Dentistry Uncensored with Howard Farran

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Howard:

It is just a huge, huge honor to be with an orthodontist, Dr. Miho Imamura.

Miho:

Nice to meet you. Welcome to . . .

Howard:

We are in Kofu Yamanashi Japan which was about an hour and a half train ride from Tokyo.

Miho:

Right.

Howard:

That train was going pretty fast. How fast was that train going?

Miho:

I don't know 200 kilos or something an hour.

Howard:

Yeah, it was moving.

Miho:

Yeah.

Howard:

I assumed it was going 200 miles an hour.

Miho:

Maybe I think, five years later we'll have our Super Express from Tokyo to here. Only 20 minutes.

Howard:

20 minutes.

Miho:

20 minutes.

Howard:

Is it working now?

Miho:

Yeah.

Howard:

Could I take that back?

Miho:

Oh no, no, no.

Howard:

Five years later. Oh five years from now?

Miho:

Yeah, yeah.

Howard:

Okay five years from now, okay. In Japan probably only about 10% of the dentists speak English.

Miho:

Right. They can understand, but they cannot speak.

Howard:

Yeah and the reason is when you study languages, it's called the Rule of Fifty Million. If you're born on earth and you have 50 million people to talk to, you usually don't learn another language. When you go to China, no one really speaks English. When you go to Brazil. Brazil has 200 million people, they all speak Portuguese. Japan has a 127 million people, but when you go to small country like Denmark, most people know five languages, because when you grow up in a country with only five million people, you'd want to learn German, Italian, Spanish and English. You learned English, because from 1985 to 2010 you made several trips, like once a month for . . .

Miho:

Yes, back and forth.

Howard:

Tell them about your journey, about why you kept going back to Iowa?

Miho:

Yeah, at the beginning I went to Iowa, that was the first time in 1985. It was just an exchange program to spend a few months to learn the prevention way and prevention against cavities.

Howard:

Were you already a dentist in '85?

Miho:

Yeah, I did. I graduated from my dental school in 1985. I just went to Iowa that year. Then I just found a good program in Iowa to prevent for the kids. Not only for the kids, but also the adults. The cavities, the perio, or any kind of prevention is kind of ahead more than Japan. I like to establish my own way prevention in Japan, here in Kofu too, for my patients. Then I went to Iowa. I had the patients at that time. That's why I came back. I have to come back to Japan, Kofu to treat my patients, three weeks here and one week in research and study in Iowa. Then back and forth every month.

Howard:

You did that every month from 1985-2010?

Miho:

Yeah. That was many trips . . .

Howard:

How many was that 25 years?

Miho:

Oh actually . . .

Howard:

What is that '85, '95, 2005.

Miho:

Yeah.

Howard:

25 years.

Miho:

Not every year. I think it was ten years back and forth every month. After that every three months, every four months, every six months, and then now . ..

Howard:

Who was paying for you to go back and forth?

Miho:

Yeah I did. I did from my salaries.

Howard:

You're like a saint. You're like a saint.

Miho:

Oh no.

Howard:

You flew back there one week a month for 25 years.

Miho:

Yeah, right.

Howard:

Just to learn about prevention to bring back to your city of Kofu.

Miho:

Not only prevention, but also every information from the United States dentistry. I'm an orthodontist. I was at the time. Just I just learned so many techniques to appliances and supplies and everything. At the time I couldn't get everything, because the Japaneses government takes a long time to have the new product from abroad. I saw something very good and new in the United States, but I couldn't get it. I can just bring it by myself with me. Then I just used for my patients. That is kind of a bonus in the treatment I did. I could. Then there's a profit to go to Iowa every month, so that is another way, another thing to do.

Howard:

You know it's something that dentists don't like to talk about, it's in the closet. I meet dentists in multiple countries all the time that take vacations to other countries with two empty suitcases. Buy tons of dental supplies, whatever that they can't get back in their country.

Miho:

Especially Asia, yeah, yeah.

Howard:

They can't get them back in their country or their country has a distributor that marks everything up, like 40%, 50%, 100%.

Miho:

Right.

Howard:

I know dentists in European countries that will go to the next country and buy all their implants at half the price and then fly back. It's done more than everybody talks about. You had a big interest in community water fluoridation?

Miho:

Yes, at that time I just wondered why Japan's government doesn't like to permit the people to have fluoridation. Halfway I found its people doesn't like to have a fluoridation in the water, because people like to have just pure water here in Japan. They don't like to have chemical things in the water. That is not only from the government's side but also the Japanese custom, Japanese and maybe people thinking, the habits or something. Then I just gave up to put fluoridation in the water. I just needed to have more special way for the people, especially I put the braces on the teeth. This is kind of risky for the gum and teeth.

Then I just put the fluoride at home, my home care, or clinical care, or clinic, or office care. These more special things I needed to establish for each patient's program. That is my way.

Howard:

Well you know water fluoridation is easy when you're like Singapore, where the government just makes a decision, end of story.

Miho:

Right, right.

Howard:

There's no elections.

Miho:

Uh-huh.

Howard:

In the United States each town votes on it. On any given day 25% of the towns vote no, so it's only in three out of every four towns in America. You're saying in Japan it's only in Nagata and Kyoto?

Miho:

Kyoto, yeah.

Howard:

Kyoto, how do you pronounce the other one?

Miho:

Nagata and Kyoto.

Howard:

Nagata and Kyoto?

Miho:

Kyoto. Not only, not for, just a small few cities they voted to accept fluoridation in the water. In Kyoto and Nagata the special city, they have a very good program for the prevention, but only a few cities in Japan still now, still.

Howard:

You have probably gone back and forth between two great nations, the United States and Japan more than any dentist on earth. I've never heard of anybody going back and forth as much as you have. What are the main differences between dentistry in the United States and Japan? What would you say?

Miho:

I think the most different thing is our insurance is so different. The Japanese insurance covers everything, because this is a government insurance means. Private insurances in Japan, in the United States, you have insurance in the private, right? Japanese government controls everything, the insurance. Then they control the price and this and this. The price of the treatment is so different. I mean the Japanese treatment is cheaper, more than American.

Howard:

Explain it. What is the Japanese insurance company called?

Miho:

We have two kinds of insurance, the government insurance and the social insurance. Then these are the two kinds of insurance.

Howard:

Japanese government insurance?

Miho:

Uh-huh.

Howard:

And social . . .

Miho:

Social. Social means a company paid.

Howard:

Okay, so Japanese government.

Miho:

The government pay or the company pay. Total treatment fees it's the same.

Howard:

The fees are the same?

Miho:

Oh yeah, the same. Everything is the same. Everywhere in Tokyo, in Osaka and here, everywhere.

Howard:

You feel that the fees are very low.

Miho:

Yeah, they're low.

Howard:

Can you give any examples, between like what something . . .

Miho:

For example a root canal and one root canal treatment . . .

Howard:

For a molar?

Miho:

Uh-huh, is only maybe I think $100 here.

Howard:

One hundred yen or $100 US dollars.

Miho:

$100 US dollars.

Howard:

Molar endo is $100 US dollars. You can't do molar endo for $100.

Miho:

How much in the United States and how much in the United States?

Howard:

$1000.

Miho:

Right. This is ten times, right?

Howard:

Yeah. How does molar endo in Japan, $100, how do you do that when in the United States, a molar endo is a $1000?

Miho:

No, I think, I have no idea. Still especially endo is very low in Japan, if I compare. Surgery is maybe double.

Howard:

Double in the United States.

Miho:

No, at least half. Half price of the American treatment fee.

Howard:

What would a molar extraction cost?

Miho:

Here, just an easy one is maybe I think, maybe $100 a tooth.

Howard:

$100 dollar US?

Miho:

Uh-huh.

Howard:

$100?

Miho:

How about the United States? Molar extraction?

Howard:

$200.

Miho:

Maybe double, right?

Howard:

Yeah.

Miho:

Also orthodontic fees are different.

Howard:

Is orthodontics covered by the government dental insurance?

Miho:

No, patients have to pay everything 100%.

Howard:

Now the government is not setting your fee?

Miho:

We have a periodontal, no.

Howard:

That makes it nice.

Miho:

Yeah, uh-huh.

Howard:

What do braces cost in Japan?

Miho:

Actually depending on the areas, different. In Tokyo, Osaka big cities, it's very expensive. Here in Kofu and Yamanashi it's very close to Tokyo, but still very small city. One treatment is maybe about $5000.

Howard:

$5000 US?

Miho:

Uh-huh, but in Tokyo maybe $700.

Howard:

$7000?

Miho:

$7000.

Howard:

Yeah, that's what the orthodontists that we talked to said. That's a great rule when the government does price fixing or price setting, whether it be setting the price of an apartment. When they went to New York and said, okay an apartment can only cost this much money, nobody built apartments.

Miho:

You can decide your own price, right?

Howard:

Yes.

Miho:

We cannot decide our own price. The general practitioners cannot, but we can because we are . . .

Howard:

Orthodontists can set their own fee and general dentists can't?

Miho:

Right.

Howard:

Is braces just not covered, because it's considered cosmetic?

Miho:

Yeah, they are thinking that it's not a disease. It's a specific thing that's why they cannot cover it by the insurance. Only, yeah you know on the cleft palates or someone gingivitis and the DNA program. Then they cover it. Very few cases. Normally they cannot cover it, both of them. We have a freedom, but still general practitioner having a very hard time to treat the patients. That's why each dentist have to treat the patients 60, 70 a day, they have to get the money.

Howard:

Because, they don't . . .

Miho:

Here in Kofu it's a very small city and then we don't have many patients, so they are having a very hard time to have the insurance and the income. Let me go through the same. For example my eye doctor, they always end up treating the patients every day, over 100 patients a day. Which means one patient three seconds and then change. That is not good treatment. I don't know, but this is Japan, Japanese way.

Howard:

Basically the payment mechanism is paying the doctor just for a visit?

Miho:

Right.

Howard:

They just want to see a visit.

Miho:

Yes.

Howard:

Ten minutes. How long would the average general dentist in Japan see a patient?

Miho:

Maybe 15 minutes or 20.

Howard:

Fifteen?

Miho:

Yeah.

Howard:

If they're seeing 70 patients a day. What are their typical hours a Japanese dentist? Would it be 8-5.

Miho:

Eight hours.

Howard:

8-5?

Miho:

Yeah.

Howard:

Monday through Friday.

Miho:

No, no 9-7.

Howard:

9-7.

Miho:

Right.

Howard:

That's a long day. That's 12, 11, 10, that's a nine hour day. They take an hour lunch.

Miho:

Yeah, maybe one or two hours lunch between.

Howard:

A one or two hour lunch?

Miho:

Uh-huh.

Howard:

Really, they take two hour lunches?

Miho:

Maybe one hour.

Howard:

That'd be a nine hour day?

Miho:

Uh-huh.

Howard:

9-7 Monday through Friday. What's 70? 9 x 4, 15 minutes, 9 x 4 would be 36 people a day. If they're seeing 70 a day, they'd have to be seeing, they'd only be able to spend seven or eight minutes a patient. What do you think?

Miho:

Still I think in Japan now, so many patients, so many dentists, excuse me, so many dentists, the number of the dentists is too many. Then they don't have enough number of the patients. Then they are having a very hard time to get new patients or patients number.

Howard:

Have any of the general dentists in Japan decided to just quit going along with the insurance, and just have their own practice, maybe a boutique practice?

Miho:

Right, uh-huh. That's why they need to do something else, except insurance and treatment, so the new surgeries or new technique or new things they like to look for. Then I'm doing also too seminars, they like to have both of them, treatment in their own clinic too.

Howard:

You're teaching orthodontics in Tokyo ten times a year.

Miho:

Right, yeah.

Howard:

That's to orthodontists and general dentists.

Miho:

Right.

Howard:

You think that general dentists are showing interest in orthodontics, because it's not a disease and the fee is not set by the government, and they can make more money?

Miho:

That is a reason, but still they need the patients to treat. Then they have already started those cases. That's why they need help. Then I just started also seminars for the general practitioners, because they need the place to ask their own patients and the treatment and the plans or the problems to solve. Because, you know, I am thinking orthodontics treatment is not so easy for everybody. Then they started their own cases in their clinic, but they have a problem that they cannot solve. The patient is very sorry about that, right? Then I like to keep the quality of the orthodontics have to be in Japan, very much more than before.

Then people like to have more good reputation of orthodontics, but people are thinking also that okay, okay just to straighten the teeth. No, no, no. Orthodontics us much more the valuable things, the important things for the people to move the teeth and to straighten the teeth and to move the jaw and the face and the growth and everything can change that do effect. That's why I like to do also, it's very good, very good treatment. If general practitioner I can do and it can be very bad, then people doesn't think about ortho is not good. That's why I started doing also seminars for the general practitioner to start their own programs for the patients, so this is a way.

Howard:

You know it's interesting, because okay we have Dentaltown with 210,000 members.

Miho:

Yeah.

Howard:

The American Dental Association.

Miho:

That's wonderful.

Howard:

Recommends endorses nine specialties. On Dentaltown you have all the specialties. You have endodontist, periodontists, pediatric dentists, prosthetics, all of them.

Miho:

All of them.

Howard:

No orthodontists. We had to start a separate website only for orthodontists and they won't let anybody, who's not an orthodontist on. I can't even get on it and I'm the owner. They won't even let the orthodontic companies who are wanting, like if all the orthodontists said, we don't like all these brackets pink. We want them black, well the orthodontic companies, they can't even see the orthodontists talking, because the orthodontic society is so close. With endodontists the endodontists expect the general dentistry the easy ones. They'll do the molars. Oral surgeons expect the general dentists are going to pull the easy teeth and they'll do the wisdom teeth. Endodontists don't want you do do any class I, any endo. If you are an American orthodontist and you were teaching general dentists like me, they wouldn't like you. You'd be in trouble. Is that not the way it is in Japan?

Miho:

Maybe I think orthodontists doesn't like to have my job, because they are thinking about the market. If general practitioner can start also. It's maybe losing the patients they fear. My problem is different. I think that general practitioners, everybody has a right, it's legal things. The general practitioner can do it also in Japan. It means that everybody have to have the responsibility to treatment of patients. Good quality for their own stability. People have to know. That's why, how can I treat the patients by themselves? Because, we cannot touch the patients in different clinics. I do like to make good plans and good diagnosis and good treatment qualities for the patients, is good. Still people have to know why professional orthodontists they like to close the markets.

Now general practitioner can do it now also, already. They cannot transfer the patients to the orthodontists anymore, because they need the patients. They don't like to transfer the patients to the orthodontists now anymore. Before, my father's generation. My father is a dentist too. They transferred.

Howard:

Your father is buried right outside your office?

Miho:

Oh yeah and my grandfather was also a dentist too.

Howard:

Your father?

Miho:

Uh-huh.

Howard:

And your grandfather?

Miho:

Grandfather, yeah.

Howard:

You're the third dentist?

Miho:

Yeah, right, right.

Howard:

The first woman dentist in your family?

Miho:

Yes, yes, yes.

Howard:

I just think it's so romantic how . . .

Miho:

Thank you.

Howard:

How you have your father's graveside by your home and your office.

Miho:

Uh-huh, uh-huh.

Howard:

Whereas in America it would be far away in a cemetery.

Miho:

Uh-huh. We have a cemetery too, but still we have our ancient cemetery in my family land. That's why we made it, my father actually made it.

Howard:

In many of the Japanese homes, when they're eating dinner. They'll prepare a little dinner?

Miho:

Just a few times a year, not every day.

Howard:

Not every day. A few times a year? How many times a year?

Miho:

Maybe in the summer and the winter. Two times.

Howard:

Just two times a year?

Miho:

Uh-huh.

Howard:

I think that is so romantic.

Miho:

Yeah, I do.

Howard:

I do. I think that is just so cool how you . . .

Miho:

Ancient is always around.

Howard:

Would that be a Japanese custom or a religious custom? Would that be Buddhism or . . .

Miho:

Buddhists.

Howard:

That's Buddhism?

Miho:

Yeah, uh-huh, uh-huh.

Howard:

I stood on where Buddha was born in Nepal.

Miho:

Uh-huh.

Howard:

I went to Buddha's birthplace.

Miho:

Oh yeah.

Howard:

That's more Buddhist, not Japanese.

Miho:

Yes, yes.

Howard:

More Buddhist, okay. Sorry to interrupt. Keep going.

Miho:

Many Buddhists like Catholics and Christians, Buddhists is different in religions too. We are, Shinto is the biggest religion in Japan, then Buddhists.

Howard:

Buddhist is?

Miho:

The family has their own temples everywhere.

Howard:

In America the largest religion is McDonalds.

Miho:

(Laughing).

Howard:

It comes with fries.

Miho:

That's a good story.

Howard:

You heard it first from me.

Miho:

That's nice.

Howard:

I interrupted you on the business, but you were talking about, back to the orthodontics.

Miho:

The general practitioner before my father's generation transfer the patients. To introduce the patients to the orthodontists. Now general practitioner cannot transfer and . . .

Howard:

Because of money? They need the money?

Miho:

They like to have their patients to take care by themselves. No work with the orthodontist anymore. That's why I think I like to ask general practitioner. They have to have the responsibility to treat the patients very good quality by themselves. I don't care about the title, orthodontist, general practitioner. It doesn't matter, but still just the treatment quality is very important. This way they can treat the patients by themselves of course, but they have to take care of the patients and take care of their treatment long term stability. They take care of them.

Howard:

Let me ask this. Whenever you're in a dental office in the United States, it's at least four chairs and a lot of staff. When you usually go to a dental office in Asia, it's usually one chair, one staff.

Miho:

Uh-huh, uh-huh.

Howard:

You have the largest office I've ever seen in Asia.

Miho:

Uh-huh, thank you.

Howard:

Is that because since you're teaching general dentist ortho, those general dentists are referring you a lot of ortho?

Miho:

Oh no.

Howard:

Do you get a lot of your referrals from dentists who you taught ortho?

Miho:

Yeah, but still, why I have this kind of big office when I started my clinic. I got a vision or mission to have my own clinic, because I didn't like to treat the patients, as many as I can in my life. Because, here is also many orthodontists here, specialists here, only four.

Howard:

There's only four where we're at?

Miho:

Orthodontists in Kofu.

Howard:

In Kofu.

Miho:

Then I do like to treat the patients.

Howard:

How many general dentists are in Kofu?

Miho:

I think there's 300.

Howard:

300, and how many of those 300 have come to your courses in orthodontics and learned how to do orthodontics?

Miho:

This area maybe only two or three dentists have attended my seminars.

Howard:

Do those three refer to you, orthodontists?

Miho:

Oh yeah, sure, sure.

Howard:

My point is like in Sydney, the largest orthodontic practice period is Derek Mahony. He has four offices. They're just huge. He's out there training all these general dentists. They usually start to do some ortho, then realize they'd rather do crown and bridge, or other stuff, or just take a few cases. They're referring to him. I keep seeing that business model where the orthodontist who teaches the locals how to do ortho, always has the biggest practice. Here you're teaching orthodontics and you have the largest practice I've seen in Asia.

Miho:

Maybe like Derek, I know him. I started my clinic. If I treat the patients in seven chairs, maybe 10,000 in my life, right? If I teach general practitioners, or the orthodontics treat patients and orthodontists in whole Japan. In Kyoto, Tokyo, anywhere. Then they have patients, 100, 1000. Then the number of the orthodontists is many. The orthodontist is good. This is my dream. That's why I treat the patients and I also teach the seminars to the people, the orthodontists. If my seminar and the student transfers the patients to me, I just send back. You can do this. You can do this, because I have a patient too, don't worry about that.

They just like to have their own responsibility to treat the patient. This is very important things. If they can give up the treatment or if they miss the diagnosis, that was bad for the patients. I do like to control that kind of things only. I don't need the number of the patients to make money. Also I'm doing the myofunctional therapy. This is no money, just a service, unlike implants, not big money. Still we are training the staff and the patients to have a promotion what we do in my clinic and for the patients. People can trust me and read me what we need to do now. This is very important things for the people. That's why we are doing.

Not only for the money but also for the people. Then the money came back to me maybe. I don't know, because I don't care about the money or staff, but staff can do the same thing. I always ask the staff that this vision is very important. Not only for the making of money but just what can I do for the patients? This is very important things. The same thing that I'm doing, asking me and myself, what can I do for my staff and the patients or a student? Because, maybe I like myofunctional therapy. I like ortho. I like to have my time to use to the people can have reversal in the myofunctional.

Howard:

A lot of people listening might not really know what myofunctional therapy is? How would you explain? What is myofunctional therapy?

Miho:

Yeah, this is actually from the United States. This is actually they started. Speech pathologists . . .

Howard:

That guy was from Iowa too.

Miho:

Hmm.

Howard:

Myofunctional therapy.

Miho:

Yeah. Then myofunctional therapy is now expanded all over the world now.

Howard:

It was Bill Bickford?

Miho:

Bickford. He's a mentor too . . .

Howard:

He passed away last year.

Miho:

Yeah, that's right. I'm so sorry about that. He came to Japan to teach myofunctional therapy every year, or every two years, maybe over 30 years he did with his wife.

Howard:

Julie.

Miho:

Julie. Yes, yes. Then she's coming this year to have a seminar on the course here again in Tokyo. Then we have a big, how can I say it, a big effect to also treatment if we have an over bite case, they need to control the tongue or tongue size, flicking or some, these functional things we have to think with the treatment. Now almost every orthodontic clinic they do myofunctional therapy in Japan. Maybe I think everybody knows this words, this technique.

Howard:

It's very common in all of Japan.

Miho:

Very, very common now.

Howard:

Would you say it's more common in Japan than in the United States?

Miho:

Yeah, I think it's a different way, because myofunctional therapy in Japan, we started in dental office, in dental clinic, especially orthodontics clinic. In the United States they start, the speech pathologists started, not dentists. The speech pathologists, also teachers, also hygienists. Different area they started myofunctional therapy, but we got the myofunctional therapy in Japan from United States.

Howard:

Who do you think is the number one expert in English in myofunctional therapy? Do you think?

Miho:

Many, I don't know, but Bill is one of them too.

Howard:

He passed away.

Miho:

Yeah, he passed away.

Howard:

It is very hard to get people who passed away to make online CE courses on Dentaltown.

Miho:

Many, many people now are having a course. That's why I think or I cannot tell who is the best or something.

Howard:

I want you to make a course.

Miho:

Yeah.

Howard:

Because, on the Dentaltown app we have, here I'll show you. We made these, if you take out your iPhone or SmartPhone. You go to the online CE, we put up 350 courses and they're extremely popular. There's one by John Nosti, there's Lauren Levine on oral cancer. Dentists love taking courses on their iPhone, their SmartPhone, their computer.

Miho:

I am so glad to know this.

Howard:

I wish you would make us a course.

Miho:

Oh yeah, that's great.

Howard:

I've never had anyone from Japan make a course.

Miho:

Yeah, I 'm so glad to know this.

Howard:

Do you think you might think about it?

Miho:

Yeah, I think so, but still I think I have to think about that for the Japanese and the speakers.

Howard:

Well, if you'd ever grace us with a course, it would be a huge honor.

Miho:

Yes.

Howard:

Myofunctional therapy was started in Iowa by a speech pathologist.

Miho:

No, no, no. In Iowa it's maybe I think a different field, but still they made some group to establish myofunctional therapy in the United States. They have an association, IOM. This is a therapists group, so they are having an annual meeting.

Howard:

What's the IOM stand for?

Miho:

International Academy of Oral Myology or something. Then the group and the many myofunctional therapists and one of them was Bill, Bill Bickford. He came to Japan to teach myofunctional therapy in Tokyo, and then over 30 years passed, and everybody knows now in Japan.

Howard:

Uh-huh. What other differences, when I see you've been traveling so much from '85.

Miho:

Right.

Howard:

On, you said the main difference was the insurance.

Miho:

Uh-huh.

Howard:

That the insurance in Japan, the fees are so low that general dentists have to see 70 people a day.

Miho:

Right.

Howard:

Besides payment, oh I was going to ask. What percent of the dentists just don't take the insurance? What percentage of the Japanese dentists, say you know what?

Miho:

I think almost everybody has the insurance I think. The Yamanashi Kofu area is the only. I don't take insurance, but other orthodontists take insurance also.

Howard:

You don't take the government insurance?

Miho:

No at all.

Howard:

You're the only you know that doesn't?

Miho:

Only one person, so I am.

Howard:

You're the only one. Congratulations.

Miho:

Thank you very much.

Howard:

Congratulations. Other than insurance, what differences do you think there are?

Miho:

Because, people are always, we started the national insurance when I was born in 1960. That time the patients, the number of the patient is a lot. My father had the patients, about 100 a day to treat the patients.

Howard:

Was he an orthodontist, or general dentist?

Miho:

Yeah, he's a general practitioner.

Howard:

Your grandfather?

Miho:

Grandfather, the same. Then that's why they needed insurance, because people needed to pay the fee. Now everybody has the insurance covered and the government controls the fee. It's not good for the patients, because so many different treatment way and different way. It's so confusing. On the other side, now the senior, the elderly is more. We need the money, the medical fee for the elderly a lot. We need to spend the money a lot for the elderly. The government doesn't like to use the money for the dental fee or something like that. They are cutting everything. The budget of the money is another way to think about the insurance.

People are still using the insurance a lot, but still everything is cutting a lot. Each general practitioner's income is getting lower and lower and lower.

Howard:

You also said there's too many dentists.

Miho:

Yes.

Howard:

Okay, so like in the United States in the last ten years has opened up six new schools. They have several more being designed. Malaysia has gone from four to 18 schools. How many dental schools are there in Japan and are they increasing the number of dental schools and graduates?

Miho:

No.

Howard:

Or are they shrinking?

Miho:

It's now shrinking?

Howard:

Shrinking the number of schools or just the classes?

Miho:

School and the classes, so both.

Howard:

Have they closed down any dental schools?

Miho:

National University is now closing, or the number of the students is now getting less. In the private it still exists, but still the number of the students is less.

Howard:

The government is decreasing the number of total dental schools and the number of total dental graduates?

Miho:

Also the government is now cutting the number, so the national exam is getting so hard to pass. For example this year 60% is the student, graduate student passed the exam, 40% couldn't get passed.

Howard:

They went all the way through dental school and 40% could not pass the test?

Miho:

Right.

Howard:

Will they just . . .

Miho:

They have to wait for the next year?

Howard:

They have to wait one year?

Miho:

Yeah.

Howard:

Wow.

Miho:

Then they have no life to pass. It's difficult. Then parents is so anxious about the kids to be dentists.

Howard:

You know it's funny, because when I got out of school in '87, they were closing dental schools. When I got out of school they were closing down Northwestern and Emory and Farleigh-Dickinson and George Washington, Georgetown. They were just closing down a slew of schools. Then it flattened out for a decade and now they're expanding. What goes up, comes down. Japan is shrinking the number of dental graduates. The United States is back expanding. I'm sure over the next thousand years.

Miho:

We are growing in America think, this is exactly, maybe ten years we'll find . . .

Howard:

I want to talk about another thing. Your grandfather was a dentist. Your dad was a dentist. In Japan there's 103,972 dentists. 75% are male, 80,000 and 25% are women. When your dad got out of dental school, was it also 25% women?

Miho:

No, no, no.

Howard:

Is the women a new thing?

Miho:

All men.

Howard:

It was all men for your grandfather and your dad.

Miho:

Maybe a few, five.

Howard:

You graduated in 1985?

Miho:

'85 yes.

Howard:

Was your class 25% women?

Miho:

Mmm, about, yeah.

Howard:

About?

Miho:

Uh-huh.

Howard:

When did it start going from all men to start adding women?

Miho:

I think when I graduated in '85. I was born in 1960.

Howard:

1960?

Miho:

Yeah.

Howard:

Now see if you're in America, you wouldn't tell your age? American women never tell their age. I just wanted to say, any man will tell you I'm 53. I was born in ' 62, but an American woman, no way. She wouldn't tell you how old she is or how much she weighs. Now I'm going to ask you, are you also going to tell us how much you weigh.

Miho:

Yeah, it's very easy, just 48 kilograms.

Howard:

Actually no Americans will know.

Miho:

Oh okay, okay. I'm small.

Howard:

They only know pounds, so if you tell them you're 48 kilos, you might as well them you're 480 kilos.

Miho:

They don't care about my weight or my age, or something like that. Increasing now in female is more. I think our National University, 50% is female now, especially in periodontics and orthodontists. A lot.

Howard:

What about pediatric dentistry?

Miho:

Hmm, maybe 50 or 60?

Howard:

In the United States for the last two years I have not been able to find a single male in a pediatric dentistry program. As far as I can see that has gone all female. Kind of like when I was young the gynecologists were all men and now they're all women. I see pediatric dentistry following in the United States. The United States is very similar on that. Our dental school classes are half women too.

Miho:

Yes, yes.

Howard:

I love your, your name is Miho.

Miho:

Uh-huh.

Howard:

Imamura. You have a Miho Institute, so your name M-i-h-o you're using as an acronym for Motivated International Health Organization.

Miho:

Right.

Howard:

Talk about your MIHO Institute.

Miho:

I am single. I have never got married.

Howard:

You never got married, so you're a genius. You're a dentist, an orthodontist and a genius. Ryan, cover your ears. I don't want her to hear my thoughts on this. My God, I think about how much money I would have saved if I didn't have Eric, Greg, Ryan an Zack. You're also a rich genius. A rich genius orthodontist.

Miho:

I'm so glad to spend whole money for myself, but anyway.

Howard:

Ryan, I'm going to send you back to Japan and I'm going to marry this woman and just stay in Japan. She's single. She's rich. She's an orthodontist.

Miho:

Oh no, no. I'd like to have some more dentists if I finish after I die and if I finish my clinic, it's finished. Not like a company. If I do something, my own program to leave if I still have my job. I can, how can I say? Leave something in the future. Usually before my father, my grandfather, asked the kids please do the same thing as a dentist, like me, but now I cannot do . . .

Howard:

Your father asked you to be a dentist?

Miho:

Actually he asked my, I have two brothers and then my brother is a dentist.

Howard:

Your brother is a dentist?

Miho:

Yes.

Howard:

You have two brothers?

Miho:

Yeah, two brothers.

Howard:

One's a dentist and what's the other one?

Miho:

He's a dentist too.

Howard:

They're all dentists.

Miho:

Yeah, everybody is a dentist.

Howard:

Your dad asked them to be a dentist?

Miho:

Yeah, yeah. Also my cousin is a dentist also. Then they asked the kids to follow my job. Now I cannot do too much, because I have no kids. Then I think this is good, because you know if I quit the job, my clinic, my patients, doesn't like to see my kids, because in the clinic it's just limited for their each dentist, not follow. If your father is a good dentist, but I'm not, the same thing. If I would be good, is good, but I don't know. The patient doesn't know that. Then I saw dentistry is just only one generation is okay, but I like to leave, make something different dentistry, like a company. If I die company be, we be okay. We be good for my family. That's why I just made MIHO, which Motivational International Health Organization.

This is an organization, if I have many plans, many [inaudible 00:44:08] and many good things for the dentistry, maybe company will take care of our plans for the future when I die or I quit the job. I just follow that. They can follow that. That's why I established two companies already to make these things already.

Howard:

You're a very cerebral, smart, philosophical.

Miho:

Because that's why I'm single and I have no kids.

Howard:

Did your brothers, did they get married and have kids.

Miho:

My older brother got married, but divorced. He has two daughters. One daughter is now a dental school student.

Howard:

Now in the United States, well I noticed all around the world about a third of the dentists have dentists in their family. Whether you're in India, Brazil, United States, a third of the class. Would you say in Japan about a third of the dentists have . . .

Miho:

Yeah, many.

Howard:

About that many?

Miho:

Many.

Howard:

Would it be more than a third, or what percentage of dentists in Japan have a family member?

Miho:

There are a few, but still many I think are 10% is second generation or third generation. Maybe 20% is second generation or maybe relatives, aunts or uncle was a dentist or something like that, so [inaudible 00:45:41] of something.

Howard:

I want to go off topic just, because I just find it interesting, but when you said you didn't have any kids. It's well known that Japan has the lowest birth rate.

Miho:

Right, like me.

Howard:

You need 2.4 children per family just to maintain even. In Europe if you backed out immigration, all the European countries are condensing. The United States the same thing. If you back out immigration, in 1950 the average American woman had five children. Now it's less than two. Japan is less than one, right?

Miho:

Less than one.

Howard:

It's .9.

Miho:

Right.

Howard:

What is your thought on that? Do you think it's just because when women get highly educated and get jobs and careers, it's just that that's what we're going to see moving forward for all advanced societies?

Miho:

Yes, uh-huh. I think almost every country in Asia too have programs, high education, high rights to spend the time, or to get good care, takes the time, so cannot use my own time for their family things to make our first, or to get married, or to have take care of the kids or something like that. That's why I'm thinking about, of course I very recommend the staff to get married and to make their kids or something like, for the good future for Japan. Still I think the small number of the children is no good for the children. In America, the brothers, sisters, can grow each other. It's better circumstances.

In Japan, like China one child in the family is spoiled. It's not good for the kids. Then I'd really like to have a good education, not only in the family but also everybody can join to help the children grow. Also orthodontics means two years, three years, four years into treatment, so they come back every month to be treated by me. I told them that education way or something, why don't you do this or something like that? Like a mother or a grandmother or so like that. This is very good for the kids. It's a good relationship. Not only the treatment but also a good relation with the families and the children.

Then they can trust me. We have a very good time too. These things are very good for the society area, community I think. Even I don't have children of my own, that's why I can have the time to talk with them, so this is good for the future.

Howard:

If you want children, I can leave Ryan and Greg here. Ryan, do you want to adopt two children? Instead of four, I'll have two and you'll have two?

Miho:

No, I envy you.

Howard:

We'll split them 50/50.

Miho:

Because working together and good business helping the father. This is so great. I'd really like to do this kind of.

Howard:

I'll leave my children here and then when they have grandchildren you can just send me back the grandchildren.

Miho:

That's good.

Howard:

Let's talk about decay rate. You and I are the same age. We've been out the same length of time. Let's go back when you got out of school in '85, all the way to 2016. In '85 to now, does Japan have more new children, they are coming into your practice, have more cavities, the same number of cavities, or less cavities?

Miho:

Oh less cavities, a lot.

Howard:

Less cavities?

Miho:

Yeah, very less.

Howard:

Yeah, a lot less?

Miho:

We did a very good job.

Howard:

You did it without water fluoridation?

Miho:

No.

Howard:

Singapore attributes a lot of their decrease to water fluoridation, so does Malaysia. Japan did it without water fluoridation. How did they do it?

Miho:

Yeah. I think we did so many promotions for the kids and for the parents. Also we always ask the patients to come back to be treated, to be cleaned. Also we went to the school every year, twice or three times to teach the teachers, or the kids, or something like that. Now I think every six months I went to the kindergarten to check the kids mouths. Now no cavities at all. Then of course parents take care of the kids too, because the number of children is less. They have time to take care. Then I think what I'd really like to do is more time to take care of each kids. Then everything is now controlled.

Then the second step is crowding. They have so many crowing in the mouth. That's why they need the braces now, more than before, so then we can . . .

Howard:

They need the crowding more in 2016, than in 1985?

Miho:

Very, very, very.

Howard:

How can there be an increase in crowded teeth in 25 years?

Miho:

Maybe I think the food is not good, eating or swallowing, and the functions.

Howard:

You do see more crowding?

Miho:

Right, a lot. Almost everybody I think in the children's mouth now.

Howard:

You said at the very beginning that the government doesn't set the fee for orthodontics, because it's not a disease.

Miho:

Right.

Howard:

They set it for general dentistry that's a disease.

Miho:

Right.

Howard:

Do you personally, do you think crowded teeth is a disease, or do you think it's cosmetic?

Miho:

No, I think we are now thinking about not only the dentistry, adult the reason why the brace is aesthetics. Now for the kids it's a health or a good growth now I'm thinking, not the aesthetic things. They don't care about the teeth as cute children, but still they are thinking about. We have many, many allergies too. Open mouth and mouth breathers. Very bad.

Howard:

Japan has many allergies.

Miho:

Yeah, many.

Howard:

In Asia, unlike the rest of the world, unlike the Americas or Africa or Europe, you always see at least, I don't know I'd say about 20% of the people wearing masks.

Miho:

Uh-huh.

Howard:

You just don't see that in LA or Detroit.

Miho:

Right, right.

Howard:

Why do 1/5th of Asians, whether you're in Singapore or Hong Kong, or Japan wear masks when they're walking outside?

Miho:

Right. We think cannot breathe naturally.

Howard:

You what?

Miho:

The close, the lips naturally. They always open the mouth. Then breathes everything through their mouth.

Howard:

You say that people wearing the masks are, because they unnaturally open their mouth, they're mouth breathers?

Miho:

No, that's why I think against infection. They're always thinking about the infection getting into their . . .

Howard:

Okay, so they're thinking about infection.

Miho:

Yeah, they always think about.

Howard:

Why do you think that's in Asia and not France or Rio De Janeiro, or Los Angeles.

Miho:

Maybe I think bite loss and protrusion and [inaudible 00:53:27] many more than America or European countries, that's why,.

Howard:

You think it actually.

Miho:

Yeah.

Howard:

You don't think it's cultural tradition, you think it's . . .

Miho:

Also especially Japan. Food is so soft, cannot eat, cannot bit, so just to swallow is okay. Then the bone in the jaw cannot grow for the teeth. There's so many crowding. They cannot bite. We are now teaching how to bite, how to eat, how to swallow. Usually they can get the normal things right, but we need to teach how to eat, how to bite. We are using the gum, chewing gum, how to . . .

Howard:

I want to ask you another question, from '85 to 2016, we've seen data where Coca Cola and Pepsi and pre-packaged food and sugar consumption has gone up considerably over the last 25 years, but Japan without water fluoridation, decay rate has gone down. To me when I travel around the countries it almost doesn't matter if sugar consumption goes up and water fluoridation goes out. It really comes down to the dental IQ of the parents brushing, flossing.

Miho:

Right.

Howard:

Would you agree with that or would you disagree?

Miho:

Yeah, that's the same thing.

Howard:

Do you think Japan, do you think the children of Japan eat more sugar in 2016, than they did in 1985?

Miho:

Right, right.

Howard:

But they have less cavities?

Miho:

Uh-huh.

Howard:

They don't have water fluoridation?

Miho:

No.

Howard:

It's the dental community.

Miho:

Yeah, we did a good job, right?

Howard:

It's the dental community.

Miho:

Yeah.

Howard:

It comes down to brushing and flossing.

Miho:

I don't have time, right? Like that. We are doing the best things for the people, because no good circumstances for the people, but still there is cavities. The next target is straighten the teeth or crowding teeth and the bimax protrusion, cannot keep the mouth closed, breathing through the mouth or something like that. This is the next target for me.

Howard:

I want to ask you a girl question. It seems like in the United States, which you're very familiar with, girls are putting a lot of dermafillers in their lips and they're trying to puff out their lips. Some of the girls that come into my office, they have so much Botox, they almost look like a duck. In Asia girls with their finger, from their nose, if they're lip is out, they want extractions and they want to pull that back. I look at the before and after pictures, it's like they were beautiful before and it's like, so do you think it's kind of strange to you that the Americans are trying to push their lip out and Asians are paying $5000 and pulling teeth to bring it back. What are your thoughts on that?

Miho:

Maybe I think a nose is higher more than Japanese. Asia the nose is more aligned.

Howard:

You say Asians have a smaller nose.

Miho:

Yeah, that's why . . .

Howard:

Is that . . .

Miho:

Protrusion is not good for the ladies I think. Also I think the orthodontist is always thinking of it. Protrusion is not sophisticated, that it's a problem. For me, protrusion means that you cannot close the lips naturally. It's not good for the health.

Howard:

You see in rest if their lips don't close, that that's not good.

Miho:

No.

Howard:

Explain why? Why you think that's not good.

Miho:

This is a mouth breather a lot. Usually a nose breather is good for the allergies, or for the health. If open mouth, mouth protrusion cannot be exposed naturally, always open the mouth and then the tongue is down. Everything is just through the mouth. It's not good for the health. Their face is getting round, round face syndrome, like that. It's not good. I'd really like to close the lips for the function and the aesthetics. This is the reason why we need to do. At the beginning we just orthodontics so are we now the prevention period three, four, five-years-old. We have trained the kids to gets the real growth. Later of course we do sometimes an extraction, but extraction rate is very late, very low now.

Howard:

I wanted to ask another question, the United States has almost two hygienists for every dentist in America. For almost every dentist doing fillings, crowns and root canals, there's two hygienists cleaning teeth. What is the state of the hygienist in Japan? We know from the Japanese Dental Association website which is on jda.or.jp that there's 103,972 dentists. How many hygienists are there? Are hygienists as common in Japan as they are?

Miho:

Yeah, but it's common. Our professional and dental association has their hygienist school and 40 hygienists graduate every year. Still they always skip a job and when they graduate or they get a child. Then the number of the hygienists is always less, more than demand. We dentists always seek to the good hygienists. Also if I compare the salary, American hygienists and Japanese hygienists, Japanese hygienists are very low, more than American hygienists, because they always do the dental assistant work and then the hygienists work both. Then maybe I think, it's no good circumstances to work for their life, until 50's or 60's. Then that's why I hire so many in their 40's and 50's and the hygienists here I have maybe seven or eight hygienists here.

Howard:

You have eight hygienists?

Miho:

Uh-huh, to work for the prevention way and also to do those way too. These good carrier for the hygienist is good education, for good motivation for the people to continue their job, the carrier. Many 20's or 30's hygienists keep a job, to change a job or something. Because, those are no good motivated and the work for them.

Howard:

To the Japanese dentists, for every ten dentists, how many hygienists would they hire? What would they average?

Miho:

Usually three chairs and the office, maybe one or two hygienists. Maybe one hygienists and two assistants or something.

Howard:

The average dentist in Japan would have a hygienist?

Miho:

Uh-huh.

Howard:

The average dentist?

Miho:

Right.

Howard:

Okay, you don't see that in Asia. You don't see that in Hong Kong, China, Malaysia, Bangkok.

Miho:

No.

Howard:

I remember the first time I went to Australia in think in 1990. They didn't even have hygienists.

Miho:

Oh right.

Howard:

Japan?

Miho:

We have our hygienists each in clinic, because insurance have to be paid with the hygienists. That's why dentists like to hire the one hygienist.

Howard:

Because does the government pay a cleaning if the dentist does the cleaning?

Miho:

A dentist can do, the hygienist can do it, that's why.

Howard:

Can do it also?

Miho:

Uh-huh, uh-huh.

Howard:

Last but not least, is there any differences in cosmetic? Like some countries think when Americans bleach their teeth, that it's too white, it looks like a clown. When they came out with standard composite shades back when we got out of school. When they started bleaching those shades weren't white enough. They came out with white shades like B1. Some countries say the American teeth, they look like toilet bowls and kitchen sinks. Where's Japan as far as bleaching? Do Japanese women like toilet bowl bleached?

Miho:

No.

Howard:

Do they think that looks silly, or?

Miho:

They like to have white teeth, but not like the Americans. Americans like to have more white teeth, but Japanese like to have a natural color teeth. They always ask me. It means they're not like American needs.

Howard:

Do they say that, not like Americans, do they say that?

Miho:

They get too white, they're thinking.

Howard:

Yeah, too white, yeah.

Miho:

Yeah, too white.

Howard:

Do any other countries you know of like it as white as Americans?

Miho:

Korea, Seoul, because I started my own practice, not practice, seminars in myofunctional therapy. They dearly like to eager European style or American style way. Also they dearly like to think about this aesthetic more than Japanese. They dearly like to have more Western style in a way. Japanese doesn't like to have the same tendency.

Howard:

Do the Korean women like their teeth as white as Americans?

Miho:

Yeah, I don't know the white teeth, they dearly like to have white teeth more than Japanese.

Howard:

Not as white as Americans?

Miho:

No, no, no. I think sometimes too white.

Howard:

Don't the Koreans also, everything I read is don't they have the most cosmetic surgeries in all of Asia?

Miho:

Korea it's very popular. Japan not so much. Korea, Seoul is so many cosmetic surgery.

Howard:

What are their most common cosmetic surgeries?

Miho:

Eyes, nose, skin.

Howard:

Eyes and what?

Miho:

Skin.

Howard:

Skin oh the bottom.

Miho:

Skin very popular. Almost everybody had the surgery already in Seoul.

Howard:

By the way, you're not going to believe this, but I've had no surgery. This is all natural.

Miho:

Me too.

Howard:

You too? This is just all me. A lot of it is just culture, like the Koreans.

Miho:

This is the culture.

Howard:

I remember when I was in China, if someone came in and they looked real flashy, the girls would say, oh you look so Korean. Even other Asian countries if you're looking real fancy, they'll tell you you're looking Korean.

Miho:

Yeah. The Korean and surgery and people have the same faces. No characteristic things. For Japanese it's not good. Sometimes the skin is very good for Japanese to see. Korean skin is very beautiful, very white skin, but Japanese is not. Surgery is too much I think for Korean people, but they love to have the surgery, they love.

Howard:

I want to ask another thing, is the diastema, the space between your two front, is that very common in Japan?

Miho:

In Japan they are thinking the spacing between the teeth means they're losing the money.

Howard:

They're losing money.

Miho:

That's why they don't like to fix.

Howard:

Is it true that Japanese have more Class 3's.

Miho:

Yes, that's true.

Howard:

Than any group of people anywhere?

Miho:

Yeah, class 1, class 2, class 3, 30, 30, 30% the same.

Howard:

30, 30, 30. What would it be in say the United States for?

Miho:

I think class 2 is many, right?

Howard:

I heard in the United States it was 80% class 1, 15% class 2, 5% class 3.

Miho:

Maybe class 2 is more, I think.

Howard:

More than 15%?

Miho:

Uh-huh.

Howard:

Well, I guess that would be a bad way to do it, because the United States is 15% African American and it's 15% Latino.

Miho:

Uh, right.

Howard:

I guess the United States would be a bad country to compare to. You would say Japanese have the highest percent of class 3's?

Miho:

Class 3's many, a lot.

Howard:

It's genetic then?

Miho:

Yes, it is, very much so.

Howard:

How do you treat your standard class 3's?

Miho:

Very easy. Just usually at the first at the beginning, three, four or five-years-old. I put it on their appliance, removable appliances. Later then . . .

Howard:

A rapid palatal expander from the front.

Miho:

No, no, no. Just appliance.

Howard:

On the lower.

Miho:

Removable.

Howard:

On the upper or lower?

Miho:

Functional appliances, but they're pre-made. It's very easy and very common now.

Howard:

You start using those on three?

Miho:

Three, four, five, six years.

Howard:

Of age?

Miho:

Age.

Howard:

You start training class 3.

Miho:

Because they can, because the doctor tell this is class 3, go to the dentist. Then puts the appliance on.

Howard:

It's not a functional problem, what would be wrong with having a class 3?

Miho:

No, the tongue is always down, that's why we always push the tongue up. Then class 3 can go to class 1.

Howard:

Is it just cosmetic, the class 3, I mean is it?

Miho:

It's just a functional way to help prevent . . .

Howard:

What I'm saying is class 3 a disease, or just a look? Are you correcting a look or a disease.

Miho:

I don't know why. This is a genetics thing, but still at the beginning of their three, four, or five-years-old. It means its not established things. This is a functional problem, the period. That's why we just, how can I say it? Puts the appliance in the mouth and then to control the function. Then they can grow. Later when the patients will grow, when teenagers, the height is higher. Then the genetics thing will occur ago. This is a class 3 and the father class 3 and everybody is class 3 in the family. Of course we have to take care of that class 3 growth. This is actually aggressive, junior growth class 3 approach in junior school and high school. Before just a functional way. We always intervention of the functional appliance to prevent the class 3 cases.

Howard:

My last question, you're so sweet. You've given me so much of your time.

Miho:

That's confusing.

Howard:

No, no, no. You're outstanding.

Miho:

My English is so not good. I'm sorry.

Howard:

No, your English is amazing. I don't know a single person in America that can say one Japanese word. The joke is if you speak two languages you're bilingual.

Miho:

Uh-huh.

Howard:

If you speak on language you're an American. I'm amazed. What about Invisalign? In some countries Invisalign is exploding. How much of this are you treating with fixed braces and brackets, and how much are you treating with removable clear liners like Invisalign?

Miho:

Oh you mean the number of the patients, or the price?

Howard:

Is Invisalign a big part of your practice?

Miho:

No very few.

Howard:

Very few.

Miho:

They're easy cases only, not many big and the extraction cases. Only relapse cases only.

Howard:

As an orthodontist in Japan you prefer brackets and banding?

Miho:

People like to have the lingual and Invisalign cosmetics and brackets more than middle. Still we have many many crowding cases a lot. Sometimes difficult for the Invisalign to treat whole treatment. If we do Invisalign or if we do half lingual or something. Maybe we can put it on the brackets a few months and maybe to finish the cases. I always ask the patients if I do the last part of the treatment, if I need the braces on to bring out the labial, I do like to finish the good result for the patients.

Howard:

What percent of your practice is Invisalign?

Miho:

I think just 5%.

Howard:

5%.

Miho:

Uh-huh.

Howard:

What percent of your practice is lingual braces instead of labial?

Miho:

Five or 10, uh-huh.

Howard:

Does that seem to be growing or?

Miho:

People are asking me a lot more than before.

Howard:

What brand of lingual braces are you using?

Miho:

You know the company Tomy is Japanese and Creepy.

Howard:

Tomy?

Miho:

Uh-huh.

Howard:

Yeah, I didn't find that website. Do you know the website for that?

Miho:

Yeah, Tommy has a website.

Howard:

Can you find it.

Miho:

Tomy.

Howard:

Tomy. T-o-m-y. Is that a Japanese company?

Miho:

Yes.

Howard:

What was the other guy using My Harmony.

Miho:

There's also Harmony too.

Howard:

My Harmony Smile, that's out of France?

Miho:

Yes.

Howard:

But Tomy is out of . . .

Miho:

This is only the brackets, not like Harmony or [inaudible 01:12:14].

Howard:

Uh-huh.

Miho:

But this is very famous brackets here in Asian countries?

Howard:

Are they in Tokyo?

Miho:

Yes. Also the factories are somewhere, but in Asia Tomy is very important kind.

Howard:

There it is. I found it. Okay tomyinc. I just was going Tomy. What percent are lingual?

Miho:

It's five or ten.

Howard:

Five or ten. Invisalign about five?

Miho:

It's five, less than five?

Howard:

What percent wold be clear brackets?

Miho:

Clear is maybe 50.

Howard:

50?

Miho:

Yeah 50.

Howard:

One last question, in America the adults like our range try to hide ortho. Maybe they go Invisalign, or they want lingual. A lot of the young girls love the wild color rubber bands, reds, blues, greens, oranges.

Miho:

The same.

Howard:

Do Japanese girls like the decorated deals?

Miho:

Yeah, the same.

Howard:

Do the boys like the decorated?

Miho:

Yeah, the same.

Howard:

The boys like it too?

Miho:

Uh-huh. Before they didn't like to have the colored elastics, but now people like to have, especially kids.

Howard:

Kids. What age do they go from wanting colorful rubber bands to hiding it? What age?

Miho:

I think teenagers they like to hide.

Howard:

Teenagers like to hide.

Miho:

10, 11 or 12. The junior high, so the students like to show the braces. Then they like to have a black or pink or something.

Howard:

Junior high, so up to about 12?

Miho:

Uh-huh.

Howard:

Or 13.

Miho:

Uh-huh. Then they like to have the color, but after high school students they like to hide.

Howard:

Starting in high school or after high school?

Miho:

After.

Howard:

After high school. As soon as high school is over, they want to hide it?

Miho:

Uh-huh. Maybe mature, I don't know.

Howard:

Anything else you're passionate about? Anything else you want to talk about?

Miho:

No, I'm so glad to spend this whole thing. I didn't think it was what can I think about these things if you ask me so many questions about. In my brain, so much clearer now to have my own visions or something like that for the future. Thank you so much.

Howard:

Well, you're an orthodontist. We have Ortho Town Website and magazine. We would be so honored to have you write an article for Ortho Town magazine.

Miho:

Just keep in touch and I . . .

Howard:

Or a class in Ortho Town.

Miho:

Yes.

Howard:

You can put a course on Dentaltown.

Miho:

Yeah, I'd love to.

Howard:

Because, you're one of the few orthodontists in the world who will talk to a low life general dentist like myself. I have to go to Australia to meet Derek, or I have to go to Canada to meet Brock Rondeau. Most American orthodontists won't teach anything to general dentists. Hey, it was a huge honor.

Miho:

Oh thank you so much for coming to.

Howard:

To feeding me and my two boys lunch.

Miho:

Oh yeah, I enjoyed.

Howard:

A tour of your house, your parents, everything.

Miho:

Well thank you, thank you, thank you.

Howard:

Just an amazing person.

Miho:

Yeah, we had a very good time together with you.

Howard:

Thank you everyone.