Dentistry Uncensored with Howard Farran

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

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Howard: It is just a huge honor for me today to be podcast interviewing Dr. Seena Patel DMD MPH thank you so much for coming over today. She currently serves as the Associate Director of oral medicine an associate professor at the Arizona School of Dentistry & oral health at AT Still University she is also an associate at Southwest Oral Facial group in Phoenix Arizona limiting your practice to oral facial pain oral medicine and dental sleep medicine since 2012 she is a diplomat of both the American board of orofacial pain and the American Board of oral medicine. Dr. Patel simultaneously earned her dental and masters in public health degrees from the Arizona School of Dentistry oral health in 2010 and completed a two-year residency in both oral facial pain and oral medicine at the Herman Ostrow School of Dentistry at the University of Southern California her educational interests are in Maya facial pain head neck cancer and dental management oral mucosal diseases management of obstructive sleep apnea with mandibular advancement devices and the dental management of medically complex patients. She has authored numerous publications and abstracts and services our reviewer of several peer-reviewed dental journals furthermore she has spoken nationally and internationally on oral facial pain oral mucosal diseases dental sleep medicine and the dental management of head and neck cancer and is given over 50 professional continue education courses she maintains your membership and the American Academy of oral facial pain american academy of oral medicine central Arizona Dental Society the ADA the list goes on and on and the special care in dentistry Association thank you so much for coming on the show today.

Seena: Thank you thanks for having me.

Howard: and thank you so much, in dentaltown magazine you've done two articles for us name that oral lesion you do that in 2017 and 2019 and I'm so proud that I didn't get any of them right but my gosh and I have to thank you the story is when I got a school in 87 and came to Phoenix I got a job as an associate with your dad and Dr. Nick Gidwani and the joke was back at the time that I would pull the top half of the tooth out and then after I gave up I would go get your dad or Nick and they would pluck a bottom ass so I want to think again your father for all the oral surgery that he taught me it was amazing I was doing my dental school my all my dental school requirements I was doing them once a week where we worked as sunshine dental I mean if you looked at your well as 56 fillings I think we had do 55 fillings and extract 15 teeth that was a slow week. So I loved it I mean I just could not believe that I was doubling my requirements every week and I felt fearless because I had guys like your dad and Nick that I knew all I do is you know try anything and if you and if you couldn't do it your dad or Nick would come get me but so how did you, why did you how did you end up in this specialty as opposed to general dentistry?

Seena: Oh well that's a good question it certainly wasn't in a decision I had going into dental school my I was pretty young when I started and I knew I liked dentistry but there's a whole world of different specialties you can get into and I want to say around third and fourth year I've really enjoyed surgery and medically complex that medically complex patients. One thing I realized by the time I was a fourth-year was that having the confidence in treating really complex patients and really knowing the connection between medicine and dentistry I felt kind of weak so then I actually paired up with a very good well known faculty of mine Dr. Michael Glick he was one of the faculty at the dental school I was at back in 2010 and I thereby got interested in oral medicine and so I thought okay actually this seems to be a better fit for me and one thing led to another I ended up at the dual oral facial pain program at University of Southern California under Dr. Glenn Clark and that's really what exposed me to this so I will say the decision to enter this field was almost on accident I'd like to tell people but I will say it was the best thing that ever happened to me because it opened a whole new aspect of Dentistry I never knew about.

Howard: There's some there's a lot of controversy I'm on dental town where whenever we're talking about making it a specialty and I guess they've been applying for different groups have been applying for a specialty longer as long as I've been a dentist what way what are your thoughts on the controversy making it a specialty, especially in light of like State Texas like the state of Texas said well that's you know the American Dental Association is not a government agency you know it's you know they just don't want you to look truth in advertising I don't want you to say you're an implantologist if you know if you're not but it's kind of what do you think about all those thoughts?

Seena: It's hard you know there's like you said it is a controversy but the reality is as these fields have evolved significantly in the last few decades they are evidence-based University based coda accredited programs that are out there for to train providers and the other thing is is that there are so many conditions that are missed because if specially if our specialty I'll use that in quotes because as you know it of course it's not an ADA recognized specialty yet but if we don't have providers limiting their practice to these conditions then it dilutes the field a little bit and it doesn't allow patients to get to the right provider so unfortunately what I've seen in my practice and at the dental school where we teach people end up seeing many different providers and not really getting the right diagnosis or care they need so if we don't highlight and develop this field as a specialty we do lose out on that and the controversy lies in the fact that the specialty in the world of orofacial pain there's just been a lot of change in terms of diagnosis and treatment over the years so you have a few different academies I suppose them who maybe have different schools of thought and I don't I can't speak to each individual and that but our academies in that world Academy of orofacial pain so those are university based programs and they are two-year code accredited programs that train so they really needs to be done in it's about time that that happens so we can only help but support that and both academies oral medicine or fascia might have applied like you mentioned so.

Howard: It seems so easy to solve because it should be patient centric.

Seena: Exactly

Howard: and you know the patient's shouldn't have to figure all this stuff out and I mean my gosh if I was having some one part of my body having a problem I would want to go to specialize than that I don't see them I don't see why a dentist turf or business or practice has anything to do with a patient centric model why is it not so obvious.

Seena: Well I'm not sure I have a good answer to that what my thoughts are probably is that in certain aspects of the field there may be overlap in terms of what some of the conditions treated some they overlap in different dental specialties that might be one thing in certain pain related conditions there like I said decades ago we thought you know TMJ related pain was due to occlusion and then there were different kinds of treatments for that and it kept evolving over time and these differences has they haven't been accepted by the community at large because of these different organizations that keep supporting different treatments so when you have this diversity that leaves two more controversy and it just takes a greater fight for one organization to say hey this is the governing body for that field and to move it forward so we're kind of just lingering in this unfortunately what I seems to be kind of like a turf war but probably just a lack of consensus on what everybody wants to do about it so it is changing though I mean I've seen so much positive evolution of this field in my short lifetime in the field so I can only imagine it's gonna get better.

Howard: Well the the the kids I feel serve the kids and you spend a lot of time around AT Still dental school so you're around the students with a lot of amazing professors like Tim Bukowski Tim Taylor just a lot of great people there but they seem you report on dentaltown or alot to me that I'm they don't see a lot of big controversies among the endodontist are the oral surgeons the periodontist but when it gets to TMJ and occlusion they almost they describe as like there's a plethora of world religions.

Seena: That's how I feel too, honestly and the way I was trained we've always been evidence-based so we're very strategic with someone who might have been trained differently I mean I've gone to excellent comet symposiums conferences and talked to very educated people who want to help their patients too but the philosophy there it's like it is it's really like talking about religion and if we keep it at that mindset we won't be able to move further that's what makes it difficult and I can't say I have figured out a good solution to that maybe we both have to keep an open mind.

Howard: So what is oral facial pain oral medicine dental sleep medicine what is your world like?

Seena: Yeah so orofacial pain is a discipline that involves basically the pain management of any condition going from the neck up so that includes neuropathic disorders like trigeminal neuralgia post-traumatic trigeminal neuropathy or what was previously known as atypical odontology or phantom tooth pain myofascial pain myojin is disorders TMDs which we would classify as joint disorders like clicking popping arthritis or myofascial pain masticatory myalgia most people will think of it as muscle pain due to bruxism or clenching grinding stress related conditions but it this this field also includes the management of headache related conditions that tie into the oral facial or maxillofacial region so that could include migraine serviço genic headache it's amazing how many of these neurological conditions are actually triggered by the maxillofacial complex so it is I mean every day I'm amazed at you know treating people and all the different things we see because it's a pretty diverse field so then from oral facebooking ties into sleep as we know pain and sleep are so interconnected so the feel of dental sleep medicine it's newer but the role of the dentist has really evolved in terms of over helping to maintain a patient's overall health screening for severe health consequences like sleep apnea we know can contribute to cardiovascular disease cognitive dysfunction I'm drawing kind of another blank here but amongst a whole host of other sequelae so and then we can also play a role in insomnia and just getting the patient to the right provider so that they can be diagnosed sooner rather than later but our main role famously is known for making oral appliances for sleep apnea so that's dental sleep medicine but even that it we have an expansion of our role as a dentist to play in these.

Howard: So a lot of people believe that you know a general dentist each three diseases you know pareo carrio and occlusion you know they have one that rhymes with pareo is there an inclusion word that rhymes that but not to throw my homies under a bridge I love them to death but in most practices if you come in and you said any one of those symptoms you know my teeth I'm grinding whatever whatever they just call in the front desk to see if their insurance on covers a night guard if they says yes the assistants come in take impressions that's TMJ for nine out of ten dental offices in America it's just alginates a bite lane what do you think of that?

Seena: I think we're jumping to symptom management rather than going back to really assess what the diagnosis is for the patient and that's what I strive to teach others to let's go back to what the patient reports let's get an adequate history let's actually figure out what we're treating Before we jump to treatments but I think as dentists were almost trained that way because it's a surgical mechanical field so we I like to take a step back to go back and say okay what are we actually treating before we just you know prescribe a night guard or something like there's so many other treatments that can be done.

Howard: and I know a big a lot of people always wonder how much is this a psychosomatic like you see someone grinding your teeth but there you're going through a divorce and they you know the kid crash the car and you know whatever whatever how much of this is stress versus mechanical?

Seena: So that's a really good question these you're right historically the pain related complaints I've always been kind of thrown under like maybe you're just stressed or you're anxious or depressed or something like that pain in general we know is associated with psychiatric comorbidities there's no doubt about that someone in chronic pain may develop anxiety or depression it's just difficult to figure out which came first but the problem is is stress as we know it causes almost every disease on the planet so there absolutely I mean we carry tension in our muscles but and we might stress out because of a certain situation in our lives but what we've known is that direct cause-and-effect relationship to grinding your teeth or bruxism it's not completely proven we know that bruxism is actually a sleep disorder probably 80% of the population grinds our teeth at night it is asymptomatic so to just label grinding your teeth you must be stressed is it's overstated in my opinion so we have to look back to see is this a motor disorder or is there some inflammatory component to the TMJ certainly if you develop myofascial pain it's a vicious feedback cycle you get a trigger point or a tight knot it tells your brain I'm in pain your brains gonna say okay the muscles in a tighten more it just keeps looping so chronic pain is a whole different entity we have to look at it very differently than looking at just mechanics and I think that's where we as dentists forget that if we're just looking at a click or a popper an arthritic joint has it turned into chronic pain which is a central nervous system disorder or is it actually is there a mechanical issue that's where we face difficulty with treatments so we try to fix the problem whereas with chronic pain we have to shift our focus to management.

Howard: I just made the most unique observation for me in 57 years I got my dog grinding his teeth while you slept I never even you never even thought but I'm sitting there right you're like okay he's grinding his seat so Bambi she was definitely reining her teeth we'll have to consult others for that dental sleep medicine when your father and I got out of school it was never mentioned now it's all the rage how did it go from didn't exist to now everyone's talking about it?

Seena: Sleep medicine even in itself within medicine is new but what they found was I believe it was in the it was decades ago I forget the exact year but a physician was trying to treat his own sleep breathing issues by pulling his tongue forward and managing it that way so that kind of sparked the whole concept of oral appliances or repositioning the mandible or repositioning the tongue in some way to open up the airway and so that's where dentists found their kind of niche into that field but in addition even when we're looking at kids to as they grow we realized there are skeletal issues that can happen in the maxillofacial complex that can affect a kid's growth and potentially affect the airway or vice versa so all these things kind of came together and and that's how we found our role and now you know you're right oral appliances are a big thing and it's another avenue where a dentist can provide care for a patient but more importantly if we look at the big picture it's us helping in the overall health of the patient so people there's greater motor vehicle accidents there's cognitive dysfunction memory loss mood disorders all kinds of things tied into poor sleep so if we can help screen for those that's a pretty big thing I mean dentists see a patient's visit dentists more often than their own physician so if we can get that conversation going there's simple tools you can teach yourself and really incorporate that so that's kind of how it started and became a big thing now.

Howard: Do you think you think then I'll say motion should be a part of every general dentist practice

Seena: Yeah absolutely it's still a discipline of dentistry and if we're looking at the role of general dentistry we should be screening for these things we now teach people to screen for TMJ disorders or oral put the pathological condition so there's no reason that sleep shouldn't be included as well.

Howard: and do you think we're doing it well or there's a lot of...?

Seena: I think that there's a really good effort but you're right I do feel that from a big picture standpoint we do need more education and a little bit more time spent and more of the academic or university based evidence-based programs sometimes we're really quick to jump because we're busy people we don't have a lot of time so it's easy to try to take a quick quick course or something on that but we just need to start with the basics start with diagnostic first to learn what dental sleep medicine is all about Before we jump into oral appliances.

Howard: Does this me you'll be making an online course?

Seena: Oh yeah

Howard: I would love that, talk about your special research projects of head neck cancer patients particularly HPV and oropharyngeal cancer.

Seena: Yeah well HPV and oropharyngeal cancer is a hot topic I mean if we look at the literature there's probably something every month coming out new in the dental literature what's really fascinating is just what I was taught in 2006 forward fast forward ten years later and we're taught the exact opposite about this virus but just like those other conditions we talked about where dentists can play a role in helping the overall health of the patient same thing here we should be asking our training our providers to discuss like whether a patient has received the HPV vaccine for the prevention of HPV related oropharyngeal cancers so one of my research projects actually i collaborating with some other faculty so dr. Anspaugh Laura Cheshire Maureen Perry and Dr. Alexis Costigan she's a public health specialist at ASU we surveyed our Arizona dental population dental providers so hygienists and dentists at the Western Regional dental convention last year to see hey how many of you are interested in this subject what do you know about this subject are you willing to talk to your provider your patients some people find it to be sensitive or would you change some practices based on more training so we have you know a really positive response overall but there are still knowledge gaps so we need to improve on those so that's something we're working on developing training modules and on the other hand we've got another trial going on with head and neck cancer patients going through radiation and we're doing fluoride application methods. So traditionally patients are prescribed fluoride trays because they're going to get dry mouth from the radiation and that's a lifelong treatment the problem is compliance with that is poor the trace can sometimes cause pain in the tissues during radiation because your tip mouth tissues are so dry you know it frankly hurts and I've seen that my patients go through that so I can empathize a little bit more now having seen that so we feel that brushing it on is perfectly acceptable and it works just as well so we're doing a trial on that but amongst this process I've seen all these complications happen in patients in terms of pain neuropathic pain musculoskeletal pain limited mouth opening mouth ulcers it's a tough process so I guess I just found a little excitement in working with these patients who are just going through a tough time with treatment.

Howard: You know the thing that you know I mean just be honest I'm not a big fan of any government I'm not a government fan like I I am 57 years old born in this country I cannot go by the HPV vaccine for me I mean I've gone to Walgreens I tell my pharmacist the the lady who I bought the house from had to sell this house and move to Scandinavia because she had brain cancer and the company that made the drug was selling it in Scandinavia but wasn't legal in the United States and I just thought how insulting that a government agency won't let and a dying American by a drug in here the HPV vaccine I want to be able to tell my patients I mean I've taken it yeah but I cannot take it because the powers of be that people surrender to have decided that I can't purchase it I mean I only know where to start people's I it's like government is the problem it's never the solution yet everybody runs the government like it's their mom mom mom what should we do well first of all quit asking that person but I know my dentist and so many of them are conservative Christians and they're just not gonna bring up HPV oral sex so what how are you a doctor when your patient is is a mammal that gives birth to live young nurses there young. I mean how why is this such an issue to talk about HPV oral cancer oral sex I mean what are your thoughts yeah I agree that is and is a different is it a generation thing like are you different about your views on this thing you say your father is my age I mean...

Seena: Yeah well certainly the generation were raised and born in the culture Society all of these impact our views on things unfortunately we have accessed fortunately or unfortunately we have access to so many different sources of media so we can get good information we get equally bad information and one important person says one thing and it runs like wildfire whether that's good or bad I don't you know that's the issue that arises my personal thoughts are I'll be very honest you know the first the first version of the HPV vaccine came out in 06 I was a first year dental student was 20 and all my friends who were going into medicine they're all so much should we get it should we not get it you know all these things and I too thought the same conservative way that you know do I really need it is that only for certain you know populations isn't that and now having gone through this program where I'm starting to get involved in the subject the research it realize how wrong I was it really has nothing to do with that it's just a stigma like anything else our society places on things we have to look at it as a cancer prevention tool so it's not looking at it is it preventing don't even look at it as an STI you know look at it as this is something that causes cancer we are preventing cancer and when we look at it and market it that way people will change their minds we can only do what we can recommend it.

Howard: Where did you go to college at, your undergrad?

Seena: University of Arizona

Howard: U of A?

Seena: Yeah

Howard: So U of A you might not have needed an HPV vaccine it's ASU

Seena: Probably

Howard: You should get at the door I think we can all agree on that but anyway yeah back the one thing I've noticed the most in my life is the losing of a trust by American people and and it was before the internet I mean like when people are talking like about an election I mean do congressmen realize they only have an eleven percent approval rating and then the news media who's always playing war with the politicians they have the same rating and it's it's kind of been a my entire 57 year experience is that all the institutions have been losing trust, my two oldest or Catholic nuns I mean the Catholic Church trust has been plummeting so when you talk about vaccines I mean I cannot go to any family function any party or whatever with strong anti-vaxxers there and when you listen to them you just realize that what what they've lost is that they lost faith they've lost trust yeah they don't know who to believe anymore so fake news is kind of a sad state of affairs that something is taking trust and faith from basic institutions away from everyday people do you see that or?

Seena: Absolutely I mean if I'm just speaking to our own industry I mean how much access to patients have to look up stuff about diseases and dental disease and medical disease beforehand then you go to the doctor and you question a bunch of things I mean I think every provider I know has shown frustration being on our side of it and how much you face just being a provider to a patient because of the fear and I can't blame them because if I flip the situation I'm fearful too you know we have all these fears about medicines treatments am I getting the right treatment somebody trying to do something I don't need there's all that out there so it's not the days where you just blindly talk trusted anybody much less your own doctor I don't know, it's our current situation.

Howard: and also so you can't anticipate white light like I've really been involved public issues on the water fluoridation I hope got it in 89 and then when it expired 20 years later and a lot of people just come up to me and said I don't care if what you're saying is true or false I just don't want the government touching my water I don't want the money you tell them the government's doing something and I completely under I I get where that's coming from you know it's um but I I think one fourth of Arizona you could never change your mind about water fluoridation which I'm fine with you do you think the HPV vaccine how how what percent of the kids that should be getting it are getting it right now?

Seena: The statistics in Arizona are around the upper 40 percent so I have the numbers in my computer but it's around 46% the the challenge is we need to get the rate a little bit higher for boys that's been a newer issue lately of course when this vaccine first came out it was targeted towards girls and now we know that they both equally need it so but we're about 46 percent we're still low I mean 20 healthy people 2020 ones 80% by 2020.

Howard: but what's interesting is when the herd starts to get vaccinated it starts helping the non vaccinated.

Seena: Yep absolutely that's what they want to reach his herd immunity so it's education you know that's the whole point of getting any vaccine is to achieve herd immunity so that even people who aren't vaccinated are benefited by that.

Howard: So a lot of kids you know they focus a lot more when they have skin in the game and it had to buy something expensive when you start getting into your field is their expensive equipment that is worth buying is there stuff that you need to do your job?

Seena: In oral facial pain?

Howard: mmmhhh

Seena: You know that's actually the kind of cool thing is in oral facial pain oral medicine I wouldn't say there's extensive expensive equipment is probably the most expensive is our imaging modality which is the CBCT machine that is very necessary to our practice but that's probably the most expensive in terms of everything else you have the tools in your practice.

Howard: Well there are some big companies that that catered to your from my electronics and I think they sell a lot of ten or fifteen thousand dollar machines do you do you see any of those is necessary or...

Seena: I really don't

Howard: You really don't

Seena: I really don't those again when we that always brings me back to when I teach my students the same thing is when you're looking at oral facial pain providers like go back to the Train or if you're going for CE courses look at what's tied to the American Academy of orofacial pain that's evidence base in a lot of other expensive equipment simply haven't been proven to be any better than our traditional tools we have in our office so I don't use them myself those other things that you mentioned.

Howard: All joking aside a trigger you know trigger points on the word neuromuscular is a trigger point for a lot of people you know you say neuromuscular and some really go defensive so what why is neuromuscular a trigger word?

Seena: So and I don't having been I guess being newer in the field I didn't get to personally experience all that evolution that oral facial pain has come through so I didn't get to firsthand see the full mouth rehabs that were gonna happen and all these other different modalities of treatment so just from reading and speaking with colleagues and other experts neuromuscular dentistry is a term for providers out there who supposedly are trained to find the appropriate occlusion that's supposed to completely manage a pain related complaint. I'm sure there are specifics to the process of how they get to a diagnosis or treatment but traditionally once they have that position the occlusion is altered by irreversible treatment modalities so the reason we get so defensive and tight when we hear that term is because it's not evidence-based and irreversible therapy is not the first line of treatment that even the ADA standard guidelines dictate for all facial pain disorders the first line of treatment is conservative therapy so reversible treatment modalities so when we see that that becomes the first thing we do get a little a little defensive about that.

Howard: and some of these some of these occlusion camps it seems like a lot of after all their workup means that you need to redo all your teeth.

Seena: Yeah

Howard: So that that's not very conservative.

Seena: Nope that's irreversible treatments not first-line

Howard: but it is that kind of what you're alluding to these people they

Seena: Yes

Howard: that has a course they show what's wrong they have all this equipment and when your whole done the transplant is always the same on 28 teeth in your mouth.

Seena: Yeah I I still get shocked to see that now I don't I think that their providers trained in that that's the one where ever the education came from they're trying to help their patients so I respect that I really do because they're trying to learn more and they're trying to do the right thing, unfortunately it's just not evidence-based and so we see these procedures that don't need to be done.

Howard: and I'll call it maybe you're more sweet than I am I mean we saw this with the anti mercury guys that right yeah I know one I don't agree with any of your science about your mercury but even when you do the dream plan replacing all the amalgam in there and I mean you charge 30,000 I mean true even if I believed all your voodoo I might gonna fix them up for maybe 1,500 or 3,000 but it was over it was always all this voodoo medicine but then the treatment plant again was always like 30,000 by someone who would do anything to get rid of her MS or her disease or whatever it's like so if I would have seen if I would have seen a hint of this where you believe all this stuff and it's from the goodness of your heart but you know could we do this for 1,500 or 5,000 but

Seena: True, that is true

Howard: Is it always come to the amount of a treatment plan that none of my alcoholic dentist friends have ever done in the last five years you know I mean so their are a lot of red flags.

Seena: Your right there's a lot of red for a lot of red flags I know there's a whole host of things that you know are like okay you're right it seems to be the same true and plan that's irreversible there's a cost we can definitely make the cause the reversible treatments that work if that are evidence-based they work effectively they are much less costly that is for sure.

Howard: Yeah and I Like Amin my mom dad had seven kids and like I think three and a half hours they were Catholic yeah so there's just a lot of people that don't have the money exactly you say your favorite procedures are trigger point injections, occipital nerve blocks and biopsies and I bet 99% of the dentists I've never done any of those things so what it would are those three things and why are they your favorite procedures?

Seena: There's a few things one I think the fact that most people haven't done those things may be why I like them so much too it makes me feel a little unique but know what really trigger point injections fascinate me every time I do that any time I can get rid of a certain pain complaint that seems to be coming from a distant site for example a toothache and then I injected the master muscle or even some of the cervical muscles and it disappears I'm just I mean ah that our body works this way so I guess it makes me feel so good that I can immediately give someone pain relief even though trigger point injections I always explain to people it's an adjunct to treatment it's not a cure by any means and it's a great diagnostic test but I love that we can use a conservative non-medication approaches we use lidocaine but that's it it's really the physical needling technique of that injection that works it's so safe and that's one of the things I always see such great instant relief from it so I love that about my field. Same with occipital nerve blocks you know you have a patient with a migraine try an occipital nerve block and it brings it right away you just gave that patient their day back I had a student who came to me with a complaint like that we did that they're so grateful and it makes me feel good so I guess it's a little selfish as to why I like that procedures away and then biopsies oral pathology is just such a fun area for me so I it lets me kind of hang on to some of that surgical technique but I'm now in a more in a field that's less procedural but I like I mentioned before I kind of wanted to be a surgeon at one point in my life and so I like to hang on to those procedural skills and this always kind of fulfills that for me so I like doing them.

Howard: are these things that general dentists could do?

Seena: Yeah I don't see why not the key thing is to learn what you're treating learn how to diagnose it and the procedure is always easy to follow.

Howard: Huh that is amazing and so are you is there a delta dental of Arizona code for this at your office in and Phoenix Arizona because you're at the dental school and you're you also a Southwest Southwest Oral Facial group and that's it that's in Cave Creek?

Seena: Is it we have three locations it's in North Phoenix Peoria and Tempe.

Howard: Oh you have one in Tempe?

Seena: Yeah yeah not too far from here.

Howard: I was not aware of that and where is that at?

Seena: 101 and southern

Howard: 101 and southern really, and is that the one you work at?

Seena: No I actually work out of the one on Cave Creek and Greenway which is in North Phoenix.

Howard: and then you also work at...

Seena: Yeah so I'm going one hour each way.

Howard: You should probably work at the Tempe location and then buy a house in the middle.

Seena: Yeah

Howard: So what are you doing at Southwest orofacial group and are all these things on insurance driven I mean to Delta pay for all that or these are just some medical insurance or this cash or but specifically back to these trigger point injections?

Seena: So the practice I work at I actually joined Dr. Rich Cohen's practice he previously owned it and I've been with it for seven years and it is completely we take we're contracted medical insurance only so we are unique in that we're probably fewer providers who do that so that's kind of a whole different ball game so they are covered through medical insurance but we do work with some experts in billing to understand the game of that but we do get very good coverage to our patients get that service when as far as like Delta Dental I can't really speak to that I don't, I'm not sure if dental insurance covers these I haven't worked with that because at the school we also use medical insurance.

Howard: So does Richard Cohen does he still own that?

Seena: He doesn't own it but he still works with it yes so he did sell it yeah.

Howard: He was I tell you what when I got here in 87 he was already the leader in that.

Seena: Yeah he's great.

Howard: He was a leader that and 87 when I got here he was the number-one guy in Phoenix doing that and back then I mean a lot of dentists didn't believe in it and they mean I mean we're seriously where do I get when I get here in 87 you referred to Joseph Cohen if you had quote a crazy lady and they were talking about action you know when they have crazy eyes and they're saying crazy things yeah that's when you send them to Joe TMJ is something man crazy Pam I know you're right though yeah telling you that's confessing to you that's that's how that field started and it's true in 32 years it's gone from the crazy lady with crazy eyes disease to now look at it I mean...

Seena: Yeah that is actually a disease it is yeah exactly I completely agree.

Howard: and it's one of the reasons the all-male Gynaecologists are now all women because they used to say you're being hysterical which is the Greek word for uterus I mean we can imagine yeah I mean can you imagine you tell somebody and that's how you're acting to like a bunch of testicles and so people weren't listening to the male gynecologist weren't listening to I know the male dentists weren't listening to TMJ in 87 you were a crazy lady and we could diagnose about your crazy eyes.

Seena: Look at it now.

Howard: So that question is do you see more female patients is this a more female disease like...

Seena: It certainly is, pain in general affects women more and there's a whole host of just gender related genetic differences but allow for that and that's a whole different realm of study but we do know that there's hormonal related changes that play into chronic pain different kinds of joint disorders things like that so but so I'd say it's probably three to one just like migraine is three to one female to male probably that's about a good ratio for my practice.

Howard: So when we said in 87 there's a crazy ladies he's we were we were partly right it was definitely a lady disease right

Seena: For the most part it is.

Howard: Three two one in migraines?

Seena: Yes

Howard: and three two one and what else?

Seena: Well I would say oral facial pain in general like pain yeah it definitely affects women more that's hands-down truth.

Howard: You know that's why I only had four boys because of just that like I specifically tried. So what is the low-hanging fruit on why it's women three to one?

Seena: Well it just goes back to the actually genetic differences in terms of our hormone levels so we know that there's a hormonal component to pain and differences in estrogen levels things like that do they predispose you to chronic pain and also persist certain pain disorders I can't speak to the exact you know mechanism but that's really where it ties into and and they have studied that they see that so.

Howard: but you know one of the things being a man and one of the trends I've seen on a lot of a lot of diseases that are more for women than to men.

Seena: Sure

Howard: A lot of times over the years I've seen a pattern where men have a problem of underreporting to raising their hand that they have a problem and that a lot of boys they just don't get help I mean it's hard to get him to ask for directions.

Seena: Yeah that is true.

Howard: So do you think this three-to-one is more because some part of it might be the fact that women are more likely to raise your hand and seek help and boys don't under it .

Seena: That might be true in general women go to the physician or dentists more because they're more proactive about seeing the doctor rather than men that's pretty well-known so I think that's part of it but there are actually large population-based studies that have stuff all over the world on migraine at least and they've really seen that consistent three to one. I don't know what the ratio is exactly for TMJ related disorders or other pain disorders but I don't think that that's the only issue is that you know men are not forthcoming in terms of their symptoms I'm not coming in to the office that might be a tiny part of it maybe 5% if I'm just going to throw a number out there but I think there really are just differences and how are the woman's body in a man's body respond to pain.

Howard: I always tell dentists you know I don't care if your clinical dentistry is in a B or C I just want your diagnosis to be an A there so I just think the diagnosis is so much more important than the treatment I just it's been more time what do you think then this could do to be better at diagnostic?

Seena: Taking a better history it always teach everyone 90% of what you need to know is coming from the history and then know what those key elements ties in to the diagnosis so studying the conditions kind of taking ourselves back to actually knowing spending time on dental Diagnostics like what are the typical oral pathologic conditions or how does a person's medical history really affect what we're gonna do or what type of pain related complaint is is it really a joint related issue is it arthritis is it myofascial pain learning just a Keis a few key differences in how to differentiate those conditions that will help you get to a better diagnosis and then you can the treatment you're right is simple it's easy but getting the right diagnosis is hard and it doesn't come right away there are so many times even today I will diagnose I will miss a major diagnosis like for example trigeminal neuralgia that's a tough one sometimes you get secondary muscle and joint pain from that nerve pain so I'm treating somebody for a tmd and then later on that neuralgic pain unfolds itself so we'd have to take our time with these patients kind of let the story unfold but be conservative in the beginning and and just know the major different major categories of pain.

Howard: and is there someone to learn more about the diagnostic side what tool would you recommend is there a textbook a course online?

Seena: Absolutely I mean there's many courses I myself give these courses in town and around the country but I would say if anyone's interested in orofacial pain the orofacial pain guidelines an assessment that's published by the American Academy of orofacial pain is an excellent first initial...

Howard: That's a book?

Seena: It's a book yeah yep.

Howard: What's the name of the

Seena: Orofacial pain guidelines and assessment something like that I can get you that.

Howard: From the American Academy?

Seena: but is yeah it's published by the American Academy

Howard: Of orofacial pain?

Seena: Uh-huh and then there's one more that's...

Howard: So what was the name of that I'm just be on their website?

Seena: It should be on their website yep under publications

Howard: Okay so American Academy of orofacial pain that's AAOP wow that's a dot Club Express is an interesting website AAOP.Club Express yeah this has been a whole bunch like that okay so professional resources and it would be you said it's a text bookright?

Seena: Yes it is, so let me help you here.

Howard: There it is, I am having so much respect that you can use that little..

Seena: Oh the touch screen.

Howard: My boys are really trying to get me to use that its like no I have to have the old...

Seena: I still use that for the most part it's okay.

Howard: So you're pointing to the orofacial pain guidelines for assessment diagnosis and management sixth edition so that's a that's a $56 book from publishing in that job that's what you like...

Seena: Yeah it's a great start for anyone who's interested in oral facial pain then there's also I'm Dr. Glen Clark helped write a book it's called pharmacology and oral facial pain.

Howard: Pharmacology and oral facial pain.

Seena: It's a bright orange book you can't miss it that is excellent.

Howard: You want to find that for me okay is it on the same website?

Seena: No

Howard: Because these aren't simple subjects to learn and the one thing I have to say is what I don't understand about young Millennials they complain about their student loan debt they complain about everything and then every time they want to learn something they fly clear across the country in an airplane standard resort drop a thousand dollars on a course and then here's this $56 textbook that you couldn't even have read in the entire weekend I just my go to is always a textbook.

Seena: I agree I'm traditional when it comes to that I need my textbooks.

Howard: yeah and I've my boys I remember one time my boys on they count him dad had 1000 textbooks read

Seena: Wow

Howard: In my office and they were just saying that um I mean you sister blow their mind and I would just sit there and think well if you really want to learn something God isn't the fastest easiest way to learn it is always going to be a textbook I mean.

Seena; I agree I like having the textbook then I'll go back and read it again or look stuff up a lot of resources out there too.

Howard: and it's kind of annoying when you go to somebody's lecture and the questions are just like dude that was that was in like the first three pages of the first chapter I mean he's like you just I mean my god is you just write of where'd the advertisement for the book on Amazon you would it would even ask that question.

Seena: That's too bad though you know you should be able to learn something new I think.

Howard: Yeah so on diagnostic dentistry you recommend those two books that would that would be the starter?

Seena: For oral facial pain yep.

Howard: For oral facial pain and then what else?

Seena: Well I like for oral medicine or medically complex there's the little and Felice book of the dental management of the medically complex patient most dental students should get that through their University and then Burkett's oral medicine.

Howard: Actually will you just send me a list?

Seena: I will send you a list, yeah.

Howard: because what I'm trying to do is I'm make everything faster easier higher quality lower cost and you know for $50 books something everyone can do but going to some of these Institute's that are $3,000 a weekend is you know I can do them because they're fun and we're older and we have that money but some of these young kids or or they're in a small town they have their their plane they got the mom had the dad had on so they got a practice they got kids at home and I don't know I just I would just read it first I think reading is so much more faster. So my question is um there's two things I don't understand dentistry is why anybody would want your job or a pediatric dentist I mean how did you how did you look at everything you could do in dentistry like when you tell me you want to be a pediatric dentist I my first thought is what went wrong in your childhood where you woke up one day and said I just want to listen to a bunch of babies screaming and crying so what attracted you, was it because pediatric dentistry wasn't painful enough?

Seena: No I like I said before this was an accident honestly I mean I went into dentists so let me take you back to my high school days I always wanted to be a physician that's what I was gonna be then I entered junior senior year you apply to those programs I thought let me apply to these fast-track medical school programs so that I don't have to you know I don't have to be afraid I don't have a seat in medical school and I did get into one of those my senior year but I realized at the time it was almost like I know it might sound a little cheesy but it really was I feel like what you're meant to do your going to do regardless of what's happening so I actually my heart was not into medicine nor was it moving all the way across the country to this program so what happened then is a few people around me started talking about dentistry my dad's a dentist though I never considered dentistry despite the fact that he the dentist that then kind of just sparked an interesting hey I really like this field it's procedural there's also a lot of Diagnostics in it this is fun. So anyway I said okay that's what I'm gonna do and then I don't look back I say this is what's me so when I got into dentistry I didn't even know what a crown was I mean I'm just being transparent here I really didn't know I was very young very naive and didn't have a lot of experience in dentistry I loved every bit of it I love the surgical skills I love the hands-on procedures but that little bit in the back of my head said hey still don't feel confident that I know all these about these diseases people report today when they show up as a new patient how do I know if I'm treating the patient the right way if they have such and such a disorder and then I got more involved in academics I always knew I wanted to be a part-time academic maybe involved in research and one thing led to another let me tell you my initial thought was oral medicine and I didn't even I just kind of went into it thinking you know what I don't really want to go into practice right away from school I want to do something more so let me take some time to grow as a professional and then I'll enter the practice relm. So what happened was I thought you know at the worst-case scenario I'll just learn a lot about oral medicine and then I'll go into general practice when I come out I got into oral facial pain completely by accident that I didn't even know what oral facial pain was and I'm gonna tell you who is challenging the first few months I was a little bit of a shock as to what did I get myself into but now I'm looking back and I thought wow I didn't even know that dentistry could involve these aspects and it's been the greatest.

Howard: That's at USC?

Seena: Yeah, yeah

Howard: and that's in LA?

Seena: It's in yep la Los Angeles

Howard: Was it you lived in Phoenix, you lived in LA?

Seena: No I lived in LA for two years.

Howard: Do you wish you're in LA?

Seena: That's a good question people ask me that, I really enjoyed my time in LA I really did but I do remember seven years ago that I was itching to come back to Phoenix I love it as a city there's so many things to do great people great academics great culture traffic it's a little congested to me Phoenix looks like a mini replica of LA so I love my hometown which is Phoenix.

Howard: Yeah I have a hard time leaving San Diego.

Seena: Well San Diego's a whole different ball game I agree that's a nice place

Howard: but yeah I just but I mean I'm a big air B&B; guy I mean you can get anybody's mansion on the beach for almost no money you know I mean really I mean I got a lot of kids and I four kids and five grandkids and you can get some of the nicest million dollar houses anywhere from San Diego to LA on those beaches for just time a couple hundred dollars a day I mean it's just so that's why I would never buy anything over there but yeah I love that area.

Seena: Yeah it's amazing for sure.

Howard: So you are glad you're doing this and

Seena: Yeah it's the best thing that ever happened to me, I think the back the high school side of me that wanted to be a physician I get to use some of those skills that I didn't realize you could use in dentistry so I get to kind of keep both is what I feel and I love it.

Howard: Yeah you say you say you like speaking if someone wants you to speak at their group how do they contact you do you have a website for that?

Seena: I do have a website but most people contacted me by my email just directly and or my office email.

Howard: So how do you want to tell them what that is?

Seena: Absolutely my email is SBPatel so it's my initials s as in Sam B as in boy Patel

Howard: Your middle name is boy your dad is a practical joker

Seena: So it's SBPatel@atsu.edu

Howard: Okay and and what is your what do you what do you like to lecture on what is your classes on?

Seena: So I started doing a lot of speaking a few years ago and it's evolved into kind of a variety of courses most of my lectures are on oral facial pain subjects so that could be pharmacology I do I can do one to two day oral facial pain subjects on kind of the whole scope of it hands-on workshops on injections things like that I also like to share on oral pathology so oral mucosal diseases I'm starting to lecture on sleep dental sleep medicine head and neck cancer patients is another great topic I love to talk about so I do that cancer and oral health is another topic.

Howard: and is pharmacology over the years is pharmacology being more of a tool the same or actually less?

Seena: You know actually most oral facial pain providers will tell you that it's coming becoming less but I think it's just important to know what tools we have so most people can be treated with physical medicine modalities orthotic therapy or and some lifestyle modifications and we use medications for a short period of time however there are some chronic conditions or neuropathic conditions just simply require medications so we I'd like to go over at least what that is so we have the exposure to it I also go over injectables that's part of pharmacology too so I love injections in our field so the interventional treatments and then the oral medicine aspect also requires a certain expertise in pharmacology so I like to train people on that.

Howard: What are the most common or pharmaceuticals for medicine?

Seena: For moral medicine chronic diseases are usually immune mediated so my first line medications are topical corticosteroids but most of the time we don't get them to the right medication or the right potency and the frequency and then how to manage the side effects most people feel a little uncomfortable as to how long a patient should be on a topical corticosteroid and then you can also inject corticosteroids in the lesions or then turn into immuno modulating therapies too so but first...

 Howard: but what are common lifestyle choices?

Seena: Well when we're talking about oral facial pain disorders lifestyle modification is huge i counsel patients every time I see them on making sure they have appropriate posture relaxed posture the tongue goes to the roof of the mouth keep your teeth apart learning how to stretch the muscles properly even taking some relaxation classes or seeing a counselor who can help them with that or try things like yoga low-impact exercise tai chi meditation these are all wellness techniques we should incorporate and then of course softer food diet for certain joint related conditions or avoiding things harmful habits becoming self aware of those things makes a big difference becoming more disciplined sleeping well things we should probably know already but.

Howard: and how much of this is because of chronic events versus acute like I wrecked my car fell off my bike?

Seena: I will say in my practice I probably see a much higher percentage of chronic and there are submit several reasons that can happen and perhaps the acute issue wasn't treated adequately and then turned into a chronic problem perhaps there's other systemic diseases that make this person more susceptible to chronic pain but I think that most primary care practice isn't including general dentists will see acute and that's actually why the percentage of TM DS is about twelve percent in the general population how many of those actually make it into the office is probably a lot fewer because most of these resolve on their own so that's why we don't jump to intervention too quickly because we know that give this some time perhaps a short-term course of medication thermal therapy like heat and ice use watch it for a few weeks and if it doesn't get better than start treating.

Howard: They say only five percent of Americans will ever see a chiropractor in a lifetime but everybody will see a dentist and how what person do you think will have an oral facial pain?

Seena: Generally the statistic is about twelve percent...

Howard: 12

Seena: Yes that's pretty high.

Howard: So it's basically two and a half times a chiropractic industry yeah so so and

Seena: Well twelve percent is probably them out affected let's see if we're talking about how many gets seen I don't know maybe I would cut that in half it's hard for me to answer I'm not too sure.

Howard: Well it's really interesting I mean I'm and then when you get to the very richest 20 countries there'll be five physicians for every dentist and then by the time you go to the 50 poorest countries reverse will be five dentists for every physician because in a very poor country you're not gonna get treated for you know prostate cancer but you will find a dentist for a toothache so the dentist is the number one yeah and you're gonna see them so probably that and everything I've read everyone's gonna see a dentist.

Seena: Absolutely well there are studies even in when we're looking at the HPV vaccination subject they've seen that they've actually counted like you almost see a million more people if we include dentists in discussing the HPV vaccine you could target a lot more people because there's people children who visit dentist more than physicians.

Howard: I know they didn't start going to do this but I mean III kind of the first Jimmy Hoffa dentistry I mean I can't give a flu vaccine, so here's grandma she's she's more likely not to come back in six months dying from pneumonia in the winter from you know I mean a couple of winters back was a was a 38,000 death winter for the for the flu and I'm not allowed to give a flu vaccine I can't even buy an HPV vaccine for me I mean and they're like say the lady I bought my house from had to leave the country to go get a medication that was made in America do you think that's gonna change in your lifetime?

Seena: I do actually yeah organ has already changed their scope of practice to include those things so that

Howard: Organ can can give a flu shot?

Seena: Yes they can give any vaccine now the issue is whether it's covered or can dentists be reimbursed that's another barrier yeah but the scope of practice has changed that was just April of this year and so that's a huge barrier barrier broken if more states could follow that model so I think it will happen in our lifetime.

Howard: and you know it's tough because I'm I mean I love my physician but I had to tell him several I mean you asked him a question the first thing out of his mouth is always well I don't know if the insurance and it's like come on come on we had this conversation every time I have a job I can't well the insurance I said I didn't ask about the insurance so I know that's a totally separate subject and that is the most important element to probably half of Americans Oh who's going to pay the hundred dollars for a vaccine because half of Americans you know they have $100 to go buy a pair of Nike tennis shoes but you know but anyway yeah I think those are just big challenges I mean I just want to see the day where I have enough freedom to give a flu shot yeah the pharmacy tech a Walgreens can give and I went to a nine-month training course and they can give the HPV vaccine if somebody checks it off and then give a flu shot but doctor Frank can't 99 years of college was not it's probably cuz I went to ADU and they know I went to ASU so why did you go to U of A because I'm sorry because what I notice is that kids just want to leave town yeah seems like everybody in Arizona goes on a Tucson event that's exactly us on well it was you late was your primary reason just to leave town?

Seena: Yeah I wasn't so keen or were my parents so keen on me going really far away at that time so and also just there were a few other factors involved that you know with my goals in life that aligned the best but yeah the most between ASU and U of A I did go to Tucson so that I could leave Phoenix for a few years.

Howard: and we went over an hour and but of all the things you listen you said you love them you love oral facial you love speaking at conferences giving CE courses teaching research focusing traveling and spirituality the last word is where did that come from what does that mean to you?

Seena: So you know I think I've always kind of been interested in that phase of life for years probably ten plus years now I think it allows me to stay calm and look at the big picture because with all of the responsibilities that we have day-to-day and God knows every year it just gets more and more I almost find that struggle in terms of taking a step back and truly relaxing knowing that how can we maintain this bigger picture in life and really realize what its purpose is but really this is all just selfish I need to figure out a way to stay calm and it that's something that we just get so busy in our lives that it teaches me to appreciate.

Howard: and what does spirituality mean to you, do organized religion does it mean...

Seena: Not necessarily

Howard: What does it mean to you?

Seena: Looking inwards fixing or not fixing but learning more about yourself before anything on the outside because if we can control our inner selves and our emotions and attachments then that's what's going to translate automatically to the outside world and that's how we can achieve what we want and do what's best for everyone around us so it's trying to keep that clarity or I guess achieve that clarity that's what it means to me.

Howard: I think that's an interesting that's an I've never heard anyone describe spirituality as looking inward that is because most people associate religion is some organized...

Seena: Yeah I think things are changing

Howard: and you're seeing it as more a self-awareness

Seena: Absolutely

Howard: Inward looking that's a really neat definition of spirituality yeah I love that because I'm everybody is so quick to backseat drive everyone else everyone else's job it's like you know if everybody could just manage the person in the mirror

Seena: That's all you have to do

Howard: That's all we'd have to say I mean there wouldn't even be there wouldn't even be government or maybe a police department and everybody could manage it but it seems like the more I hear a person backseat driving how that person I did it right and it's like they always are smarter than you know the president of the country is fortune 500 it's like they're smarter than all these organizations and you're like looking at their own little upside-down dental office that's running back maybe you should just focus on your dental office.

Seena: Yeah

Howard: and you weren't there to figure out what I mean like like apples made some just incredibly bizarre decisions but my humble self always thinks well I'm sure they had meetings that I didn't get to attend and discussed events that I'm not aware of and just maybe there's more to that but I'm love what you're doing would love to have a courses on these blocks I mean I there I bet there's so many dentists out there that have never even seen one.

Seena: Yeah that's true they're popular I do yeah they're very interested which is encouraging.

Howard: and how is it, last but not least how is it do you have fun at AT Still?

Seena: Oh I love it yeah it's a great environment to work in the people I'm around the patients we see the residents of students I can't say enough good things.

Howard: I love the to Tim's over their Tim Lukavsky, Tim Taylor are they the life of the party?

Seena: Oh yeah absolutely I work with Dr. Tim Lukavsky twice a week so we work really closely he's a wonderful human being.

Howard: I've known him since Creighton University yeah what an amazing man. Seena thank you so much for driving down.

Seena: Thanks for having me

Howard: and tell your dad that I said he did a very good job with you and telling your dad hello and thanks for all they did for me years ago.

Seena: Thank you, thanks for having me.