Dentistry Uncensored with Howard Farran

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

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Dr. Jeanette MacLean is a Diplomate of the American Board of Pediatric Dentistry, Fellow of the American Academy of Pediatric Dentistry, private practice owner, and mother of two.  She received her dental degree, with honors, from the University of Southern California in 2003 and completed her specialty training in pediatric dentistry in 2005 at Sunrise Children’s Hospital through the University of Nevada School of Medicine.  Dr. MacLean has become an internationally recognized advocate and expert on silver diamine fluoride, appearing in newspapers, magazines, television, and continuing education lectures on this hot topic.  Most notably, she was featured in the July 2016 New York Times article “A Cavity Fighting Liquid Helps Kids Avoid Dentists’ Drills,” which brought national attention to the option of treating cavities non-invasively with silver diamine fluoride.

http://kidsteethandbraces.com/

Howard: It is just a huge honor for me today to be podcast interviewing my buddy, my role model, my idol, Dr Jeanette MacLean, who is a diplomat of the American Board of Pediatric Dentistry, fellow of the American Academy of Pediatric Dentistry, private practice owner, and mother of two. She received her dental degree with honors from the University of Southern California in 2003 and completed her specialty training in pediatric dentistry in 2005 at Sunrise Children's Hospital through the University of Nevada School of Medicine. Dr MacLean has become an international recognized advocate and expert on silver diamine fluoride appearing in newspapers, The New York Times, I can't believe I have someone in my house that was on the cover of the New York Times, magazines, television, and continuing education lectures on this hot topic. By the way, her Dentaltown online course on silver diamine fluoride, I think we have four hundred and forty-one courses and yours is top viewed.

Jeanette: For 2017.

Howard: Yeah. I think it's four hundred and seventy courses and yours was most viewed. That's frickin impressive. Most notably, she was featured in the July 2016 New York Times article, "A cavity fighting liquid helps kids avoid dentists and drills", which brought national attention to the option of treating cavities noninvasively with silver diamine fluoride. Thanks so much for coming here. 

Jeanette: Thanks for having me.

Howard: And she's wearing a shirt... She brought me a girly bag. Well only a girl would bring you...

Jeanette: A gift bag.

Howard: ...a bag and a treat. But a shirt "BACK IN BLACK," that is so damn cool. GV Black - I don't think he even went to dental school, did he?

Jeanette: That's a good question. I don't think so either. 

Howard: Yeah, I think they were all apprentices back then. I really do.

Jeanette: I'll have to study that. I don't even know.

Howard: Yeah. Google that Ryan: Did GV Black go to dental school? 

Jeanette: And if so, where? 

Howard: He was from Illinois, wasn't he? 

Jeanette: I'm not sure. 

Howard: You remind me more of Pierre Fauchard. You just look more Frenchie. I don't know that means. 

Jeanette: It's the stripes.

Howard: It's the stripes. Yeah, you need to wear a French hat.

Jeanette: A beret. Absolutely.

Howard: I used to always tease because when you look at the nine specialties, if you've got a hundred endodontists in the room, they don't argue with each other. But when it comes to occlusion, it's really like world religions. I mean, you have the Buddhists and the Hindus... My oldest sister is a Catholic nun...

Jeanette: Or carries.

Howard: ...I couldn't send her a book and turn her into a Lutheran. I mean, I don't even know if she thinks Lutherans go to heaven. I mean, they're just that fanatic in their camps. But I always say if you got a hundred pediatric dentists in the room or endodontists, they wouldn't disagree on anything. But gosh darn, pediatric dentists, now they have an argument: silver diamine fluoride.

Jeanette: I was going to say, I disagree with people. Or not even on just SDF but if you put a case or X-rays, you will have, from 10 dentists, 10 opinions on how to best treat that. 

Howard: Well, we have research on that because... you're so young. I don't know if you remember the reader's digest story?

Jeanette: I remember Reader's Digest. 

Howard: They had a guy and he took study models and FMX to thirty different dentists and he got thirty different treatment plans. And it was the feature story on Reader's Digest and all the dentists were all mad and I said, "Well, don't shoot the messenger." Reader's Digest is not fake news. My mom, dad, and grandmas and grandpas all have it on their end table and it's true. 

Jeanette: It is true.

Howard: Sometimes the truth is an inconvenient fact. So then the NHS said, "Is it true? We don't know." So they said, "We're going to expand it to a hundred." So they went and redid the study, went to a hundred different dentists, 98 different treatment plans. Two of them were the same; those were the two guys that said. "Do nothing." So two people said do nothing, and then number three to a hundred had a different treatment plan. And that's when you have to realize that dentistry isn't math; It's an art and a science and it's got huge opinions.

Jeanette: That's the truth and I don't know that that's necessarily a bad thing...

Howard: Really?

Jeanette: ...because there's not like one gospel way to treat things... To me, I like giving parents or patients options, meaning that there's not one,... It's not what I want to do; I can tell you the options and then you have to decide what's most appropriate to you...

Howard: This is dentistry uncensored, so I want to start below the belt, the biggest punch I can give you, and that is: you and I practice in Arizona and we both know that down in Yuma, twice, a baby has died. And the news to me is very unfair because they don't ever portray, well, why does your two-year-old baby need put to sleep and need a half dozen root canals? Is that parent abuse? Are you kissing that baby with rotted mouth, is a babysitter, your grandmother that has gum disease and five cavities? But the dentist... 

Jeanette: You bring up many interesting points.

Howard: ...but it wasn't a sham. I mean, it was a board certified pediatric dentist, correct? 

Jeanette: At the Kool Smiles? They're general dentists. 

Howard: Oh. And Yuma was a general dentist?

Jeanette: To the best of my knowledge, yeah. It's general dentistry.

Howard: I want to start with this: I have four grandchildren. I don't want them to die in the OR, getting pulpotomies and Kromasil crowns. So how old... And then whenever it happens, it's all over social media. 

Jeanette: Let's start there. When that tragedy in Yuma happened and that came out in the media, it wasn't until January and it had occurred in December. But when that hit the news, the same week, we saw headlines about a Department of Justice settlement against Kool Smiles clinics to the tune of $24 million for fraudulent billing, either for procedures that didn't need to be done or never were done. When that was going on, I mean I guess I'm a glutton for punishment, but I was looking at the comments online and the recurring theme from mothers was, "I'm not taking my kid to the dentist." And what does that accomplish? If you don't bring your kid in, do they stay disease-free? Does the disease get better by itself? No. It usually gets worse. It usually gets to the point where you have to do the more invasive procedures like sedation and pulpotomies and stainless steel crowns.

Jeanette: So, we have a dilemma where we're almost like our own worst enemy. And in terms of bad PR, when you see these headlines of kids going in under a dental anesthesia or general anesthesia to get dental treatment and then having the adverse outcomes... The problem is that there's always going to be a need in my specialty, pediatric dentistry, for sedation and general anesthesia because many of these children have disease that's beyond the minimally invasive treatments like silver diamine fluoride or whatnot because they have decay that's into the pulp or they have an active infection and pain and we have to use that. 

Jeanette: But the issue is that sedation is now being used more and more frequently, which is a whole other topic in of itself. Is it just because we're seeing more disease? Is it our style or training as pediatric dentists? Or is it the parents or lack of parenting and parenting styles today where they want the kid just to be asleep and not remember anything, and then the convenience of it? There's all these factors it's a very complicated issue and there's no right or wrong answer. Like you said earlier, you know, we all have these different opinions. You know, the problem is the public, they're... We talk about access to care issues and it's not just that there aren't enough dentists out there, but part of it is, sometimes the parents don't want to bring the kids to us because they have that fear of when they see the headlines of death or they see a headline about unnecessary treatment being done. We have to regain trust, I think, in the public's eye. 

Howard: In my fifty-five year, my thirty years... My dental practice turned thirty last September 21, 1987. 

Jeanette: Congratulations.

Howard: My marriage only lasted twenty, but my dental office lasted thirty. How's that? My dental office went 50% longer. The biggest change I've noticed in society in the thirty years that I've owned a business is trust is going downhill in our leaders. I mean for twenty years... I think it's embarrassing when people are proud of being a particular party. Both parties have had an 11% approval rating for twenty years. So you're proud of your party when 89% of the people don't trust it? 

Howard: I grew up with five sisters. I played Barbie dolls until I was twelve. So when the engine light comes on, for me it's the idiot light. I've never looked under a hood one time. So when the man comes out and says I need a new alternator, I...

Jeanette: You trust what they say.

Howard: I have to trust. So when I take my granddaughter to you and you say she's got four cavities, I have to trust you. 

Jeanette: And most people still trust that but then you see that declining because then people... and part of it might be the media or living in the electronic age where we could go online and email friends or we could go on Facebook or in chat rooms and the mommy groups and discuss, just say, "Hey, I went to the dentist and my kid had ten cavities. What do you guys think about it?" And they're looking to their friends for the opinions as opposed to trusting the dentist...

Howard: Now are dads allowed in mommy groups? Are you guys just sexist animals? 

Jeanette: It's just women. And we are sexist I guess. 

Howard: Oh my gosh, I'm being discriminated against. 

Jeanette: There's definitely a trend where we're losing trust in people in positions of authority, not just in dentists, or car mechanics, or politicians. The problem is because there's a few bad apples when that hits the media and get shared over and over again...

Howard: Oh, the guy across the street from me owns Greulich auto supply...

Jeanette: ...we get grouped in. We get grouped in with the bad apples...

Howard: ...He says he gets all his business from his school, his church, to little league guilds, because nobody trusts his trade. And when they're meeting him on the playground, they're like, "Will you not lie to me if I bring my car to you?" 

Jeanette: I mean, it's frustrating because the majority of us obviously got into this because we want to help people and we are honest and we're doing the best that we can to the best of our knowledge. But there are instances where there are people with unscrupulous business practices who do negative...

Howard: ...What percent of the general dentists do you think that you... How long have you had your pediatric dental practice in Arizona? 

Jeanette: I moved back in 2005 when I graduated and... 

Howard: ...So thirteen years. 

Jeanette: ...I've been at the same practice, but the practice is much longer than, much older than me, more like forty years. To get that reputation...

Howard: ...In your thirteen years, what percentage of dentists do you think are unscrupulous? That you've seen it with your own eyes? 

Jeanette: I think it's this small minority..

Howard: But how small?

Jeanette: Really small.

Howard: How small? 

Jeanette: I never even thought about it to put a number of it, but... a small percentage. The problem is too it's..

Howard: But, I mean, it's one out of a hundred? Do you think it's one in ten?

Jeanette: ...not just about greed or fraudulence, sometimes we're doing things because we were taught... 

Howard: Differently.

Jeanette: ...that it was the right thing. 

Howard: We have a big dilemma here in Ahwatukee because we're all friends, we're all drinking alcoholic buddies, we all eat cheeseburgers and drink together, but I swear to God, you show a bite wing to one of the guys, he doesn't see any cavities. And then my other buddy sees like eight and I see like four.

Jeanette: I think of myself as...

Howard: ...and it's three good guys that disagree. 

Jeanette: So I think of myself as very conservative, but the way I was trained, I now like to refer to it as Medicaid mentality, where we were trained that we were somehow doing the kids a favor by aggressively treatment planning them. So any white spot lesion, they're getting a filling...

Howard: ...because it might not ever be back. 

Jeanette: That was the mentality. Or any inter proximal lesion was automatic stainless steel crown. But then when I got into private practice where it wasn't a majority Medicaid population and it was mostly ..

Howard: I thought you were in Phoenix...

Jeanette: ...cash pay or private insurance, that did not fly. When they were footing the bill and you say, "Well that's a class two, let's do a stainless steel crown," they're like, "Whoa, whoa, whoa, whoa, whoa," because all they're seeing are dollar signs. And there was this demand to try to be more conservative and I would do a filling instead of a crown. And then to my surprise and delight, did that tooth abscess and blow up like I thought that it would? No. Usually they fared very well and the composites held up well. So it just showed me that I didn't always have to be so aggressive. I mean, that's just one step in me changing. 

Howard: I'm going to hold your feet to the fire, though. I'm going back to death. I'm the Grim Reaper. Is the papoose board not an option? I mean, if putting you under...

Jeanette: No, it's still an option. It's still an option. Absolutely. 

Howard: It's still an option?

Jeanette: Yeah. It's a very controversial thing but for me, I do have papoose boards in my practice and we use them when we're doing oral conscious sedation because I don't want the kid...

Howard: ...and what is your oral conscious sedation?

Jeanette: ...rolling on the floor... That's when you drink the sedative medication...

Howard: ...Right, but what is your cocktail? 

Jeanette: Most often I use Versed.

Howard: Versed?

Jeanette: Un huh. When I first started out...

Howard: Which is... Valium?

Jeanette: It's in that...

Howard: ...Family.

Jeanette: ...benzodiazepine family. When I first started out I was doing triple cocktail, which I don't...

Howard: ...and what was the triple? 

Jeanette: ...do anymore. That's when the kids were more deeply sedated...

Howard: ...and what was in that?

Jeanette: ...so we would use chloral hydrate, demerol, hydroxyzine. I've really put the brakes on... 

Howard: ...the narcotics.

Jeanette: ...sedation. Right. Because we were seeing more adverse outcomes. And then also becoming a mother, my approach to treatment planning is different because having been on the flip side of it... My daughter had surgery when she was nine months and it's one of those life changing experiences when you're on the other side of the table and they're saying, "Your kid needs surgery,"... Like the joke, when you know too much, you worry too much. But of course in my mind was...

Howard: Were you a bad patient parent?

Jeanette: ...everything bad. Yeah, questioning everything. When I was younger and I didn't have kids of my own, I had that like, the doctor, you have to do what I said and my word is the gospel. And I used to get annoyed when parents would have all the questions because I was very dismissive of their fears until I became a parent and I was the one with all the questions and the fears. So now I feel I can empathize better with the parents and take the time to acknowledge their concern and engage in a discussion and build their trust. 

Howard: I'm going to interupt you with a funny story: I met a dentist in Albuquerque and he practiced in Los Alamos. It's all nuclear scientists and they're all on the edge of the scientific universe and he quit because every frigging scientist would come in with thirty questions for a filling and he couldn't even answer half the questions about these resin model... And he finally said, I can't do an hour scientific lecture for every stupid filling. So he left.

Jeanette: I get it. It's frustrating because, like another joke is, we dread the moms and dads that are nurses or engineers because they always have all the questions, like the more high maintenance, but having been on the flip side of that, now I find that if I take the time to discuss with them, I build their trust and they become the most loyal, best advocates of our practice. We really don't spend anything on advertising. It's all word of mouth from existing patients or pediatricians or people in the community, and I think that's a big part of it. And that parent that was questioning everything initially, once you build that trust, then they become like the town crier that "This is the great office and you've got to go here" and they're the best and people trust what they have to say. 

Jeanette: So it's worth taking that extra time even though it might be annoying or exhausting. But I think that they deserve that from us. If I brought my children to the pediatrician... Or for example, like the concept of whether or not to allow parents back for treatment. When I first started out I was trained not to let the parents back, but now I let the parents back because I'm a parent and there's no way I would go to the pediatrician and just send my kid back. Like, "Bye." I want to be there and learn and hear and ask questions. It just seemed kind of crazy to me: why wouldn't we want the parents there to see what we're doing? Especially because there's a lack of trust now or question of us...

Howard: ...even the Catholic church one point zero miles from my house, right around the corner; Huge lawsuits, and the whole Catholic community I will tell you is shaken. Penn State coaches... When you read the media, your kid's dying at the pediatric dentist, the priests are crazy, the coaches at Penn State are crazy... 

Jeanette: That's their news feed, so of course they're afraid. So I can build their trust and then eventually we get to the point where often they're like, "Go ahead, I'm going to sit out here on my smart phone and you go do your appointment." Eventually we do get to that point once we've established the trust. But if it's someone new to me and they don't know me, I don't blame them for having those concerns.

Howard: So then why do some kids need IV sedation if you can sedate them and put them in a papoose board?

Jeanette: Why do they need IV sedation? It depends on a lot of factors. Oral conscious sedation doesn't work on everyone. One in five kids will have what we call a paradoxical reaction where they're actually worse when you sedate them, especially with Versed, they'll get what we call the angry drunk reaction. It's like an exorcism. And you can't work on them...

Howard: Are you talking to me or Ryan? 

Jeanette: So it's a lot of things. There are some three-year olds that will let me give them a shot, put a rubber dam, drill their tooth, fill their tooth, and they just sit there like an angel. No problem. Then you'll get a ten-year old who's like, they look at you walking in the door and they're screaming and crying and freaking out. So it depends on the behavior and that child's coping skills, which, you know, in our era of the snowflake children, a lot of kids today don't have good coping skills. That's why they're going off to college and they can't cope. Anyway, that's another story. 

Howard: That is really crazy. You're supposed to feel guilty if you didn't help your kids do homework. Could you imagine going up to my dad and saying, "Dad, will you help me with your homework?" I bet if I handed him the book, he would have taken the book, hit me over the head with it and thrown it on the floor. 

Jeanette: Right. It goes back to what I mentioned earlier...

Howard: My dad went to one wrestling match. I was a varsity wrestler for four years; he went to one match. Now if a child misses a match, you know it's...

Jeanette: Right. If you're not there at every single one, you're a bad parent. Yeah. The parenting styles have changed dramatically. And that's a huge reason why we're often forced to do more sedation is because parents have the expectation that their child shouldn't cry for anything. You know, there's some kids who don't even, or some parents who don't even want us to do a cleaning on the kid because they're crying or they won't brush their kids' teeth at home because they cry. Like, who is the parent? My kids used to cry because they had a poopy diaper and they didn't want their diaper changed or they used to cry when I tried to put them in the car seat. Am I going to like leave them sitting in poop and not put them in a car seat? It's just, "Duh." I don't get... Where did that stem from?

Howard: It's almost like we're dumbing down the society. 

Jeanette: Yes.

Howard: I mean, we really are. I've seen some really well done scientific studies that... back then everyone was working. And they were working a lot just to pay the bills and eat and survive and they were happier. But now that they're working less and they have more free time, they're playing with their navel and getting unhappy. You know what I mean? 

Jeanette: Or looking at their newsfeed and seeing everyone having their highlight reel of everything is fabulous and then there's a lot of depression. 

Howard: So I've never heard anybody say the angry drunk reaction... 

Jeanette: We were talking about what would lead to needing IV sedation. Some kids you can work on them with just behavior management: Tell, Show, Do. Some kids are fine with nitrous oxide. Then you have kids who need a little more, like they might be afraid to put the nitrous hood on them, so you could give them oral sedatives and they might do very well. But there are those that their behavior almost gets worse when you do the oral sedation. 

Howard: So which one of those patients do you think Ryan is? 

Jeanette: He seems like nice and pleasant, so usually those are the happy drunks. But the kids who start out like they won't look at you and they're like... those often become worse. Although once in a while the hellion kids become an angel and the parents are like, "Can I get a bottle of this for at home or for a car ride?" But the thing is, you have less of a working window with the oral conscious sedation and there're some children who come to us with a full mouth... twenty rotted abscess baby teeth and we really have no other option, like it's better to do the general anesthetic. 

Howard: ...and get it all done with. I want to go back to that because to me, it's hard to say anything came good out of AIDS. But I lived through the AIDS. I mean it was, it was in '79. I graduated high school in '80 please don't tell me you weren't born then. Were you born in...

Jeanette: I was born in '76. 

Howard: All right. Made my day. So it was in '79 and it was just... like Reagan never mentioned...

Jeanette: I very much remember watching all that in the media as a child. 

Howard: Like Reagan never mentioned HIV or AIDS or gay or homosexual his entire presidency and it was just... the story was just slowly dribbling out. It started off as gay cancer, all this stuff. But the one positive thing of the whole HIV thing is the entire planet got religion on STDs. The only one who fought it really was South Africa, which now has a 25% HIV-positive rate. Ryan and I have lectured there and when you go to every dental office, the dentist's like, "Well who cares about their decay? They're all HIV-positive." So it's all... You go to dental offices and the whole dental office is, HIV, all this stuff like that. Because their president thought it was a lie, thought it was a conspiracy, didn't let the World Health Organization come in. But all the other countries in Africa, Asia, Latin America, they all got religion and I feel like that process hasn't even started yet with the other end of the body. I mean, everybody knows that you can get gonorrhea, syphilis, chlamydia down below the belt, but they don't realize when this newborn baby is born, you hand it to grandma and she's got an upper denture, lower partials, six millimeter pockets, hasn't been a dentist in five years and she kisses the baby on the mouth. So here's my gut feeling, and I got ten times more guts than you - I have a lot of gut feelings, and when I see a two-year old that had that bombed-out mouth, mom has a bombed out mouth, dad has a bombed-out mouth, the babysitter... - it's a family thing. 

Jeanette: Yes and no. Yes and no...

Howard: So then we're eating, the family,... Like, here, try this pumpkin pie and and she's handing streptoccocus mutans on you... 

Jeanette: Let's back that up. The new hot research is in the human oral microbiome and I can give you some articles I'd love for you to read about that. And the point that that makes is our body has more bacterial cells than human cells... 

Howard: Ten to one. 

Jeanette: ...so we're never going to be bacteria-free. And in our mouths, we're always gonna have bacteria. And even when a baby is born, they take on the microbiome of their mother. So yeah, you're going to get that transfer but the thing is even healthy enamel will have bacteria that can cause caries on it. When you have a child with more decay, yes, you're going to see higher levels of the more cariogenic bacteria. But that shift, more often is happening because of their behaviors, meaning frequent consumption of carbohydrate or frequent consumption of acidic or sugary beverage. So you know, if they're sipping apple juice...

Howard: So you think it's more dietary than microbiomes.

Jeanette: It's both. It's bacteria and fermentable carbohydrates. So if a baby is...

Howard: Now I'm Irish. Did you know that vodka is not sugar? Did you know that? Beer and wine are fermentable carbohydrates? 

Jeanette: We'll recommend bottles of vodka, then? It should help the baby sleep, too.

Howard: Vodka is not... That's true. Didn't a dentist on the show tell me that? It was a dentist on the show told me that, that beer and wine... Anyway...

Jeanette: But if your mouth is in this constant acidic state because you're constantly eating and drinking these things, your bacteria, your biofilm, shifts to the more cariogenic bacteria and they thrive. The more acidogenic and more aciduric bacteria is having a party and your teeth are going to rot. It's not because, "I have soft teeth," which they love to say. Right? Like, "It's genetic." No, it's more your behaviors. Yes, you can have congenital enamel defects like hypoplasia, amelogenesis imperfecta, but it's more what you do to those teeth... 

Howard: So you think when a two-year-old comes in and needs eight pulpotomies and Kromasil crowns that the diet is just the main cause? 

Jeanette: More often than not, yes, because there's no brushing, they're not getting fluoride, they're snacking. Our kids today, they graze all day long. No wonder there's so much childhood obesity and type-two diabetes because these kids go to the mall and what do you see? You see a kid in the stroller with their snack cup tethered to the stroller. They got their sippy cup or like a fountain drink, lemonade, and they're eating crackers. Crackers is one of the worst snacks you could possibly have but parents are kind of duped into thinking it's healthy because of the boxes. It's "whole grain" or it's organic whole grain bunny crackers. They think it's healthy. They don't understand when their kid nibbles that all day long, they're just feeding the bacteria. It sticks to their teeth like paste. Remember making paper mache and it was flour and water and it made paste, right? So bunny crackers, mix it with your saliva, it literally makes orange paste on their teeth and it just rots their teeth. So if you have those poor feeding habits, you're going to get a lot of cavities. 

Howard: So as a pediatric dentist, do you think you ever change mom's behavior? With the decay?

Jeanette: Sure. Of course. There are some highly motivated parents who genuinely didn't know that. Like they'll say, "Gosh, well I was giving them 100% juice," or "I give them only organic this and that." They truly believe they were doing the right thing. Or they were exclusively breastfeeding or breastfeeding all night long because La Leche League had told them that "Breast milk can't give you cavities." Well, once you introduce carbohydrates, it's almost more cariogenic, especially if you're co-sleeping and letting the kid nurse all night long that is the most devastating...

Howard: I have to interrupt you on that because... in economics, the law of unintended consequences: you do something good and it can be bad. So I think it's really cool that now when my daughter-in-laws are giving birth to a baby, a lady comes in to go over breastfeeding. I mean obviously I don't think they needed lessons the last two million years...

Jeanette: And now we do.

Howard: ...but someone's going to come in and give you a deal. But a lot of those girls that come in and do that, they look into the baby's tongue and they say, "Oh, he's tongue tied, he needs to have a laser phrenectomy." And that's another big debate. In fact, I even, I had a patient... 

Jeanette: You emailed me about it too. Sometimes they legitimately need it and benefit from it, but if you think that humans have existed... 
Howard: ...Two million years. A hundred and eight billion humans...

Jeanette: How did we ever survive in a world where we didn't have pediatric dentists or dentists with lasers, you know what I mean, like you can overcome some of the things...

Howard: But are you doing a lot of that in your practice? Do you see a lot of…

Jeanette: I don't, but if I see someone with a legit tongue or lip tie, I will refer to a colleague that does it, but I would definitely say...

Howard: And who's that, an oral surgeon or a...

Jeanette: I have a pediatrician in North...

Howard: That has a laser?

Jeanette: ...Phoenix that will... Well, he actually uses scissors or scalpel...

Howard: So you just don't want to do it? 

Jeanette: Well I don't find that... I think 75%, especially of the maxillary tie, most of that will self-correct as the alveolar bone grows. But if they have a true lip tie or true tongue tie, then sure, I'll recommend to have it done. But I think that there are...

Howard: But you won't do it yourself?

Jeanette: ...more being done than really need to be done because it's another billable procedure... 

Howard: So I want to back up on another deal. I got so many. I'm coming at you from so many angles. So very interesting: ASU is a big anthropology hotspot. I mean we have Lucy, the 1.6 million year old complete hominid: thirty-six inch tall, seventeen-year old girl... But anyway, the anthropologists, independent of dentistry, have really been posting a lot of studies amongst themselves saying, "Why is there no malocclusions over the last two million years and then a hundred and fifty years ago they just explode?" And then their own non-dental mind are saying, well probably because they were nursing for a couple of years and now if the baby has a trouble nursing you give it some sippy cup with a gorilla-size or a whale-size nipple on it and then... Back in the last two million years, your mom probably threw you a mastodon bone and you were chewing on it. Now she's feeding you puree apple sauce... 

Jeanette: Goo in a pouch. That's really good for business too, have you... Everything is pureed and sweet and in a pouch So you have all these kids with flavor aversion...

Howard: So there's no forces.

Jeanette: Right. They don't know how to... They have to go to feeding therapy because they don't know how to eat food. Sit your kid at the table, eat a meal as a family. Don't just hand them crackers and goo in a stroller... 

Howard: But we have ten thousand eight hundred orthodontists putting the babies of three hundred and twenty-five million people, the herd's three hundred and twenty-five million, and they're throwing all their babies through a ten thousand eight hundred person orthodontic machine because the kid never fought nursing, he never chewed, he never had any forces spreading out his maxilla. And that's what the anthropologists are saying. What do you as a pediatric dentist say to what they're saying? 

Jeanette: I've seen those comments that if you were breastfed, you won't need braces. And that's such a loaded statement. I'm sorry, there's plenty of kids who were breastfed... Like I was breastfed until I was one; my mouth was a hot mess. I had two oral surgeries, impacted canine, braces, and still my teeth aren't perfect. So, it's not just the breastfeeding...

Howard: It's multi-variable. It's a multi-variable..

Jeanette: It's a wonderful thing to do, I breastfed both of my kids, but... 

Howard: But it does beg the question... They say we're two-million years old as a species. A hundred-and-eight million have come and died and there's seven-and-a-half billion alive today. And of that first hundred-and-eight million, there's almost no malocclusions. So then you look at the herd today of seven-and-a-half billion and it's rampant widespread. So I am sure it's multivariate.

Jeanette: I'm sure processed food probably has a lot to do with it because like you said, you know back then and you're hunting and gathering and you're tearing, whereas now things are highly processed. So I'm sure that has something to do with it. 

Howard: But do you see any like pediatric dentists, like coaching parents that you could prevent ortho if you were eating mastodon shit and chewing on a goat rib...
Jeanette: I have not done that, but maybe that's like a new way we need to... I haven't seen that as trend.

Howard: Because I still don't see dentistry... Like in Phoenix, we fluoridated the water and that's preventative. But the profession as a whole, I don't see any of the orthodontists in any of the schools taking the lead to try to find out why the first 108 billion humans didn't need an orthodontist. I don't see any of the practices talking...

Jeanette: It is an interesting question. I mean as a pediatric dentist...

Howard: It reminds me of HIV in 1979, it just doesn't exist. And I mean they, they talk about prevention and fluoridated cavities, but they don't talk about prevention... And the media... Whenever a child dies in office, of course, a lot of stuff went wrong, 

Jeanette: It's like the bad dentist...

Howard: But the media never, ever, singley will ask, "Well Jeanette, why did your child need eight root canals age two?" 

Howard: What a dad. What a mom and dad. 

Jeanette: I know. And that's my frustration, too. We're trying to fix the problems. We didn't put the cavities there, you know? Then we become the doormat, like it's all our fault when we're just trying to help and it's frustrated because when...

Howard: Your job reminds me of that. I was talking to a friend of mine and his son was there and his son was all upset because his... What grade are you in in ten, is that fourth grade?

Jeanette: When you're 10 years old? Yeah. About. 

Howard: They wanted to hold his son back because he can't read and he's all mad at the school and he's all mad and all this stuff like that. And I'm just looking at him and say, "Buddy, that's not the teacher's baby. That's frickin your baby. So you're telling me you have a ten-year-old baby that can't read. How about you're a really shitty parent."

Jeanette: Right. Well that's the thing. It's like we have to take ownership of the problem and the problem with many parents is they don't want to take ownership of the fact that the cavities are in many ways their own fault for lack of hygiene and poor feeding. They want to blame it on something else. Soft teeth. Dad has bad teeth like they want the excuse. That is a delicate discussion because again, I want to empathize with the parents and they don't like when you're like, "You're a crappy parent. Here's your $5,000 treatment plan for general..." There's a way to sort of kindly open that discussion of, "Okay, you're here now to fix this problem and I want to help you do that and let's get back to the root cause of the problem. What can we do to help prevent this from happening again? What can we do with their diet?" And I give them a handout on a food-based approach to cavity prevention. I use one from Roger Lucas who, I don't know if you podcasted with him but I'll have to have you connect with him.

Howard: Where's he from?

Jeanette: From Washington. But a diet-based approach to cavity prevention because again, it's often what you're eating and when and we'll look at that...

Howard: Do you ever recommend that for their next baby they choose a different mate? 

Jeanette: No.

Howard: We're talking about colleagues. I got to ask you one thing before I forget it. You have another friend, we both have a common... Joel Berg, who was a pediatric dentist - Seattle. 

Jeanette: Yes. 

Howard: There's a big... that made newspapers. What was that all about? Or do you not want to talk about that? 

Jeanette: I honestly don't know enough about it. I know that he is moving here. 

Howard: He's moving to Phoenix?

Jeanette: Um-hum. But I know there's...

Howard: No way. When's he moving to Phoenix?

Jeanette: I think he is already here. It's a recent thing. 

Howard: Do you have his contact information? 

Jeanette: Yeah. 

Howard: Do you have his cell phone?

Jeanette: Yeah.

Howard: Oh my God. Let's call him right now on the podcast. Is he going to practice? 

Jeanette: I think he does more on the business end now and practices... 

Howard: Because he's a board-certified pediatric dentist, right?

Jeanette: Yeah. So I mean... 

Howard: Did you know I am too?

Jeanette: ...having not gone to university of... You're a board-certified pediatric dentist?

Howard: I am. I bought it on Ebay. 

Jeanette: That's news to me.

Howard: And a black belt in karate and an eagle scout. It was all for $9.99. 

Jeanette: You paid too much. 

Howard: Gosh, I did not know Joel Berg moved here. 

Jeanette: I don't know. I know that there were... 

Howard: So he's a business consultant? 

Jeanette: ...financial issues with... 

Howard: The budget.

Jeanette: ...with the program and...

Howard: But I wasn't talking about the budget and the school. I was talking about the silver diamine fluoride research. 

Jeanette: Well, he wasn't really involved with that. Are you thinking of Jeremy Horse at UCSF? Because he does...

Howard: I thought it was University of Seattle did a big silver diamine fluoride...

Jeanette: San Francisco had a big paper on it. 

Howard: University of Washington didn't? 

Jeanette: You're probably thinking of the UCSF protocol for SDF. That was a huge turning point... The New York Times article brought a lot of public and dentists' attention to this as an option because it wasn't...

Howard: You were a Rockstar for a month on social media. I didn't run into a single dentist in Arizona for over a month where they didn't say, "See one of our local homeys made the New York Times?"
Jeanette: Well, it's funny because it was good and bad because there was a lot of backlash to that article and I certainly took the heat for it. One of the things that people were most upset about was the fact that the mom said how much she paid for the SDF and people were pissed...

Howard: How much did she say she paid?

Jeanette: $25 and the thing is... 

Howard: That was too much?

Jeanette: I didn't... The reporter asked me and I said, "Listen, as dentists we don't feel comfortable discussing fees because it's considered collusion or price fixing. And I wouldn't tell her what I charged for a filling and what I charged for the SDF. So she went to the mom and the mom was like, "Oh yeah, well I paid this and then I paid that." And then that made the article. So of course everyone jumped on me like, "I can't believe that... and you're in Arizona and I'm in this hoity toity this and that." And people were really upset and I explained that I wasn't the one who put the price out there. But I mean, come on, if one drop is basically pennies per tooth, when you really think about it, it's like, well, how much upcharge can you really put? 

Howard: Well. it's...One of the biggest problems in healthcare is 80% of the cost or variable cost of labor. Like the SMP 500 average is 53% labor. Well you pay the dentist 35%, staff 25%, or Fifty-five. It's all the same. Then you have lab: 10, you have supplies: 6, you have mortgage: five. And then when you go to the hospital they don't have a time bill. Well, you were in the hospital for twelve hours and we charge a thousand dollars an hour so they have to go off things they bill. So then the media makes fun; Well they charged me $500 for Tylenol. Yeah. But when I go to the Hilton, I mean imagine if the Hilton couldn't charge me for a room. They had to say, well, you used toilet paper. 

Jeanette: You used too much toilet paper.

Howard: You used the towel and you used the sheet and you're like, well, I didn't crawl under the... When 80% of your costs are time-based, you need just a fricking hourly rate. When I was getting my MBA from ASU, it was frightening because there are two-hundred kids in there and some are these little hospitals and they said Medicaid or Medicare insurance will pay us like $40 for an exam and that exam will cost us $200. But they'll give us $100,000 for a bypass and $70,000 for colon cancer surgery. So we have to do... As long as we do three or four surgeries a day that are the big ones: coronary artery bypass graft, a mastectomy, colon cancer. So as long as we do three or four big surgeries a day, we cover everything we do at a loss. I'm like, well damn, that's fright...

Jeanette: That brings us to another problem...

Howard: ...And you're a woman doctor... United States has the highest Caesarean rate of any advanced country. So you have countries where the doctors are on salary... 

Jeanette: This is very controversial.

Howard: But I've seen solid data where the OB-GYNs are on salary and they have about a 4% OBS Caesarean section. And then I see America with one in four. I have a staff member: four babies, all four C-sections. And it's just like, none of her four children needed a C-section. 

Jeanette: Why is that? And why have many left that profession? Because their malpractice rates were obscene because they're all getting sued. Anytime anything went wrong, we're suing the doctor where, not everyone has this easy perfect birth. Like everyone wants... again, people want to blame someone and then it's easy to blame the deepest pockets, so let's blame the OB-GYN and let's sue them. So then the fear is like, if I delayed, if I waited too long for the natural vaginal birth... So now maybe some are jumping to the Caesarean because there's that fear of litigation. And then the flip side is, are we doing it because you get reimbursed more...

Howard: Do you know where that name came from?

Jeanette: From Caesar?

Howard: Did you know that? 

Jeanette: Yeah. 

Howard: Isn't' that is just amazing. It was the first city. 

Jeanette: It's disturbing to think back...

Howard: It was the first city. Kind of a weird fact just came out from these same anthropologists. Rome was the first city to hit a million, but you always found all the ancient hominid fossils in eastern Africa. And now Germany just found a 9.8 million tooth. Because it didn't make sense, I was like, well the oldest people were in Africa. You'd think that's where the Great Wall of China would be, or the pyramids or you would just think... So the first city had a million. Now they just found a 9.8 million-year-old tooth. Caesar... one in 10 women died during childbirth. And if they thought the woman was dying on the side of the road with a moving baby, the soldiers would pull their sword, lance open the stomach to save the child. Wow. 

Jeanette: Yeah. It's barbaric.

Howard: And now you get an honor trophy just for participating in your child's sport. 

Jeanette: That was my article for Dentaltown. Everyone gets a trophy. So here's another dilemma, is we're fee for service based, right? So we get paid or incentivized by the procedures that we do. So the problem is that the most invasive procedures are reimbursed the highest, but they don't necessarily produce the best result, i.e. better health for the patient. Whereas the things that do have the highest impact, for example sealants, an 80% reduction of caries or SDF and upwards of 80% arrest of carries. Those things are reimbursed the smallest. So if you have someone who's only going to get x dollars to do SDF, but I can go do a stainless steel crown, like it's a problem... Another controversial topic is like, do we stay fee for service or do we go to capitation? Are we measured on health... 

Howard: Do you have any relationships with any of the Arizona insurance companies? I mean, are you... 

Jeanette: No.

Howard: You're not drinking buddies with the head of Delta or Metlife? 

Jeanette: Unh-uh. I am on the Arizona Dental Association's AHCCCS subcommittee. AHCCCS is our Medicaid here, so we... 

Howard: Which was Obama's craziest thing he did. He obviously never owned a business because when he rolled out Obamacare, he had a federal Medicare program that everybody knows, but what did he decide to do? He decided to go through Medicaid, which every state is different and I had so many patients saying, "Oh, I hate Obamacare." I'm like, well, you're on AHCCCS, that's Obamacare. No, it's not, it's AHCCCS. And so you had all these people who loved their state Medicaid telling me they hated Obamacare. And it's like, imagine going to market with a product and it was going to have a different name in every state. I mean you just can't do that. 

Jeanette: Well, and then the funny thing here is we have so many different plans under AHCCCS and they each have their own rules and you have to credential through them separately. It's like you have to go through flaming hoops when you want to be a Medicaid provider, which...

Howard: And you are a Medicaid provider? 

Jeanette: I am a Medicaid provider. 

Howard: And why did you do that? I mean, it's not for...

Jeanette: Why not? 

Howard: ...financial reasons.

Jeanette: Right. I mean, the reimbursements are terrible. To me, I have a duty to take care of kids. 

Howard: So you know you're losing money on Medicaid and you do it anyway. 

Jeanette: I do it anyway. 

Howard: I've always thought you're just... I told Ryan when you came over, I said she is the most solid person.

Jeanette: This is the problem. Let's get back to access to care. So, right now we have the debate going on in Arizona with dental therapists. If I thought dental therapists would solve our access to care program, I would be the first person in line saying, "Whoo, I want dental therapy." But having more bodies to do more of the same old, same old that hasn't cut caries rate in children, it's not the answer.

Howard: So are you for dental therapists are against them? 

Jeanette: Again, if I thought it would solve access to care problems in our state, I would be the first one in line. But graduating a bunch of dental therapy...

Howard: Were you for it or against it?

Jeanette: Against. Especially in the way it's currently written because the problem is there's nothing that's going to guarantee that the dental therapists would actually go into the areas that need them. I would bet money that what's going to happen is they're all going to settle into the metropolitan areas. 

Howard: So you've been here since 2005. When did A.T. Still open? About that time? 

Jeanette: It was right around then. Right. So now we have two dental schools. When I went to dental school, we didn't have any dental schools in Arizona and now we have two. So we have lots... It's not a... 

Howard: How many does does Midwestern graduate a year?

Jeanette: ...provider problem, it's distribution problem. 

Howard: How many does does Midwestern graduate a year?

Jeanette: Is it a hundred and fif... I honestly don't know. A hundred?

Howard: Ryan, can you see what the graduating size class of Midwestern in Glendale and A.T. Still. 

Jeanette: They're big size classes.

Howard: I've been watching this prob... It's a distribution problem, for thirty years. There would be a dentist in a small town in Kansas, you know, half the way from Wichita to Denver, in the middle of nowhere, and he can't get a girl born and raised in Wichita or Kansas City, Kansas to move to his hometown and be a hygienist. So then he goes to the local high school and he knows he's got to get a girl born in this town of 5,000 and then he'll say, okay, write me an essay on why you want to be a hygienist. You might win a scholarship. So two girls wrote an essay and he was like, dude, I need two hygienists. So he said, I'm writing the check for you to go to hygiene school. But then when they apply to hygiene school, they didn't get accepted because they needed a 3.85 GPA. So they fill up this class with all these kids born in the metropolitans who get 4.0s in algebra and geometry and trig, and then Blythe, Arizona, the rest of its life doesn't get a dentist, a hygienist, a registered nurse. 

Howard: So to go in to those deans, you talk to those deans say it's a distribution problem. Do me a favor, don't accept anybody in your dental school from a town that's larger than two hundred and fifty thousand. And then what do they say? Well, you know, the U.S. News and World Report, you know, they say what our average DAT score is and we want to have our... Well, are you serving U.S. News and World Report? Are you serving the taxpayer base of Arizona? And I mean, I think if every... And then you look at the largest, fastest growing economies in Arizona and there's mines out in the middle of nowhere and you talk to these mine owners and they say, I need right now, today, ten mechanical engineers. But guess where they all are? In Tempe and Scottsdale. And then I say, well, can you live out here? And they're like, what are you out of your mind? But the kids born in that town, they love the fact that their kid can go ride a motorcycle and shoot a 22 rifle. You can carry a 22 rifle into the gasoline station when you're ten. But those people were born in that lifestyle. And the schools, the government, the hygiene schools, they're so worried about that you got an A in geometry and I've never used geometry, calculus or trig in thirty years of dentistry. And I bet I spent a thousand hours in the library memorizing that useless crap. 

Jeanette: So we agree it's a distribution problem. Let's talk about what the other pro... It's not just distribution...

Howard: Just real quick: Midwestern class size is one-fourty-one.

Jeanette: I was close. 

Howard: And the average GPA was 3.47. A.T. Still class size is seventy-six and they accept 2.3%. So when people say, why did the dental schools raise their price ten thousand a year? Well, A.T. Still it's a hundred grand, $100,000 a year and they only accepted 2.3% of their applicants. And then that dentist says, well, why are they raised the price. Dude, if you could double the price of your crown to Delta Dental, you would do it. So don't be mad at the schools. So, their graduates, what is that combined? One fourty-one, sorry, I'm blind, and seventy-six. So what's six plus one? Two-hundred-and-seventeen.