Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
How to perform dentistry faster, easier, higher in quality and lower in cost.
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1215 Marc Ackerman DMD, MBA, Director of American Teledentistry Association : Dentistry Uncensored with Howard Farran

1215 Marc Ackerman DMD, MBA, Director of American Teledentistry Association : Dentistry Uncensored with Howard Farran

6/27/2019 8:33:32 PM   |   Comments: 0   |   Views: 152

Dr. Ackerman is the Executive Director of the American Teledentistry Association. Clinically, he specializes in the orthodontic treatment of patients with dentofacial deformity, intellectual and physical disabilities and sleep disordered breathing. Dr. Ackerman is the Director of Orthodontics at Boston Children’s Hospital where he practices orthodontics full time. He also teaches residents in both pediatric dentistry and orthodontics at the Harvard School of Dental Medicine.

VIDEO - DUwHF #1215 - Marc Ackerman

AUDIO - DUwHF #1215 - Marc Ackerman

Dr. Ackerman has published numerous peer-reviewed articles in orthodontics and professional ethics and his monograph, Enhancement Orthodontics: Theory and Practice, was released in 2007 by Blackwell-Wiley.  He is a co-recipient of the 2004 B.F. and Helen E. Dewel Award from the American Journal of Orthodontics and Dentofacial Orthopedics which is given annually to the highest-rated clinical research article published in the previous year.  Dr. Ackerman was the Editor-in-Chief of Special Care in Dentistry Journal from 2013-2016.

Howard: it is just a huge honor for me today to be podcast interviewing Dr. Marc Ackerman: DMD MBA the executive director of the American Telemedicine Association clinically he specializes in orthodontic treatment of patients with dental facial deformity intellectual and physical disabilities and sleep disorder breathing dr. Ackerman is a director of orthodontics at Boston Children's Hospital where he practices ortho full-time he also teaches residents in both pediatric dentistry and orthodontics at no less than the grade school in the universe Harvard School of Dental Medicine dr. Ackerman has published numerous peer-reviewed articles on orthodontics and professional ethics and his monograph is enhanced orthodontics theory and practice it was released by Blackwell and Wiley in 2007 he is co recipient of the 2004 BF and Helen E dual Awards the American journal of orthodontics and dental facial orthopedics which is given annually to the highest-rated clinical research article published in the pries this year I can't believe I got this guy to come on the show he was the editor in chief of special care in the dentistry Journal from 2013 to 2016 my god what did you ever sleep and I loved your article low-income and rural New Mexicans seeking access to oral healthcare are hurting today by you I mean you just died my gosh so many and what was that other article I liked who needs braces socially necessary versus medically necessary treatment unlike treating a disease with a known cause and having the ability to select a therapy that cures that disease orthodontics is limited to managing the irregularity of teeth in simple terms we orthodontists constrain your teeth but we really have little idea how or why they went crooked in the first place and that was on The Huffington Post you're a legend dude and  I'm so glad I got a orthodontist to come on the show because you went with this tell a dentist I mean to hear about tell a dentistry most people are thinking uh this is something for expanded duty dental assistants or dental therapists or whatever  but man when you're an orthodontist it means smiles direct Club it means Invisalign centers huh there's five smiles direct clubs right in my backyard and so my gosh great to have a legend in orthodontics come on the show and talk about all things dentistry so this telehealth tell the dentistry why did this pique your interest was it smiles dark Club no well

Dr. Marc Ackerman:  I always had an interest in technology and I was watching telehealth for years and when my own physician and particularly my cardiologist said hey I can have you remote visit with me we'll run your labs every six months and we'll just basically do the version of Skype through our medical record and it'll say you know what keep taking the medicine these are your numbers and that's it you don't have to come in and see me that was one reason the other reason is if you hand something to the average group of dentists or organized dentistry they'll screw the damn thing up so I thought you know what let's make a tell the dentistry Association and basically bringing all the players outside of dentistry and inside demonstrating 

Howard: well you know it when I look at your resume it looks like it was I you know if I made that resume I would had to photoshop the whole thing Harvard Medical School you got a stuck n in bioethics medical ethics Jackson University got a MBA I mean tella dentistry speaks to both ethics and the business of accessibility availability price where do you where do you draw the line between ethics and MBA when when people like swallows drug clubber trying to do tella dentistry ortho 

Dr. Marc Ackerman: well that's a great question there's a thing called business ethics and most people think it's like a conflict of terms essentially when you look at any enterprise particularly in healthcare you have to weigh the risk benefits and right now from my own research I mean you talked about in a minute what smile direct and those other companies like candid company smile love they're all out there what they do works if you're treating someone for six millimeters or less of crowding six millimeters or less of spacing in the front teeth it works it's a model that really has been tested by us and general practitioners for you know at least a decade and a half now and right now I can tell you having looked at a randomized series of 50 cases every single one worked to a significant degree

Howard: I mean that that's that's huge so I'm you said you looked at 50 cases and if they were all six millimeters or less crowding they all worked yes 

Dr. Marc Ackerman: for spacing so it was a mixed case series but the kicker was it was 25 treated by general practitioners 25 treated by orthodontist 

Howard:so do you think there was a difference in outcome between the specialists in the general dentist

Dr. Marc Ackerman:  no because a third party is making the diagnosis and trees crack not really it was the dentist making the diagnosis and approving the treatment plan so again I had to speak to these guys who were endorsed providers who used the system and they're the ones who get like the clem check do you do any Invisalign yeah yeah so but the content for Invisalign that's all in Costa Rica yeah I don't know where these companies do it a smile direct us but essentially these providers said to me we get the you know cleanse check or smile check whatever they're calling it we do the tweaks and then these aligners are made in our request 

Howard: and who did the better on the 50 case you said 25 were general dentists 25 ortho how do they compare 

Dr. Marc Ackerman: no statistically significant difference oh my god they they have to hate you there are you like are you I got ten arrows in your back um you know what I'm so sick of the that ORS on us put out there like like I wrote that article or thoughts like to play both sides of the coin one is well we know everyone looks better for braces feels better about their you know social situation their teeth straightened and look better by the other side of the coin well but you know it's medically necessary Ortho has to be medically necessary well there's no data to support that and and it's sort of a major myth it is someone who's in general practice you treat patients along the entire age spectrum I can only name in child and adolescent care one type of or thy diagnosis it's absolutely medically necessary and that's a single tooth cross bite where you have a tooth that's being knocked out of the socket in general recession if you look at posterior cross bites no one ever died from them excessive overjet no one's ever died from them crowded there been studies since the 1970s that show if you take the time to floss and brush your teeth you're not going to lose your teeth because you've got crowding so I guess what I'm trying to say is in writing the enhancement book and some other stuff there are lots of good reasons for doing braces but it's usually not the ones that worth us tell you  need to do braces for and on these 50 

Howard: or so cases that you analyze have them 

Dr. Marc Ackerman: by Rossana general Dennis did you publish that anywhere yes I did I'll send you the article it's in the Journal of dental research and reports I'll send you a PDF and you can post it to dinner town Journal of dental research reports research and reports yep ha and oh my gosh did I wonder what did the words I want to say of that I haven't gone to an ortho meeting subsequent it came out about two months ago I'm sure they're not happy about it but you know I tend to get ignore it anyway because I tend to speak truth to power so yeah you know I always give you know I own or two 

Howard: I own dental town ortho town in hygiene town I'm not even allowed to go on or go down and then you go to dental town and the orthodontists there are like you and there you know we all work together in the team no one's suggesting we go back to 1900 with no specialists and but you know it just seems like if anybody asking and honest Ralph and endo they they help him everybody helps but the orthodontists don't seem to like to play in the same sandbox

Dr. Marc Ackerman:  absolutely they like to flood the sandbox flood the sandbox yeah I mean essentially I mean this is the thing the biggest the biggest sham in the last 50 years of dental education is that orthodontist teach undergrads next to nothing and they make ortho a black box and so essentially you don't get enough in dental school even to figure out you know what you're looking at it's remarkable can you imagine in dental school if they didn't let you do a molar endo I mean that would never happen this day and age right it's still it's still minimalistic ortho exposure I mean it's that's that's a crime and you love itself ah that is so so

Howard:  I'm they they're trying to now use you know it usually in economics and business you know you have the people and you have the business class and then you have the government class and the business gets together at the government informs cartels they regulate import they tag you know they're trying to get rid of competition so now the dental orthodontic business class is trying to get in bed with the government to stop these tella dentistry north Oh business models do you think they'll have any success

Dr. Marc Ackerman:  no I I think that you know thirty complaints the state boards were lodged and smile direct by the American Association with us none of them have significant you know none of them has ever gone to the point where there's been an impact on smuggler at clubs opera patience at this point they filed with the FDA they filed with the Federal Trade Commission that is the orthodontist and at a certain point you start looking silly because you're using all of your members dues and resources to essentially act like a guild and that's essentially what they're doing they're saying oh you know this is going to hurt us therefore they take the tack that this is a save the public or protect the public type argument I don't think they're gonna win I think that if you look at the North Carolina Dental Board with tooth whitening that that set the stage for how the court system views trade associations trying to restrict trade 

Howard: well then and that is a new view that I'm hearing for the first I mean I I just heard it last year the first time a senator called a that dental board in Asheville a cartel protecting their members Wow when I was little that was the sacred government protecting us and now people are starting to realize that is it really protecting us or is it a cartel and where I draw the line might might my line in the sand for me was the last house I bought the lady was born America had brain cancer a company in America pharmaceutical developed a drug she couldn't get in the FDA research lung stirs her she had to sell her home and moved to Scandinavia to get this damn trim and I thought and I told McCain I told Sir Manhasset look it is one thing for the FDA to use my tax dollars say Howard there's no proof that this drug is gonna grow your male pattern baldness hair back and we don't recommend it or approve it but we're not gonna stop you from trying it and when you're talking about someone that's gonna die of cancer mean what's the worst thing is gonna happen to a lady with inoperable brain cancer trying to experimental drug she's already gonna die and I just thought that shows me that it's not about helping me it's about jobs a cartel an agency I'll get Social Security all the government workers to get Social Security and a pension and that's when I just started to just really question my own government I'm like I I don't know if they're my friend or they're just helping the business class donors make more money were you weigh in on that

Dr. Marc Ackerman: um I'm not a big well let's start small to him I'm not a big fan of organized dentistry either the a da Bao any group trying to set rules and regulations that put constraints on any given dentist we know that the biggest innovators when they first set up shop and started doing things we're always tarred as heretics or you know people who are on the crazy fringe going larger of course I don't like the government we're straining things either I mean I think there's a place but like you bring up there's a compassionate use provision for a lot of these experimental drugs I work with dana-farber Cancer Center and a lot of these trials they will let patients in desperate need have access to the drugs so it's really really important I so I agree with you I think I'm on the same page

Howard:  and another guy I remember I'm not too uh diver but and there was an orthodontist and I'm Arkansas Ben Burris and he just thought you know my vision hurt I think they shed their teeth cleaned and just to have a hygienist in orthodontic practice that I mean it just went crazy you remember that yeah that story number 

Dr. Marc Ackerman: I know Ben very well and yeah it was sort of like okay my patients need more frequent cleanings I can have that service here okay it's really important you got braces on because kids don't brush that well and I can do it at an affordable fee and that just absolutely blew up I guess with the State Board they they were not gonna have any of that so but let me speak so the New York State Legislature just broke its session just finished the other day last week there was a bill sponsored by Senator that was called the orthodontic tele-dentistry Consumer Protection Act and they essentially wanted warning labels on any of these companies doing teller orthotics warning the public that this could this could basically ruin their mouths and have long lasting negative effects and you read it and it was just really really draconian and was basically trying to scare people away from even considering it the interesting thing is when you look at the way it when it's written you could ask this question give an average orthotic practice they start 200 patients a year at the end of two years when you look at those 200 patients how many bites were worse than when they started well if you look at the average practice I'll tell you a lot more bites in traditional braces get screwed up than having the front teeth straightened with clear aligners so again I mean you imagine a warning label on endo that you come in to consent a patient and they've got you know an endo on a molar and the success rate for endodontics is 86 percent so are you gonna say you've got you know you've got a 14% risk of losing the tooth I think it's absurd and fortunately that New York Act got killed never left about committee to a floor vote ha so

Howard: so you were in you published that in the Journal of dental research is that the end is that sage is that the Journal of dental research and reports it's not the JDR which is the big research journal this is an open access online journal it's peer-reviewed but it's free essentially when authors do is they publish on it because they want to make sure that anyone who wants to read it can download it for free unlike member society journals where you've got to pay download it so Howard: it's it's six thousand kids that just walked out at dental school last week what is this look like in their future 

Dr. Marc Ackerman: well I think right now it's mostly been public health driven so you've had like Paul glass winners at university of Pacific who's like the father of Teledyne Street they set up the virtual dental home and so it was areas that didn't have great access to care be it like nursing homes rural health clinics or fairly qualified health centers without a dentist and they used you know live synchronous tell the dentistry for dentist or hygienists to basically interface with patients with very little access to care and to triage what their dental needs might be so as these programs have gotten more and more sophisticated there are services that do emergency tell the dentistry in the sense that through pictures or video they look at a patient they say you know what this tooth is blowing up you got to go to the emergency room where they look and they say you know what I got to put you on some antibiotics and then let me route you to the nearest Medicaid dentist so that's one side there's the teleported onyx which we already talked about and then they're gonna be programs of Hygiene education hygiene maintenance where you've got clinics of hygienists and you've got remote doctors supervising them you know in those states words general supervision meaning you don't need a doc on premises that's going to be a major shift in how hygiene is practiced in my view in the next 20 years

Howard:  you know a lot of things like lately take music you and I had I don't know we're the same age or whatever but I mean the the coolest thing for me being born in 62 was the new technology of the electric guitar and the electric keyboard and it completely changed all of music um do you see this tella dentistry the same thing that this technology is just gonna be a huge game-changer

Dr. Marc Ackerman: yes and no I mean the bottom line is tell the dentistry is dentistry it's not a subspecialty it's merely the use of communication technology bring a dentist or ancillary personnel member like hygienists to the patient you can't drill and fill through the phone or through the computer but you can use certain dental you know you can do dental diagnosis you can do triage what I predict - is that for pediatric dentistry you know they're gonna be home kits for fluoride varnish we already prescribed Priven and or gel cam which is stannis fluoride pediatric dentistry is gone - trying to remove remineralize caries you know that they're trying to take incipient lesions and treat them so I think tella dentistry is good you know is technology Laden and all it does is increase access and perhaps saves the practitioner chair time creates more efficiencies in the practice and on the other end you know it's been studied Millennials today prefer to interact by text or video chat they don't want to go to offices and have you know lengthy forms to fill out large waiting times they want to connect on the phone get the initial intake get an initial clue on what they need and then come in and get it done

Howard:  see I've already um been to this rodeo before I remember when my um and I was in high school then I went to Westside bank in Wichita Kansas I was on West Road and central and they installed this new ATM machine and down there walk it in we saw a buddy we knew and he's standing there we went looked over his shoulder and my dad looked at me and rolled his eyes and then we went in there and we did all of our banking and then we came out you know ten minutes later and that guy's still there and I said oh my god that'll never take off well it turns out that that was the preference more people would rather do it without a human interaction and and then the same thing is texting I have four boys if I call for my boys to answer and to immediately hang up the call and text what a dad I'm like you know they just they just prefer that humans are complex and so yeah I think humans are stressful and they're challenging and so anytime you can get technology and get rid of the human interface it's gonna have a huge market 

Dr. Marc Ackerman: yeah I mean I think so I found a company I was I'm a member of the American Telemedicine Association - which has been around 25 years I mean they threw the gauntlet down years ago and are so far ahead of Dentistry it's amazing I saw a blog post about a company called Taito TYT O it's essentially a platform that physicians can use for primary care they sell for 300 bucks a kit that the you know patient can buy and in it it's got various sensors to take blood pressure you know measurements of the heart heartbeat etc rhythms as well as an otoscope to look in the ear look up the nose and essentially if your practice has this the triage emergency care never have to go in and and it's remarkable this technology

Howard:  um when you go to that website of the American Tele Denitstry org American tell identity org it says no it's white oh yeah oh that's your website yeah oh okay I okay I did I didn't know that was your ones like when it when it talks about modernizing access to better oral health it says you can download the 2019 state telehealth laws man that was a work that's a 420 page PDF yes how does whatever you married to an attorney or how did how did you pull off a 420 page report 

Dr. Marc Ackerman: so I the truth is I didn't write it that there's another group I work with called the Center for connected tell health policy they for years have been doing updates of the telemedicine statutes for the first time this year they looked up all of the tele dentistry statutes which they're few and far between like maybe 12 states have some type of you know tella dentistry language in the dental practice acts so all they did was send me the large file and I put it up there for you know everyone do download 

Howard: and that's you said that's the Center for connected health policy connected to health policy that's the same it's also the C CHP CA right yeah so um so when did telehealth Paul see us when was that necessary for to come into existence

Dr. Marc Ackerman: probably at least 15 years maybe even 20 as the physician started doing you know tell from telepsychiatry tell a derm tell a stroke but they realized that there was a lot of advocacy that needed to be done because the medical boards started to do what the dental boards are currently doing and so in this organization lots of nonprofit that is the American Telemedicine Association there were a lot of spin-offs either regionally and nationally that were nonprofits that looked into you know what's the law what should be done about it what are the best standards of practice and so in telemedicine it's  amazing if you remember you go to the American Telemedicine Association site their resources are unbelievable 

Howard: so that's the that's just Center for connected health policy CCH PCA and that not what that's one and then there's WW American Telemedicine org W say it again 

Dr. Marc Ackerman: w w telemedicine or American Telemedicine okay dot org okay and tell us about that one so that's it's 26 year of existence this is this is the you know the big player in tel L this is physicians it's got all the court partners it's got the insurance industry if you want to enter the fray and tell health it usually goes through the American Telemedicine Association their advocacy is  second of none you know they've worked with legislators for years now and you know in in any state when something comes up that group will pick it up first and literally have one of their committees or one of their groups within the organization run with it it's pretty amazing

Howard:  well you know I remember my military friends you know paint paper patients for 30 years as being a dentist's I've had military people say from the Navy they said you know I was on you know you think of an aircraft carrier with 5,000 but most of those boats have less than a thousand or 600 and they said when they come back it's okay we were in a submarine we would go under and we wouldn't come back for six months so if you got sick you just radio and it had artificial intelligence and it would you would just ask you all of these questions and they said all the research was showing that those guys had about a 96 percent accuracy on the diagnosis and treatment plan and if you went to any emergency room in America you couldn't even ask for 80 percent is that true

Dr. Marc Ackerman: that's absolutely true and so in dentistry there there's some research articles and there listen in on my site the American tell the dentistry org they looked at studies looked at diagnosing caries from photographs and there was a remarkably high sensitivity such that true positives were picked up like 89 percent of the time and false negatives which is specificity was something like in the high 70s low 80s so it's remarkable there at least a couple studies that show you can accurately diagnose surface caries from photos they're also open studies where you could diagnose oral pathology from photos there was a study done in a nursing home really a group of nursing homes that looked at lesions you know floor of the mouth tongue buccal mucosa and it was remarkable this was life-saving doing Teledyne tele dental diagnosis picked up more oral cancer in the elderly than probably most office visits

Howard:  that is amazing so I can imagine my um say smiles direct club would  be all for this I I could see you know if you're being cynical I could see all that but what about like DSOs like like what does a Heartland Dental think about Telle do they see this as a threat to their DSO business model now they have a thousand locations or do they see as an asset 

Dr. Marc Ackerman: so Rick workman's on my advisory board and Heartland about to roll out its own Teledyne distri strategy what I can tell you is most dsos or looking closely because any type of efficiency we can save chair time save a visit or give some type of service to a patient is you know what any dental business is about so for instance if you know they can triage emergencies and again I don't know their specific policy or what their strategy is I can only tell you the DSOs are rapidly embracing tella dental techniques and technology 

Howard: well Rick is a true pioneer he's a legend I remember meeting him in courses back in the 80s at Dustin seminar Woody Oaks you know he's just a an open-minded he's just a great guy again I can see a smiles drug club or candy but there's another one on clinical box which is right in your backyard tell them about clinical box and is that part of the Boston tella medicine in at mafia

Dr. Marc Ackerman: um it's an interesting use of telemedicine my colleague we're all in isolation surgeon that I work with here Children's was a founder of that company they look at implants like medical grade hip implants you know prosthetic knees any other body implant and all of those have serial numbers and they're coded so that they through a cloud and application or cord these products that are going into patients bodies through the electronic medical record so if there's a recall on a pelvic mesh or something they know exactly what patients have that product by serial number so it's kind of an innovative use of you know they I guess health data through a cloud platform 

Howard: so that you're driving back dr. Farb mood on GG PhD MPH CEO and founder of clinical box well I'm talking about sell-offs are you should be on their board of directors um I'll sell sell after af-s har Salim as far yes yes that's him oh he so he was the founder of the clinical box yes Wow

Dr. Marc Ackerman: he's a young look at dude so listen I he's the best oral surgeon I've ever worked with in the country in 20 years this guy can do worth agnostic surgery like you wouldn't believe but at the same token he's an incredible innovator he sees the landscape and intuitively figure stuff out it's really an amazing guy

Howard:  ha that is right so so woody um what's next for Teledyne story and what would percent of the market ever just the United States just physicians and or dentists where when was a zero and where is it at now and where do you think it'll be in ten III 

Dr. Marc Ackerman: think right now it's probably at 10% being you know being very liberal in the estimate I think it was at zero probably five no actually because all glass but let's say ten years ago it started but it was really in just academic centers there was no private practice way to get involved there companies now like mouth watch that are basically allowing private practices and group practices to start up with you know synchronous tell the dentistry but none of that existed ten years ago I see it in five years that if 50 percent of dental practices are not using some form of tell ademma Street I'd be surprised 

Howard: so you talking about mouth watch talk about that one more why I am what what is their unique selling proposition so 

Dr. Marc Ackerman: so their proposition is they have a I believe it's a web based platform where you can go onto the cloud-based server and patients can send and receive communications that are encrypted and compliant via HIPAA but they also these software's are able to link they sell intraoral cameras they're kind of like wand cameras so let's say you've got a practice listen you're a small DSO you've got a whole bunch of GP based practices but you've got a specialist working at one and somebody in the other practice needs a consult for would say endo you can use this platform basically to create tella dental encounters cross practices 

Howard: so internal cameras I remember a night out at school in 87 Patterson dental had just bought a Fuji dennah cam it was $38,000 it was like two of your dormitory room refrigerators stacked on top of each other and it wasn't even it was even five to ten years ever down to 12,000 now they're under you know a thousand was the internal camera the breakout technology for tell identity or was it digital x-rays or what what do you think the breakout technology was 

Dr. Marc Ackerman: I think the breakout technology are the easy to use apps that are either mobile or desktop I think you know right now according and I can't remember the exact price but we had our first CD course up at Rochester Eastman Institute two weeks ago and the CEO Brant Furman of mouth watch I think said the whole rig in total between the camera and what you need to get started under 200 bucks so I think yeah I think a lot of these things oh and the iPhone I mean you can take phenomenal photos extraordinarily with a simple iPhone I think that was the game changer as soon as you had a piece of technology at your fingertips they could run apps and take photos and take video that was it that's what broke it open but 

Howard: when you talk about the founder and CEO Matt mouth watch on brand Herman he's another New York City your boss and a lot of these are New York about you know that there's a little band of about 50 million people that live on that little from Boston on down to Philadelphia is it is that where it's taking off or do you see this in the middle America and flyover States is this high tech Silicon Valley and the power strip from Philly to Boston or is this where I was born I was born in the exact center of the universe in Wichita Kansas I'm pretty sure it's the middle

Dr. Marc Ackerman: isn't it is that where spaceships land I'm sorry I had to say it um I think you're right I think things happen and start up on the coast but here's the deal I spent a year in New Mexico working with the state legislature looking at the world poor with no access to care I mean their towns like jail wagon mal unbelievably remote places where there may be no dentists and I tried to craft a tell a Dennis Tree act that was pretty much a mimic exactly tella Medicine Act the teller dentistry exactly act that exists in the state says the definition of Teledyne industry is one dentist talking to another dentist by video and it has to be a dentist to a dentist so we came up with a great act we went out there I traveled all around the state it went through both houses in the legislature it was a you know no  votes in the house and in the Senate there were two no votes so was near unanimously pass it had two weeks to go to the governor what do you think happened he found out how much money he would make passier and how much he would lose uh he he counted his dollars and when where the money was so she took a meeting with two organized orthodontic groups I'm not gonna mention their names and they basically said this act is gonna be just for smile direct candid and the citizens of New Mexico are going to be harmed so her health person called me called some other people and I said look the point of this act is for basic world care to route patients to medicate dentists and by the way there very few Medicaid dentists out there and there overall very few dentists in the state of New Mexico I said this act is to basically get people on the radar screen of dentists and all the public health people loved it it was really good and she panicked the governor and vetoed it okay so when you talk about flyover States I've been working with five or six states in the middle and countries trying to get tella dentistry in those states and basically the powers that be are trying to block every effort we've done whereas on the coast they're more forward-thinking that's where the money is that's where the jobs are so

Howard: so your buddy the oral surgeon started a clinical box he also started implant box how was uh how is color dentistry could act clinical box and implant box how are those are the same 

Dr. Marc Ackerman: well I'm most familiar with implant box I should say I don't know as much about clinical box it's not so much so that it Stella dentistry it's the fact that he's an innovator and bringing his team to the table as a corporate partner has really been helpful in terms of our visioning at the American tell the demonstrate Association you know we if you hang out with smart people you tend to get smarter yeah you should

Howard:  I mean the the smartest people in the world that run the largest companies in the world are always trying to be the dumbest person in the room and for some reason say you have a programmer and he needs help he wants to get a junior it's like wouldn't you like to be the junior why would you hire a programmer that was three times better than you and it's it's so counterintuitive that you're a summary of your five people you spend the most time with so why don't you why don't you spend it with four people who are smarter than you and they'll be dragging you to success I do that freshman year of college I did it so successfully I would born or raised in Wichita Kansas that didn't have a dental school I went to Creighton they had their own dental school undergrad your preference and there were 88 guys on the top floor and that whole first week I was thinking okay hmm do you know under no circumstances I mean they'll obviously get into dental school and I picked them out it was a Joe Duncan it was a Gary it was a Randy Kerwin it was Gary he's Aldi and me and I just chose them I'm only gonna hang with you guys because I know you're gonna get in and I would say Randy Kerwin Gary Saul D and Joe Duncan we're the greatest Senate honest ever dragged me all the way down when I got accepted a year under I you know I got accepted after three years so just you know and they do it with staff to like they'll need an assistant they'll say well we've got a really good one so we don't need another good one for 20 now our looks good let's get someone for just an entry level 10 I'm like why don't you go get someone that lives under a bridge for $3 I mean I mean I mean what why stop there why don't you get a reptile 1 why don't you just get a plant I mean get a fungus and you carry out a prokaryote I mean it's so obvious

Dr. Marc Ackerman: I have a great story about under estimating how smart someone was so my freshman year I went to Bucknell in central Pennsylvania and I wrote crew and there was a guy 2 years ahead of me named Doug leb Doug and Doug was really smart and he was a big leader he was captain the crew team and I had a few classes like economics maybe with him and he graduated but now I went to the Tuck Business School at Dartmouth and Gotha school I think he was freshly married or his engaged and he was looking to buy a house and remember the day when you used to go to the local paper and you look up mortgage rates and you'd go into a bank that day you'd say oh I saw in the paper they'd say no that was yesterday and it really took lots of time Doug Leptis started Lending Tree okay and here's a guy I spent a lot of time with in college and had no idea how smart he was so you know in I've always said to myself by and large I hang out with people outside of dentistry the people in dentistry are still in the cottage trade mouths okay dentistry is gone beyond the cottage trade and and where is it out I think dentistry is a consumer service I think that obviously you know their  ethical components where it is patient care but the patient is just as much a patient as they are a consumer and I think that there are certain things in practice that one has to do that mimic other services out there so you need you know consumer hours you need to make your fees in you know in line with the socio-economic group that you're surrounded by in your community I think that having one practice and you know an old-fashioned high overhead high fee doesn't work anymore I think there are quote you know I've got colleagues who say well I've got a boutique practice and I said well yeah you've been in practice for about seven years you haven't practiced during the recession wing till the next recession hits and you'll be you know same with yourself boutique boutique I should have a practice that makes sense as a business machine not a holdover from the 1960s 

Howard: you know my boys it took me you know they're they're all between like twenty-five and thirty and I love it when they spend time with their ninety five year old grandfather because they're the saving mentality where you don't spend you live below your means is because they live through the depression and I thought it was the luckiest economies I graduate high school in eighty and that was the worst I've ever seen into this day was twenty one percent interest rate was double-digit unemployment I really was just horrible but by the time I graduated dental school eighty-seven it was rock and roll again and I graduated May and then October was Black Monday I got slapped again and then I had the longest expansion all the way to the end of the y2k bubble pop to march in 2000 so when this Lehman Brothers they hit in 2009 like dude that's the fourth time I've seen this rodeo and I smell it again I mean I'd smelled this smell what I smell the smell and and I I think they're they're proactive things people should start being thinking out but for a lot of dentists out there they should be in fear because it's coming and it's coming soon brother it's really uh ok ok so the Givens specific advice because podcasters aren't old and decrepit at fifty-six like me they're they're all the Millennials okay and so what what what what killed these people like in 1980 they had refinanced the farm to buy a John Deere tractor but it was a floating interest rates so when interest rates exploded from five to twenty one he lost the farm so all your long-term debt has to be fixed in Arizona in 2009 Lehman's day about eighty-five dental practices went under which ones went under they were all the high-end specially only did veneers and all these twenty five fifty thousand dollar cases these all on fours and and when it crashed I mean they were in my front room and I said well just go back to extractions in molar end up they didn't know they lost all their skill sets exactly also when people start time at the fear and how bad it's gonna be did I've lived through it for years I mean when it's real good or real bad it's really all the same why do you smell what right now lemon so let me rephrase that 

Dr. Marc Ackerman: I think the fear should be with the Millennials and the recent grads because they really had no clue run businesses you know for those people who've been to the rodeo I mean I remember 2007 2008 2009 when the housing bubble blu but what I see now are several things and one of them is buying expensive technology in your office okay for instance cone beam CT machines okay it's the biggest waste of money in the sense that there are very few indications where you really need one particularly in Orthodox so I could see in implant placement and  other things like you know North Atlantic surgery it would be important but in orthodontics aside from severely impacted teeth to take a con be on every patient as a standard record it is kind of like taking an elephant gun to shoot a squirrel so what I see is happening is that there's gonna be a lot more shared technology okay why would you want to buy something when there may be a service where you can rent a thing you can get in with a bunch of other Docs to purchase let's say a CBC team machine but like you say dentists don't like to play together sometimes particularly your thoughts 

Howard: well we did a podcast on radiology on that very subject with dr. Tara ZB za h-e-b I and she was up hold at how much radiation these people were given to kids I mean they come in six years old and Maggie need ortho Sunday boom a CBC teeth out of their head and throat and thyroid she was not a fan of this all you should share those expensive machines right 

Dr. Marc Ackerman: so that that's one thing in terms of your office you know if if you're in a building and you're not happy with it and your rents you know let's say it's class a real estate you're paying high rent don't be lazy and reuptake professional space these developers are dying to give deals and you know I think for people getting out of school you know find a decent lease you know maybe if it's a condominium but going out buying a home or buying you know a building prior to a recession I don't think is a good idea particularly in certain states and the funny thing is when they start talking about buying gold it's like okay and if your little apocalypse happened 

Howard: what do you can do with the gold bar you're gonna eat it I'd rather have a bag of flour than a bag of gold I mean it's not even it doesn't even have any utility but yeah you just always live below your means you the reason you buy all this expensive equipment is because it makes you feel good when it's like a congressman when they get to Congress they don't feel like you're a congressman until they pass some huge bill with lots of money and lots of right it just makes you feel better so you just have to understand how your psychology works and just don't don't just live below below your means you know another thing go ahead so no one one of the things that I'm

Dr. Marc Ackerman: I didn't mention earlier but in order for people to really embrace innovation now they're people who are you know leading-edge so they're adopting early adopters they're sort of mid-range adopters and they're laggards okay most in my experience in 20 years in dentistry has been the laggers of the ones we're always saying Oh things are terrible you know you can't do this you can't do that and I get probably ten pieces of email a day more I've got texting direct to my American television web site people saying oh you know what is this is this gonna make a difference you can't do this what are you about or you just smile direct club or candid and what I say is the American Teledyne Association is a place for all parties to come together patients providers corporations and our state you know our motto is we want to support anything that can improve care access to care quality of care etc etc so going back to what we were just talking about in terms of you know people not preparing for when there is a downturn we're trying to educate people on how they can make more efficiencies in their practice that's the key in terms of longevity I mean I think that anyone who can't shave a few points of overhead in any given year really doesn't know what they're doing 

Howard: so that smiles direct Club is in Nashville Tennessee and right in Nashville is another very famous orthodontist like you the CEO of Rena Graham orthodontist a Keith Dressler DDS MSD do you know him and what do you don't you

Dr. Marc Ackerman: so Keith has been a great adviser to American Teledyne Street he donated rhino gram and it's different use I'm using it for it's bolted into the American Teledyne Surrey web site so when you click on contact and up pops a box to basically talk to membership etc it's rhino Graham you'll see this as running around I looked at his product and out of all of the tell a dental apps right now again I don't have any stock he doesn't pay me I would get that at its HIPAA compliant texting and the way that neat thing is it bolts onto any practice management software it converts your landline at the office to be able to receive texts so that essentially your patients can text you directly to your landline and you can set it up that these get routed to either billing scheduling the doctor hygienist and so it Creed's practice efficiencies it brings in encrypted photos and it basically gives patients the opportunity to literally 24/7 interact with components of the practice it's not just being used for medicine I mean for dentistry there are a ton of medical practices using it and there was sweetgrass pediatrics in South Carolina got something like eighteen hundred texts in a month once they went to Ronnie ray can you imagine I mean your kids subs that are tow what did we used to do years ago take him to the pediatrician office here you take a picture of the foot you send it in the nurse practitioner looks at it and says you know what clean it out put a bandaid on you're fine we'll talk to you in two days

Howard:  wow so he just is easy he's really loves technology I mean how did he how did Keith see all this I mean it was born at 30,000 feet 

Dr. Marc Ackerman: I think he's always been an innovator his last company is worth o Bank which I believe is like a third party finance second company I never used ortho Bank but he's always been years ahead and he spoke for me at the Rochester meeting and really has forward-thinking view on communications and  that's the key I mean offices that are gonna do well have great internal communications and external and the most important is when you're gonna treat you know Gen Y and Millennials you need to be able to respond in a very fast time frame very thoroughly and essentially meet the expectations of the customer / patient and I think he gets it 

Howard: um I wanna switch gears completely you wrote a textbook enhancement orthodontics theory in practice by no other than Mark Barnard Ackerman you I always said that writing books like having a baby I mean it takes a year to make it what was your lessons are you glad you wrote enhancement orthodontics how was that in your journey um

Dr. Marc Ackerman: I was really glad a buddy of mine who was working with Blackwell which before was black widows monk scarlet monk's card Blackwell Wiley you know they they have a lot of mergers and acquisitions he said you know you want to write a book you could talk to the publisher you know I'll introduce you give them a pitch because I think you've got some good ideas so I wrote a 3-page kind of outlined in the book pitched it to the publisher they got back today said this sounds great we'll give you a year to do it you know it should be this amount of pages etc etc they don't pay you at all so anyone who thinks that you're getting paid upfront totally doesn't happen and royalties are minimal I mean I think I spent more money on the art design out of pocket than what I ever made on it but once I loved it in I got the letter saying we know we'd like you to write this I came home to my wife and I said honey I just got this book deal she said great you've got nine months to write and I said what do you mean nine months she said well I'm pregnant so having written that book on weekends for about eight months was um was pretty unreal I don't think I could do it again but I'm really thrilled that I did it it really shaped my view of practice back then and was ignored when it came out and has a cult following right now so I'm glad I did it 

Howard: will you also wrote another book with someone we talked about earlier I'm Ben Burris I you guys wrote the rules of orthodontics and don't talk about that 

Dr. Marc Ackerman: well I've been you know talking to Ben for the last couple years saying you know most patients come in and their expectation is to have their teeth straighter they want a recognizable difference in how their teeth look that's why either getting braces they're not come I've never in a patient 20 years come in and say I've got a malocclusion and my bites off their dentists might have said to him you've got a malocclusion you better seen or thumbs but there's never been a self-refer referral that has said you know I've got this problem they just say I want to look better so we talked back and forth and we came with the concept of straighter the rules of orthotics and it basically is 15 practice management tips you know in a very small paperback book talking about how orthodontist or general dentists who do ortho should view the service and and what the customer is all about and and that was actually even more enjoyable to write than the other one because it only took a couple months to sort of write it down so how many rules were there 15 so do you know I'm off the top of your head the re-argue out there you wanna tell them or look it up it would you go home 15 rules of orthodontics right so it's straighter the rules of orthotics and they were 15 of them and I can go through it this give me one sec because at this hour after seeing a full day of patients you can only my brains a little bit fried you've got here this tree or what so here are here are the rules and in one set because I don't want to mess them up because they're in a specific order on purpose okay here it goes so we broke the book up into three sections and we did that on purpose because a lot of these rules fall into different categories and so we wanted to make three categories so the first one that we called it attitude and so you know that anyone who's been successful as a positive outlook and so we said it's really important to have that attitude succeeding so ready here's rule 1 consumers choose an orthodontic provider on affability and accessibility more often than ability absolutely okay and and the point is I've had more people interview versed even more than I did we're like yeah I was resonant you know chief resident my ortho program great you're a little shithead you know you might think that you've got all these credentials but that's not what patients are looking for they want someone who's nice who's easy to access it cetera rule number two the most significant goal is consumer satisfaction okay your result of plaster on the table is not what patients are looking for they want to be satisfied by the entire experience number three an orthodontic success is the extent to which the service render and practice experience fulfilled the consumers original expectation meaning they came to your office they paid you five grand aren't they at that point gonna say you know I'm glad I did it agree with that one absolutely number four orthodontic consumers parents and or buying enhancement of their appearance with the hope of improving their own or their child's education ploy ability and marriage ability I made the years ago if you look better someone will hire you take you in college and maybe even marry so and the last one in the first section was assumptions of belief in false premises will constrain your business limit consumers access to care and reduce your market share I mean that goes without saying I mean it just straightforward things but you know we know so many dentists and with nuns who just don't understand those business principles do you do want more yeah what wouldn't whatever you think I will I'm actually if I go to the

Howard: if I go to the tele dentistry if I type in Intel identity on dental town the first mother of all tella dentistry threads and was actually started under insurance sub for malpractice insurance the first thing everybody is talking about is well my malpractice carrier me I'm one guy said I spoke to med pro and they said we don't cover you on tala dentistry so the first thing the dentists are gonna think of is there's greed and fear and fears much bigger than greed and all you gotta do is think about you're in the Serengeti and you're really really thirsty so you greedy want to drink some water but there's a big old crocodile sit in that pond and you're not that thirsty so the ten biggest drops in the stock market are far bigger than the ten biggest gains so the first thing dentists are gonna go to reasonably is fear should they be fearful of their medical malpractice legal situation 

Dr. Marc Ackerman: that's a great question so I called some of the four big players in dental malpractice insurance and I said do you guys have a writer that's telling Emma Street and they all were like no however it depends what you mean by tell identity and I said well what does that mean they said well if you've got a patient of record and you're communicating that with texts or photos if you are HIPAA compliant we don't consider that tele-dentistry we consider it normal practice okay the hitch here is if you want to grab new patients or consumers you've never seen and you're reaching out to them or they're reaching out to you through telling them legends that's where these insurers aren't necessarily going to cover you whereas in telemedicine you know there are all sorts of policies I'm going to the National Association of dental plans meeting I'm speaking in the fall is it Meredith it is yeah it's in Orlando yeah I spoke here a couple of years ago great group of people yeah like really good so so they said okay we want to know about tell the dentistry what do we need to do and that's the number one thing I'm basically saying you can only offer certain tella dental services through your network of providers if it's legal or not legal legal number one but then two if the provider is going to be covered for it through malpractice so I always say to everyone who calls me I get calls about can I do this can I do that my first thought is call your state dental board okay call your attorney and call your malpractice carrier okay those are the people who give the blessings 

Howard: the thing that frustrates me the most of a bigger was that the national dental injured dental benefits of zero plans the National Association of dental plans yeah NADP yeah and what I what bothers me the most is that um dentists providers have had such a car tankers relationship with the dental insurance industry they see each other as they don't have a working relationship like if you went to Intel or Dell or General Motors the whole supply chain is one family a wining and dining and golfing and then you walk into it somebody for Delta Delta CEO and tell him your dentist he'll run in hell a cab and when I went down there with those guys they were showing me the most amazing data but none of them would let me have it or post it on dental town references and even when I was talking to the chief economist at the American Dental Association Rubio his name it's very her name deal um he's never even see add access to Delta dentals hundreds of millions of claims that go back to nine keep it like they were show me cases where if it ended honest did a molar in sixty months five percent I'm were gone and if a general dentist at a molar root canal ten percent were gone I said well I want to publish that now how do we get that group to start realizing that not all dentists I mean here's what they tell me you go meet a delta dental CEO or whatever he says you know what I've been given this this dentist here you know three four hundred thousand dollars a year for twenty years I've only heard from him twice and he has both letters and they didn't cover something you bastard bed net and it's like dude is that how your momma taught you to win friends and influence people here's somebody giving you six figures a year and you've never even gone to lunch with them and you live in the same town or you went to that town for something else and you didn't even stop by and bring cookies and say hey mister insurance man you gave my office a hundred grand last year you're my new best friend they don't how do we get them to have a healthy functional relationship with their supply chain so they can look at the economics of dentistry 

Dr. Marc Ackerman: that's a really good question i I think that both sides have to be a little more transparent I mean they've got you know they sort of report to their stockholders their shareholders okay they're flat out in business they  may say they want to improve health access and health care I think so but they also want to run a business make profit so do dentists okay and it's really hard for both sides to give something you know Dennis don't want to relinquish you know high usual  and customary reimbursement rates okay and insurers don't want to pay more for claims so I think that one of the things my hospital did which I thought was really interesting was they negotiated with some health plans that the big-ticket items like the transplants you know solid organ transplants open-heart surgery for children you know really big things we're gonna be billed at what they needed to be built that in order to maintain the program I mean these surgery programs tons of personnel it's a long hospital stay etc etc but on some of the smaller ticket items okay like maybe getting tubes in your ears you know Marion Gotham an ear nose and throat they would take a little reimbursement because you know what they didn't need the higher one to cover the service so I think it's both sides coming to the table doors shut you know no press and basically saying okay let's start somewhere and in finding more of a medium I might be out true istic but I think at some point it's got it's got to happen and and letting blend on this

Howard:  I can't believe we went well over an hour God were our 15 last question and and you know I I'm not being a jerk saying this I'm just saying something I feel obvious like that when you get on dental town several hundred pediatric dentists that are posting all the time I mean if you are ever curious about PPO it's all there same with endo same with all but orthodontist neither the supper site they wanted ortho town do you think they're the most challenging to work for general dentists of all the 10 specialties do I think who's the most challenging orthodontist as opposed to end it on as periodontist Pina pediatric dentists all do you think they're more understand and less of a relationship in the value chain like we're talking about the value chain of dentist and insurance companies the value chain of general dentists and orthodontists it seems more strained than any other relationship with any other specialty

Dr. Marc Ackerman: I agree a hundred percent I mean I am I'll never forget when I was really in my early days of practice I went to a lecture by the late Vince coach who was in Seattle we did a lot of multidisciplinary lecture care and he sort of made you might not use these words but he basically was like the orthodontist is the quarterback of these complex cases I thought to myself that's we're like body and fender work it's  the restorative dentist implantology who's got the harder and we've just gotta line things up so they can drive at home why on earth would we make those decisions and it's stuck with me that's why I've never well in recent times I don't think I've offended the process and general dentists I work with because I'm like you know what you tell me here's all the records what do you think is achievable from your in and then I'll tell you if I can put the teeth there so yeah I agree and 

Howard; I'll give you another really hard core piece of undeniable evidence when you go look at these huge companies Cheyne Patterson Danner her you're just huge good they don't have to have a different cells forced to sell endodontic files to ended honest and general dentists or none of that it goes on but it's the standard operating procedure for that onyx orthodontist finds out that my rep has been selling brackets to a non orthodontist never see me again and that's something you only seen ortho yep I agree yeah so I that's so - last but not least and just talk to the dental kindergarteners they just got out of school a couple of weeks ago 6000 I'm in America they got two hundred eighty three thousand dollars of student loan debt and they're like how do I learn more about telehealth tella dentistry and what is it gonna do for me and my $285,000 student loans 

Dr. Marc Ackerman: well I would say just read our website I mean we've got you know quite a bit of blog posting I've posted all sorts of resources that are free downloads we had our first course so they've just missed it but next spring we'll have our second course on Toto dentistry and I would say think about think about what you want to do in practice okay and obviously most were the orthotic graduates have to go into private practice I mean I think they're mean debt I read somewhere is like five hundred thousand dollars which is which is pretty insane first ice list for first yeah for specialists but I mean that's the mean I had a kid at Harvard who graduated about four years ago eight hundred and fifty thousand dollars worth of debt private college private dental school private residency I  would say make a strategic plan from day one do not least yourself a Tesla do not try and buy someone's you know practice just because it's the Tony practice around I would say make a strata strategy stick to it and kind of follow the tea leaves of where all this technology may be leading us there are very few use cases like I said to you there's triage of emergencies there's teller orthodontic remote aligner care there's hygiene education and preventive stuff with fluorides it's in its infancy but I think they just need to keep it on the radar that's the best advice I can give to new grads so you would you would recommend going to your website American Teledyne astray dot org yep and is it cost to join right now there's no membership fee we got our IRS nonprofit designation this year we are gonna be billing potential membership dues for those who've signed up probably will be doing January 1 2020 and the statements will go out in the fall it's going to be very affordable there'll be three member types professional members corporate members and then academic or trade group members so we'll have you know a membership scale but for the average professional it's going to be you know equivalent to having Starbucks once a week for the year let's say 

Howard: well anything dental town magazine or a website or anything we can do to help I mean I what I love about your values is basically you know it's everything that history didn't want to talk about transparency accessibility collaboration innovation advocacy accountability I mean how do you disagree with any of those values and competition is good transparency everyone wants to know what every other person is doing but they don't want to tell you what they're doing I mean look at governments in war I mean you know they don't have transparency next thing you know they're invading you accessibility is more important than all the initials behind your name in fact I don't even put any initials behind my name is just howard farran when your real estate agent gives you a card and there's twenty nine letters behind their name do you know what does any of that mean anything to you at all close eye collaboration work with your supply chain you want to learn how to place implants walk across the street to the periodontist walk across street don't fly across the country collaborate with the people in your backyard but you won't because you think you're competing with them and as far as innovation I mean my gosh that the telegraph turned into the telephone turned into the Internet why are you doing you just graduated middle school you're don't you went back to practice with your mom and she's been doing this denture realign the same way since 1912 there's always going to be a better faster easier way to do anything but just I can't believe I got you come on the show I can't believe you got so many of my idols written workmen on your advisory board Salima shower Lisa Levine Steven Perlman Keith Dressler and the gals Sean I mean you are really you're something else man the only thing I'm worried about you is that you're friends with Ben Burris so I know you're crazy and and uh are you crazy hanging out with them you know 

Dr. Marc Ackerman: I think I'm beginning to his game so I I'm the same one I can and checked in uh you know we we both balance each other's craziness out last thing I wanted to say is thank you for having me I'm gonna send you that research relic because I think the biggest gift you could give me is put it out there on dental town it's the only research of its type when I post it why don't you post it let me just go into dental town or post it yeah also I'll send you the link to where you should post it I just sent it right now all right okay because if you if you posted it'll mean so much more to those guys okay I will post it you'll just tell me where and I say I say the link to where I talked about you already and I just be perfect okay Howard thank you it's been fun and I look forward to the reaction I'll get a bulletproof vest to wear until

Howard: tell Ben bursts that he's my favorite orthodontist ah he always was because he I mean my god he'd there's just nothing about that guy that reminds you of an or thoughts he just I he's fearless he's episode 439 orthodontic practices without Ben verse and now he has his website is what is it ortho pundit calm but the guy I don't know if he just has thick skin or thinks it's a joke but I love his freedom from fear and I oh and I can't tell you how many times I told my boys that about President Roosevelt when they told him that Pearl Harbor been bombed and the whole military was around and said look you don't understand Germany and Japan those are the two biggest countries on earth Lee we just came out of the depression we don't have the military we don't have the money we're gonna have to set this one out we can't win and and Roosevelt just looked out and said well living in fear is not an option so you're gonna go round up six million boys and you're gonna go get them and they and that was the military didn't want to go get them they go no you don't understand he goes no I understand and living in fear is not an option Ben Burris has been fear another one was Howard Stern I mean he knew what a funny joke was but all the proper people just kept firing him and firing him and he the whole movie on it stay true to yourself I mean when you tell all your friends a joke and they all laugh then you sit on the roadie radio and everyone fires you and the advertisers all go away you know they're hypocrites the the joke is funny and if you you know so members is the Howard Stern a dentistry passionate smart fearless and you're sure and from the same mold so thank you so much for coming on the show and be a fearless innovator in dentistry well thank you very much Howard pleasure to talk to you  

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