

HEINE, ...

Howard:

Spell that.

Bethany:

... and there's only one flip-up loop by HEINE that we recommend.

Howard:

How do you spell HEINE?

Bethany:

H-E-I-N-E.

Howard:

H-E-I-N-E.

Bethany:

Mm-hmm (affirmative).

Howard:

That's almost Heinz Ketchup, but it's HEINE.

Bethany:

Right.

Howard:

H-E-I-N-E.

Bethany:

And Zeiss.

Howard:

Zeiss, the German company.

Bethany:

Correct.

Howard:

I swear to God, when I see a dentist that spends all their money on a Porsche, I'm thinking, "Dude, if you would have got a Zeiss microscope, you almost think you're on an Apollo mission landing on the moon." Those Germans can over-engineer anything, and their microscope is ... What are the difference in prices of these? Is there any big variance in price? What ...

Bethany:

There shouldn't be a huge variance among those four. They're all between $1000 and $1500 or so.

Howard:

For OSH ... What is it, Oregon Health Science University?

Bethany:

Right. Uh-huh (affirmative).

Howard:

For Portland, Oregon's dental school, is wearing loops in lab or clinic mandatory ... ?

Bethany:

Yeah.

Howard:

... or just recommended ... ? It's mandatory?

Bethany:

It is mandatory.

Howard:

For undergraduate lab work on a mannequin or for patients or ... ?

Bethany:

Both. The first year, actually, within about three weeks, we introduce ergonomics, and I give the magnification lecture on how to select the right type of magnification that will improve your health and not make it worse, and ...

Howard:

Oh my God. I'd love to have that on Dentaltown just to piss off all my advertisers.

Bethany:

Yeah. Well, we could do that.

Howard:

That's [inaudible 00:36:04] Dentaltown and so many others is the fact that I just simply don't care. My sales team that sells advertisements in our magazine and website, they say that I am the anti-salesman. They say, "The things you say, the members you piss off," but if you want to put that course on Dentaltown, I'd be honored.

Bethany:

I would love to do that [crosstalk 00:36:25] ...

Howard:

Do you want to redo your 2005, or do you just want to leave that one there and add more?

Bethany:

I think it would be a good idea to ... Because we don't talk at all about neck pain and magnification at all in the low back pain course, I think it we be good to do one on magnification, and how does properly select magnification and ...

Howard:

I've never even heard of Q- ... I've been a dentist for twenty years. I've never even heard of Q-Optics or HEINE.

Bethany:

Oh.

Howard:

SurgiTel and Zeiss are big brands, but where's Q-Optics out of?

Bethany:

They're out of Texas.

Howard:

Texas. Where's HEINE?

Bethany:

HEINE, I'm not sure, to tell you the truth.

Howard:

HEINE. That's a weird name. It looks like Heinz, but it's HEINE.

Bethany:

Right.

Howard:

They're all about $1000 to $1500. When I was in school, we thought our dean was insane because he made us wear ... Our class, we had to wear gloves during lab because that was ... I was a freshman in 1984, and we had to wear gloves in lab. They'd sweat and all that, but it was really neat, because I never got to do dentistry with my hands. It was all I knew, and you're doing that with the students. You're just going to use magnification out of the gate. We're not going to just let you learn all these bad habits, and then you self-correct ten years out of school. I think that's amazing.

Bethany:

We learn them first on the mannequin and gaining control of the occlusal plane on the mannequin, and then we have another lecture, the DS2, the second year, we have a different lecture. DS3s have a different yet in ergonomic lecture, in practicum with live patients. On the last year, the dental students have a lecture on all of their ergonomic challenges and decisions they're going to have to make when they buy a new practice, are they going to buy a practice with equipment that worsens their health or does it improve their health? It's very important that these dental students, by the time they're, know, which delivery systems are going to be best for their health, how to adjust the delivery system, how to position their assistant, how to position themselves, how to position a flat head rest, first as a double articulating head rest, and it just goes on and on. My standard lecture is six hours.

Howard:

How could we get you to put the whole thing up on Dentaltown? I'm serious. Some of these guys like Carl Misch, puts up an implant course. His was four hours. Some of these lectures we do are six hours.

Bethany:

We can talk.

Howard:

Yeah. Yeah. We can talk, and we sell them at different prices. Some people charge $18 for a course. Some of them charge $400, so I think people would pay bank for your information just because there's a lot of pain. In fact, what do you think ... If someone just said to you, "What are the top three most common ergonomic mistakes that lead to pain and injury?" What would you say?

Bethany:

The three most common ergonomic mistakes, again, are the buying non-ergonomic loops and being poorly positioned, not getting the occlusal plane of upper arch behind the vertical, and not sitting in the 12 o'clock position for about 70% of the time.

Howard:

See, I'm messing up with all those, because I have the 3.8 hot dog things, and I redid my whole dental office. I opened in '87, then I remodeled in '94, then I just did it again two years, and they designed these beautiful operatories, but I can't get 12 o'clock, because of the cabinets they put in there.

Bethany:

Oh.

Howard:

I know. It's so sad. If I would have known ... I spent several hundred thousand dollars redoing all my operatories, and of course, my staff's picking out all this cabinetry and all this stuff. It looks gorgeous, but then when I went in there, the first minute, I'm like, "Are you shitting me? I can't get 12 o'clock?"

Bethany:

Yeah. Now, depending on who installed your chairs, if they're smart, they would have given you a nice space between the base of the chair the electrical box or the floor plug where it plugs in so you can scoop the chair down, away from the counter. The other thing you can do, and usually, I end up doing both of these things in ergonomic consultations where there's not 22 to 24 inches of clearance between the end of the patient chair and counter, is we scoot the patient chair down towards the foot of the chair towards the electrical box, and we rotate the patient chair about 20 degrees or so, and then most of the team can get into that 12 o'clock position.

Howard:

I want to see one of the ... So much of what we do, like when kids tell you what food they like, "Well, you don't like that food." When you tell me what your favorite foods are, I can just tell you what country you were born in. You know what I mean? You think it's good food, but it's just because you were born in that country. They stuck it in your mouth when you were little. Like in India, they love curry, all the stuff like that.

Dentistry, we spend a third of our lives, 40 hours out of 168 hours, so a quarter of our lives in these operatories, and they design them like 10 by 11, and the smartest in my class, Bryan Neuwirth, when he built his dental office, he said, "Well shit, if I'm going to spend 25% of my life in this operatory," he built all of his rooms 20 by 20. Someone could carry in a La-Z-Boy in one of those rooms, and he's got big counters and all this stuff. I thought, "God, I'm out in the middle of Arizona. You leave Phoenix, and it's nine hours and nothing to Albuquerque. It's six hours and nothing to LA. Go straight north, it's twelve hours of absolutely nothing to Salt Lake City. Why in the hell did I design a dental operatory that's 10 foot by 8 foot or 10 by 12?"

So I think all the operatories should just be hugely bigger, and then number 2, I've never seen a dental office who, after they designed it and built it and opened it up, where within three to five years, are kicking themselves in the teeth wishing they would have built it better, bigger. More operatories, more everything. We just think with our brakes on and fearing. These tiny little offices, and we rented the 1000 square feet instead of the 5000 square feet.

Bethany:

You know, Howard, the other thing is it's not even the size. Some of the best ergonomic operatories are very small, but they're built wisely, because, quite frankly, you really don't want a really wide operatory so that you have to leave the patient and reach long distances to your equipment. You want to be able to have everything close by, but it needs to be strategically placed.

Howard:

All I heard you say, Bethany, was size doesn't matter, and we're just going with that. We're just going to have a size does not matter. No, I'm just kidding. Go on.

You're saying it's not the 20 by 20. It's that what you do is correct.

Bethany:

Exactly. How it's designed ...

Howard:

The main things again, the top three would be the angle of the loops. The loops is a big issue, and you want them flip-ups so that they can look down at a better angle. The number two was the patient position, and you want them at 12 o'clock.

Bethany:

Operator position at 12 o'clock.

Howard:

The dentist operator at 12 o'clock.

Bethany:

Right.

Howard:

Then the patient position, you want their head leaned back so their maxillary arch is behind the vertical arch.

Bethany:

Right. When I say operator in 12 o'clock position, of course, there's going to be times when you're going to need to be in the 9 or 10 o'clock. For the lingual of number 19 or something, you're going to need to be in the 9 or 10 o'clock for some of those, but I'm saying you should strive for up to 70% of the time delivering dentistry from the 12 o'clock position. You can do that most of the time if you have control of that occlusal plane, especially treating the upper arch.

Howard:

What do you do when you walk by and Keith is in the wrong position? Do you have a frying pan, and you smack him upside the head, or do you just pull the chair out from underneath him?

Bethany:

Do you know what's the most powerful thing? Is taking a picture.

Howard:

Oh yeah.

Bethany:

I'll tell you. A picture is worth a thousand words. You take a picture, and I'm not kidding, in my consults, almost every team member says, "Wow. I didn't know I sat like that." It's just a big A-Ha mom- ...

Howard:

Ah! You should write an article for Dentaltown and call it, "Everyone needs to take a picture," because everybody in the staff has selfies and smart phones and iPhones, ...

Bethany:

Yeah. Yeah.

Howard:

... and if there's dentists, your team loves you. They want to help you. The last thing the team wants is the dentist to be calling in sick or laying on the break room floor with his back out or whatever.

Bethany:

Right.

Howard:

Just tell the staff, "Hey, if you come back ... " Tell your whole team, "You come back there to give the doctor a message, your front office, take a picture."

Bethany:

Right.

Howard:

I noticed that when I started doing ... Three years ago, I signed up for Iron Man, and I've done one every year per year, and when my swim coach and my bike coach would take pictures of me while I'm swimming, every one of those pictures blew my mind. You think you're laying horizontal on top of the water, yet you're swimming at, like a 45 degree angle.

Bethany:

Right.

Howard:

That leads me to my next question. Guys like me, at 50, sign up for Iron Man, or they start P90X, Crossfit.

Bethany:

Yeah.

Howard:

They're doing all these things because of their lower back and their jacked neck and all that stuff, so that's a good thing, right? Or not always?

Bethany:

Okay. We're in the new year ...

Howard:

Please tell me I can stop exercising. I would love you for the rest of my life if you told me I could stop, fire both of my personal trainers.

Bethany:

All right. We're going to get you the home exercise DVD, all right? Having said that, the new year is here. Everyone is concerned about getting in shape. It's the big push for the new year. What I see is a lot of dental professionals, they'll go to the gym, hire a personal trainer. Do you know what the average education of the personal trainer is in the United States, Howard?

Howard:

What?

Bethany:

High School.

Howard:

Yeah.

Bethany:

High School. The doctor is trusting this person to understand very sophisticated muscle imbalances in the body that are taught in the masters and doctorate programs of PT school. This is a big problem is what happens is the doctor goes in. They have very specific and unique muscle imbalances in their body, but the personal trainer gives them the same program or a generic program like P90X. They just do these generic programs that everyone does, that aren't a problem for the average individual that walks in off the street, but ...

Howard:

But see, I pay top dollar for my personal trainers, and she uses aromatherapy.

Bethany:

Okay. Well, we can talk about that.

The problem is that the dentist has a personal trainer. They give them these generic exercises that throw them into a vicious pain cycle because they're addressing muscles that are already short, tight, and ischemic, where the programs aren't a problem for the average Joe that walks into the gym off the street, but for the doctor, it needs to be very specific. Pilates programs have exercises that aren't a problem for the general public, but for a dentist and a hygienist, it can throw them into the vicious pain cycle. Very much, even Yoga needs to be modified for women in dentistry due to some of the ligament problems in their hands and their wrists, so we have some very specific guidelines there, as well.

Howard:

Women have extra problems in their hand? [crosstalk 00:49:05]

Bethany:

Women are very prone to hand and wrist injury plus ... ?

Howard:

Is that from open-hand slapping their husband?

Bethany:

Probably varies from person to person, yeah. Women also tend to have hyper-mobile joints, and so in yoga, when they go into some of these positions, women can overstretch some of these joints, but then, when you're already predisposed to hand and wrist injury, as hygienists and women dentists are, that can further the problem.

Howard:

Tell me, sometimes you have a bad attitude about someone. Like when I was little, I had a bad attitude about homeless people, and then when I got older and I met Kris Volcheck and Dennis [inaudible 00:49:48], and I go down and spend time at the [inaudible 00:49:51] Center, he'd explain to me how they're all mental illness. Something like 80% schizophrenia, and I didn't know that when I was a kid, but as you get older ... Tell me if I have a bad attitude now or am I smart. I've got several, several dental friends, good friends who have had the carpal tunnel syndrome, and when they're telling me all about it, and they've had their surgery and all that, in the back of my mind, I'm thinking, "You dumbass. You haven't even done a push-up in 25 years, and you're talking about this and that and time off and all those [inaudible 00:50:25]," and I always think, "If just got your fat ass on the floor and did ten push-ups everyday, would this even be there?" Is that true or false? Do I have a negative attitude or am I kind of close?

Bethany:

Okay. You're right and you're wrong.

Howard:

Just tell me the right part. I don't want to ever be told I'm wrong.

Bethany:

You're right in the sense that they need to be doing something. You're wrong in the sense that it's a push-up, because once again, this is an exercise that is probably one of the more problematic ones for dental professionals. They're strengthening the pectoralis muscles, which are already short, tight, and ischemic, and pull the shoulders forward, lead to shoulder problems. It is putting a lot of strain on the shoulder joint, which is the most unstable joint in the body, but among dental professionals, this shoulder is highly prone to injury. Also, you're weight-bearing through the wrist in an extended position, which exponentially increases the forces in the carpal tunnel, to which dentists are already prone to problems in the first place.

For all these reasons, I teach a modified push-up that is much better for dental professionals. Again, Howard, I can't emphasize enough how exercise has to be modified for dental professionals, and that is why I created the home exercise DVD, because I just saw dentists doing the wrong exercise over and ...

Howard:

For the month of January, all the month of January, it's $20 off?

Bethany:

Right. Correct.

Howard:

How much is it $20 off?

Bethany:

It's normally $127 for the entire kit. That includes the ball, the exercise band, the door anchor, the instruction manual, cue cards, and DVD, so it's normally $127, and it's $107 for ...

Howard:

$107. That's at posturedontics.com.

You keep saying about a short, tight, and ischemic, and my job is to guess what thousands of dentists, they're all driving to work, the good ones are on a treadmill right now, but they're driving to work. Someone, short, tight ... What do you mean by ischemic? Why do keep saying, "Short, tight, and ischemic?" What's the ischemic part?

Bethany:

Short, tight, and ischemic, meaning, like the upper traps. The upper trapezius muscles are the most used muscles in dentistry. They're also the most prone to becoming short and tight and ischemic, meaning that they get deprived of blood, because when a muscle is in a sustained contraction, when the upper traps very often are in dentistry, that sustained contraction starts to occlude blood flow to the muscle, and it can develop a very painful, ischemic position and also develop trigger points. Trigger points that develop in this muscle can refer pain to the neck. It can refer a headache behind your eye that won't go away with pain medication. That's a very common one, especially among hygienists, and so the way that we address these, and I teach another course on this.

This is a backnobber tool for treating trigger points, and we go in here to the trigger point, find that upper trapezius trigger point, and just by relaxing the armrest on the tool, it starts to compress the trigger point. You compress it until it hurts so good, and then tiny little rolls across that trigger point for five count, compression. You do this for about 30 to 60 seconds per trigger point, and then you do a sustained stretch for 30 to 60 seconds, and that's a very effective way to home treat, to self treat trigger points, and that's, again, based on research.

Howard:

Based on research or from Dr. John Cougar Mellencamp? Hurts so good.

Okay. I always try to guess what these guys are thinking, and I know what a lot of them are thinking. They say, "Well, I don't really have time for all that, but I see a chiropractor twice a week," or, "Friday, I only do a half-day, then I go get a massage." What are your thoughts on that?

Bethany:

I love that you brought this up, Howard, because I say in my lectures, probably 80% of people go to the chiropractor that are in my lectures, and we talk about muscle imbalances, where muscles become short, tight on one side of the spine and joint, longer and weaker on the other of spine or joint, and it holds it out of alignment, and I asked the audience, I said, "Does a chiropractic adjustment resolve that muscle imbalance that's causing pain?" No. Every dentist knows. No, it doesn't address that. It's a temporary fix, and so, in order to resolve the problem permanently, the muscle imbalance needs to be addressed.

Usually, that will be with a physical therapist. A physical therapist who specializes in orthopedic treatment, and along those same lines, I have people that talk about massage. They've gone to a massage therapist. Is that a good thing? Yes. However, you want to make sure that your massage therapist is trained in treating the trigger points, and you'll know if they are trained at treating trigger points, because they will have a certain book on their shelves. I'll show it to you.

This is Dr. Janet Travell's. Dr Janet Travell was John F. Kennedy's personal physician. She is the founder of trigger point therapy, and she wrote two very big books called Myofascial Pain and Dysfunction. If a massage therapist is truly a trigger point therapist, they will have these two books on their shelves, so it's very simple. You ask the massage therapist. Do you have Dr. Travell's two big red books? If they do, awesome. You have an awesome massage therapist for treating your trigger points, but if a dentist is going to be spending money on massage therapist, it makes sense to make sure that they are a certified, neuromuscular therapist and treat trigger points.

Howard:

I always loved word association, name origination, but orthodontist: Ortho, Greek, straight. Dontist, Greek, tooth. Orthopedic is interesting, because ortho means straight, and pedic means feet. Straight feet. It kind of got turned into a straight spine, but the word originated, straight feet. I thought that was interesting.

What do you think is the most dangerous exercise dentists are doing?

Bethany:

One of the most damaging is the vertical row. In my home exercise instruction manual that comes with the DVD, I talk about the exercises that can actually worsen your health. What gym machines, what exercises to steer clear of that can worsen the short, tight, ischemic muscles. This is one of them, is the vertical row. Can you see that?

Howard:

Yeah.

Bethany:

Okay. Anything strengthening the upper traps, doing heavy resistance on the upper traps. Military presses are another one. Another one is the lifting dumbbells straight out to the sides, because [crosstalk 00:58:34] ...

Howard:

You're saying these are specifically for clinical dental?

Bethany:

Not a problem for the general public, ...

Howard:

But for dentists?

Bethany:

... but dentists tend to develop overly hypertrophied deltoids and supraspinatus from having their arms slightly elevated away from the sides when they're working, and that causes an imbalance of the rotator cuff mechanism, and doing this type of exercise can be the little bit that puts them over the edge to develop a rotator cuff impingement.

Howard:

Then I've got to ask you my last question. A really, really good friend of mine, a dentist, he runs from mental health, but he jacks up his spine, so he knows he shouldn't run anymore, because he's 60. But when he doesn't run, he doesn't have that bet. He goes back to it. I'll tell you that on the Iron Man, I started at 50, I'm 53. It's swim, bike, run, and when I go swim laps two and half miles, it takes about an hour and fifty. When I get out of there, I just feel great. The bike is 112 miles, so those deals are usually 50 miles, three hours. When I get off the bike after three hours, I feel tired. But the runs, when I go run eight, ten miles, I feel like I was hit by a car. This just goes on every third day of my life the last three years. My long-winded question is do you think running overall is bad for 50 year old people? Do you think their exercise should be non-traumatic? What do they call it, non- ... ?

Bethany:

Impact?

Howard:

Non-impact.

Bethany:

Full-impact.

Howard:

Swimming, biking, and not running and jumping and things that jar up your 212 bones?

Bethany:

Yeah. As we get older, cartilage naturally degenerates. It just degenerates as a process of age, so for a lot of people, their knees can become problematic when they get into the 50s and 60s with jogging, but there's people, just genetically, are less prone to problems with cartilage degeneration, so you see 60 and 70 year old people jogging, but usually, Howard, you see them, and they are very thin. It's the body mass with that pounding on the pavement.

Howard:

I've noticed that. All my friends who love to run, they all have a body of a gazelle.

Bethany:

Yeah. Exactly.

Howard:

I have the body of a gorilla. In fact, my mother told me something very, very interesting just yesterday. She told me, she said, "Did you know that your grandfather was short, fat, bald guy?" That's a joke. Get it? That joke did not work right. I have to polish that one up. Well, we are out of time. Bethany, I would like to say, I've been your biggest fan since 2005. That was 11 years ago. I'm so damn proud of you that you're going to become a doctor. Send me, howard@dentaltown.com, and then cc it to ryan@ ... Are you at ryan@dentaltown.com? R-Y-A-N. That's my son, ryan@dentaltown.com, and I'll push those out on all those things. Seriously, thank you for all that you've done for dentistry. Thank you for all that you've done for Dentaltown. Thank you for all that you've done for me personally by listening to your advice for the last 11 years, and I just think you're one of dentistry's rock stars. Thank you for spending an hour with me today.

Bethany:

Thank you, Howard. It was a pleasure being here with you.

Howard:

Email HoGo@dentaltown.com if you want to put up any more courses or anything. I think it's so imperative, and then that article in Dentaltown, boy that would be so controversial. Could you imagine? What are the loop manufacturers that don't sell flip-ups?

Bethany:

That don't sell flip-ups?

Howard:

Yeah.

Bethany:

I think Designs for Vision does not sell flip-up.

Howard:

What's the other one?

Bethany:

I'm sure there's others. Small ones, I'm not sure.

Howard:

I've been reading your research, and I've been looking at the ones that everybody's recommending on the message boards, I'm like ... Then you go to that guy that's recommending that, and then he's on another thread, whining about lower back pain.

Bethany:

Uh-huh (affirmative).

Howard:

You're like, "Dude, so you're telling everybody to buy these loops on this thread. Now you're on this other thread, whining about your back, and you're trying to do all these exercises, and it's not all adding up."