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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929 All Things Perio and Implant with Jennifer Hirsch Doobrow, DMD, FICD : Dentistry Uncensored with Howard Farran

929 All Things Perio and Implant with Jennifer Hirsch Doobrow, DMD, FICD : Dentistry Uncensored with Howard Farran

1/24/2018 8:27:24 AM   |   Comments: 0   |   Views: 503

929 All Things Perio and Implant with Jennifer Hirsch Doobrow, DMD, FICD : Dentistry Uncensored with Howard Farran

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929 All Things Perio and Implant with Jennifer Hirsch Doobrow, DMD, FICD : Dentistry Uncensored with Howard Farran

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AUDIO - DUwHF #929 - Jennifer Doobrow

Dr. Jennifer Hirsch Doobrow, a Board Certified Periodontist, is the Owner and CEO of Periodontal and Implant Associates, Inc. located in Cullman, AL.  She earned her DMD at the Medical University of South Carolina in 2007 and received her certification in Periodontics from the University of Alabama at Birmingham (UAB) in 2010.  She serves as a faculty member for the Pikos Institute, was the General Chair for the 2017 Gulf Coast Dental Conference and is the 2017-2018 Chair of the Leadership Council for the UAB School of Dentistry. Dr. Doobrow is on the Executive Council and serves as the Corporate Advisory Chair for the Southern Academy of Periodontology and sits on several committees for the American Academy of Periodontology.  She holds Past-President positions in the Alabama Society of Periodontists and the Wilson Chenault Dental Study Club.  In 2012, Dr. Doobrow was recognized as one of the University of Georgia's (UGA) prestigious 40 Under 40. Most recently, Dr. Doobrow was selected as one of the Top 10 Young Educators in America for 2017 by The Seattle Study Club, was inducted as a Fellow of the International College of Dentists as well as a Fellow of the American College of Dentists.  She was also awarded the UAB School of Dentistry Outstanding Young Alumnus Award and was featured on Lifetime Network’s “The Balancing Act.” She has published articles in Compendium, Implant Dentistry, DentistryIQ, Surgical Restorative Resource and Perio-Implant Advisory, and lectures extensively throughout the United States on dental implants and periodontal regenerative therapies. Dr. Doobrow’s office hosts an annual dental symposium in Cullman, AL with 1,000 attendees in 2016.

Howard: It's just a great honor for me today to be podcast interviewing Dr. Jennifer Hirsch Doobrow, a board-certified periodontist; is the owner and CEO of Periodontal Associates located in Cullman, Alabama. She earned her DMD at the Medical University of South Carolina in 2007 and received her certification in Periodontics from the University of Alabama at Birmingham in 2010. She serves as a faculty member for the Pikos Institute, who I think was podcast number one eighty-seven for us; was the general chair for 2017 Gulf Coast Dental Conference and is a 2017/2018 Chair of the Leadership Council for the University of Alabama School of Dentistry. 

Dr. Doobrow is on the Executive Council and serves as the Corporate Advisory Chair for the Southern Academy of Periodontology and sits on several committees for the American Academy of Periodontology. She holds past president positions in the Alabama Society of Periodontists and the Wilson-Chennault Dental Study Club. In 2012, Dr. Doobrow was recognized as one of the University of Georgia's prestigious Forty and Under. Most recently, she was selected as one of the Top Ten Young Educators in America for 2017 by the Seattle Study Club. Wow. Was inducted as a fellow of the International College of Dentists, as well as fellow of the American College of Dentists. 

She was also awarded the UAB School of Dentistry Outstanding Young Alumnus Award and was featured on Lifetime Networks: The Balancing Act. She has published articles in compendium; implant dentistry, dentistry IQ, surgical restorative research, and perio implant advisory; and lectures extensively throughout the United States on dental implants and periodontal regenerative therapies. Dr. Doobrow hosts an annual dental symposium in Cullman Alabama with one thousand attendees in 2016, and you can find her on a Lifetime Channel interview on 'The Balancing Act'. We'll put the link in the notes to that, but man, you must not sleep. Are you one of those sleep apnea people who only sleeps two hours a night? 

Jennifer: The rest is for the weary. 

Howard: I got to tell you as a periodontist, I graduated thirty years ago in 1987, and I looked at all the nine specialties, and I think periodontal, periodontist, that specialty, changed more than all the other ones. I mean I look at what changed in like pediatric dentistry and orthodontics and just kind of minor stuff, incremental improvements over the years, but when I got into school, periodontal surgery was all about periodontal surgery and then it switched to, "Why would you do periodontal surgery? Just pull that thing and treat it with titanium." And now the literature is saying that at sixty months, 20% of implants have peri-implantitis; now you see the pendulum coming back and now you see a lot of dentists saying, "You know that periodontal surgery looks better than before." Do you see it that way, the pendulum swinging left to right and coming back? 

Jennifer: Absolutely, I think it's a dynamic process, very fluid. It's really interesting how... My Dad was actually a practicing periodontist as well, and right around the same time that you guys came out, and maybe we'll get into that at some point. But you know, why do we call it practicing? It's an evolving profession. It's an evolving environment that we're in; very dynamic and it's exciting. That's why I'm so passionate about what we do every day because we're always learning new technology, we're always learning new philosophies and it's really, "What's the best way that we can treat our patients at this moment in time?"

Howard: Well, I have another historical question that I want to ask you. In 1900, only 1% of the GDP was health care, and by 2000 it was 14%. And in 1900, it was 1%, no specialties. By 2000, it was 14% and fifty-eight specialties. Now at 2017 it's 17%. And now I see these dentists come out of school and they want to master implants and ortho and pediatric dentistry and endo and it's like, "Are we going back to 1900 where this one doctor does everything?" Do you know what I mean? 

Jennifer: Absolutely.

Howard: It's kind of like the super... And then when young kids say to me, "I want to learn sleep apnea", being an old man the first thing I ask, "OK, well if you're gonna learn sleep apnea, what are you going to give up?" Because it would be a full time job for years just to learn sleep apnea and then go, "Oh no, I'm not going to give up everything. I wanna do ortho, sleep apnea; I want to learn how to place implants, bone grafts." Can you really be the super dentist from 1900 with no specialties? 

Jennifer: I think it's a phenomenal question Howard. Can I personally? No. That is why I specifically picked a specialty to go into. There may be others that can have a multitude of techniques and technology that they use and they feel comfortable with. The best advice that I can give those that are starting to try to figure out the future and the direction they want to go, is: find out what you're passionate about. Do your due diligence, look at the science, look at where the direction we're going with that specific technology that you want to use and be darn good at what you do. Because the best thing that we can do as a profession is be the experts, and leading experts, in our field. 

Howard: I got this question. I lectured yesterday, Ryan and I were in Toronto and a young dentist who was twenty-seven, she said, "This implant company has a 98.5%  success rate but then it had all these pros and cons and the other one had a 97.9%; would you go with the 98%?" What do you say to these kids when they see these full page ads and Web and Facebook ads and all this stuff, and they're saying that their implant has a 98.5% success rate? 

Jennifer: Well, like I said, what I was mentioning before was, do your due diligence, understand the science of that specific product that you're using; the technology behind it, what went into it. Look at histology, make relationships, long lasting relationships with those companies. Because I can tell you, being involved in... Howard you may be able to attest and speak to this as well. Being involved with dentistry my whole life; my Dad was a practicing periodontist for what would have been forty plus years; my Mom sells dental supplies, so I've got a unique background, that's for sure. I mean, you asked me about sleeping; we sleep, eat and breathe dentistry in our family and always have. And the best thing that I can tell those individuals coming out is: know who you're working with, because you and I know this, what happens? You've got somebody that's got the latest, greatest product, and the next thing you know, they're down the street working for another company, having the latest, greatest product. So you need to know who you're working with, and what you're working with, before you stick your hands into that environment, that technology, that science. 

Howard: Last year at the Greater New York meeting, Amazon had a booth there. And when we started Dentaltown in '98, a lot of people said, "Well you should sell supplies." And I said, "Well, we're trying to form a community so that no dentist has to practice solo again." And right now before the internet and Dentaltown, your only link to the community was your reps that would come by and see you. And I said, "They don't want to cut off that rep." And if you start buying everything through Amazon, who would be...I mean I ask my rep questions like, " Who uses this Endo file?" And she just starts rattling off the names, and if she says, "Well Brad Gettleman, your favorite endodontist uses this." Well, that means a hell of a lot to me. Not that I can buy three and get one free. 

Jennifer: Yeah. No, you're exactly right. And you know, talk to your colleagues. This is what I would tell a rising dentists and individuals coming out of school: talk to your colleagues, hear who they speak with, learn about how their experiences have been. I always say there's no panacea. What we do, there's no make or model that's going to fit perfectly for one person that's going to fit for the other. So, get opinions, get advice. The best thing that I could have done along my journey is form these relationships, these partnerships and quite frankly the mentorships that I've gained. You mentioned Dr. Pikos, if I hadn't been part of that experience and gotten to know an individual that's been practicing for that long, who knows where I would have been. So find those partnerships and mentorships early on for sure. 

Howard: Yeah and he's been practicing a long time. He's a lot older than me; just a lot older; in fact, I think I'm younger than his children. I want to separate this into  two things. Well first of all, let's just realize this, I always tell my guests, shoot me an email,; tell me your name and how old you are, because you just don't know who's listening to this stuff on iTunes and Facebook and all that stuff. And what's bizarre is about 5% are applying to dental school, a quarter of them are in dental school, but almost every other one of them is under thirty. I only get like, one email a month that says, "Dude, I'm as old as you. I'm a grandpa. Love your show" whatever.  But one of the things that really troubles them is that they’ll have a patient with periodontal disease and they can't... How do you wrap your head around periodontal surgery versus, "The hell with it, just extract it and do implants." And then they're reading on these older cases on Dentaltown that were done ten, fifteen, twenty years ago; that implants get periodontal disease. Hell, 20% have peri-implantitis at five years out. So how was she supposed to go with that diagnosing and treatment planning of when to the old-fashioned ancient periodontal surgery versus space age titanium?

Jennifer: That's a great question, and what's so fun about going out and having the opportunity to lecture and meet different people is you get these wonderful questions and depending on demographics, maybe answer differently, depending on the locations that we are. You know, I'm in Birmingham Alabama and my practice is in rural Alabama. So how I address that question may be different than if I was in some large urban city. So that's the first thing I can say. But what we have to remember Howard, and as a periodontist I know you know this; we sleep, eat and breathe this; that over half of the American U.S. population over the age of thirty has some form of periodontal disease. And what we forget is this, that periodontal disease comes in many shapes, forms and sizes, because you're looking at everything from an  inflammatory diseases that can be reversible like gingivitis, to severe periodontal disease. Right? But what we also forget is, when we look at an individual, what else is periodontal disease? Periodontal recession. There's bone loss there which has instituted gum loss. So we have to look at the big picture here and again what I was saying about technology and procedures as well as instrumentation, there is no panacea. You know I don't look at one mouth and say, "This is an implant case." The first I can tell you is, all of our patients we consider are friends and not as patients. That's a huge piece of advice that I can give individuals: don't think that when somebody walks in... When we leave dental school,  it's ingrained in us that we have to reach this curriculum and these statistics, right, we need to, what's the word for it Howard...?

Howard: Requirements? Curriculum?

Jennifer: Requirements, right. So you're now practicing on individuals each and every day that are coming to you because they trust you. They're not a requirement fill anymore. So to all that to be said is that you need to treat them like a person. Howard, if you came into my office, I'd want to treat you just like I would treat if you were a family member or my brother/ cousin whoever. And that's what you have to think about when you see a patient, don't look up the mouth and see thirty-two white things and a black hole. Right. Look at the patient, look at their family history, look at their medical history, look at what they do, look at their educational background because again, another way to look at it; I'm not going to talk to a truck driver that walks into my office the same way I'm going to talk to a hairdresser. I'm not going to talk to somebody that's got a PHD in astronautical engineering, that I am going to talk to somebody that's a farmer. So we need to look at those individuals as individuals and not as patients and not as a requirement that we have to fill and not as a dollar sign that we need to recoup. 

Howard: Well said, I love that. Yeah, Alabama  has a lot of astrophysicists, they made the solid rocket booster, what in Huntsville?

Jennifer: Absolutely, Huntsville, yep. Where I live is in Birmingham, where my practices are an hour north of where I live, so I actually commute an hour each way every day. And then Nassau, Huntsville is about an hour north of that, so where we are, we're kind of centrally located in different areas and it's amazing. I mean it's very diverse with the, what's the best way to say, maybe dental IQ in our state. So you have to understand how to relate to everybody. 

Howard: And I lectured one time in Alabama on the Gulf Coast in a casino.

Jennifer: You did?

Howard: That was so beautiful; that was gorgeous. So should I assume that since you're in Alabama you use BioHorizons, since they are out of the area? 

Jennifer: Yep, they are out of Birmingham. And going back to your question Howard, about the companies that you use and the products that you use, and going back to relationships; for me it is very important to be able to support local groups if I have the ability to do that and there's a lot to be said because it's a partnership, it's a win-win. If I need something, my rep, my territory manager can just bring it up to me, versus, as you mentioned, a mail order; you can't get that in twenty-five, thirty minutes. 

Howard: So was I right? You seriously use BioHorizons?

Jennifer: Yes, sir, I do. 

Howard: Oh, that is so cool. Yeah, I was born in a small town, Wichita, Kansas, and now I'm in Ahwatukee, which is really a small town of eighty-five thousand; separated from Phoenix by a big mountain preserve and Indian reservation and interstate. And I always told my kids, if you have a chance, if you need a La-Z-Boy, buy it in Ahwatukee, don't go over to Tempe and Phoenix. 

Jennifer: Absolutely.

Howard: I do all my shopping in the backyard. So you do use BioHorizons, that is an amazingly good deal. So again, I don't know what to talk to you about, periodontal disease or implants but let's start with periodontal disease. What's got you most passionate today about treating periodontal disease? 

Jennifer: I love that question, thank you. I can tell you, I don't have my scrubs on right now but our scrubs say, for our team, "Changing lives, one mouth at a time." And I like to pause when I say that because to me changing lives, as one month at a time, that's what we're doing each and every day, or we should be. So, I was mentioning something about my back when we first started. My Dad, Howard, was a periodontist and in the intervening summer between my first and second year, my three year residency, he passed away suddenly.

Howard: Aww, I'm sorry.

Jennifer: And he was, you mentioned your age; he was 53 years old. 

Howard: Oh, my.

Jennifer: Yep. So what I can tell you was, my experiences at the University of Alabama where I did my periodontal residency; if it wasn't for my faculty there and the mentorship that I've gained, through this really horrific experience, but really to turn it around in the best way that you can possible, to use that as a motivator and to help others. It had such a huge impact in how I practice today and all to be said, that taught me about what is the foundation about what we do. You know, whether as an implant or periodontal disease, my mind will think, especially being in Alabama... You know you hear a lot of people say, "Bless her heart." Well it's true because we really believe in our practice, we tell our patients, "God gave us our teeth for a reason, we want to try to help you save them." If we had the ability to save your teeth, or at least give them the option, don't you think that that patient is going to trust you, and they're going to send their mother, their brother, their cousin to you because they know you've at least given them a chance. And then if they need an implant down the road, then you've already built that trust, that relationship between the two of you. And there's no stronger bond between a doctor and a patient, in your team member, to be able to cultivate that trust. Especially in a small town of where we are, it's all about the word of mouth. 

Howard: So now the most important question, "Did your Dad like the bear?" 

Jennifer: So it's funny, my Dad is actually from upstate New York. So he became, I guess by proxy, an Alabama fan. So my dad was from upstate New York, actually in the New York area, in New York- New Jersey, but when you come to Alabama it becomes ingrained in you. But today is actually a pretty dark day in our household because I cheer at the University of Georgia, so yesterday was not a promising day for us.

Howard: Man, I love the bear. He was so fun to watch. My gosh. He was a legend. So, I want to talk about BioHorizons just for a second and the fact that when I look at... Well, first of all, you just need to have a high quality implant company that's been in existence ten or twenty years. The biggest disasters I see is, you know, there's over seven hundred and fifty different dental implant systems in the world today. There's over seventy-five just in the country of Italy and these people, they buy these implants and they do these big cases, then five or ten years later that company is gone, and then they need a part or a screw or fixer and the company's gone; so you've got to have staying power. And then the other thing I've seen is there's just a handful of companies where if you did get sued and you're using an implant that has no research or no R and D or anything like that; that can look very bad. But whenever I meet anyone who made it past placing one hundred implants, they always have a human relationship in the field, and that human relationship is so important for getting over the tipping point. Maybe your rep will say, "Well, you know what, that's a great question. Let's go to lunch with Dr. So-and-So" and they're working the grapevine. I mean the implant company I use, is basically an alcoholic drinking club at least once a month; five, six, seven of us dentists are at the bar and it's so fun to go after work and have drinks and talk about it all night long. So I think the human capital in the field, is so important to do. So you talk about, specifically, regenerative periodontal therapy. Talk about that. 

Jennifer: Yeah, so as what you were asking before about treating a periodontal disease. I mean as a periodontist, what I want to do, I want to save teeth if it's possible. And again, I really mean it, that that trust that you build with your patients... What you have to remember, what we all have to remember is you don't ever want to over promise to your patients because you don't want to be the one to under deliver. I think you were spot on Howard earlier when you asked about, "Can we all do it all?" So number one is: you don't want to over promise so you don't wanna under deliver. And so with that being said, when I do regenerative medicine, I mean we're talking about regenerating bone,  cementum and PDL around teeth that have fourteen and fifteen millimeter pockets and seven/eight years later, I clinically have results where we're able to see, these patients still have the teeth in their mouth. And not only are there still teeth in there now, it has truly changed their lives. Because what I think we all tend to forget, Howard, is just like if God forbid, a patient of yours, a friend of yours, a family member has to lose a limb, a lot of these times these patients feel that if they have to lose a tooth out of their mouth, that they've had for thirty, forty, fifty years; it's just as significant and impactful on the life as losing an arm or a leg. And I can't tell you that we can we can save every fourteen and fifteen millimeter pocket around a tooth, that we can keep that tooth. But what I can tell you is we're darn well going to try if we have the ability. But going back to what we are saying, knowing those individuals in your office, you have to understand that so many patients related factors... (truncated 00:19:58).

So what we need to understand is it all about the host response and host response goes back to a lot of things. Is the patient healthy, are they not healthy, do they have comorbidities, are they a smoker, do they use alcohol in excess? There's so many factors that you're going to do... If they tell you they're going to brush, are they going to brush with the wrong side of the toothbrush? One thing I've learned is don't ever ask a patient a yes or no question because what's always going to be the answer? Yes; if you're trying to look for a positive response. You need to ask a patient, "How often do you brush. How often do you floss." So all to be said that we need to understand that there's limiting factors, that we need to be aware that they all are different from one patient to the next. And even so Howard, with that being said, one side of the mouth, I may treat differently than another side. One quadrant I'm going to be treating different than another quadrant. 

Howard: These kids are coming out of school with a lot of student loans. A lot of them are coming out with three hundred and fifty thousand dollar student loans. So I want to ask you a big dollar question. A lot of times, if they're interested in perio, they start thinking of LANAP, but LANAP is a hundred and thirty-five thousand dollar commitment. What are your thoughts about LANAP, and is it worth the hundred and thirty-five thousand dollar commitment?

Jennifer: Well I can't speak specifically to LANAP, Howard, I don't personally use that technology in my practice at the moment. But what I can tell you, are there certain additions to my practice that I feel are game changers, that have a pending cost on them. For instance my 3D Cone Beam technology, I mean that's something I couldn't live or practice without. So specifically about LANAP, like I said, I can't speak to that, but there's certainly going to be a cost that you have to really weigh.  Just like your patients do with the treatment that you're going to recommend to them, there's gotta be a cost benefit analysis that you need to do, throughout this entire process. 

Howard: But you are all that and a bag of chips and you're doing all that and a bag of chips without LANAP, so that speaks volumes to me. So you're doing it all. I mean god dang, the Seattle Study Club, that's the hardest speaking gig on Earth. And they gave you the Top Ten Young Educators in America by the Seattle Study Club. So if you got that and you did all that without a laser... Well, was that presumptuous? Maybe do you use another laser? 

Jennifer: Not currently I don't but...

Howard: So you're able to do it all without lasers. I want to ask you two more questions, just because they gotta watch pennies. I mean if you come out of school three hundred and fifty thousand dollars in student loans; there's some expensive courses, one is the pinhole technique, one is the gumdrop technique. Are these great courses in your opinion or have you taken those courses?

Jennifer: So I have not taken those two specific courses I can say that, but what I can tell you is there's so much value in quality CE. Whatever it is, whatever excites you, whatever you're passionate about, be sure to follow through with that. Because none of us are doing anything that we're doing today that we were yesterday, and the same thing will change and evolve, as you are asking about the pendulum; it will swing again. You know what do they say, when you go to a CE course, the information becomes transient, it becomes cyclical, where two to three years from now that same speaker may be speaking on a totally different topic. You know that, I know you attend so many of these courses; you got to know what's your value, what are you trying to get out of this course.

Howard: You know what's the best periodontal and implant course I ever took in my life. 

Jennifer: What's that?

Howard: The one that you're going to submit next month for, for the online. I want you to put up a course so bad. I mean seriously, I think that'd be so amazing. Here's another periodontal question, a lot of patients; do you believe this, true or false; should use a manual brush or an electric toothbrush? Some people would say: "Jennifer, if you're going to cut this table in half, would you use a handsaw or a table saw?" Is that a fair analogy or is that not really a fair analogy? And what do you recommend: manual brush or an automatic? 

Jennifer: Yeah, absolutely. No, in our practice we really discuss in length with our patients, using electric toothbrushes. We actually have something called a test drive, which gives them the top of the toothbrush. We actually let them hold the toothbrush, we show them how to use it so they can see the difference between the manual and the electric in their own hands. And especially with those... You know again it's about a dental IQ, it's about manual dexterity; there's so many factors that play a part in that; so why not take part of that out of the equation and let instrumentation that has so much science behind it, do the work. And there's so many products, but you know you were asking about companies, there are tons of different companies out there, that if you're recommending a specific toothbrush or toothpaste or whatever it is, just know the science. Do your own due diligence because you want to be recommending something that you would potentially be using in your hands as well.

Howard: Well, speaking of that, you just walked into the next question. There's a lot of research that says that you don't need any toothpaste, that dry brushing is just as effective as removing plaque. Do you think there's science for toothpaste or do you think dry brushing is just as effective for removing plaque? 

Jennifer: Well being a parent, and as you probably know this, you just opened up Pandora's box with that question. Because depending on who you speak too and depending on the literature, some say that even using a toothpaste, a denture paste, can lead to a fraction; a fraction lesion right. So, in our office I can tell you that we do recommend using a denture paste, we recommend using an ADA approved... How many products... You're talking about, you asked about Amazon earlier, how many products out there now... I've heard some that are made out of charcoal, and I can't even go in that direction because I don't even know how to speak about what products are out there anymore. In our office, we go with the science based products that have the histology and everything else behind it. 

Howard: I want to ask you the most controversial question, the most controversial podcast I ever did in my life. You talk about emdogain, L-PRF... Let's go to PRF, I did a podcast interview with Carl Misch on his deathbed, and my shows an hour because all my homies say they have an hour commute, like you have an hour commute. That's our typical podcast audience and they can't listen to politics anymore, they're so sick of everything in politics and Putin and North Korea and all that stuff. But anyway Carl went on for two and a half hours, and I sure as hell wasn't going to stop or interrupt him. But he said that that was voodoo; he said there's no research for that. He said, "These people drawn on blood and spit on blood" and my god, that set off a firestorm on Dentaltown. What is your thoughts on PRF?

Jennifer: So it's really interesting you asked that because as I have been talking about it , you need to know the evidence; you need to know the science. 

Howard: And by the way, Carl Misch was involved with BioHorizons in the beginning. 

Jennifer: Yep. Yep absolutely. And it's really very fascinating you just mentioned Dr. Misch because I really had an amazing opportunity and good fortune; I was able to attend one of his very last lectures, it was actually in his honor. Going back to Dr. Pekos, he did an honorarium in his honor; he wanted to have him present in the moment before anything... Unfortunately, he wasn't going to be with us any longer. And he was supposed to go on for 30 minutes, Howard; I think he also went on for two and a half hours. And he was in his element and to experience Carl Misch at that level, and knowing what he was experiencing within his own body, I mean I get the chills just thinking about what that was and to be present there for that. 

Anyway, you kinda got me off on a little tangent there, but I will tell you from a clinical standpoint what leukocytes... And I use L-PRF, I use Leukocytes Platelet Rich Fibrin in our practice. What I can tell you from a clinical standpoint, the patients that are coming back, the individuals in our practice; when we are doing very large cases, full mouth surgeries; these patients are coming back and they are not having to use any adjunct for pain or medicaments to treat any pain. I shouldn't say any but few and far between, in comparison to what we used to do prior to using this type of technology. From a marking standpoint, in the sense of telling a patient that you're going to use their own blood, send down their own blood and show them exactly what you're going to do; it blows them away. Because what do people want nowadays? At least for the most part, at least in our area, they want an all natural alternative. They don't want to have all these medicines thrown down their throat, they don't want to be on steroids, they don't want this, they don't want that. So if you're going to give a patient the opportunity to use what they have from their own body; it is such an amazing connection that you have with these patients. Like, "Wait, you're going to use my blood to do what?" So from your question, what I can tell you from a clinical standpoint, Howard, the response, the reduction of pain and discomfort and quite frankly swelling as well, has been remarkable. I mean between the use of, you mentioned emdogain earlier, and the enamel matrix derivative proteins and L-RPF in my practice, and the Cone Beam CT's 3D technology; those are three major game changers in our practice are far.

Howard: So that means, you're a periodontist and a vampire. 

Jennifer: Exactly. Just don't tell anybody.  

Howard: Well, the difference between my age and your age, you were talking about a CBCT; you know what the hot update was the year and a half after I got out of school? You could update your Pano, so it had an L on one side and an R on the other. And I thought that was the coolest thing in the world because every time you showed a Pano to someone, they'd always say, "Is this my right side?" and that was just so cool.  

Jennifer: Isn't it exciting though? Don't you love being in dentistry because of just what you said; it is always evolving. And you know what, we as the leading experts in this dental field need to stay on top of it. I mean, I think it's our duty to do that because, why else do what we do?

Howard: Well, you might be talking to a lot of kids, you were talking about L-PRF, they've only heard about Palette Rich Fibrin, PRF. I think this might be the first time a lot of them heard L, and a lot of them probably never heard of emdogain again. So can you go back and say what's the difference between PRF and L for Leukocyte-PRF. And then explain again emdogain, which is made by Straumann right?

Jennifer: Yes it is, yep. So what L-PRF, Leukocyte Platelet Rich Fibrin; what that's going to be is when you're actually going to take a patients' blood, so oftentimes out of an antecubital fossa, sometimes in the hand, wherever you can get the best blood draw, and you're actually going to spin down that patients own blood in a multitude of tubes. And what you're going to be able to get out of that, I wish I had a drawing, even though my schematics are not very good. 

Howard: You could put it on your online CE course. 

Jennifer: Absolutely, I love it. We'll do some videos for ya. How does that sound? 

Howard: I would love it.

Jennifer: So, basically what you're able to do, is you're able to use their blood; and if you look at it in a tube, it separates out into a liquid, into a fibrin, a membrane; and the membrane, you can literally use as a membrane, you can use as a plug for an extraction site. You can also use it underneath on the palatal lingual buccal aspect of flap. And basically what it is, it's yours and you are up-regulating growth factors, is the best way to describe it, and so the difference between that and something like an enamel matrix derivative protein; that is now going to be from a poor side derivative so not from the own host. And that's actually, like you said, manufactured from Straumann, it comes in a tube; and basically that right now is one of the top products out there that has the most science and literature to prove periodontal regeneration; so regenerating the peridontium, the bone, (inaudible 00:32:03 precementum) and the PDL. So I use those, Howard, in cases of deep periodontal pockets, whereas the PRF, L-PRF; I’ve been using those in conjunction with the emdogain. Does that help to clarify some stuff?

Howard: Yeah, that's very good. It seems like in my thirty years, women are at least two thirds to three fourths of my perio program. I can get the average mom in every three to six months but her husband, every year or every other year. It seems like when I talk about, "We can do this or we can extract it and do the implant." It seems like women, where I live, would go to the end of the earth to keep their natural tooth, more than a man. Do you think that is a fair assessment of women versus men in wanting to keep their body part....? 

Jennifer: I mean yeah, if you're going to look at it globally, potentially yes but I think it's up to us, really Howard,to educate those patients; male, female, young, old. In the global perspective to answer that, yes, but that's kind of my mantra to try and change that mentality, and it shouldn't matter what your gender is. Now is that going to still be the case? Possibly. I mean, I guess you're a man, maybe you can answer it better; would you rather just do something quick; take out that tooth and put an implant in? But to answer that, in this perspective, I have to explain the difference between a (truncation 00:33:30) and an implant and make sure they understand that. Sometimes they have periodontal disease; if you're losing a tooth due to periodontal disease, you can potentially have the same effect on an implant as well.

Howard: Back to the difference between men and women, when a woman has a gummy smile, it really, really bothers her. A lot of the men that have a gummy smile, I don't even think they know they have a gummy smile. What do you do for a really gummy smile?

Jennifer: Yes. So, the specific techniques you're referring to? 

Howard: Yeah.

Jennifer: Ok, very good. Well, I love this as well, because this brings me to how important interdisciplinary approach to dentistry is. So I would never just look at you and say, "Well, you've got a gummy smile, Howard, let's just remove this issue. We're going to remove some of your gums, and I'm going to give you your smile that you think you want." So what's very important with that process is- and I actually have a couple of these different cases going on currently- I work very, very closely with my referring doctors. And to approach these, we're going to make sure that there's going to be a wax-up, that I'm going to have a stent from that specific referring doctor, based off of, if they're planning on having restorations or not, and then depending on what my potential diagnosis is for the cause of the gummy smile,  if it's (inaudible 00:34:44), if it's vertical maxillary access. It's all going to depend on how I treat that case. 

So sometimes in a crown lengthening procedure, for those individuals that are just coming out and trying to understand the difference and how we do procedures, you need to look at: what's the reason why this has occurred? Are you going to just be removing excess gingival display or are you just removing excess tissue, or actually are you going to re-contour the underlying bone in order to get the potential and point that we're trying to reach? And I think, Howard, it's really important to understand this. I think we all need to look at dentistry maybe a little bit differently than we do. I think a lot of people go into dentistry and again they think: look at this place; thirty-two white things and a black hole. Right?

Howard: All right.

Jennifer: But, instead why don't we look at it with the end in mind? If you're placing an implant or you're doing a full arch rehab, we need to be- especially as a periodontist- I need to be prosthetically driven as far as what my end result and my end point is going to be. And it's the same thing with the crown lengthening case, it's even the same thing about doing periodontal regeneration; I need to know what the end point is. Is occlusion the factor here, is that why? And if I treat... For instance, if I go and I treat a full mouth of four quadrants of periodontal surgery, or a full mouth of periodontal recession; if occlusion of a factor here, and I don't work with the referring doctor and the patient to understand this, what have I achieved? That patient is probably going to arrive back in my chair, two to three years from now. 

Howard: This question... I don't want to throw any of my homies under a bridge, I love my homies and when I see my homies disagree, I always tell the young kids that I'm 55; every major Supreme Court decision I've ever seen in my life is five to four. They both read the same constitution, they both went to the same law school and one saw red and one saw yellow; but when I look at my friends and just the ones that have drinking problems that I hang out with at bars; it seems like half of them, never have done a crown lengthening procedure or referred it to a periodontist, and the other half can't live without it. I mean that's real world America, is half these dentists, they just don't do that. So why do you think half do crown lengthening and refer to periodontists? I mean what percent of the dentists, do you think in America, in the last year, did not do one crown lengthening, refer one crown lengthening, what percent did refer? Just I want to ask you that first. What do you think the macroeconomics is in the United States on crown lengthening? 

Jennifer: Oh, it's gotta be low, right, but it's the same thing for referring for periodontal recession. I mean how many times do you think that we wait, watch- I'm just gonna say it- in maybe a general dentist practice. I can tell you that I see this with different practices, especially traveling around the United States and speaking, that with periodontal recession lesion, they waited and watched, and now instead of being a class one, it may be a Miller classification three. They're past the mucogingival junction. So it's the same thing potentially with something like a crown lengthening. A lot of times it's not identified as disease, because in the case of a crown lengthening, are we doing it for aesthetic, or is it a functional purpose? I would tell you, from a functional crown lengthening standpoint, I would think that the numbers are much higher, because the referring doctor needs that surgeon to possibly reduce the periodontum, reduce the bony structure underneath, in order to place a restoration on it. But for an aesthetic reason, unless the patient brings that to their attention, I think very rarely are those patients going to be referred. 

Howard: She's a little girl, she's twenty-five, she just got out of dental kindergarten and she goes into practice with her mom, who's a dentist, and her moms never done a crown lengthening procedure in her life, so you've got her ear right now; why should someone do crown lengthening? And she's never going to get exposed to it because her mom's been doing this for thirty years, reminding her every day that she's been doing this for thirty years, so what would you tell this young kid that just walked out of dental school,  why would someone do crown lengthening, and why do over half the dentists never do it? 

Jennifer: I think it's a great question. I think it goes back, Howard, to understanding the needs of your patients, to understanding the desires and the wants and the needs of our patients, so if crown lengthening and aesthetic crown lengthening is more than anything, if you look at it from one perspective, an elective procedure; and unless a patient finds that this is a strong desire that they have; oftentimes if you were Janie, that twenty-five year old new dentist coming out, if you don't have a patient that's interested in doing that, than more than likely they're not going to refer it. What we need to look for differently, because I guess... Let me kind of retract here. 

I think as a new or younger graduate, Howard, I think a lot of the time we are more potentially timid on the discussions that we have with our patients. If I look at you, and you were this young twenty-five year old patient; I am a young dentist and I'm looking at somebody that's one of my contemporaries, it may be very hard for me to say to you, if you didn't bring up, that, "I think you have a gummy smile". It may be hard for me to say, "Hey, does it bother you that excess gum is showing?" So what I can tell you, my advice to these individuals is this: give a patient a mirror, put it in front of them and ask them, "What do you see?" And if a patient says, "Well, I see some gums showing here, and I see a long tooth here, and I see a (inaudible 00:40:18) here", then what you're going to be able to do is start a conversation. And that may be one approach that you can have, if you're coming out and you don't feel comfortable starting that initial conversation with the patient. 

Howard: I only like to say...I mean this is dentistry uncensored, I don't like to talk about anything everyone agrees on,  I always go right for the controversy. You know when talking about crown lengthening, I mean half don't, half never do it, half can't live without it. Another huge controversy, especially on Dentaltown, is this oral systemic link; some people think that periodontal disease and gum disease is causing cardiovascular disease, that's showing up in Alzheimer's plaque, you know, on and on and on. Then other people say, "Hey, when I get up in the morning and make my coffee, the sun comes up. Me drinking coffee did not make the sun come up. It's a correlation it's not a cause effect." Where do you sit on that?


Jennifer: Yeah, absolutely, great question. So I'm going to go back to what my new patient experience is when they walk in the door, ok. What we always tell our patients is, "Our goal is to get you healthy in the quickest manner possible." And whether they're coming in, Howard, for an aesthetic crown lengthening as you mentioned before, or they're coming in because their doctor referred them for periodontal disease, or they're coming in for periodontal recession treatment; the way that we're going to approach it is that, "Our goal is to get you healthy in the quickest manner possible." And the way that we explain that we're going to do that, we do that in a handful of ways. The number one way is educating you as a patient, and this is what I'll say to the patient, "So before we do any type of art", we call it a dental tour of your mouth, "before we do a tour of the mouth, in your mouth..." I'm treating you as a patient right now, Howard ok. "So before we do a tour of your mouth, I'm going to explain to you, why we're doing this and the importance of it." And what we'll explain to our patients is, "We know that there's a very strong relationship- we can't tell you that this will cause this problem- but there's a strong relationship between the mouth and the body." And we'll tell our patients, "The mouth is the window to the body. And we know that if this isn't healthy, if there's inflammation in the body, then the bacteria that's causing inflammation for the infection, can travel into the bloodstream and be associated"- I'm going to tell them again" not causative- but can be associated with heart attacks, strokes, high blood pressure, cancers, Alzheimer's." And then when you throw out the Turkish study of  erectile dysfunction, that's when men really... You were asking about how to get the attention of men? You tweak it to what makes sense to them. And then the second part of that, Howard, is we're going to explain to you, the patient, we're going to say, "And, did you know that periodontal disease can be contagious?" And you pause for a second. And when you tell somebody that periodontal disease can be contagious, and their spouse is sitting across the way from them, all you have to do is get up and walk out of the room, because you're going to start hearing them scream back and forth. Not really, but there's an argument that can ensue. 

Howard: Well, I mean it's so crazy, if you saw someone every three months for an STD,  say it was Chlamydia, every three months; you wouldn't see them every three months for years and years and years, just saying, "Hey, can I see your husband?" I mean this is a heard disease. And I think it's insane, when you go into a dental office and you're seeing Grandma every three months for the last ten years, and she says has bleeding gums, and you've never seen Grandpa, when they know that just a mild kiss transfers eighty million bacteria, fungi, micro-organisms. And when people say, "Well, it's not contagious." I want to remind you of something, you know dentists, when you say, "What causes a cavity, they say streptococcus mutans." Research today shows that at four millimeters deep into the lesion, there is no more streptococcus mutans, and when they're analyzing decay four to six millimeters deep, they discover a new species of bacteria every quarter. So just because we think we're so smart because we have an iPhone and we went to the moon, I guarantee you a thousand years from today, we're going to realize that we were making a lot of decisions without a lot of the data and a lot of the knowledge. 

Jennifer: Right.

Howard: And I mean, god, look how much smarter, how much more they know now today, than they did thirty years ago, when I got out of school. I don't see how it couldn't be contagious. I mean it blows my mind.

Jennifer: Well, it's interesting, you did say something really interesting a moment ago, you said there's controversy about the oral systemic link; we refer to it as a perio systemic link. Because how many microbes do we have in the mouth, that don't necessarily result in what we're discussing here, periodontal disease or bone loss, loss of the periodontium; it's actually the microbes from- the way that I believe, the way that I studied- it's the microbes that are getting in the periodontist sulcus or the pocket. And that's what we find to be traveling around, into the bloodstream and that they found in the plaques around the heart for sure. I mean, you've seen the literature, whether you believe that it's causative or associative; I mean I believe that it's associative like you mentioned, but like you just said, what are we doing each and every day? We're trying to educate our patients.

So if you can educate them on stuff like you mentioned, that there is- you know, you're potentially passing saliva back and forth between that one little smooch... You know we got to joke about it, you make it fun in your practice. Your patients don't need to come to you and you scare the hell out of them. I mean it's just like telling a kid, if I told my seven year old he's got bugs crawling in his mouth, it's going to freak out, he's going to run the other way. But if I tell him he's got bacteria; he's a seven year old,  he understands just like the twenty-one old and the fifty-five year old in my practice. You need to talk to your patients, you need to relate to them, but you also don't want to (inaudible 00:46:03) mean what you're saying. The best advice that I can give to anybody is: get your patients to own their disease. 

Howard: I'm doing everything I can do to get you in trouble. 

Jennifer: How?

Howard: This is a very controversial question. Twelve percent of the dentists work in corporate America, and they have a lot of clinical directors, many times they're not even dentists, telling them what they have to do. But a lot of them, if any patient has anything over a five millimeter pocket, they have to place an arestin in because there's an insurance code and corporates about big money. What do you think of the practice... Would you work at an office where everybody that had a five or six millimeter pocket or greater had to place an arestin in and build their insurance for. What are your thoughts on that? 

Jennifer: You're trying to get me in trouble. You're not kidding, huh? 

Howard: And arestin is the minocycline,  and there's another one, what's the other one besides arestin, it was a chlorhexidine chip. What was that one called? Perichip?

Jennifer: Perichip, yeah. You know, here's what I can tell you, four millimeter pockets and beyond; we know that with blind methods, depending on the literature that you read, that we are missing the debris. In a four millimeter pocket and beyond, anywhere between thirty-six and I believe the literature says forty-seven (inaudible 00:47:27). On average it's about forty-one percent of the time. So whether you're putting a chip in there or whether you're flips, chips, whips, whatever you want to call it, in the pocket; the problem is, if you're not getting out that debris, if you're not getting rid of the irritant, if you're not getting rid of the microbes, what is the medicament going to do in that pocket? And think about it; listen as a periodontist, how many times in our office...Sometimes what we'll do is we'll seal a replay in the pocket before we open it up. Because what happens when we open up that pocket, even if it's a four to five or six millimeter pocket, you open it up and this beautiful shiny piece of dark thing staring at us, cause we just burnish that calculus over and over and over again. So I have a hard time understanding that by keeping that potential irritant in the area; how is any type of medicament really going to work? 

Howard: Again, not to throw my homies under a bridge, but if you're my age, fifty-five or older, still practicing, all the way to seventy-five, a lot of these old doctors, whenever their hygienist does replaying curettage, they write them a script for Pen V.K.. So is that your same thought? Well, what's your thought on that? What would you think if a dentist, I mean, I could just start naming out names; every time their hygienist does two quadrants, they do right side, left side; they scan the right side and the left side, and they scale the right side; give them Pen V.K. five hundred milligrams, two stat, twenty-eight grams, and then they come back and do the left side; they do it again. What do you think of that antibiotic protocol? 

Jennifer: Yeah, I mean, listen, fortunately I don't see that a lot anymore. I see people trying to really get to the root of the problem. I encourage really... I mean if you're going to do a closed approach, really understand how deep can your instrumentation go, if you're six, seven millimeters. So, if you're going to be doing a closed approach, you better darn well do it right, and you really need to understand where the pocket is. My thing is instead of using antibiotics, understand... Again, it goes back to understanding your host, why are you using antibiotics? Are these individuals, Howard, I throw that back to you; these individuals that are prescribing these prescriptions, what are you doing by prescribing the prescriptions? What is the science behind that? What is it, evidence based, is that why they're doing it? 

And that's what I'm going to ask why my clinicians... If they're doing something, whether it's sticking an (unsure) in there... Unfortunately, and I think this is a good point to make at this time and this juncture in this conversation, going back to having those awkward conversations with your patients when you're not used to having them cause you're first coming out; the same thing as a specialist, we get alarmed and concerned sometimes; we don't want to upset the referring doctor. So a lot of times, we don't have these strong conversations because we're afraid we're going to, for lack of a better word, piss them off. You don't want to piss off your referrals. I mean you said we're uncensored, so we're just going to go there, but you can't be afraid; I don't want to say challenge them, but positively challenge them.

Understand why somebody's doing something. If they have great science behind it, so be it, but I can tell you in our practice, if somebody challenges me, I'm going to be able to throw a piece of literature right in their lap, because I want them to know that the only reason I'm doing it is because it's got the evidence based behind it. And then, as you asked me with the L-PRF or the emdogain, if I can clinically back it up as well and see the positive results, well “hey, winner, winner, chicken dinner.” You know, what do we do? It's the art and science of what we do. It's being able to prove it, it's evidence based, clinically sound results that I want to be able to provide in my practice.  

Howard: So I know you love the literature, so they probably want to know, what electric toothbrush did you go with?

Jennifer: Let me put disclosure in, I mean you know a lot of us that do speak, we are supported by certain companies. So is that fair enough to say right now?

Howard: Sure. Absolutely.

Jennifer: I want to absolutely say that. But, with that being said, I get involved only with the companies that I want to partner with. You know, there's a lot of people out there, and I am going to... Can I digress for one second here?

Howard: Please

Jennifer: So here's what's really interesting. As you train, with those of you who may want to get involved with leadership, or you want to be get involved with speaking or writing or whatever it is, make sure you understand that everybody's got their different approaches. Because how many speakers have we seen get up on the lecture, the lectern, get on these main podiums, and I like to say when I showed things it's the good, the bad and the ugly, Howard; but how many times do we just see the good and the really good, and there's no bad. So for me that's to their discredit because I'm going to tune out very quickly when I see somebody that shows all perfect, all beautiful. So we also need to understand that there's a lot of speakers that have been backed by different companies, so you're asking a very apropos question, I love it. Cause I only, for me as a speaker as a lecturer, I'm only going to speak about products or support products because I'm using them clinically as well. So in our practice what we primarily use is the Oral B products, and that's based off of the science that's been provided to us and that we've studied, the literature, the evidence and the results. 

Howard: And which Oral  B electric toothbrush, what model?

Jennifer: Right now they've recently come out, I'm not even sure if you can actually purchase this in the consumer world, I know that they provide them through a lot of the practices, but there's a product out there called the Genius. Have you heard of it?

Howard: Well I'm a genius, so of course.

Jennifer: You are a genius. A genius or a Genius.

Howard: They named it after you and me. 

Jennifer: I like that because again, going back, Howard, to what we said, you gotta have the patient's own their disease. The Genius is Bluetooth technology so there's actually ways to communicate with your dental practice, and that's really cool because I don't do this with a lot of (unclear 00:53:21) patients, but some patients want that interaction, they want that technology, they want to know that you're one step ahead. So if there's a way that I can communicate via Bluetooth technology with my patients, how cool is that? 

Howard: Well they have the Oral B Genius 8000 and they have the Oral B Genius Pro Electric. I like the 8000, they sell it at Wal-Mart for $156, but you get the Genius for $99.99. Gosh darn, the hours gone. We went up, and I still have one more question. Can we go into overtime for one more question? 

Jennifer: As long as you don't ask my height, my weight or my age, we're good. 

Howard: Last and final question,  and I want to talk about what stressed out...So here's in the field, here's reality: you're in Kansas, Oklahoma, Arkansas; Grandpa comes in there, he has no pain, he loves his implant, supported bridge or Zolon 4  or whatever. You're twenty-five years old, out of school; he's got 25% bone loss on these things, they've got eight millimeter pockets and she says, "You know, you got to go get treatment." And he's like, " I don't have any problems, I don't have any pain, and I can eat a bacon cheeseburger, and I can bite your finger off." And then when she goes on Dentaltown, it's pretty obvious that there is not even a consensus among periodontists what the protocol is for peri-implantitis. So she's kind of like, the patient doesn't know it's there, the periodontists really don't have a consensus or a protocol on peri-implantitis. Should she just tell them to get a water pick and start using a lot of mouthwash, or... I just vomited twenty-five peri-implantitis things, just grab one of them and answer it. 

Jennifer: Before I answer it, I think everything that we've really said today goes back to the point of: understand that we're going to have to be out of our comfort zone. I think I lost you again. Are you there? 

Howard: I'm there.

Jennifer: There are going to be uncomfortable conversations, that's number one. Whether it's with the patient, whether it's with another dentist, whether it's with the referring dentist. That's the one things we have to realize, what we do, again, they call it practicing for a reason. I don't think there's one right way or one wrong way to do something. Well, maybe there's a wrong way but not necessarily the right way. So I think the number one thing you have to do is you've got to inform your patients. Howard, are you talking about a general dentist, that the patient walks into a general dentists practice?

Howard: Yeah.

Jennifer: And so the general dentist is the one that's graduated within the past couple years.

Howard: Right. 

Jennifer: Right, ok, so the number one thing is, that general dentist may not understand, just like you said, there's no consensus for surgeons or periodontists or oral surgeons or whoever it is, on how to treat peri-implantitis. You don't have to bomb it out of your mouth, the treatment options, like you just said; but what you do have to do, you know we are held morally, legally, ethically up to a certain standard; and that is to inform our patients about disease. What is one of the number one things that we see in dentistry that, unfortunately, goes into the litigious world, is because of either misdiagnosis or no diagnosis. Is that an accurate statement? 

Howard: Yes. And failure to refer.

Jennifer: Yes, right, but it's also because of misdiagnosis or no diagnosis. Correct?

Howard: Right.

Jennifer: So you as that new dentist out, you don't necessarily have to say, "This is how they're going to treat it", but you have to, in my best recommendation, for whatever that's worth today, for the last hour that we've been with; you have to inform the patient that there is disease present. You have to take the proper documentation, radio graphically, and show them what's going on because every patient is going to have a different level of understanding. And you may think they understood, but how many of those patients look at you with blank stares and they just don't say anything, and that's the scariest patient to me is when they don't ask a question. So, you have to make sure that you inform; that they acknowledge that you've informed it, and what's the most important thing? If it's not written, it never happened. So you make sure you document that conversation as well, that is so, so, so important. And you know what, there's going to be a lot of patients that you're not going to be able to win the fight in this battle. That sixty-five year old patient that's had those implants for twenty-five years, and they can still eat bacon; they may not ever damn well do anything. Correct? And you and I both know this, but it is up to us to at least inform them, that's my take on it. 

Howard: Yeah, and also young doctors: don't be judgemental. One of the things I don't like is when these young doctors, they want to dismiss a patient because they're not doing it right or they're smoking or whatever. Look, I can name you ten ladies that come to my office in wheelchairs with oxygen tanks in their nose and they're smoking outside my front door, and I love them to death. I give him a hug, I kiss them on the cheek; I mean that eighty year old lady shouldn't be smoking next to an oxygen canter but she's never going to change her mind, and she needs a doctor, and she needs a doctor who is not judgemental. Everybody needs a doctor. So humans are crazy, in fact the older I get the more I realize I'm probably the only normal person on Earth. I think we can all agree on that. But hey Jennifer, seriously, god, I hope someday we get an online CE course or an article from you. I think you're amazing, your resume is just to die for, you've done so much. I mean gosh Top 10 Young Educators of America, Seattle Study Club, you're already in the International College of Dentists and American College of Dentists. You are all that and two bags of chips. I want to thank you so much for coming on my show today and talking to my homies. It was an absolute honor to podcast interview you. 

Jennifer: Well, Howard, this has been a true honor, a privilege, and I'm beyond humbled I've had this experience, I really am. Thank you so much. 

Howard: Aww, thank you. And thank you Ryan. 

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