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: So we're throwing two hundred and seventeen dentists in the city every year. 

Jeanette: And not many are near retiring because not many dentists can retire now because of what has happened with their portfolios - a lot of people lost a lot of money... 

Howard: No it's the alimony payments!

Jeanette: And that! 

Howard: Just keep your husband for financial reasons. 

Jeanette: So it's a distribution problem. But then another problem too is, let's get back to the ideology of the disease. What is caries? Do fillings and crowns cure caries? No, they're just treatments for the disease. So just having more people doing more of the things that are not cutting the disease incidence is not going to improve our oral health. So now let's look at spending. The oral health initiative, I believe it was, looked from 1990 to 2010 that the rate of untreated caries in children remained stagnant at 30%. 

Howard: For Arizona?

Speaker 1: Just overall, nationally. And then in the underserved population it was worse at 50%. So we have not improved that. But our spending went from 1 billion to 7 billion and then it's projected to go to 15 billion by 2020. Is that sustainable - to keep doing more of what hasn't worked? So that's where you start to look at we need to redirect the bus. Where is this bus headed? 

Howard: How would you redirect the bus? 

Jeanette: We need to get back to the disease process, focus more on prevention. Like we talked earlier, the headline of: “Oh, the baby dies at the dentist.” Well again what are you feeding your kid? Are you using fluoride? Are you brushing their teeth? Let's prevent the problems from happening where the teeth get so rotted and infected that they have to be sedated for work. Don't blame it on the dentist. Let's get back to preventing the disease. 

Jeanette: Do you know Kirk Robertson from Flagstaff, Around the Mountain Paediatric Dentistry? 

Howard: Kirk who?

Jeanette: Robertson.

Howard: No. 

Jeanette: He had a really profound, I thought, statement about trying to rationalise the issue with why dental therapy is not going to improve our situation in that, like when we were dealing with the problems of smoking and lung cancer, how did we tackle that? Did we say, “We need more surgeons to cut out the diseased lungs?” No, we need to put money into prevention and education to teach people what will happen if you smoke. You know, let's get back to prevention or shifting the focus of treating the disease, especially with children. 

Jeanette: How can we reduce costs and improve outcomes? And for me, I've been able to do that with Silver Diamine Fluoride. So since 2014 i.e. before SDF in my practice, I've reduced my use of sedation 67%. 

Howard: Damn!

Jeanette: If you think of that in a state with one of the worst caries rates in the country... 

Howard: Why are we that state?

Jeanette: The Southwest in general has higher caries incidence. So a lot of it is diet, hygiene, low SES…

Howard: Low SES?

Jeanette: Socioeconomic status, or you see higher instances of caries in those populations. But as I'm reducing my sedation, I'm also reducing costs to access. When I can do less invasive procedures like SDF or smart fillings or hall crowns... 

Howard: Smart fillings? 

Jeanette: So silver-modified atraumatic restorative treatment. 

Howard: Say that again, you're talking over my head. I know I’m old, senile and slow, but you’re over my head.

Jeanette: So SMART…

Howard: What is a smart filling?

Jeanette: ... is an acronym for Silver Modified Atraumatic Restorative Treatment. 

Jeanette: So ART, or atraumatic restorative treatment, really came into the eye in 1994... 

Howard: Silver modified atraumatic …

Jeanette: Restorative treatment. You know ART, atraumatic restorative treatment, using glass ionomer... 

Howard: Can I take you off on a detail real quick? Another thing I lived through, where I think dentistry is going the wrong way is, when I started this thirty years ago, all the fillings were silver and all the crowns were gold. 

Jeanette: And did you see a lot of recurrent caries around those silver fillings? 

Howard: No.

Jeanette: And why is that? 

Howard: Because silver's half mercury, which I've never found in a multivitamin. And the other half is silver, zinc, copper, tin – stannous fluoride is tin. Silver Diamine Fluoride – the whole amalgam's out... 

Jeanette: Right. The silver is antimicrobial.

Howard: I know. And now you're a horrible dentist if you use amalgam and they're using these..

Jeanette: Resin composits, yeah.

Howard: ... inert plastic deposits which are basically... And I’m telling you this, that for thirty years, taking it out and then the dentists are just so dumb. They say, “Oh, you cracked a tooth.” Dude, it was in there thirty-eight years, you moron, and now you're taking them out and putting in a plastic filling... 

Jeanette: That's going to last on average how long? 

Howard: Six years. And they say, “Well look at those amalgams – there's black scuz.” Well look at her composite. 

Jeanette: Black is beautiful.

Howard: Number four round burr, mush oatmeal coming out of it. So why do all the paediatric dentists not use amalgam? 

Jeanette: I use amalgam. I still use amalgam, it’s a great (inaudible: 5.44)

Howard: So what percentage of your fillings are amalgam? 

Jeanette: It's a small percentage because most parents are, again, thanks to this electronic age and social media, they're afraid of the 'silver fillings' and it's 'toxic'...

Howard: Tell them they'll never see the silver because the orange cheez it will cover the amalgam. 

Jeanette: That's a great point. But there is this demand for the white fillings but it's not just that. There's concern for what's in the material, but there's also concern for the appearance because if the mouth is full of silver caps and fillings it makes them look like a bad parent.

Howard: Do you think amalgam is toxic for a child? 

Jeanette: Well mercury is toxic at certain levels, sure. 

Howard: But do you think a silver filling is toxic for a child?

Jeanette: No. 

Howard: And that's the other thing with these dentists, how did you get out of dental school? Silver, an amalgam, it's an insoluble solid. All you've got to do is (indistinct) one, swallow it and the next morning there it is in your stool and you can get it out and weigh it and swallow it again. But through burning coal in my lifetime, the ocean has gone from one part per million mercury to four part per million. And that's a free absorbable, ethyl- methylmercury. You know who the top scientist really is on that? (Indistinct) - and he did a ton of research on aborted babies and all the ethyl- and methyl mercury in their brains was from eating seafood, not from a dental filling. And so you see these dentists taking out all these silver fillings and they're wearing a NASA spacesuit and and making a psycho show out of it. And then at lunch they go eat six popcorn shrimp and have salmon in their salad... 

Jeanette: I still have amalgam. I think it's a great material. There's very little interest in it. You know, it's not always people's choice. It's funny how much more accepting they are of it when that's what their insurance pays for. All of a sudden it’s okay. 

Howard: Do you think Medicaid, and Medicare for the poor, getting their filling done with redistributing money from other people, do you think they should just say we only cover amalgams? 

Jeanette: I don't think that's fair either - let's get back to self esteem issues. Some kids think their silver fillings and crowns are so cool and then all their friends want it and I've actually had siblings fight over who had more silver caps, which is a way to have a positive attitude! But there are some kids who are mortified by it, which is really sad. So I like to give options and if they want the white, let them have the white filling. 

Howard: I had a problem with an insurance company when I got here in '87 and the guy lived right around the corner, he never even thought about it. He was paying, I forget the average fees, but it was $1 cheaper to pull it. No, it was $5 cheaper to pull it than to do the amalgam. So I'm sitting there at this Medicaid Clinic in (indistinct) and the moms say it's cheaper to pull it. And I'm like, “Yeah, but then you don't have a tooth.” So I got them to flip those. 

Jeanette: I have a problem with them forcing, like you can only have this or that. And that brings us into another fear that dentists have about SDF - there's this fear that somehow, especially Medicaid, will then say that's all you're allowed to do. And I don't want that either. I think that's ridiculous because SDF is not a cure-all. It's a treatment for caries... 

Howard: How many paediatric dentists are there and how many are endorsing this? How many peadiatric dentists are there? How many would you say?

Jeanette: SDF has had the quickest adoption – the people who brought it – Elevate Oral Care – the people associated with that also brought Fluoride Varnish to the market in the US. 

Howard: Elevate Oral Care, out of Florida? 

Jeanette: Yes. I should look at newer numbers, but they estimate that the adoption of SDF has been four to six times faster than Varnish.

Howard: Can you send me that Ryan? Elevate Oral.

Jeanette: I remember a day and time when Varnish was new and some people used it, some people didn't, but now if you go to the average paediatric dentist's office, we're all using Fluoride Varnish. And now not every paediatric dentist is using SDF yet, but there has been this astronomical rise of adoption of incorporating SDF into their practice. And I do give a lot of that credit to the New York Times article for not only bringing their attention to it, because they maybe didn't learn about it in dental school, not maybe, actually. And then also the public demand because you have patients asking for it by name. 

Howard: So that's where you buy yours. If my homies want to order this, that's where you're ordering it.

Jeanette: That's the only place in the US that you can get it. They are the exclusive distributors of Silver Diamine Fluoride in the United States.

Howard: And they distribute it from where? Who's making it? 

Jeanette: Palm Beach, Florida. It's their own small company. They're don’t have a second party. 

Howard: So, they're not a distributor, they actually make it.

Jeanette: They make it and distribute it themselves.

Howard: Elevate Oral Care?

Jeanette: And they also make varnish and other mostly preventive products. But, I don’t think... 

Howard: So, the website is Elevate Oral Care, elevateoralcare.com – the only place that makes and sells it. And they've got they got Sodium Fluoride Varnish. You liked that too? 

Jeanette: I liked their varnish is a 2.5% varnish. it's more like a Shellac, so it's nice and thin. That's probably the other most common product that I use from that. And it comes in a bottle, so you can put out just a little bit as opposed to wasting a whole unit dose because I put varnish over my SDF applications. 

Howard: So, I'm going to read something off their website. The Back Black. The Dr. GV Black, often revered as the father of modern dentistry, described the use of silver compounds to treat teeth as far back as the late eighteen hundreds. In 1906 Dr Black published a paper on silver nitrate, the predecessor of the 2014 FDA-cleared formula for Silver Diamine Fluoride 38%. Elevate Oral Care is proud to pay tribute to GV Black with our Back in Black T-shirt, while raising money and awareness for children's dental charities with a focus on access to care solutions. Join the movement and show your support with your own Back in Black T-shirt. 100% of the proceeds will benefit children's dental charities. 

Jeanette: Right. So that's the shirt that I brought to you. 

Howard: I still think that you look more like Pierre Ferchaud.

Jeanette: That came out of a gift for Jeremy Horst, who wrote the UCSF protocol for SDF, which is a wonderful resource, a lot of people have used that. So, I made him a little black onesie for his baby with "Back in Black, with G.V. Black, And then, you know, our little group of SDF nerd friends were like, Ooh, that's cool. I want one of those too. So, I started making them and then my friends at Elevate were like, you know, can we make those shirts and sell them and then we'll give all the proceeds to children's dental charities? 

Howard: So, who's the owner of that?

Jeanette: Kevin Thomas, Steve Pardue... Is it four? There's managing members. Those are the two that I know the most.

Howard: But who's the owner?

Jeanette: They're partners in it, they call it managing members. 

Howard: There's two guys, each own half?

Jeanette: I think it's actually four. I know Kevin Thomas, Steve Pardue...

Howard: Are they all dentists?

Jeanette: Not the ones that I know. 

Howard: So, there's four managing partners? 

Jeanette: I can't remember off the top of my head. The ones that I mostly talk to are Kevin and Stephen. They're some of the nicest, smartest people that I have met and they're pretty incredible. 

Howard: I know and it's so embarrassing because here's a dentist all day long selling dentistry and he says I hate to sell or I don't want to sell dentistry. And then when I started Dentaltown in '98 – I owned Dentist Town, but I started Dentaltown because if it wasn't for five hundred dental companies, we'd be sitting out on a rug, chucking teeth with stuff we bought at Home Depot and I would get messages like once a once a week, to this day, well so and so's on there and he works for a dental supply company. He's selling stuff. And I'm like, well, what are you – a volunteer? What do you work at – a homeless shelter? And to this day Orthotown, (inaudible) in Orthotown. There's five thousand orthodontists on there. They won't let anybody on unless you're an orthodontist. And so, I have all these people asking me from these big orthodontic companies, well, what do the orthodontists think about this? I don't know. I'm not allowed to go on either because I'm not an orthodontist. I can't go on Orthotown and I own the site and I think of how many... 

Jeanette: Makes you want to be on there even more, right? It's like when you're not invited into the club. 

Howard: Well it's like the orthodontists would be served so better if all the companies making all their shit could see what they're saying about their stuff. And, keeping them out of the equation, I don't know… And America is the most dysfunctional because when you go to Europe... Have you ever been to the IDF meeting in Cologne? So, you go to the European meetings and the guy that lectures is the owner of the company and all the Europeans figure, well this is your company, this is all you do your whole life, you know more about it than anybody else. In America we're like, oh, I don't trust you. You're selling something. And then they go listen to some dentist mediator who's an expert in like four hundred million things, you know, it's crazy. And so, when you go to the IDF meeting, there's no lectures. So it's the biggest meeting in the world, a hundred thousand dentists go, it's every other year in Cologne, Germany. And Cologne is the coolest town. It was the furthest outreach of the Roman Empire. So they still have the Roman wall around there and it's the only place you can get Italian food in Germany that's really Italian food. I just love that place. But there's no lectures. And so those guys that own that company, they would be answering all the questions and all the Germans and Europeans want to talk to the owner and they don't give a shit if you have a DDS or a DMD. It's like if all you do is make orthodontic brackets your whole life, I'm sure you've thought about it before. You know what I mean? 

Howard: So is there any glass ionomer use in your practice? 

Jeanette: Oh, I'm glad you brought that up. So, going back to materials, I still have amalgam, I still do resin and I do lots of SDF, but I'm using more and more glass ionomer cement. And my feeling is in the US we have a love affair with resin, right? Like we were bonded on it. That’s how I was trained, and I got little to no experience with true glass ionomer in dental school. Like our glass ionomer was vitro bond, which really is a RMGI or like a liner, you know. So, I wasn't placing glass ionomer restorations. So now I'm using the Fuji Glass ionomer product, it's like EQUIA forte for fillings. I use the triage for sealants or the Fuji 2LC, which is a like our MGI. But the problem is if you're used to dealing with resin and you don't know how to properly handle glass ionomer cement, you're likely to get failures and what would the classic American dentist's attitude be if they have a failure of the material? They're going to blame the material and not that they don't know what they're doing. 

Howard: So you go to America and they have three amazing car companies called Chevy, Chrysler and Ford. You know what I mean? Then you go to Japan – my Lexus is a 2004 with a hundred and fifty thousand miles on it. The car hasn't even burped or farted the whole time and yet every one of my children and friends who had bought an American car since that... So, you go to Japan, what do they use more of? Glass ionomer or resin?

Jeanette: Glass ionomer 

Howard: and they affect New Zealand and Australia huge

Jeanette: It's big in Australia. 

Howard: Grant Millisage, who's the guy? 

Jeanette: Jeff Knight 

Howard: Jeffrey Knight. And then the Americans here are like, the Chevy, Chevy works better. 

Jeanette: It's really difficult. Like you talked about religions earlier, we get so focused on what we were taught or what we learned, and we forget to look at the big picture or to remember that, you know, our education is a lifelong journey. We didn't learn it all in dental school. It's just the beginning.

Howard: Do you think glass ionomers prevent recurrent decay better than resin?

Jeanette: I do, I mean they chemically bond to the tooth structure. It's not micro mechanical resin tags like with the resin. Technically speaking on a microscopic level, as soon as you light-cure it that is leaking, and you get bacteria in there and you can get recurrent decay. Whereas when you place a glass ionomer cement, it's actually transferring ions, fluoride, aluminium, strontium into the dentin and the enamel and it's a stronger bond. It's a better bond. It's not going to have the microleakage. Yes, for example the triage sealants, in time they can wash out.

Howard: That should be the brand name - better bond. 

Jeanette: In time, they can wash out. I was given these misconceptions of glass ionomer and never really used it much because I was taught that it fractures, or it washes out blah, blah blah. But, you know, going back to your car that has lasted forever, if you look at the Fuji line of glass ionomer cements, I mean they have been around for decades. They're the tried and true perfected materials that are just underused and undervalued in our country. I think they only represent like maybe 3% of the market share because everyone is using resin here.

Howard: In the United States?

Jeanette: Yes, everyone is using resins. 

Howard: By the way, some people have commented, they've told me that Fuji is no longer in Japan, that it's in Switzerland. 

Jeanette: Well GC America is. So for Canada, the United States, GC Europe, so they are in Switzerland too. 

Howard: Fuji moved to Switzerland for tax purposes. Their management is still Japanese and lives in Tokyo. 

Jeanette: Correct

Howard: What is your most common filling in a paediatric bracket? Is it a six-year molar or is it a primary? 

Jeanette: You know what, it's a class two on a primary molar because the parents aren't flossing. So again, there's the education we want to get the kids in earlier. 

Howard: So your most common filling is a class two on primary molar. And what percent of those are in pairs? 

Jeanette: Oh, they're almost always kissing cabby. It's the anatomy of the molar, the primary molars are like these big rectangles with this flat broad contact. So, getting back to the ideology of the disease as a biofilm and bacteria or behavioural disease, if you have the biofilm in that tight contact the saliva, which is like our natural defence against caries because it's bringing back the calcium and phosphate into our enamel, it can't pass through that context. You have this stagnant area where the biofilm is just having a party and the parents aren't going in there and flossing because little Johnny cries and you know, I don't want to make little Johnny cry, so they're not flossing their kids' teeth. The other problem too is a lot of times they have those cute little gaps in their front teeth, so it never even occurs to the parent when the kid is three, four, five that their primary molars have that really tight contact. They're not flossing their own teeth, let alone flossing their kids' teeth. And that's like classic. So they'll end up with, especially if they delay going to the dentist, they'll come in because all of a sudden there's this huge visible hole trapping food between the molars. 

Howard: So your most common is primary first and second molar. 

Jeanette: Yeah. 

Howard: And what percent of those are MODO, same time kissing cavities. 

Jeanette: You know, we have so many kids where every quadrant has kissing legions...

Howard: But the point I'm trying to make to the young kids is that they're staring at this bitewing and they go, oh, well there's an MO on A but B looks good. No B has a cavity too – your X Ray is done open contact. What percent of the time? 

Jeanette: What I would do in that scenario is I am not going to overtreat that. If there is a true cavitation and let's say the deal would be, and let's say there's an incipient lesion on the mesial of A, I'll place the glass ionomer restoration in B. I'll treat the mesial surface of a with Silver Diamine Fluoride, and then in time, every time they brush with a fluoride toothpaste, it's going to recharge that glass ionomer and it's going to release. It's going to share the love with the neighbour and help remineralise so it's going to help prevent the lesion on the adjacent surface. And it's really good if you have it on the distal of a second primary molar and you have an incipient lesion on the mesial of the permanent molar. In my lecture I have some X-rays where I show where I've placed the Fuji EQUIA Forte as a class two on the distal of the primary molar and then SDF on the mesial of the permanent first molar, and you can literally see that little black triangle, that little incipient lesion, disappear. 

Howard: Now do you see why her online CE course is crushing it? 

Jeanette: So you know, we need to be less is more, you know, we have to stop. 

Howard: You've already talked about five different articles you should write for Dentaltown magazine. You have cases on that you could do? 

Jeanette: I have so many. 

Howard: Do you talk to Tom regularly? 

Jeanette: I'm starting to get this almost overwhelming demand to comment and lecture and you know, before we started taping I mentioned how I never sought out in life to do this. This all has kind of happened by accident. I'm just a mom and a dentist and you know... 

Howard: How old are your kids? 

Jeanette: Now they're six and eight. But you know, public speaking scares the crap out of me. 

Howard: Really? You seem like a natural. 

Jeanette: I'm good one-on-one and can be self-confident but when you get up in front of this audience, and especially if it's like the people who question everything and something controversial and my fear is like they're all going to come at me. And I know I'm supposed to picture them in their underwear, but... 

Howard: Really, I never heard that! 

Jeanette: No? Well that's just because you're confident and you do a lot of public speaking and stand-up and stuff. But that's one of the things they tell you. Like if you're scared, just pretend the audience is naked or in their underwear and you'll be okay. It doesn't work. 

Howard: You know why you don't have to be scared. It's actually insultory to tell them why it doesn't (inaudible). Like I love stand-up and I've done every comedy place in the valley five, ten times each in the last twenty years. But it's that I don't respect you enough to be insulted. And you know if I say a joke and you say I don't like the joke, I don't care you don't like the joke, I thought it was funny. 

Jeanette: My problem is I care too much.

Howard: Yeah, exactly. And so, when I'm lecturing, if you don't agree, well buddy, I don't agree with everything you say and it's okay to disagree. So, I don't care if you don't think I'm funny and I don't care if you don't agree with me because the first hundred and eight billion humans are all dead. And of the seven and a half billion humans alive today, what percent will you never ever meet? I mean, how many humans are you going to meet in your life? 

Jeanette: 99%?

Howard: So, you add the hundred and eight billion that are already dead and the 99.99999% that are alive that you're never going to meet. So your whole life is really one-on-one. So no matter how big that room is, you're just talking to me, you're talking to one on one. 

Jeanette: The more I do it the more confident I get and the more relaxed, you know, it becomes second habit. It's not like I sought out to do this, it just sort of happened.

Howard: Right, it's a law of unintended consequences. 

Jeanette: The thing is, especially when it comes to SDF, there's a lot of interest in it and a lot of what was initially available were like more people in research and academia where they can tell you all how cool it is and the science and the literature, but for the wet-handed dentists we want the how-to, you know. So I think that's why what I have to say resonates with dentists as they want to know how does this translate into my everyday practice? What is my private paediatric dental practice? What does this mean for me in 2018 if I add this in? And I feel like I'm that voice of reason showing people how I've incorporated it into my practice and how it's benefited me. Because a big misconception is people think that because I'm so vocal about SDF, they think somehow I'm saying that that's all teeth need or that somehow it's all I do and that couldn't be further from the truth. I mean, the truth is my stance is take nothing out of your toolbox. I still do all the bread and butter paediatric dentistry – fillings, crowns, extractions, space maintainer, sedation – I still do all of that. This is just one more thing that I've added in. It's like having one more item on the menu. 

Howard: Did you get the memo that humans hate change? 

Jeanette: That's what I bring up too, it’s like I'm such a creature of habit. You know, dentists are very type A. It's hard to change and a question I'll get is like, well how did you end up doing this? And really what it was is as a mom, like we talked about earlier with my daughter having surgery and that changing the way I wanted to empathize more with parents. And then we talked also about the risks of sedation, which, you know, it, it's always going to be necessary in my specialty, but if we could do it less, if it could be a last resort. That would be great. 

Howard: Have you reduced your sedation two thirds? 

Jeanette: But like I had an emergency situation with an IV sedation patient in my practice many years ago and you know, it was such, it was one of those events where you're like, you feel like you're watching from the corner of the room and everything's in slow motion. And those two things made me...

Howard: How did it turn out?

Jeanette: The child was fine. He recovered, but it's still that scary moment where it made me question, you know, what can I do better for my patients or what can I do differently? And it was around that time that I read an article by a friend of mine now, John Forcella, on SDF in an online article. And my initial impression, you know, because we're sceptical, I'm highly sceptical, I don't like change – was what is this like some hippy tree-hugging crap? Like I just thought it was bs. And that's the thing is that, you know, that's the initial, because we didn't learn about it in dental school. The knee-jerk reaction of many dentists – and I don't blame them because I did the same thing – is they think like, this is like bs. 

Jeanette: They don't know that there's this massive body of scientific literature to support its efficacy and beyond that, like beyond when it was created in Japan, if you go back to US dentistry in the eighteen hundreds or in the early nineteen hundreds where we were using silver nitrate, which is the precursor to Silver Diamine Fluoride, you know, that I never knew that. It's fascinating.

Howard: Talk about how it was used. 

Jeanette: It was used to arrest caries. I mean they would apply it to carious lesions and it could arrest caries but the problem...

Howard: And they used it all over the body –

Jeanette: Sure, well, that's the thing. 

Howard: Open wounds, sores…

Jeanette: We've known for centuries that silver is antimicrobial. 

Howard: And tin.

Jeanette: Right. So, going back to the amalgam fillings that's why you don't see all these recurrent caries around the amalgam fillings and they last forever and ever.

Howard: Thirty-eight years. But who's counting? Obviously not Americans.

Jeanette: But you know, silver nitrate was flawed in that it leached calcium and phosphate from the tooth. So it did leave the tooth brittle. It wasn't perfect. And then I forget, I think it was 1908, but GV Black went to Colorado to study the mysterious Colorado brown stain, which proved to be fluoride or fluorosis really. So when the US, kind of in the 1950s or so, we went all in on fluoride like we thought fluoride was going to be the cure-all and we left silver nitrate by the wayside. But you know, here we are, it's 2018 and caries are still rampant, you know, 91% of the population has caries. So, has fluoride cured all our ailments? No, it's a wonderful and important thing, but it's not a cure-all. 

Howard: And then compare that to STDs, which have almost vanished. 

Jeanette: Right, and why did they vanish? We focused on prevention.

Howard: Because they changed behaviour.

Jeanette: Right, so if we're going to fix caries, let's get back to the disease and prevention and not about we need more soldiers and dental therapists and more dentists drilling and filling. You can't drill your way out of a bacterial and behaviour disease. 

Howard: That's going to be your quote - you can't drill your way out of this disease. 

Jeanette: But again, you know, there's always going to be a need for fillings and crowns and cosmetic. Like yes, you know, it's not going to put us out of business and even if it did, wouldn't that be a great thing? Do you think if we discovered a cure for cancer are the oncologists going to be pissed that they're out of a job? They should be celebrating!

Howard: Do you know how many of my cousins and uncles in Kansas believe that there is a cure for cancer and that there's a conspiracy? 

Jeanette: It almost makes me like this conspiracy theorist. It's like, well, how did I not do it? But again, you know, SDF is not a panacea. It's not a cure-all, it's another treatment. And what's special about it is it's non-invasive. So in my patient population – young children – who could be traumatized by treatment or who could have adverse outcomes from treatment or the treatment is more expensive when we're having to do sedation and you know, again remember our spending is projected to go to $15 billion. 

Howard: Was that fifteen billion spent in Medicaid or just insurance or just the whole... 

Jeanette: Dental expenditures.

Howard: Dental expenditures for children?

Jeanette: Here. You want me to look at the stats? You're a nerd like me.

Howard: I know I love the numbers because dentistry last year, 2017, I believe it was $118 billion for USA. So this fifteen billion... 

Jeanette: I'm pretty sure it's on children's dental expenditures in Medicaid.

Howard: Okay that makes sense. 

Jeanette: That's why it's a smaller number. 

Howard: It'd be 10% of the whole pie. 

Howard: Oh my god, that's how I know how you're young enough to be my daughter. If you're fifty-five, you have to have this size phone with readers. 

Jeanette: Well my text is much bigger than that because my eyes are starting to go... Read the whole thing. Why not? 

Howard: So what have our current approaches to caries prevention... Is this your slide? 

Jeanette: That's a slide from my lecture.

Howard: Oh my God. The healthy people (inaudible) report that from 1990 to 2010, the percentage of children with untreated decay remained virtually unchanged at almost 30% and in underserved, rural and minority populations the percentage is significantly higher – 50% during the same period yearly. Governmental dental expenditures for children increased from one billion to seven billion. Spending is expected to reach fifteen billion by 2020. This data indicates that oral health is not improving in concert with the spending. Nice. 

Jeanette: Right, so do you think throwing dental therapists at this problem is going to solve the problem?

Howard: Well I like your analogy of the lung cancer – we don't need another hundred surgeons cutting out...

Jeanette: Yeah, we need to approach the disease differently. So what I'm a proponent of is what the concept of the medical management of caries and I credit to my friend and mentor Steven Duffin who has a CE on Dentaltown on the medical management of caries. 

Howard: He's in California?

Jeanette: He's in Oregon and he was an early adopter of silver nitrate covered by fluoride varnish, which at the time was like DIY Silver Diamine Fluoride because up until 2015 you couldn't purchase, legally purchase, SDF in the country. That being said, people would smuggle it in from Japan. I have a friend in LA – Bernard Gross shout-out – who you know would smuggle in (indistinct), which is just so funny. Like it's just, it's freaking fluoride. 

Howard: And guess who I bought this house from. 

Jeanette: Tell me. 

Howard: I don't want to, I don’t know if I can legally say this, but a person in America couldn't get the chemo for her cancer. So she sold her house and went to Sweden. So it's like, okay, so I'm an American, I'm dying of cancer. I'm allowed to die, but I can't be a lab rat. That was the most un-American thing I'd ever seen in my life that you have to leave the country and die in a foreign land because your government thinks you're so damn dumb that you can't take a drug because they haven't approved it. How about burn the FDA down? No, I'm serious.

Jeanette: I mean FDA has more to do with the sale of things. 

Howard: Right, complete corruption. 

Jeanette: So wait, where did this come from? Oh, so the medical management of caries... 

Howard: Because they had to illegally bring the stuff in. 

Jeanette: Okay. So the medical management of caries is this concept of treating the disease with medicine first as opposed to surgery. So surgery would be the drilling and the filling, the cutting of the tooth surface. That's the surgical intervention, right? But if our first line of defence against the disease of bacterial and behavioural disease could be prevention, education, diet modification, topical antimicrobials, bioactive materials like glass ionomer cement that release fluoride and have all these benefits to the neighbouring teeth. My hope is that we will at some point hopefully shift somehow. I mean it's a monumental task like changing people's mindsets, especially dentists. It's so hard because what they were trained and indoctrinated in in dental school is almost like a religion. 

Howard: It is a religion.

Jeanette: Let's discuss for example the concept of complete caries removal. You know, I was trained that you had to do complete caries removal, which meant drill until you see white. You know, we were almost like dentine racist, like drill till you see white. The problem is sometimes you saw pink because you were into the pulp. But you know, if you look now at how that's more of a myth, like the concept of complete caries removal, you're never going to get all the bacteria out of the tooth. It's down in the tubules. Right? And then if you place resin that leaks at the margins, you're going to get all this mush...

Howard: It glues the walls together.

Jeanette: It doesn't.

Howard: And the tooth is stronger than it was before. 

Jeanette: It's a cure! So, you know, we have to get over these hurdles and I should mention there's a newer group or organization called the American Academy of Cariology which has emerged and that's one of the hopes is to impact education in the US because depending where you go to dental school, there is not consistent... 

Howard: What's the name, the American Academy... 

Jeanette: American Academy of Cariology. 

Howard: Where are they based out of?

Jeanette: Well, it's a national and there's people from different states. The one I know in particular is Doug Young who's from University of Pacific. Their meeting this year will be in conjunction with Canberra which, will be in Denver. And then their initial, like their inaugural meeting, was in Atlanta at the ADA last fall. And I mean talk about being in a group of like-minded people – I felt like I was at church. They were like, hey man, like because people were talking about what we were just talking about how, you know, how we have to get back to the ideology of disease and you know, doing more fillings isn't going to improve people's health. 

Howard: So that's AAcariology.org 

Jeanette: Yes.

Howard: But you know, for thirty years whenever I was with Senator McCain and his wife Cindy, I always said, you know, we got all these great hospitals and you put casinos on reservations. Why don't you have an FDA-free zone on these Indian reservations and it'll be a billion-dollar business. Because again, when this lady had to move, I was saddened because not only are you going off to get chemo and eventually die, but would you rather die in your home or in a foreign country? I mean, what's the whole point of hospice, is that so you can die at home, and this lady had to die in a foreign country because of our government. And I'm like, I'm a libertarian. I mean, I've been a registered libertarian my whole life and I just thought that was the most insulting thing. 

Jeanette: Well, on a positive note with the FDA, they did grant STF the breakthrough therapy designation, which is reserved for, usually it's given to cancer-fighting medicines like lifesaving drugs for diseases which have no cure. So to give that to a medicine that treats caries, that's like it's the only oral medicine to ever receive that designation, which that's a big frikken deal. 

Howard: You know what's still insulting though? Right now, people in Phoenix who have lung cancer, have to fly Southwest Airlines to Havana, Cuba because the government, we're running like a 0% five-year survival rate and they're running over a quarter with this vaccine. But the FDA is investigating it for three years. Meanwhile you have to fly Southwest Airlines publicly traded to Havana, Cuba to have a one-in-four shot. 

Jeanette: Well, I mean the classical American arrogance is that we know it all and we're the best and the brightest and the (inaudible), but when it comes to dentistry and medicine, we're really behind. 

Howard: Whenever I hear an Americans say we're number one, it's like, oh, so you've never left the country. I've never been to Denmark, Sweden, Switzerland. 

Jeanette: We joked about it – I was just in Vancouver lecturing at the Pacific dental conference, which was awesome. I mean literally standing room only crowds and that was one of the things I joked about as this American arrogance that somehow we're better. But meanwhile, like no one knows how to use glass ionomer and they're not... The Canadians are using glass ionomer. 

Howard: Let me give you a couple of examples – like have you ever seen the dike in New Orleans that got hit by that hurricane and flooded the whole town? 

Jeanette: Oh yeah. I'm sure I have. 

Howard: And then have you ever seen the dikes in Scandinavia? I mean their’s looks like Star Wars built it, all these seam-out walls and locks and channels. Then you go to the American dyke and it's a dirt mound. It's like it's going to happen again and they've already been flooded. They'll be completely washed out again and we're the greatest. Another one. What's another example? Oh, Sydney, Australia. So in America, all the interstates are on the top and there's not enough of them. You know what they did in Australia – they bore tunnels under the ground. So, my brother lives like an hour from the airport and in a surface car we would be like an hour and you get in a taxi or an Uber and you'd go about three blocks and he drops into some tunnel and is shooting a hundred miles an hour and you pop up on the other side. And it's like why? And then like in Arizona right now, the I10 – they just bought... No, you can't even make this shit up. They just bought a block of houses from 48th Street to 51st Avenue and tore them all down so they can build their little flat interstate. Australia would have tunneled under them. And what would the difference in costs be because you wouldn't have had to buy two rows of houses a hundred blocks long. 

Jeanette: So, let's go one step further. Like think about when I was in dental school, living in Pasadena, you know, the traffic in LA is horrible, right? And they just more recently started having more of the street cars. Or even here in Phoenix, you know, now we have the metro link, the light rail. But those were the same train track lines that were used way back when, like when the car industry came about and they got rid of all the streetcars and basically forced everyone to have a car, you know, it's like ridiculous. Like what happened to the public transportation? 

Howard: And have you had gone down to San Fran and seen the building that's falling over, have you seen that? They just built a forty/fifty story building, but it's all condos but it's slowly sliding over. So it's lawsuit galore. People are moving out and all that kind of stuff. And it's the same thing, like, well, why didn't you go fifty stories down? Because do you think they'll ever get an earthquake again that's a size eight? 

Jeanette: They could. 

Howard: And how do you think the fifty-story building's going to do? 

Jeanette: Not very well.

Howard: Yeah, and it's already falling over now and if it went fifty story, I don't know. But anyway, but it's all progress. Thanks for turning 

Jeanette: We've gone on so many tangents here. This has been an interesting conversation. 

Howard: I'm discovering. Did I miss anything? 

Jeanette: We have the same thinking pattern... all over the place. 

Howard: Yeah. You know what? But seriously, I want to say one thing. I've known you for a long time, your course is the most viewed, and I know so many people in Phoenix that know you, but you're everyone's mentor. You're everyone's idol. I mean, you're just the most solid person inside out – dentist, mom, everything. It was just a complete honour that you would drive down to the poor part of town in Phoenix and come do a podcast with me and Ryan. It's truly been an honour and thank you so much for the shirt. 

Jeanette: You're welcome. I hope you wear it and send me a picture of you in it. 

Howard: I will.